OBJECTIVE: Managing postoperative complications is crucial in reconstructive surgery. Indocyanine green fluorescence video-angiography (ICGA) aids in assessing flap vascularization intraoperatively, potentially reducing complications.
METHODS: An ambispective study enrolled head and neck cancer patients undergoing ablative surgery with soft tissue reconstruction. An experimental arm (March 2021-May 2023) used ICGA, while a control arm (January 2017-December 2020) did not. Complications were graded by Clavien-Dindo classification. We also evaluated the effect of systemic inflammation on the sensitivity of ICGA in detecting hypoperfused areas of the flap.
RESULTS: Complications were less frequent in the experimental arm, both overall (11.4% vs. 36.4%) and major ones (Clavien-Dindo ≥ 3) (8.6% vs. 30.9%). ICGA showed a protective effect in univariate and multivariate analyses. Previous radiation and ICGA were independent predictors of major complications. ICGA altered the surgical strategy in 25.7% of cases.
CONCLUSIONS: Real-time perfusion assessment, particularly with ICGA, can improve outcomes in head and neck cancer patients undergoing soft tissue reconstruction by reducing complications. Further research with larger cohorts is warranted for validation.

Background: Nitroglycerin is suggested to improve flap survival based on promising results; however, there are no data on the effectiveness of treatment initiation time. This study aimed to compare the effect of various nitroglycerin treatment initiation times on partial flap survival. Materials and Methods: The study included 50 Sprague-Dawley rats. Modified McFarlane flaps were elevated on the dorsum of each rat. Group A received placebo treatment. Groups B, C, D, and E received topical nitroglycerin 2% starting 1 day before surgery, on the day of surgery, postoperative d 2, and postoperative d 4, respectively. After 7 days, the flap survival rates were calculated. Afterward, the severity and extent of inflammation and ischemia, and the severity of edema were evaluated histologically. Results: The flap survival rate was highest in group B, followed by groups C, D, E, and A. The difference between groups B and C was not significant, whereas the difference between group B and groups A, D, and E was. In addition, the difference between groups A, D, and E was not significant. Histological analysis showed that inflammation was less severe in groups B and C than in groups A, D, and E. Ischemia was the most severe in groups A and D and was the least severe in group C. Conclusion: Topical nitroglycerin treatment increases flap survival when initiated before or on the day of surgery, but has no benefit when initiated on postsurgery d 2 or 4. Preoperative initiation of nitroglycerin treatment positively affects flap survival.
Contexte: L’utilisation de la nitroglycérine a été proposée pour améliorer la survie d’un lambeau à partir de résultats prometteurs. Il n’y a cependant aucune donnée sur l’efficacité du délai d’instauration du traitement. Cette étude a visé à comparer l’effet de différents moments d’instauration du traitement avec la nitroglycérine sur la survie d’un lambeau partiel. Matériels et méthodes: L’étude a inclus 50 rats Sprague-Dawley. Des lambeaux modifiés de McFarlane ont été surélevés sur le dos de chaque rat. Le groupe A a reçu un placebo, tandis que les groupes B, C, D et E ont reçu de la nitroglycérine topique à 2% en commençant, respectivement, la veille de la chirurgie, le jour de la chirurgie, 2 jours et 4 jours postopératoires. Les taux de survie du volet ont été calculés après 7 jours. Ensuite, la sévérité et l’étendue de l’inflammation et de l’ischémie ainsi que la sévérité de l’œdème ont été évaluées histologiquement. Résultats: Le taux de survie des volets a été le plus élevé dans le groupe B, suivi des groupes C, D, E et A. La différence entre les groupes B et C n’était pas significative, tandis que la différence entre le groupe B et les groupes A, D et E l’était. En outre, la différence entre les groupes A, et E n’était pas significative. L’analyse histologique a montré que l’inflammation était moins sévère dans les groupes B et C que dans les groupes A, D et E. L’ischémie a été la plus importante dans les groupes A et D et la moins importante dans le groupe C. Conclusion: Le traitement topique avec la nitroglycérine augmente la survie d’un lambeau quand il est commencé le jour de la chirurgie ou avant, mais il n’apporte pas d’avantage s’il est instauré au 2e ou au 4e jour postopératoire. L’instauration d’un traitement par la nitroglycérine en préopératoire a un effet positif sur la survie des lambeaux.

OBJECTIVE: To compare the clinical outcomes of anterolateral femoral interregional flap with turbocharge technique and traditional anterolateral femoral flap in repair of large limb wounds.
METHODS: Clinical data of 38 patients with large limb surface wound (11 cm×39 cm-16 cm×65 cm) admitted to the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from May 2018 to May 2022 were retrospectively analyzed. Eighteen patients were treated by anterolateral thigh perforator flap combined with superficial circumflex iliac artery flap (ALTP-SCIAP) with turbocharge technique (interregional flap group); while 20 patients were treated with unilateral or bilateral anterolateral femoral flaps, combined with skin grafting if necessary (traditional anterolateral femoral flap group). The survival of skin flap, repair of donor area, complications and patient satisfaction were compared between the two groups.
RESULTS: In interregional flap group, 18 flaps were harvested and transplanted, the flap width, length and the viable area were (9.9±2.0) cm, (44.2±3.5) cm and (343.2±79.9) cm2, respectively. In traditional anterolateral femoral flap group, 29 flaps were harvested and transplanted, the flap width, length and the viable area were (11.0±2.8) cm, (21.7±3.2) cm and (186.4±49.2) cm2, respectively. There were significant differences in the flap length and the viable area between the two groups (t=22.365 and 8.345, both P<0.05). In the interregional flap group, the donor site of flap was closed by direct suture in 11 flaps, by skin retractor assisted suture in 6 flaps, and by skin grafting in one flap. In traditional anterolateral femoral flap group, the donor site of flap was closed by direct suture in 12 flaps, by skin retractor assisted suture in 11 flaps, and by skin grafting in 6 flaps. The skin graft rates of the two groups were 5.6% (1/18) and 20.7% (6/29), respectively (χ2=2.007, P>0.05). The interregional flap group had lower postoperative complications rate (5.6% vs. 35.0%, χ2=4.942, P<0.05) and higher patient satisfaction rate (94.4% vs. 70.0%, χ2=4.448, P<0.05) than traditional anterolateral femoral flap group.
CONCLUSIONS: Compared with the traditional anterolateral femoral flap, the anterolateral femoral interregional flap with turbocharge technique has a larger flap area, most of the donor areas of the flap can be sutured directly without skin grafting and with less complications and a higher patient satisfaction rate.
目的: 对比结合内增压技术的股前外侧跨区皮瓣与传统股前外侧皮瓣在修复肢体较大创面缺损中的临床疗效。方法: 回顾性分析2018年5月—2022年5月浙江大学医学院附属邵逸夫医院收治的肢体较大创面缺损共38例患者（缺损面积达到11 cm×39 cm~16 cm×65 cm）的临床资料。按照修复方式的不同，将患者分为跨区皮瓣修复组（18例）和传统皮瓣修复组（20例）。跨区皮瓣修复组采用结合内增压技术的股前外侧穿支皮瓣联合旋髂浅动脉皮瓣（ALTP-SCIAP）治疗，传统皮瓣修复组采用单侧或双侧股前外侧皮瓣，必要时联合植皮。比较两组术后皮瓣存活情况、供区修复情况、并发症、患者满意度等。结果: 跨区皮瓣修复组中，切取移植皮瓣18例次，瓣宽（9.9±2.0）cm，瓣长（44.2±3.5）cm，存活面积（343.2±79.9）cm2。传统皮瓣修复组中，切取移植皮瓣29例次，瓣宽（11.0±2.8）cm，瓣长（21.7±3.2）cm，存活面积（186.4±49.2）cm2。瓣长和存活面积跨区皮瓣修复组显著大于传统皮瓣修复组（t=22.365和8.345，均P<0.05）。跨区皮瓣修复组皮瓣供区采用直接缝合11例次，皮肤牵拉器辅助下缝合6例次，部分植皮修复1例次。传统皮瓣修复组皮瓣供区采用直接缝合12例次，皮肤牵拉器辅助下缝合11例次，部分植皮修复6例次。两组皮瓣供区修复的植皮率分别为5.6%（1/18）和20.7%（6/29），差异无统计学意义（χ2=2.007，P>0.05）。跨区皮瓣修复组中出现并发症1例（5.6%），患者满意度达到94.4%；而传统皮瓣修复组中出现并发症7例35.0%，患者满意度为70.0%。相比传统皮瓣修复组，跨区皮瓣修复组并发症发生率降低（χ2=4.942，P<0.05），患者满意度升高（χ2=4.448，P<0.05）。结论: 与传统股前外侧皮瓣比较，结合内增压技术的股前外侧跨区皮瓣切取面积更大，皮瓣供区大多可Ⅰ期直接缝合，不需要植皮修复，并发症更少，患者满意度更高。.

BACKGROUND: This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR).
METHODS: A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as \"maintained\" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare \"downsized\" or \"upsized.\" Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively.
RESULTS: Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (β = -13, 95% confidence interval: -21 to -5.4; p = 0.001).
CONCLUSIONS: Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.

BACKGROUND: The perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective.
METHODS: This study used cadavers to observe the branches and courses of perforators on the calf and the distribution of skin branches using microdissection techniques, digital X-ray photography, and micro-computed tomography techniques.
RESULTS: The perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network.
CONCLUSIONS: We observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.

BACKGROUND: Flaps have become an integral part of plastic and reconstructive surgery. The robust blood supply of such flaps is a prerequisite to reduce flap failure. Despite the reported versatility of the occipital flap, comprehensive anatomical studies on its perforators and perforasomes are lacking. Hence, we examined the perforators originating from the occipital artery and their associated perforasomes, aiming to fill this knowledge gap for reconstructive surgery techniques.
METHODS: 39 of 40 occipital arteries of 20 fresh anatomical head specimens were dissected. Perforators with a least an outer diameter of 0.50 mm were identified and injected with dye to color their respective perforasomes. Location and size of the colored skin areas were determined as well as the location of their perforators were documented and analyzed.
RESULTS: In total, 183 perforators were found and described. The mean diameter of these vessels was 0.88 ± 0.27 mm (0.5-2.1 mm). The mean area of the perforasomes was 1288.26 ± 662.51 mm2 (144.60-3890.60 mm2). They were localized over the whole nuchal and occipital area. Lastly, perforator diameters were significantly associated with the size of their resulting perforasomes.
CONCLUSIONS: This study is the first comprehensive overview of perforators and associated perforasomes of the occipital artery on a respectable amount of specimen. The arterial supply of big portions of the occipital and nuchal area is provided solely by the perforators of the occipital artery. For flap surgery, perforator diameter is a crucial detail to be considered in the decision-making process.

UNASSIGNED: Hypospadias is a common congenital urogenital anomaly. Despite advancements in surgical techniques, still it presents challenges in management. An important aspect of hypospadias repair is the use of protective layers to cover neourethra. This review focuses on comparing the Single Dartos Flap (SDF) and Double Dartos Flap (DDF) techniques, used to cover the neourethra. These techniques differ in terms of the number of dartos layers used to cover the neourethra.
UNASSIGNED: This systematic review, follows PRISMA guidelines, included six RCTs from PubMed/MEDLINE, Cochrane Library, Scopus, Web of Science, and CINAHL. Patients with hypospadias repair with use of SDF or DDF were analyzed for outcome, Urethrocutaneous fistula, meatal stenosis, glans dehiscence, penile torsion and cosmetic outcomes. Statistical analysis was done using Review Manager, with TSA and FI ensuring result robustness.
UNASSIGNED: Six studies met inclusion criteria, and risk of bias assessment indicated low risk across all domains. Meta-analysis results favored DDF over SDF for reducing urethrocutaneous fistula (RR 0.37, 95% CI 0.20-0.68) but showed no significant difference in meatal stenosis and glans dehiscence. DDF also associated with lower risk of penile torsion (RR 0.05, 95% CI 0.01-0.35).
UNASSIGNED: The systematic review, based on randomized controlled trials (RCTs), provides evidence supporting the use of DDF over SDF in hypospadias repair, particularly in distal hypospadias using the TIP procedure. The article emphasizes the potential advantages of DDF in reducing UCF but further robust evidence is needed to confirm these results based on the findings of TSA and FI.

The study aimed to assess the efficacy of buccinator myomucosal flap (BMF) compared to Bardach two-flap use in primary cleft palatoplasty on palatal length and fistulation rate. Palatal length in relation to the pharynx is a critical factor regarding velopharyngeal function. The goal was to predict the risk of velopharyngeal insufficiency by comparing the potential of two different techniques in lengthening the palate and to decrease the fistulation rate. A total of 46 patients with complete wide cleft palate were randomly divided into two equal groups: a study group, in which the cleft palate defect was repaired by BMF; and a control group, in which patients\' clefts were repaired by Bardach (two-flap) palatoplasty during primary repair. All patients were evaluated at 1-, 3- and 6-month intervals to detect the fistulation rate and to measure the palatal length by taking impressions, pouring casts to measure the palatal length from anterior reference point (incisive foramen) to the posterior reference point(uvula) and calculating the change of palatal length. There was a significant increase in the palatal length measurements in the study (BMF) group (immediate postoperatively and at 3 and 6 months) compared to the control group (p < 0.001). Regarding the fistulation rate, there was no statistically significant difference (p = 0.346). The use of the buccinator flap during primary repair of cleft palate decreased the fistulation rate.

OBJECTIVE: After oropharyngeal reconstruction surgery, excessive flap volume within the oral cavity may increase the risk of pharyngeal obstruction during sleep. This prospective observational study aimed to test a hypothesis that the skin-flap oropharyngeal reconstructive surgery increases nocturnal apnea-hypopnea index (nAHI, primary variable) after surgery.
METHODS: Adult patients undergoing oropharyngeal reconstruction surgery participated in this study. The hypothesis was tested by comparing the results of portable type 4 sleep study and craniofacial assessments with lateral head and neck computed tomography scout image before and after surgery. Multiple linear regression analyses were performed to identify predictors for nAHI increase after the surgery.
RESULTS: In 15 patients, a postoperative sleep study was performed at 41 (27, 59) (median (IQR)) days after the surgery. nAHI did not increase after the surgery (mean (95% CI), 13.0 (7.2 to 18.7) to 18.4 (10.2 to 26.6) events.hour-1, p = 0.277), while apnea index significantly increased after the surgery (p = 0.026). Use of the pedicle flap for the oropharyngeal reconstruction (p = 0.051), small mandible (p = 0.008), longer lower face (0.005), and larger tongue size (p = 0.008) were independent predictors for worsening of nAHI after surgery. Hospital stay was significantly longer in patients with the pedicle flap (n = 8) than in those with the free flap (n = 7) (p = 0.014), and the period of hospital stay was directly associated with increase of nAHI after surgery (r = 0.788, p < 0.001, n = 15).
CONCLUSIONS: Oropharyngeal reconstruction surgery worsens sleep-disordered breathing in some patients with craniofacial and surgical risk factors.
BACKGROUND: UMIN Clinical Trial Registry (UMIN000036260, March 22, 2019), https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000036260.

UNASSIGNED: The modified nail folding approach, a new surgical technique, has been shown to be safe and effective for the treatment of subungual glomus tumors, providing clinicians with a new treatment option for patients with this condition.
UNASSIGNED: Glomus tumors (GTs) are rare benign tumors that originate from the glomus body in the skin of the fingertips, toes, and nail beds. GTs are more prevalent in women than in men and can occur sporadically or as part of an inherited condition known as multiple GTs. The exact cause of GTs is unknown, but it is believed that mutations in the cells of the glomus body contribute to their development. In this study, we present the efficacy of a novel surgical technique called the modified nail folding approach for treating subungual GTs. We report a case series involving 17 patients who underwent the nail folding approach for surgical removal of subungual GTs. The primary objective of this article is to provide evidence supporting the safety and effectiveness of this technique. Additionally, we aim to introduce clinicians to a new, secure, and efficient treatment option for patients with subungual GTs.