Tao Zan

Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander.

Background: Resurfacing of facial massive soft tissue defect is a formidable challenge because of the unique character of the region and the limitation of well‐matched donor site. In this report, we introduce a technique for using the prefabricated cervicothoracic skin flap for facial resurfacing, in an attempt to meet the principle of flap selection in face reconstructive surgery for matching the color and texture, large dimension, and thinner thickness (MLT) of the recipient. Materials: Eleven patients with massive facial scars underwent resurfacing procedures with prefabricated cervicothoracic flaps. The vasculature of the lateral thigh fascial flap, including the descending branch of the lateral femoral circumflex vessels and the surrounding muscle fascia, was used as the vascular carrier, and the pedicles of the fascial flap were anastomosed to either the superior thyroid or facial vessels in flap prefabrication. A tissue expander was placed beneath the fascial flap to enlarge the size and reduce the thickness of the flap. Results: The average size of the harvested fascia flap was 6.5 × 11.7 cm. After a mean interval of 21.5 weeks, the expanders were filled to a mean volume of 1,685 ml. The sizes of the prefabricated skin flaps ranged from 12 × 15 cm to 15 × 32 cm. The prefabricated skin flaps were then transferred to the recipient site as pedicled flaps for facial resurfacing. All facial soft tissue defects were successfully covered by the flaps. The donor sites were primarily closed and healed without complications. Although varied degrees of venous congestion were developed after flap transfers, the marginal necrosis only occurred in two cases. The results in follow‐up showed most resurfaced faces restored natural contour and regained emotional expression. Conclusion: MLT is the principle for flap selection in resurfacing of the massive facial soft tissue defect. Our experience in this series of patients demonstrated that the prefabricated cervicothoracic skin flap could be a reliable alternative tool for resurfacing of massive facial soft tissue defects.

Reconstruction of the face and neck with different types of pre-expanded anterior chest flaps: a comprehensive strategy for multiple techniques.

BACKGROUND For large defects or deformities of the face and neck, the anterior chest area appears to be an excellent donor site that provides well-matched skin colour and texture. Many flap techniques based on the anterior chest area have been reported; however, there are few reports that focus on a treatment strategy for these different flap techniques. METHODS A retrospective study was performed to propose a treatment algorithm. A total of 69 cases were reviewed from May 2005 to July 2011, in which different types of anterior chest flaps were performed for face and neck reconstruction. The reconstructive procedures, the defect characteristics and the complications were collected and analysed. RESULTS Thirty-three pedicled thoracic branch of the supraclavicular artery flaps (the pedicled TBSA flap), 11 pedicled internal mammary artery perforator flaps (the pedicled IMAP flap), 8 free internal mammary artery perforator flaps (the free IMAP flap), 4 supercharged TBSA flaps, 17 prefabricated flaps and 3 supercharged prefabricated flaps were performed. The applications of six types of pre-expanded anterior chest flaps were described in an algorithmic approach. CONCLUSIONS A treatment strategy for face and neck reconstruction using six anterior chest flap techniques is proposed. It recommended a personalised flap planning according to the characteristics of deformities/defects and the regionally dominant vessels of the anterior chest area.

Flap prefabrication and stem cell-assisted tissue expansion: how we acquire a monoblock flap for full face resurfacing.

AbstractTotal face skin and soft-tissue defects remain one of the biggest challenges in reconstructive surgery. Reconstruction of the entire face with uniform coverage and delicate features is difficult to achieve. To avoid the patchwork result seen in multiple flaps and skin grafts, 1 monoblock flap that has similar color, texture, and thickness might be an ideal option to minimize the incisional scars and several surgical procedures but is unavailable with current approaches because of the lack of sufficient matched tissue and the unreliable blood supply for such a large flap. To acquire a monoblock flap for full face reconstruction, we combine the prefabricated flaps, skin overexpansion, and bone marrow mononuclear stem cell transplantation for total facial resurfacing. In this article, we present our experience from our case series that provides universally matched skin and near-normal facial contour. It is a reliable and an excellent reconstructive option for massive facial skin defect.

A study of blood flow dynamics in flap delay using the full-field laser perfusion imager.

It is crucial to monitor spatio-temporal changes in the microcirculation of flaps. A laser speckle imaging technique based on speckle contrast analysis compensates for disadvantages and can assess regional blood flow distribution at high resolution. In this paper, temporal changes in circulation were investigated with full-field laser perfusion imaging (FLPI) in rat dorsal delay random flaps. Twenty Sprague-Dawley rats were randomized into two groups (delay procedures and controls) with a standardized dorsal random pattern flap (caudally based, 3 × 10 cm). Blood flow dynamics in both groups were studied with FLPI at different timepoints, and the size of the surviving and necrotic areas of the flaps, vessel distribution, microvessel density and vessel diameters were appraised. The results showed that blood flow after secondary elevation of the flap did not rapidly decrease in the delay group compared to the control group. Viability of the skin flaps, vessel diameter, and micro-vessel density was significantly improved in the delay group. Delay procedure work by diminishing the resistance to blood flow of the flap with FLPI real-time detection, and laser speckle imaging could be a better method for studying microcirculation and judging flap vascularity.

Application of the expanded lateral thoracic pedicle flap in face and neck reconstruction

BACKGROUND Massive scars of face and neck cause severe esthetic and functional problems in patients. To achieve better outcomes, in this study, we demonstrate the use of the expanded lateral thoracic pedicle flap, which provides a large and thin flap that matches the face and neck area in color and texture with minimal donor site morbidities. METHODS Firstly, a tissue expander was embedded in the lateral thoracic region. After water inflation, the expanded lateral thoracic flap was elevated as a pedicle flap and was then transferred to replace scar tissue of the head and neck. Doppler ultrasound examinations were employed pre-operatively to identify the path of the nutrient arteries of the flap. A surgical delay procedure was performed two weeks prior to flap transfer. RESULTS Ten patients were treated with this method. For 9 patients, the outcomes were satisfactory and were not characterized by obvious flap contraction after 3-17 months of follow-up. The final patient sustained flap necrosis in the distal one-third of the flap. The donor sites were primarily closed in 80% of the cases. CONCLUSIONS The expanded lateral thoracic pedicle flap proved to be a reliable method with satisfactory outcomes for skin reconstruction of the face and neck.

Enhanced endothelial progenitor cell mobilization and function through direct manipulation of hypoxia inducible factor‐1α

Endothelial progenitor cells (EPCs) play a significant role in physiological and pathological hypoxia resistance and neovascularization processes. The ability to mobilize EPCs from bone marrow usually indicates a prognostic endpoint of several vascular diseases. Thus, it is of great value to study possible approaches for activating functional EPCs. The mobilization/homing of EPCs from bone marrow is signalled by stromal‐derived factor‐1 (SDF‐1), which is regulated by the hypoxia‐inducible factor‐1α (HIF‐1α). This study investigated the effects of directly manipulating HIF‐1α on human EPCs in vitro. EPCs were isolated from human umbilical cord blood. Lentiviral vectors carrying HIF‐1α and shRNA targeting HIF‐1α were constructed for gene modification of the EPCs. Results demonstrated that after overexpression of HIF‐1α by lentiviral transfection, the proliferative capacity of EPCs was elevated while the apoptosis was inhibited and vice versa. On the other hand, the expression of angiogenic‐related cytokines including SDF‐1 was upregulated on both gene and protein levels when EPCs were transfected with HIF‐1α. These results indicate that direct HIF‐1α manipulation over human EPCs is an effective method to promote EPC function and mobilization, thus suggest that drugs or reagents that elevate HIF‐1α expression are capable of treating ischemic diseases. Copyright

Strategies for customized neck reconstruction based on the pre-expanded superficial cervical artery flap.

BACKGROUND It is still highly challenging to restore the esthetic neck contour for postburn deformities. In many patients with burns, the back skin remains intact, which is a useful donor site for extensive contracture release. As the main technique, the refinement of the pre-expanded superficial cervical artery (SCA) flaps may improve its application in diverse neck contractures. METHODS This study reviewed the cases of three types of neck contractures that were reconstructed with pre-expanded SCA flaps: (1) for unilateral neck contractures, the flaps were harvested as pedicled perforator flaps including a small amount of muscle; (2) for lateral and anterior neck contractures, vascular augmentation with circumflex scapular vessels was used to increase the flap size; (3) for contractures of the entire neck, maximal flap release with pedicle dissection toward the origin of the superficial cervical vessels allowed for reaching contralateral defects. RESULTS From March 2010 to September 2012, pre-expanded SCA flaps were recommended in 15 patients with severe neck contracture. Tip necrosis occurred in one patient. The donor sites were closed primarily in all cases. One patient had donor-site wound dehiscence that healed within 2 weeks by conservative management. All patients had restored neck extension to a near-normal position without the sense of restricted neck flexion or rotation. CONCLUSIONS Pre-expanded SCA flaps are practical and flexible for the reconstruction of diverse scar contractures ranging from unilateral to total neck lesions. Considering the reconstructive efficiency and the reduced donor-site morbidity, this flap may be an ideal option for the reconstruction of severe neck scar contractures.

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.

Surgical treatment of facial soft-tissue deformities in postburn patients: a proposed classification based on a retrospective study.

BACKGROUND Postburn soft-tissue defects or scars can cause disfigurement and functional impairment and constitute a major therapeutic challenge. In the past 30 years, developments in reconstructive techniques have improved the treatment outcomes. However, these techniques are selected mainly according to the surgeons preference. There is no classification for postburn facial deformities that might contribute to high-level evidence and optimize management. METHODS The authors reviewed the clinical cases of preexpanded local flaps, perforator flaps, and prefabricated flaps between January of 2005 and September of 2012 in their unit. Deformities were categorized according to their size and location, in accordance with the concept of facial aesthetic units, to show the relationship between different deformities and the indicated surgical techniques. The findings were assessed to develop a classification system. RESULTS The study included 174 patients with facial deformities ranging from partial unit to total face defects. The authors classified postburn facial skin and soft-tissue deformities as follows: type I, single partial unit defect; type II, total unit defect or deformities that partially involved two adjacent units; type III, multiunit defects; and type IV, total/subtotal defects. The authors recommended reconstructive techniques for each deformity and developed a system to score postoperative aesthetic and functional improvements. CONCLUSIONS The authors have proposed a classification and scoring system for postburn facial deformities that will aid in the selection of reconstructive techniques. The proposed systems may facilitate multicenter studies with high-level evidence and improve the outcomes of postburn patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.