Background Autologous fat grafting has become an increasingly common procedure for soft tissue augmentation throughout the body. However, the long-term outcome is always unpredictable because of inconsistent graft survival. Based on the "law of use and disuse," we speculate that the volume loss of fat grafts will occur when transferred into a site where there is less fat. The purpose of this study is to investigate the cause of high resorption rate from the perspective of fat function after transplantation. Methods Adipose aspirates obtained from routine liposuction were injected into the dorsal site of athymic mice, which have no subcutaneous fat layer. The fat grafts were explanted at days 7, 15, and 30 after transplantation. Changes in fat function were evaluated by measuring the adipocyte size and the expression level of adipose differentiation-related protein. Results After grafting, adipose tissue was replaced by fibrosis, inflammation, and vacuolar tissues gradually over time. The size of fat cells decreased sharply from day 0 to day 7, increased at day 15, and further declined at day 30. Adipose differentiation-related protein expression experienced a dramatic increase at day 7 and then continuously decreased until day 30. Conclusions Assuming that the extrinsic factors influencing fat function and distribution remain stable, capabilities of the redistributed fat to handle free fatty acid and store lipid substance are reduced, leading to substantial tissue atrophy and volume decline after grafting.
Background In East Asia, intraoral facial skeletal contour surgeries (intraoral FSCSs), including reduction gonioplasty, reduction malarplasty, and genioplasty, have become increasingly popular. Nonetheless, intraoral FSCSs are technically difficult and have a steep learning curve. An effective simulator could be beneficial for intraoral FSCS training. However, there is no intraoral FSCS simulator available. We introduced an intraoral FSCS simulator and assessed its effectiveness. Methods An intraoral FSCS simulator was established by covering a 3-dimensional printed skull with elastic cloth. Twenty residents were enrolled and randomly divided into experimental group A and control group B. Group A performed the intraoral FSCS on the simulator for 3 times. Group B performed the intraoral FSCS on skull model for 3 times. The intraoral FSCS simulator and trainees' performance were evaluated by a trainee-reported questionnaire before and after training, the surgical outcomes were graded by 3 senior attending physicians. All questions and the surgical outcome were scored based on a 5-point Likert scale (1 = very poor, 5 = very good). The surgical times were recorded. Results The intraoral FSCS simulator (4.13 +/- 0.64) simulated the surgical reality significantly better than the skull (2.6 +/- 0.63). In intraoral FSCS simulator training, the restriction and compliance of the facial soft tissue were vividly mimicked (4.4 +/- 0.51); the intraoral approach was vividly mimicked (4.07 +/- 0.59). The intraoral FSCS simulator is significantly superior to the skull in improving participants' confidence in performing intraoral FSCS, power system control, and intraoral approach adoption (<0.001). The average surgical outcome score was 3.11 +/- 0.45 in group A and 3.91 +/- 0.24 in group B. The average surgical time was 177.78 +/- 28.38 minutes in group A and 65.26 +/- 15.38 minutes in group B. Conclusions We developed the first intraoral FSCS simulator and proved its effectiveness preliminarily. Randomized controlled study with clinical cases is needed to further test its effectiveness.
Objective Choke vessels, vascular anastomosis between adjacent angiosome, play an important role in flap expansion and survival. Here we established a flap model with single and multiple perforators to detect and compare the changes in choke vessels, discuss the effect of hemodynamics on the vascular morphology, and explore the underlying mechanism. Methods One hundred mice (7-8 weeks) were subjected to a "choke zone" surrounded by 4 perforators on their backs. Delayed surgery was performed by the ligation of 1, 2, or 3 perforators to establish flap models. The blood flow of the choke zone was measured by laser Doppler flowmetry preoperatively and 6 hours and 1, 3, 5, and 7 days. The morphological changes of choke vessels in the choke zone were observed by gross and histological analyses. Levels of angiogenesis-related markers such as endothelial nitric oxide synthase (eNOS), metalloproteinase 2, hypoxia-inducible factor 1 alpha (HIF-1 alpha), and intercellular adhesion molecule 2 (ICAM-2) were detected by Western blotting and enzyme-linked immunosorbent assay. Results Blood flow and microvascular count were obviously increased postoperatively and peaked and were maintained for 1 week (P < 0.01). Meanwhile, the diameters of the choke vessels expanded. The eNOS level was increased at 7 days (P < 0.05); however, the enzyme-linked immunosorbent assay results showed that the HIF-1 alpha and ICAM-2 levels were decreased at 7 days. Conclusions (1) The delayed surgery that kept a single perforator had the greatest impact on the choke zone. (2) Changes in choke vessels were closely related to the shear stress caused by enhanced blood perfusion after surgery. (3) Choke vessel growth was regulated by eNOS, metalloproteinase 2, HIF-1 alpha, and ICAM-2.
Background The closure of massive skin defects remains challenging, particularly in children. In this report, we describe a technique to achieve primary donor site closure using the kiss deep inferior epigastric perforator (DIEP) flap for the reconstruction of large soft tissue defects located in the extremities of children. Methods From May 2011 to May 2016, a retrospective analysis was conducted on 10 pediatric patients with extensive soft tissue defects and reconstruction with double-skin paddle DIEP flap. After harvesting the flap, the skin paddle was divided into 2 separate paddles with a common vascular supply, and then the 2 paddles were sutured side by side through translating 2 paddles or rotating one of the paddles by 90 or 180 degrees, effectively doubling the width of the flap and rejoining it at the recipient site. Data on patient age, medical history, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow-up were reviewed retrospectively. Results Nine children had major soft tissue defects of the lower limb, and the remaining one had an upper limb defect. Only 1 case was complicated by partial necrosis of 1 paddle. Primary donor site closure was accomplished in all cases. The flaps were well matched on texture and contour, except that the 2 flaps were bulky at postoperative follow-up. There was no donor site breakdown, with only a slightly noticeable linear scar. Conclusion The kiss DIEP flap could be an alternative for reconstruction of large soft tissue defects of the extremities in children, with lower morbidity and improved cosmetic of the donor site.
Background: This study aims to evaluate the effect of a modified approach on severe congenital ptosis treatment. Methods: Through anterior approach, Muller muscle was preserved, meanwhile the upper tarsus was suspended to combined fascia sheath (CFS) and levator muscle (LM) complex. The main outcome measures included marginal reflex distance1 (MRD1), palpebral fissure height (PFH), MRD1 regression, MRD1 improvement, and patient self-satisfaction. Results: There were 70 patients (90 eyelids) with severe congenital ptosis received treatment of modified operation, including 20 bilateral and 50 unilateral ptosis. The average LF was 2.53 +/- 1.06 mm. The preoperative MRD1 and PFH was -0.06 +/- 0.76 mm and 4.25 +/- 0.85 mm, respectively. The follow-up was at least 6 months with average of 12.67 +/- 4.92 months. The immediate postoperative MRD1 and PFH average was 4.52 +/- 0.39 mm and 9.24 +/- 0.26, respectively. The last follow-up MRD1 and PFH average was 2.43 +/- 0.57 mm and 7.16 +/- 0.69 mm, respectively, which was improved significantly (P < 0.01). Therewere variety degrees ofMRD1 regression especially in the firstmonth after operation, and the last follow-up MRD1 regression was 2.09 +/- 0.67 mm. The lagophthalmos was obvious immediately after operation and regularly released after 6 months. Objective curative effect assessment showed 78 (86.7%) satisfactory eyes, 4 (4.4%) improved eyes, and 8 (8.9%) noneffective eyes. Two noneffective eyes required reoperation of frontalis suspension. Self-satisfaction rate was 93.3%. Parameters analysis showed that LF had positive correlation with last follow-up MRD1 and negative correlation with MRD1 improvement (P < 0.01). Five eyes had levator shorten history, which was associated remarkably with CFS + LMcurative effect (P < 0.01). Mean swelling timewas 0.53 +/- 0.41months, and no complications were observed until the last visit. Conclusions: This modified method gives powerful correction and vivid eyelid contour, featured with simple surgical procedures, few complications, and satisfactory effect, which is worth to wide application.
Background Infantile hemangioma (IH) is the most common childhood benign vascular tumor. Recently, propranolol has been found to be an effective therapy for IH, but its mechanism of action is not yet understood. Hemangioma stem cells (HemSCs) have a mesenchymal morphology, robust proliferation, and multilineage differentiation (into adipocytes). Therefore, we hypothesized that propranolol could accelerate the transdifferentiation of HemSCs and prevent the growth of proliferating IH. In this study, the fibrofatty tissue of IH that received therapy with propranolol appeared much earlier than without the treatment. Methods We isolated HemSCs with CD133-tagged immunomagnetic beads, and then we used flow cytometry technology to analyze the HemSC phenotypes and determine whether propranolol induced HemSC death. The proliferation and adipogenesis abilities of propranolol-treated HemSCs were analyzed by 3-(4,5)-dimethylthiahiazo(-z-y1)-3,5-diphenytetrazoliumromide assay, Oil red O staining, and Western blotting. Results We observed that the HemSC morphological traits gradually became spindle shaped, like fibroblasts, and the average extraction yield of HemSCs was about 0.25%. The HemSCs had high rates of expression for CD90 (98.8%) and CD105 (97.8%) but did not significantly express CD31 (0.7%). We also found a 100 mu M concentration of propranolol cutoff point. Propranolol did not affect HemSC survival significantly at low concentrations (6.25, 12.5, 25.0, and 50.0 mu M). However, propranolol resulted in a sharp and significant variation in cell morphology and survival rates at high concentrations (100, 200, and 400 mu M). The results suggest that treatment with propranolol inhibited HemSC proliferation and induced cell death and apoptosis in a concentration-dependent manner. Oil droplets determined by Oil red O staining showed that propranolol increased the transdifferentiation rate of HemSCs into adipocytes. Furthermore, the expressions of phosphorylated AKT and peroxisome proliferator-activated receptor gamma (PPAR gamma) were increased with a 100 mu M concentration of propranolol in HemSC culture. Conclusions Our study found that propranolol inhibited proliferation, induced apoptosis and necrosis, and promoted differentiation of HemSCs. Propranolol may upregulate PPAR gamma via PI3K pathways, thereby accelerating lipogenesis and enhancing IH HemSC adipogenesis.
Background From infancy to adulthood, the mandible develops increased ramus height, prominence of the chin, and laterally widened gonial angles. In Crouzon and Apert syndromes, both relative retrognathia and prognathic jaws have been reported. Growth is influenced by a variety of factors, including the growth and relative position of the skull base, functional coordination, and the spatial influence of the laryngopharynx. Thus, this study aimed to explore in detail the evolution of the mandible in both syndromes and its relationship with the entire facial structure and skull base. Methods One hundred twenty-three preoperative computed tomographic scans (Crouzon, n = 36; Apert, n = 33; control, n = 54) were included and divided into 5 age subgroups. Computed tomographic scans were measured using Materialise software. Cephalometrics relating to the mandible, facial structures, and cranial base were collected. Statistical analyses were performed using t test and statistical power analysis. Results In Crouzon syndrome, the angle between the cranial base and gnathion was increased prior to 6 months of age by 10.29 degrees (P < 0.001) and by adulthood to 11.95 degrees (P = 0.003) compared with normal. After 6 months of age, the distance between bilateral mandibular condylions (COR-COL) was narrower by 15% (P < 0.001) in Crouzon syndrome compared with control subjects. Before 6 months of age, Apert COR-COL decreased 16% (P < 0.001) compared with control subjects and 13% (P = 0.006) narrower than Crouzon. During 2 to 6 years of age, Apert mandibular ramus height caught up to, and became longer than, Crouzon by 12% (P = 0.011). The nasion-sella-articulare angle of the Apert skull was 5.04 degrees (P < 0.001) less than Crouzon overall. Conclusions In Crouzon syndrome, the changes of the spatial relationship of the mandible to the cranial base develop earlier than the mandibular shape deformity, whereas in Apert syndrome, the spatial and morphological changes are synchronous. The morphological changes of the mandible are disproportional in 3 directions, initially significant shortening of the mandibular width and length, and, subsequently, reduced height. Crouzon has more shortening in mandibular height compared with Apert, reflecting the more shortened posterior cranial base length. The narrowed angle between the mandible and the posterior cranial base in Apert skulls is consistent with the more limited nasopharyngeal and oropharyngeal airway space.
Identification of risk factors for recurrence of tenosynovial giant cell tumors of the hand is crucial to provide adequate preoperative counseling and tailor surgical treatment. However, the risk factors are still controversial, which are the subject of this research. Recently, we conducted a retrospective cohort study of 135 consecutive patients with giant cell tumors of the tendon sheath of the hand from January 2010 to July 2016. All patients underwent surgical excision, received necessary imaging examinations, and had routine follow-up and thus were identified as those who had recurrence by confirmation of reoperation, and the duration ranged from 24 to 103 months (mean, 53.5 +/- 21.4 months). There were 14 local recurrences (10.4%) within 6 to 24 months, respectively, after surgery. Data pertaining to sex, age, tumor sites, tumor size, tumor number, course of disease, bone erosion, tumor growth patterns, anesthesia mode, and the surgeon's experience were all extracted, and Cox regression models were used to estimate recurrence rate with adjustment for potential confounders. According to the Cox regression analysis, the recurrence rate after surgery was significantly higher in patients with a diffused form than in those with a localized one (P = 0.001); in addition, patients with 2 or more tumors had a much higher postoperative recurrence rate than did those with only 1 tumor (P = 0.023). This study suggested that the recurrence rate of tenosynovial giant cell tumors of the hand was closely related to the tumor number and tumor growth patterns.
Background Studies of using mesenchymal stem cells to assist skin and soft tissue expansion have shown that stem cells can improve expansion efficiency through promoting tissue regeneration. However, the issue that whether the flap viability is also improved is unknown. Methods Sixteen pigs were equally divided into 2 groups. A pair of 150 mL expanders was symmetrically inserted into each pig's dorsum. Group 1 received adipose-derived stem cells (ADSCs) injection before expansion, and group 2 received ADSCs grafting after flap elevation. After 4 weeks' expansion, a random flap measuring 2 cm x 16 cm was elevated along the long axis of each expanded flap on the pigs' back. Flap viability was measured at postoperative day 7. Histological analysis and cell tracking were performed. The expression of vascular endothelial growth factor was determined. Results The flap viability of the ADSCs-grafted expanded flap (75.5 +/- 6.6%) was similar to the control (69.4 +/- 8.4%) in group 1 (transplantation before expansion). However, in group 2 (transplantation after flap elevation), the ADSCs-grafted expanded flap had a higher flap viability (92.6 +/- 5.7%) compared with control (66.2 +/- 7.4%). Moreover, the ADSCs-grafted expanded flap in group 1 showed increased skin thickness, collagen content, cells proliferation, vascularization, and vascular endothelial growth factor expression. Cell tracking showed that the positively stained cell differentiating into an endotheliocyte could be seen in group 2. Conclusions Transplantation of ADSCs before tissue expansion does not improve flap viability but can promote tissue regeneration. Injection of ADSCs after flap elevation can increase the surviving rate of the expanded flap.
Background Correction of Tanzer type IIB constricted ears requires sufficient expansion of the auricular skin to cover the reconstructed cartilaginous framework. To obtain an adequately sized skin cover, skin flap transposition from periauricular donor sites has been described; however, it remains challenging to obtain enough skin to enable satisfactory reconstruction. Herein, we describe a novel method that uses 2 local flaps comprising superoauricular, retroauricular, and preauricular soft tissue to expand the skin cover and correct Tanzer type IIB deformity. Methods Fifteen constricted ears in 15 patients were treated via this novel method from June 2013 to July 2017. Two adjoining V-Y advancement flaps shaped like a backward "Z" were created to expand the skin envelope of the upper one-third of the ear. The advancement of these 2 flaps toward each other expanded the skin of the upper one-third of the ear by creating a skin arch, which was then used to wrap the reconstructed cartilaginous framework. The auricular cartilage was refashioned via a method that combined several previously reported techniques. Results A satisfactory outcome was achieved in all 15 constricted ears, with resultant improvements in size and shape, and an elevated auricular position. Conclusions The preauricular, superoauricular, and retroauricular skin areas can be used to successfully expand the skin envelope of the upper auricle via the creation of 2 adjoining V-Y advancement flaps. This results in an ample skin cover with which to accommodate the auricular cartilaginous framework reconstructed by multiple techniques. This novel Z-shaped double V-Y advancement flap method can effectively correct Tanzer type IIB constricted ears.
Introduction Complicated elbow injuries (elbow injuries with bone and soft tissue injury) with distal biceps tendon ruptures (DBTRs) are not uncommon. There are several treatment modalities in different situations of injuries. In this article, we reported 3 successful individual treatments of delayed DBTR with complicated elbow injuries. Materials and Methods Three cases of complicated elbow injuries treated between 2010 and 2016 were reviewed. The delayed DBTR cases were summarized and treated. Mayo Elbow Performance Score value, range of motion, and visual analog scale score were used to assess outcomes after a minimum follow-up of 12 months. Results All 3 patients were male, aged 47 to 54 years (mean, 49.6 years). Patients received surgical treatments. After a mean follow-up of 13.7 months, in cases 1 and 2, Mayo Elbow Performance Score values improved by 50% and 100%, elbow flexion-extension arc were 115 degrees and 110 degrees, pronation-supination arc were 130 degrees and 120 degrees. Arthrodesis case reported pain relief; visual analog scale score for pain was 0 to 1. No postoperative complications were observed, and all patients were satisfied with the results. Conclusions Individual treatment is advised in DBTR with complicated elbow injuries. Secondary treatment of DBTR can achieve satisfactory results using individual strategies depending on patients' overall condition.
Introduction: Breast reconstruction for Chinese patients is vastly different given cultural differences, patient preferences, access to resources, and insurance coverage in China. Given these unique factors, a different approach for optimizing outcomes should be considered. Methods: Retrospective review of all patients undergoing implant-based breast reconstruction from January 2013 to May 2016 was performed. Esthetic evaluationswere made both by the patients and 1 nonoperative surgeon at least 6months postoperative, and patient satisfaction was assessed using the Breast-Q. Results: Overall, 135 patients undergoing 141 implant-based breast reconstructions were reviewed. The majority of implants (n = 134) were placed in a subpectoral position, whereas 7 were placed prepectorally, and no acellular dermal matrix was used. Given the limitations in acellular dermal matrix usage, soft-tissue coverage was augmented with local regional flaps. Ninety-four reconstructions (66.7%) used latissimus dorsi, 39 (27.7%) used serratus anterior, and 7 (5.0%) used mastectomy skin flaps only for implant coverage. Four patients (2.8%) underwent revision surgery to the reconstructed breasts. Grade III and grade IV capsular contracturewas observed in 10 (7.1%) and 2 (1.4%) reconstructions, respectively. Both the patient's and the surgeon's satisfaction were higher than 80% in breast symmetry. Conclusions: Our implant selectionmethod fit the Chinese population characteristics and could be extended to different types of implant-based breast reconstruction. It produced good esthetic outcomes and was reproducible, predictable, and simple to master in the clinical setting.
Objective: In this report, we present our experience on the use of bilateral lateral hallux osteo-onychocutaneous free flaps for reconstruction of distal finger and the aesthetic and functional results of this technique in a series of cases. Patients andMethods: From February 2005 to May 2015, 7 patients underwent finger reconstruction distal to the distal interphalangeal joint using the bilateral lateral hallux osteo-onychocutaneous free flaps. The mean age was 29.3 years (range, 24-33 years). The lateral hallux osteo-onychocutaneous flaps were harvested from bilateral donor sites. The size of each flap was designed based on the size of half distal finger defect. The lateral hallux osteo-onychocutaneous free flaps from both donor sites were combined to reconstruct the distal finger. More than 50% of hallux nail was preserved in each of donor sites, which was covered with a local flap. Results: All flaps used for reconstruction survived without complications after surgery. The average length of follow-up was 93.4months (range, 16-163months). All reconstructed distal fingers showed good aesthetic appearance, except one that underwent a secondary debulking procedure. The average total active motion of the finger was 215.7 degrees (range, 200-230 degrees). Neither pain nor numbness sensation in the reconstructed fingers was complained by the patients. The donor site morbidity was minimal. All patients had pain-free and good function outcome in both feet. Conclusions: The use of the bilateral lateral hallux osteo-onychocutaneous free flaps may provide an option for distal finger reconstruction with satisfactory function and anesthetic outcomes with minimal hallux donor site morbidity.
Purpose Free flap reconstruction in head and neck cancer patients with prior tumor resection, neck dissection, and irradiation is clinically challenging. The purpose of this study was to investigate the reliability and outcome of using the anterolateral thigh (ALT) flap and transverse cervical recipient vessels for microvascular reconstruction in patients with depleted vessels in the head and neck region caused by previous surgery and irradiation. Methods Between January 2015 and December 2017, microsurgical head and neck reconstruction was performed using the ALT flap and transverse cervical artery (TCA) as the recipient vessel in 15 patients who had undergone previous neck dissections and irradiation for cancer treatment. All patients had a "vessel-depleted neck" resulting from severe scarring and radiation fibrosis. Clinical data of each patient were recorded. Results All ipsilateral TCAs were found to be damage free. Subsequently, free ALT flaps were revascularized using the TCAs. One patient developed venous thrombosis, and another patient developed arterial thrombosis. They were both salvaged within 6 hours postoperatively. No flap failure or mortalities were reported within the 30-day postoperative period. Two patients developed orocutaneous fistula and were further managed with wound care. The mean follow-up time was 11.9 +/- 6.0 months (range, 5-23 months). Five patients died during the follow-up period from cancer progression. Conclusions The use of the free ALT flap and TCA as the recipient vessel provides favorable microsurgical outcomes in patients with depleted recipient vessels in the head and neck region caused by previous neck dissections and radiation therapy.