OBJECTIVE: Proximal femur tumor resection often leads to hip joint instability and functional loss. Various methods have been clinically applied to repair hip joint soft tissue function, but deficiencies remain. This study aims to evaluate the advantages and disadvantages of the ligament advanced reinforcement system (LARS) tumor tube in assisting soft tissue function reconstruction in patients undergoing tumor type artificial hip replacement surgery.
METHODS: This study included 85 patients (41 males, 44 females) with proximal femoral tumors treated at the Xiangya Bone Tumor Treatment Center from January 2012 to January 2022, aged 10 to 79 (38.5±18.2) years. Among them, 13 cases had benign aggressive tumors, 45 had primary malignant bone tumors, and 27 had bone metastases. Clinical data, imaging data, and intraoperative photos were collected. Patients were followed up and postoperative functional evaluations were conducted using the Musculoskeletal Tumor Society (MSTS) scoring system and Harris hip joint scoring system to assess limb function and hip joint function.
RESULTS: Preoperative pathological fractures were present in 37 cases (43.5%), with a lesion length of (9.4±2.9) cm. Among non-metastatic tumor patients, 7 experienced postoperative recurrence, including 6 cases of osteosarcoma and 1 case of fibrosarcoma. Pulmonary metastases occurred in 9 osteosarcoma patients. Five patients required reoperation due to postoperative complications, including 3 cases of deep vein thrombosis, 1 case of giant cell granuloma, and 1 case of prosthesis infection. Postoperatively, 5 patients exhibited Trendelenburg gait, and 6 had leg length discrepancies. The postoperative MSTS score was 26.7±1.4, and the Harris score was 89.6±5.3.
CONCLUSIONS: The LARS tumor tube can effectively assist in reconstructing the soft tissue function of the hip joint and greatly reduce postoperative complications, making it an effective technical improvement in joint function reconstruction in tumor type artificial hip replacement surgery.
目的: 股骨近端肿瘤切除常导致髋关节不稳定和功能缺失，临床上已有多种方法用于修复髋关节软组织功能，但仍存在不足。本研究旨在评价韧带高级加固系统(ligament advanced reinforcement system，LARS)肿瘤管对辅助肿瘤型人工髋关节置换术患者软组织功能重建的优势与不足。方法: 2012年1月至2022年1月本研究共纳入湘雅骨肿瘤治疗中心的股骨近端肿瘤患者85例(男41例，女44例)，年龄10~79(38.5±18.2)岁，其中良性侵袭性肿瘤13例，原发恶性骨肿瘤45例，骨转移瘤27例。收集患者的临床资料、影像学资料和术中照片，对患者进行随访和术后功能评价。分别采用肌肉骨骼肿瘤学会(Musculoskeletal Tumor Society，MSTS)评分系统和Harris髋关节评分系统评价患者的肢体功能和髋关节功能。结果: 37例(43.5%)患者术前合并病理性骨折，病灶长度为(9.4±2.9) cm。非转移瘤患者术后复发7例，其中骨肉瘤6例，纤维肉瘤1例。9例骨肉瘤患者出现肺转移。5例因术后并发症再次手术，其中3例为深静脉血栓形成，1例为巨细胞肉芽肿，1例为假体周围感染。5例术后出现Trendelenburg步态。6例术后出现双下肢不等长。患者术后MSTS评分为26.7±1.4，Harris评分为89.6±5.3。结论: LARS肿瘤管可以有效辅助重建患者髋关节的软组织功能，并极大地减少了术后并发症的发生，是肿瘤型人工髋关节置换术中关节功能重建的有效技术改良。.

UNASSIGNED: The reconstruction of both extra- and intra-oral soft tissue defects, particularly in restoring the morphology of the lip and the corners of the mouth, has posed a significant challenge for surgeons. Inappropriate methods often lead to maxillofacial deformity which then causes psychological and functional problems. This study aimed to address the challenge of reconstructing extensive and complex maxillofacial soft tissue defects, mainly focusing on the lip, the corners of the mouth, and the surrounding areas.
UNASSIGNED: We developed a reconstruction approach by combining the 3dMDface System (3dMD) with the cone beam computed tomography (CBCT). Firstly, with the extra-oral incision line, we evaluated the shape and the size of the extra-oral defect with 3dMD digitally. Then we used the corresponding maxillary and mandible tooth positions to record the intra-oral defect, which was then converted to digital images by combining 3dMD and CBCT. The islands of the anterolateral thigh perforator flap were then designed after the locations of the perforators were detected with Doppler ultrasonography.
UNASSIGNED: A clinical case diagnosed as dermatofibrosarcoma protuberans was presented to illustrate the approach. The patient\'s tumor resection and the size of multiple defects were measured and simulated via the virtual surgery system. A three-island perforator flap from the descending branch of the lateral femoral circumflex artery was designed accurately. Two weeks postoperatively, the flap was healed as anticipated and the patient was satisfied with the profile.
UNASSIGNED: The combination of the 3dMD and CBCT technologies improves the accuracy and fitness of extra- and intra-oral soft tissue reconstruction.

BACKGROUND: Autologous adipose tissue often experiences ischemia and hypoxia after transplantation, leading to low retention rates and unstable operative impacts due to necrotic absorption. Platelet-rich plasma (PRP) can enhance fat regeneration and increase the fat retention rate after transplantation. However, the quick release of growth factors (GFs) in PRP decreases therapeutic efficiency. This study aimed to achieve a slow release of PRP to promote fat retention.
METHODS: We prepared a dual-network hydrogel (DN gel) based on FDA-approved PRP and sodium alginate (SA) through a simple \"one-step\" activation process. In vivo study, adipose tissue with saline (control group), SA gel (SA gel group), PRP gel (PRP gel group), and DN gel (DN gel group) was injected subcutaneously into the dorsum of nude mice. At 4 and 12 weeks after injection, tissues were assessed for volume and weight. Hematoxylin and eosin staining (HE) and immunofluorescence staining were performed for histological assessment.
RESULTS: DN gel exhibits long-lasting growth factor effects, surpassing conventional clinical PRP gel regarding vascularization potential. In fat transplantation experiments, DN gel demonstrated improved vascularization of transplanted fat and increased retention rates, showing promise for clinical applications.
CONCLUSIONS: DN gel-assisted lipofilling can significantly improve the retention rate and quality of transplanted fat. DN gel-assisted lipofilling, which is considered convenient, is a promising technique to improve neovascularization and fat survival.
METHODS: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

OBJECTIVE: In soft tissue reconstructive surgery, perforator localization and flap harvesting have always been critical challenges, but augmented reality (AR) has become a dominant technology to help map perforators.
METHODS: The lateral circumflex femoral artery (LCFA) and its perforators were reconstructed by CTA in consecutive patients (N = 14). Then, the anterolateral thigh perforators and the points from which the perforators emerged from the deep fascia were marked and projected onto the skin surface. As the virtual images were projected onto patients according to bony markers, the courses of the LCFA and its perforators were depicted on the skin surface for intraoperative guidance. Finally, the locations of the emergence points were verified by intraoperative findings and compared to those determined by handheld Doppler ultrasound.
RESULTS: The sources, locations, and numbers of perforators were determined by CTA. The perforators and their emergence points were accurately mapped on the skin surface by a portable projector to harvest the anterolateral thigh perforator flap. During the operation, the accuracy of the CTA & AR method was 90.2% (37/41), and the sensitivity reached 97.4% (37/38), which were much higher than the corresponding values of Doppler ultrasound. Additionally, the differences between the AR-marked points and the intraoperative findings were much smaller than those seen with Doppler ultrasound (P < 0.001). Consequently, all of the flaps were well designed and survived, and only one complication occurred.
CONCLUSIONS: Augmented reality, namely, CTA combined with projection in this study, plays a vital and reliable role in locating the perforator emergence points and guiding the procedure to harvest flaps and has fewer potential risks.

External volume expansion (EVE) has been shown to improve fat graft survival. In this study, we investigated the xenogenic implantation of human allograft adipose matrix (AAM) in non-immunocompromised mice in combination with pre- and post-conditioning with EVE to assess long-term adipose tissue survival. Sixty-eight recipient sites in thirty-four eight-week-old wild type (C57BL/6J) mice were separated into four groups. Thirty-four sites received no conditioning and either a subcutaneous injection of 300 μl saline (n= 17; PBS group) or AAM (n= 17; AAM group). Thirty-four sites received pre-conditioning with EVE (Day -7-3 pre-grafting) and 300 μl of AAM. Seventeen of these sites received immediate post-conditioning (Day 1-5 post-grafting) and 17 delayed post-conditioning (Day 28-32 post-grafting). Tissue was harvested at week 12 for analysis. At 12 weeks, immediate and delayed post-conditioning enabled higher volume retention (p= 0.02 andp< 0.0001, respectively). Adipose Stem Cells were greater in the AAM+Del-EVE group compared to the AAM (p= 0.01). Microvessel density was lower in the AAM group compared to the AAM+Imm-EVE (p= 0.04) and AAM+Del-EVE group (p= 0.02). Macrophage infiltration was lower in the AAM+Imm-EVE (p= 0.002) and AAM+Del-EVE (p= 0.003) groups compared to the AAM group. PCR analysis and Western blotting identified a significantly higher expression of PPAR-γ, LPL and VEGF with delayed-conditioning. Pre- and post-conditioning, particularly delayed-post-conditioning, of the recipient site optimized the microenvironment allowing significant adipogenesis and survival of neo-adipose tissue through robust angiogenesis. This study supports that xenogenic transplantation of adipose matrix allows adipose tissue formation and survival with EVE as an adjuvant.

BACKGROUND: Autologous fat grafting has become a popular tool in plastic surgery to solve soft tissue defects and achieve skin rejuvenation, but the volume loss after transplantation remains a disturbing problem. In recent years, some new strategies have improved the outcome to some extent, but the fat graft retention is still far from ideal, so there remains a wide development prospect in this field. Macrophages are closely related to the local microenvironment and tissue regeneration, and their role in fat grafting has been increasingly highlighted.
OBJECTIVE: This article was aimed to review the efficacy, possible mechanisms, and potential application of macrophage regulation on fat grafting, as well as concerns and future perspectives of this filed.
METHODS: A retrospective review of the published data was conducted.
RESULTS: Most studies indicated that up-regulating M2 macrophages during fat grafting would improve fat retention via promoting neovascularization. M2 macrophages could secrete several pro-angiogenic factors, accelerate extracellular matrix (ECM) remodeling, and directly function on endothelial cells to encourage vascular expansion. In addition, macrophages could influence the proliferation, apoptosis, and adipogenic differentiation of preadipocytes.
CONCLUSIONS: During autologous fat grafting, appropriately regulating macrophages may become a promising method to increase fat retention. Nevertheless, the M2 macrophage polarizing agents, treatment opportunity, and contraindications require further discussion. We hope our work could promote more in-depth studies in this field, and we are looking forward to a standard procedure for the macrophage therapy in clinical practice.

OBJECTIVE: This study aimed to retrospectively analyze clinical data of a series of patients with severe open fractures of extremities (Gustilo IIIb or IIIc), who achieved a satisfactory outcome through radical orthoplastic surgery, so as to provide a reference for determining the treatment of severe open fractures of extremities.
METHODS: The clinical data of 41 consecutive patients with severe open fracture (Gustilo IIIb or IIIc) of the limb, who underwent successful surgical debridement, fixation, and soft tissue reconstruction in one stage between January 2008 and January 2019, were retrospectively reviewed. Postoperative indicators, including infection rate and union time, were acquired by a regular follow-up and analyzed.
RESULTS: The mean (±SD) age of the patients was 38 ± 16 years. A total of 90 open fractures and severe soft tissue damages were analyzed. The soft tissue cover was achieved within 72 h. The overall rate of infection was 14.6% (6/41). Sex and the Mangled Extremity Severity Score were associated with infection. The median union time of 40 patients (one amputation) was 32 weeks.
CONCLUSIONS: The overall rate of infection exhibited a lower tendency in this study compared with previous studies on high-grade open fractures following a two-stage orthopedic approach. The consequence of infection rate and union time was similar to that in previous studies. These results indicated that the single-stage radical orthoplastic treatment was an effective and reliable option for reconstructing severe open fractures.

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm2 in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.

The lateral arm flap (LAF) may offer an alternative option for oral cavity repair. Twenty-five Chinese patients with oral cavity defects were reconstructed with a LAF. The anatomical characteristics of the flap, the donor site complications, and the functional and aesthetic assessments of recipient site were reviewed. The overall flap survival was 96.0% (24/25patients). The average pedicle length was 7.07±1.09cm when it was cut off at the insert of the deltoid, with an average arterial diameter of 1.30±0.37mm and vein diameter of 2.06±0.48mm. The average flap length was 7.06±1.01cm, and the average flap breadth was 5.28±0.66cm, with the average flap size ranging from 18 to 42cm2. One to three reliable perforators supplied the flap, with the proximal, middle, and distal perforators being located at 9.9±1.1cm, 8.6±1.4cm, and 5.7±1.2cm from the lateral epicondyle, respectively. The donor defect was closed primarily and healed uneventfully. A longitudinal scar was the most common morbidity of the donor site. The function and shape of the reconstructed tissues were well restored. The LAF provides a reliable choice for reconstructing medium-sized oral cavity defects, with minimal donor-site morbidity and ideally functional and aesthetic rehabilitation of the recipient site.

In reconstructive surgery, tissues are routinely transferred to repair a defect caused by trauma, cancer, chronic diseases, or congenital malformations; surgical transfer intrinsically impairs metabolic supply to tissues placing a risk of ischemia-related complications such as necrosis, impaired healing, or infection. Pre-surgical induction of angiogenesis in tissues (preconditioning) can limit postsurgical ischemic complications and improve outcomes, but very few preconditioning strategies have successfully been translated to clinical practice due to the invasiveness of most proposed approaches, their suboptimal effects, and their challenging regulatory approval. We optimized a method that adopts noninvasive external suction to precondition tissues through the induction of hypoxia-mediated angiogenesis. Using a sequential approach in a rodent model, we determined the parameters of application (frequency, suction levels, duration, and interfaces) that fine-tune the balance of enhanced angiogenesis, attenuation of hypoxic tissue damage, and length of treatment. The optimized repeated short-intermittent applications of intermediate suction induced a 1.7-fold increase in tissue vascular density after only 5 days of treatment (p < 0.05); foam interfaces showed the same effectiveness and caused less complications. In a second separate experiment, our model showed that the optimized technique significantly improves survival of transferred tissues. Here we demonstrate that noninvasive external suction can successfully, safely, and promptly enhance vascularity of soft tissues: these translational principles can help design effective preconditioning strategies, transform best clinical practice in surgery, and improve patient outcomes.