Hainan Zhu

Resurfacing severe facial burn scars: an algorithm based on three different types of prefabricated expanded flaps.

BACKGROUND In the reconstruction of facial burn scars, large, thin, color-matching flaps are desirable due to aesthetic and functional demands. There have been many reports using prefabricated flaps to resurface facial skin lesions. However, an algorithm to select the most suitable treatment option for the individual patient is lacking. METHODS An algorithm for facial resurfacing based on three types of prefabricated flaps from the cervical, periclavicular, and lateral thoracic area was setup, and 15 were patients treated accordingly. RESULTS All 15 prefabricated flaps survived. Minor necrosis at the distal flap edge developed in three cases. After a follow-up of at least 6 months, all patients showed satisfactory aesthetic and functional outcomes. CONCLUSION By individual selection of the most suitable option among these three types of prefabricated flaps, satisfactory resurfacing can be achieved for most facial burn scars.

Prevention of necrosis of adjacent expanded flaps by surgical delay.

AbstractAlthough expanded flaps have been shown to survive longer than unexpanded flaps, flap necrosis still occurs, particularly when a deep back cut has been made. Overcautious design can avoid necrosis but leads to inefficient usage of the expanded flap. In this study, we tested a surgical delay method to prevent partial necrosis and maximize the use of the expanded flap. Ten patients with 13 expanders were included in this series. The surgical delay was performed 2 weeks before the final flap transfer. The survival of the delayed flaps was compared with that in previous cases without surgical delay. All 13 expanded flaps exhibited complete survival, which was significantly better than the 27.5% partial flap necrosis observed in nondelayed cases. Surgical delay can decrease the risk of necrosis in an expanded flap caused by a back cut and can thus maximize flap use.

Reconstruction of Postburn Full Facial Deformities With an Integrated Method.

Background:The face is one of the most important regions of the human body and contains complicated and delicate features that define the identity of a person. Treatment for extensive facial deformities requires resurfacing of the extensive skin defects and restoring the missing features. To date, it remains a major challenge to the reconstructive surgeons. Methods:The authors reviewed their patients of Type III and Type IV facial deformities to introduce an integrated method for total facial reconstruction. The entire management included flap prefabrication, skin over-expansion, bone marrow mononuclear cell transplantation, and multistaged revisions to reshape the face contours. The treatment details and postoperative results were presented. Aesthetic and functional status scores were independently evaluated to analyze the effectiveness of this intervention. Results:Forty-two patients with severe facial deformities were included. In 2 patients of total face reconstruction, bone marrow mononuclear cell transplantation was conducted. Each patient had facial reconstruction with a prefabricated flap (range 23 × 18–32 × 30 cm2) that resurfaced the entire defect. Tip necrosis occurred in 2 patients. The aesthetic and functional status scores were statistically improved. Good skin compliance, normal contours, and emotional expression were noted. Conclusions:The integrated method is a reliable and excellent option for extensive facial deformities involving both central and peripheral facial units while avoiding multiflap reconstructions. It creates a desirable coverage with minimal scars, which are both important for a “perceived normal” face.

An algorithm for using expanded cervical flaps to resurface facial defects based on five different methods.

BACKGROUND For patients with healthy skin in the cervical region, the expanded cervical flap method is highly recommended for resurfacing facial skin defects. Many methods exist that use an expanded cervical flap. However, a gold standard for selecting the appropriate method for each patient is lacking. Here, we introduce 5 basic principles for how to use an expanded cervical flap and an algorithm for selecting the appropriate method. METHODS The authors reviewed the medical records for all patients treated with an expanded cervical flap to restore a facial skin lesion in Shanghais Ninth Peoples Hospital between 2010 and 2015. RESULTS We summarized the 5 techniques according to different types of facial deformities: (1) an advancement of the expanded cervical flap; (2) an expanded cervical flap that is rotated toward the temporal side (the rotation pivot is located in the angle of the mandible); (3) an expanded cervical flap that is rotated toward the nasal side (the rotation pivot is located in the mentum; (4) an expanded cervical flap that is rotated cephalically along the midline toward the lower third of the face (the rotation pivot is located in the bilateral angle of the mandible); and (5) a prefabricated cervical flap that is used with superficial temporal vessels. CONCLUSION By using this algorithm and following five basic principles, all facial defects except for those on the nose and forehead can be resurfaced using an expanded cervical skin flap.

Rat model of heterotopic toe allotransplantation.

BACKGROUND Finger allotransplantation is a promising treatment for severe finger destruction. However, more research is required to decrease the risks of this procedure to a level at which the clinical use of this non-life-saving procedure is justified. A proper animal model is essential for the required experiments. METHODS In this article, we established a toe transplantation model based on anatomic studies. A tapered dose of Cyclosporine A (CsA) was used as an immunosuppressive therapy in the Brown Norway-to-Lewis allotransplantation experimental group, whereas isotransplantation or allotransplantation without treatment or with ligated pedicles was performed on the control groups. Recipients were assessed daily after operation for any signs of rejection and complications. On postoperative day 90, skin graft test was used to test the level of donor-specific tolerance in the recipients. On postoperative day 120, x-rays and micro-computed tomographies were performed for bone morphology evaluation. The chimerism in the recipient peripheral blood, lymph node, spleen, and thymus was tested by flow cytometry and immunohistochemical staining. And histologic study of the toe grafts and skin grafts were carried out. RESULTS The blood supply of the toe graft was confirmed, and accordingly, transplantations were performed. The isografts survived indefinitely. The allografts with ligated pedicles experienced necrosis within 5 d. The allografts without treatment exhibited necrosis within 14 d. Forty percent, 20%, and 40% of the allografts associated with the CsA treatment experienced severe rejection, mild rejection, and nonrejection, according to gross graft appearance, respectively. Skin grafting tests showed three different types of results. X-rays and micro-computed tomographies reveal nearly normal bone morphologies in the bone structures of all surviving animals with grafts. Low levels of donor-specific chimerism were detected in the peripheral blood samples. Spleen, lymph node, and thymus chimerism were also confirmed in the long-term surviving animals with allografts. Histologic evaluation of the long-term survivals revealed similar graft morphologies in the isografts and the nonrejected allografts, inflammatory cell infiltration in the mildly rejected allografts, and degraded cutaneous appendages in the severely rejected allografts. CONCLUSIONS We established a toe allotransplantation model. Moreover, the low rate of chimerism did not introduce specific tolerance, which might explain the high rejection rate. This model might facilitate future research in finger allotransplantation.

Application of Tissue Expansion with Perforator Flaps for Reconstruction of Challenging Skin Lesions

Background One set of perforators can supply its own perforasome as well as the adjacent perforasome. The process of tissue expansion can mimic the effect of surgical delay to include more perforasomes into the perforator flap. By combining the perforasome theory with the technique of tissue expansion, large and various expanded perforator flaps can be achieved. Methods From July 2007 to July 2014, we performed eight different types of expanded perforator flaps in a total of 83 cases: 41 supraclavicular artery perforator flaps, 11 superficial cervical artery perforator flaps, 15 lateral thoracic perforator flaps, 6 internal mammary artery perforator flaps, 6 thoracoabdominal perforator flaps, 2 facial artery perforator flaps, 1 posterior interosseous perforator flap, and 1 ulnar collateral artery perforator flap. During the follow‐up period, the survival rate, color, texture, and retraction of the flaps were assessed. Results The dimensions of the flaps ranged from 8 × 6 to 25 × 25 cm. Minor flap necrosis occurred in 20.5% of the cases, and severe flap necrosis developed in 2.4% of the cases. The donor sites were closed primarily in all but three cases. During the follow‐up period (average, 13 months; range, 8‐18 months), no flap contracture was observed with a good color and texture match. Conclusion By combining the concept of perforasome with the technique of tissue expansion, flaps with large dimensions and reliable blood supply can be achieved, allowing a more flexible design to reconstruct various and challenging skin lesions.

“Stamp Perforation” Technique for Correction of Prominent Mandibular Angle: 10 Years of Experience in Mandibular Reshaping in Asians

Abstract Resection of a prominent mandibular angle is commonly used in Eastern society to improve the lower one third facial proportion. Historically, this procedure had a high complication rate, such as severe bleeding, asymmetry of the angle reduction, and “second mandibular angle.” A safer and more effective way of performing such procedures is needed. The aim of this study is to introduce 3 instruments, a tunable guide handpiece, milling cutter, and flywheel, which were invented by the author, as well as a related ostectomy technique for correcting prominent mandibular angles using a modified full-thickness marginal ostectomy of the mandibular corpus angle, named the “stamp perforation” technique. This technique has 4 highlights: First, it ensures a smooth symmetric contour. Second, it prevents the risks of rupture of the inferior alveolar vessel and facial artery, ensuring the safety of this approach. Third, the “stamp perforation” technique eases the removal of bone fragments, shortening the operation time. Fourth, the recovery time of patients treated with this approach is much shorter than with the traditional approaches. From January 2006 to January 2016, 1106 patients underwent the surgery to contour the prominent mandible angles, and satisfactory results were achieved. Thus, we recommend the instruments as well as the “stamp perforation” technique for correcting prominent mandibular angles, and we hope that our 10 years of experience could provide a reference for other plastic surgeons.

Orthotopic forelimb allotransplantation in the rat model

In this report, we present a rat orthotopic forelimb allotransplantation model. Eight forelimbs were transplanted from Brown Norway rats to Lewis rats. Axillary vessels of transplant were used as the vascular pedicles, which were anastomosed to the external jugular vein and common carotid artery of the recipient rat. The ulnar, radial, and median nerves were also repaired. Among rats, a tapered dose of cyclosporine was administered in five rats. In other three rats, no immunosuppressive therapy was given. The viability and signs of rejection of transplanted forelimbs, sensation recovery, bone healing, and histology were assessed up to the 90th postoperative day. All of rats but one survived surgery. All of transplanted forelimbs survived. In the rats treated with cyclosporine the transplanted forelimbs achieved long‐term survival with motion and sensation recovery. On 90th day after surgery, bone healing was achieved. There was no sign of rejection in histology. In the rats without cyclosporine treatment, the transplanted forelimbs experienced tissue necrosis started from day 12 postoperatively. This experimental study showed the feasibility of orthotopic forelimb allotransplantation in the rat model.

A vascularized elbow allotransplantation model in the rat

BACKGROUND The aim of this research was to develop a rat model for vascularized composite allotransplantation (VCA) of the elbow. METHODS We developed an animal model for VCA of the elbow in rats. Microvascular VCA was performed in 9 rats across a major histocompatibility barrier. Three different immunosuppressive regimens were provided. Joint mobility and weight-bearing capability were assessed throughout 90 days of life. Pedicle patency, bone blood flow, and histologic analyses were performed. RESULTS In the cyclosporine group, forelimb activity was recovered during the postoperative 90 days. The extremity that was operated on was used in daily activities. There was minimal motion or use of the limb in the cyclosporine taper and control groups. The vascular pedicles were patent at the time of death in the cyclosporine-treated group but not in the remaining groups. Micro-computed tomography scan performed 3 months after transplantation revealed union at the bone junctions, and the elbow joint appeared grossly normal on death in the cyclosporine treatment group only. Incomplete healing was observed in the other 2 groups, and the elbow joints were grossly destroyed. Histologic examination revealed normal cartilage and bone cells in the cyclosporine-treated group, whereas the nontreated groups demonstrated lymphocytic infiltration and loss of normal histologic features. Flow cytometry of blood samples obtained on days 14, 30, 60, and 90 showed no recipient cell chimerism in any of the groups. CONCLUSIONS We developed an animal model for elbow VCA. Immunosuppressed animals regained nearly normal function of forelimbs and maintained grossly normal elbow cartilage. Without cyclosporine treatment, the elbow transplants were rejected.

New findings in anatomy of blood supply to rat femur isolated vascularized bone marrow transplantation model.

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