Microsurgical reconstruction for head and neck in patients with end-stage renal disease undergoing dialysis.

INTRODUCTION: Free flap transfer for head and neck defects has gained worldwide acceptance. Because flap failure is a devastating outcome, studies have attempted to identify risk factors-including renal failure. We sought to determine whether end-stage renal disease (ESRD) patients undergoing dialysis are at increased risk of flap failure following microsurgical head and neck reconstruction. PATIENTS AND METHODS: The study's participants were patients who underwent free flap reconstruction in the head and neck region at Hualien Tzu Chi Hospital between January 2010 and December 2019. We used the National Health Insurance "Specific Diagnosis and Treatment Code" to identify patients undergoing dialysis; these patients comprised the dialysis group, whose members were matched to a non-dialysis group for age and gender. The dependent variables were flap survival rate, take-back rate, and flap failure risk between the dialysis and non-dialysis groups. RESULTS: We included 154 patients in the dialysis (n = 14) and non-dialysis (n = 140) groups. The groups were similar in terms of age and most comorbidities, except diabetes mellitus, hypertension, and coronary artery disease, which were more prevalent in the dialysis group. The dialysis and non-dialysis groups had similar flap survival rates (100% vs. 92.9%; p = .600). Twenty-three patients underwent take-back surgery, most in the non-dialysis group (14.3% vs. 15.0%; p = 1.000). Patients in the dialysis group were more likely to have prolonged intensive care unit stays; however, dialysis alone did not predict flap failure (OR: 0.83; p = .864). CONCLUSION: This study found no significant differences in free flap survival and take-back rates between patients with and without dialysis. Dialysis did not increase the risk of flap failure following microsurgical head and neck reconstruction in this study; however, prospective, randomized controlled trials are needed.

[Bupleuri Radix-Paeoniae Radix Alba medicated plasma exerts effects on HepG2 hepatoma cells by regulating miR-1297/PTEN signaling axis].

The present study aimed to investigate the effect and mechanism of Bupleuri Radix-Paeoniae Radix Alba medicated plasma on HepG2 hepatoma cells by regulating the microRNA-1297(miR-1297)/phosphatase and tensin homologue deleted on chromosome 10(PTEN) signaling axis. Real-time quantitative PCR(RT-qPCR) was carried out to determine the mRNA levels of miR-1297 and PTEN in different hepatoma cell lines. The dual luciferase reporter assay was employed to verify the targeted interaction between miR-1297 and PTEN. The cell counting kit-8(CCK-8) was used to detect cell proliferation, and the optimal concentration and intervention time of the medicated plasma were determined. The cell invasion and migration were examined by Transwell assay and wound healing assay. Cell cycle distribution was detected by PI staining, and the apoptosis of cells was detected by Annexin V-FITC/PI double staining. The mRNA levels of miR-1297, PTEN, protein kinase B(Akt), and phosphatidylinositol 3-kinase(PI3K) were determined by RT-qPCR. Western blot was employed to determine the protein levels of PTEN, Akt, p-Akt, caspase-3, caspase-9, B-cell lymphoma-2(Bcl-2), and Bcl-2-associated X protein(Bax). The results showed that HepG2 cells were the best cell line for subsequent experiments. The dual luciferase reporter assay confirmed that miR-1297 could bind to the 3'-untranslated region(3'UTR) in the mRNA of PTEN. The medicated plasma inhibited the proliferation of HepG2 cells, and the optimal intervention concentration and time were 20% and 72 h. Compared with the blank plasma, the Bupleuri Radix-Paeoniae Radix Alba medicated plasma, miR-1297 inhibitor, miR-1297 inhibitor + medicated plasma all inhibited the proliferation, invasion, and migration of HepG2 cells, increased the proportion of cells in the G_0/G_1 phase, decreased the proportion of cells in the S phase, and increased the apoptosis rate. The medicated plasma down-regulated the mRNA levels of miR-1297, PI3K, and Akt and up-regulated the mRNA level of PTEN. In addition, it up-regulated the protein levels of PTEN, Bax, caspase-3, and caspsae-9 and down-regulated the protein levels of p-Akt, p-PI3K, and Bcl-2. In conclusion, Bupleuri Radix-Paeoniae Radix Alba medicated plasma can inhibit the expression of miR-1297 in HepG2 hepatoma cells, promote the expression of PTEN, and negatively regulate PI3K/Akt signaling pathway, thereby inhibiting the proliferation and inducing the apoptosis of HepG2 cells.

Reconstruction of Plantar Forefoot Area with Lateral Toe Pulp Flap: Case Report and Literature Review.

Reconstruction of the plantar forefoot area is challenging because it performs important functions, including carrying the body weight and balancing the ambulation gait, and lacks similar skin and soft tissues to manage the adjacent region. Herein, we shared our experience of using a lateral toe pulp flap and reviewed the relevant literature on this topic. A 33-year-old man presented with a large granuloma in the left plantar forefoot area after undergoing multiple operations owing to the diagnosis of callus. After tumor excision, the wound exhibited tendon exposure and a large infected dead space in the myofascial layer. After serial debridement with negative pressure wound therapy, the wound, which measured ~3.5 × 2.5 cm2, was reconstructed using a lateral toe pulp flap. The flap was transposed to obliterate the dead space; the remaining skin defect (size: ~2 × 2 cm2) was resurfaced with a full-thickness skin graft, harvested from the left inguinal region, followed by primary closure of the flap donor site. The flap completely survived. The lateral toe pulp flap is an easy, effective, and reliable option for reconstruction of the defects in the plantar forefoot area.

Short-term and long-term outcomes of free flap reconstruction versus amputation for diabetic foot reconstruction in patients with end-stage renal disease.

BACKGROUND: In Taiwan, the prevalence of diabetes mellitus complicated by end-stage renal disease (ESRD) has been increasing and diabetes-related foot amputation is commonplace. In recent years, limb salvage has become top priority. The long-term outcomes of patients on hemodialysis undergoing diabetic foot reconstruction using free flaps remain unknown. METHODS: Data from the National Health Insurance Research Database on hemodialysis patients with type 2 diabetes who received amputation or free flap reconstruction surgery for diabetic foot ulcer were analyzed from 2000 to 2013 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. After 1:4 propensity score matching, 86 and 344 patients were assigned to the free flap reconstruction and amputation groups, respectively. RESULTS: The 5-year survival rate was significantly higher in patients who received free flap compared to the amputated group (1-year survival rate = 80.0% vs. 67.6%, p = 0.030; 3-year survival rate = 49.7% vs. 35.5%, p = 0.024; 5-year rate=30.1% vs. 19.9%, p = 0.018; however, after 5 years, the overall long-term survival rate was similar in both groups (p = 0.064). Patients who had lower limb amputation after flap reconstruction were susceptible to mortality (adjusted HR = 1.39; p = 0.069). Peripheral arterial disease was a dependent risk factor (HR = 1.45; p = 0.037) for long-term survival, whereas old age (> 75 years; HR = 1.65; p = 0.004), cerebrovascular disease (adjusted HR = 1.36; p = 0.011), and sepsis (adjusted HR = 1.85; p = 0.035) served as independent risk factors. Hemodialysis patients with diabetic foot ulcer who had limb salvaged showed a higher 5-year survival rate as compared to the amputated group.

Reconstruction of Diabetic Foot Defects With the Proximal Lateral Leg Perforator Flap.

BACKGROUND: In patients with diabetic foot ulcers requiring flap reconstruction, the choice of local flaps is limited by the lack of adequate tissue available. Free flaps are often bulky, presenting footwear difficulty due to poor contouring. Here, we present our experience of using the proximal lateral leg perforator flap in the reconstruction of thin diabetic foot ulcers. METHODS: This is a retrospective study of 17 patients with diabetic foot ulcers reconstructed with the proximal lateral leg perforator flap during January 2013 and December 2015. RESULTS: Nine patients had varying degrees of peripheral arterial disease. The perforator was located 7 to 14 cm (mean, 9.7 cm) from the fibula head. The pedicle length ranged from 5 to 9 cm (mean, 6.9 cm). The arterial diameter of the pedicle measured 0.8 to 1.9 mm (mean, 1.4 mm). There was 1 total flap failure. One other flap complicated by venous thrombosis was successfully salvaged. All donor sites were closed primarily without morbidities. All the wounds were stable without recurrent ulceration during a mean follow-up time of 12 months. CONCLUSION: The thin, pliable proximal lateral leg perforator flap is an option for the reconstruction of small to moderate diabetic foot defects especially when it is located over the dorsal foot or the ankle. The flap is simple and quick to harvest without sacrificing a major artery. Although it is limited by the short length and the small diameter of the pedicle, for experienced microsurgeons, the success rate is high.

Lateral Toe Pulp Flap Used in Reconstruction of Distal Dorsal Toe Defect: Case Report and Review of the Literature.

BACKGROUND: When the distal dorsal part of the great toe is injured, especially with exposure of a tendon, bone, or joint, applying a free or local flap is difficult because of the lack of locally available tissue for reconstruction. Management of the distal dorsal part of a great toe soft tissue defect can be challenging for plastic surgeons. PATIENT AND METHOD: An 18-year-old woman presented with an injury to the dorsal aspect of her right great toe caused by a cobra bite. After fasciotomy, the wound showed exposure of the extensor hallucis longus tendon. After demarcation and infection control, the wound was reconstructed using a lateral toe pulp flap of approximately 3.5 × 1.0 cm. The flap was transposed to the defect, and the donor site was closed primarily. Toe pulp flaps are mainly used to reconstruct finger pulp defects and are useful because they provide a glabrous skin flap suitable for resurfacing fingertip injuries. A lateral toe pulp flap uses a homodigital adjacent skin flap, which is transposed to cover the soft tissue defect. Using a quick and straightforward procedure, we designed this flap to reconstruct a distal dorsal defect of the great toe, with minimal morbidity at the donor site. RESULTS: The flap initially showed mild congestion but survived completely. CONCLUSIONS: Applying a lateral toe pulp flap is a quick, simple, and reliable 1-stage procedure. It may be an effective option in reconstructing distal dorsal defects of the great toe.

Simple Skin-Stretching Device in Assisted Tension-Free Wound Closure.

BACKGROUND: Numerous conventional wound reconstruction methods, such as wound undermining with direct suture, skin graft, and flap surgery, can be used to treat large wounds. The adequate undermining of the skin flaps of a wound is a commonly used technique for achieving the closure of large tension wounds; however, the use of tension to approximate and suture the skin flaps can cause ischemic marginal necrosis. The purpose of this study is to use elastic rubber bands to relieve the tension of direct wound closure for simultaneously minimizing the risks of wound dehiscence and wound edge ischemia that lead to necrosis. MATERIALS AND METHODS: This retrospective study was conducted to evaluate our clinical experiences with 22 large wounds, which involved performing primary closures under a considerable amount of tension by using elastic rubber bands in a skin-stretching technique after a wide undermining procedure. Assessment of the results entailed complete wound healing and related complications. RESULTS: All 22 wounds in our study showed fair to good results except for one. The mean success rate was approximately 95.45%. CONCLUSIONS: The simple skin-stretching design enabled tension-free skin closure, which pulled the bilateral undermining skin flaps as bilateral fasciocutaneous advancement flaps. The skin-stretching technique was generally successful.

Nanodiamonds protect skin from ultraviolet B-induced damage in mice.

BACKGROUND: Solar ultraviolet (UV) radiation causes various deleterious effects, and UV blockage is recommended for avoiding sunburn. Nanosized titanium dioxide and zinc oxide offer effective protection and enhance cosmetic appearance but entail health concerns regarding their photocatalytic activity, which generates reactive oxygen species. These concerns are absent in nanodiamonds (NDs). Among the UV wavelengths in sunlight, UVB irradiation primarily threatens human health. RESULTS: The efficacy and safety of NDs in UVB protection were evaluated using cell cultures and mouse models. We determined that 2 mg/cm(2) of NDs efficiently reduced over 95% of UVB radiation. Direct UVB exposure caused cell death of cultured keratinocyte, fibroblasts and skin damage in mice. By contrast, ND-shielding significantly protected the aforementioned pathogenic alterations in both cell cultures and mouse models. CONCLUSIONS: NDs are feasible and safe materials for preventing UVB-induced skin damage.

The proximal lateral lower leg perforator flap revisited: anatomical study and clinical applications.

BACKGROUND: The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this study was to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically. METHODS: The location, number, and size of perforator vessels in the proximal third of the lateral lower leg were investigated in 20 fresh frozen cadaveric lower limbs. This was analyzed together with 22 clinical cases. RESULTS: Cadaveric dissection showed that there were 1-2 perforators in the proximal third of the lateral lower leg and these perforator vessels were found to be 63% septocutaneous and 37% musculocutaneous. The source vessel of the perforators was variable. Clinically the recipient site consisted of the head and neck in 8 cases, the foot and ankle region in 13 cases, and 1 case in the hand. The mean thickness of this flap was 5.8 ± 0.8 mm. Vascular pedicle length ranged from 5 to 8.5 cm. The mean diameter of flap artery was 1.3 ± 0.3 mm. One flap failure was seen due to arterial thrombosis. The overall flap survival rate was 95%. CONCLUSIONS: The proximal lateral lower leg flap has the advantages of being thin and pliable, quick to harvest with no major arteries sacrificed. There is minimal donor site morbidity and primary closure of the donor site is possible in the majority of cases.

Effects of temperature acclimation on body mass and energy budget in the Chinese bulbul Pycnonotus sinensis.

Chinese bulbuls (Pycnonotus sinensis) are small passerine birds that inhabit areas of central, southern and eastern China. Previous observations suggest that free-living individuals of this species may change their food intake in response to seasonal changes in ambient temperature. In the present study, we randomly assigned Chinese bulbuls to either a 30℃ or 10℃ group, and measured their body mass (BM), body temperature, gross energy intake (GEI), digestible energy intake (DEI), and the length and mass of their digestive tracts over 28 days of acclimation at these temperatures. As predicted, birds in the 30℃ group had lower body mass, GEI and DEI relative to those in the 10℃ group. The length and mass of the digestive tract was also lower in the 30℃ group and trends in these parameters were positively correlated with BM, GEI and DEI. These results suggest that Chinese bulbuls reduced their absolute energy demands at relatively high temperatures by decreasing their body mass, GEI and DEI, and digestive tract size.

A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction.

Free flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm flap used to be the workhorse flap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg flap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap.

Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps.

We describe our experience in expanding the use of pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. A total of 33 patients underwent 34 flaps between March 2003 and January 2012. The defects included 18 ischial, 3 trochanteric, 5 lower abdomen, 2 perineogenital, 1 groin, and 5 knee defects. There were 29 proximal pedicled (2 of which were preexpanded), 3 distal pedicled, and 2 propeller flaps. Complications included 1 total necrosis, 1 partial necrosis, 3 wound dehiscence in recipient site, 1 hematoma, and 1 donor-site dehiscence. The total flap survival rate was 94%. There were no donor-site morbidities except poor cosmesis in the skin-grafted sites. Pedicled anterolateral thigh flap is highly versatile with a wide arc of rotation. A proximal pedicled flap can be used for lower abdomen, perineogenital, ischial, and trochanteric defects and the distal pedicled or a propeller flap for knee and proximal lower leg defects.