Multiple Diffused Cavernous Hemangiomas Associated with Venous Calculi Formation in the Right Upper Limb and Back: A Case Report.

Cavernous hemangioma, a benign soft tissue and intramuscular tumor, is commonly located in the head, neck, and maxillofacial regions. They can sometimes occur in the limbs and trunk, although rarely. Treatment of cavernous hemangiomas includes surgical and nonsurgical means. Cases of extensive diffused cavernous hemangiomas of an entire limb are rare. In this case presentation, we report the case of chronic diffused cavernous hemangioma associated with venous calculi of the right upper limb and back in a 31-year-old Chinese man. Due to the long history, chronic articular impairments and extensive damage to the skeletal and musculature, surgical amputation of the limb was performed. The aim of this report is to provide further understanding of treatment prioritization and the risks of delayed treatment of cavernous hemangiomas.

Motion Correction in Optical Resolution Photoacoustic Microscopy.

In this paper, we are proposing a novel motion correction algorithm for high-resolution OR-PAM imaging. Our algorithm combines a modified demons-based tracking approach with a newly developed multi-scale vascular feature matching method to track motion between adjacent B-scan images without needing any reference object. We first applied this algorithm to correct motion artifacts within one three-dimensional (3D) data segment of rat iris obtained with OR-PAM imaging. We then extended the application of this algorithm to correct motions to obtain vasculature imaging in the whole mouse back. In here, we stitched five adjacent 3D data segments (large field-of-view) obtained while changing the focus of OR-PAM differently for each subarea. The results showed that the motion artifacts of both large blood vessels and microvessels could be accurately corrected in both cases. Compared to the manually stitching method and the traditional SIFT algorithm, the algorithm proposed in this paper has better performance in stitching adjacent data segments. The high accuracy of the motion correction algorithm makes it valuable in OR-PAM for high-resolution imaging of large animals and for quantitative functional imaging.

Variability of Directly Measured First-Pass Hepatic Insulin Extraction and Its Association With Insulin Sensitivity and Plasma Insulin.

Although the ß-cells secrete insulin, the liver, with its first-pass insulin extraction (FPE), regulates the amount of insulin allowed into circulation for action on target tissues. The metabolic clearance rate of insulin, of which FPE is the dominant component, is a major determinant of insulin sensitivity (SI). We studied the intricate relationship among FPE, SI, and fasting insulin. We used a direct method of measuring FPE, the paired portal/peripheral infusion protocol, where insulin is infused stepwise through either the portal vein or a peripheral vein in healthy young dogs (n = 12). FPE is calculated as the difference in clearance rates (slope of infusion rate vs. steady insulin plot) between the paired experiments. Significant correlations were found between FPE and clamp-assessed SI (rs = 0.74), FPE and fasting insulin (rs = -0.64), and SI and fasting insulin (rs = -0.67). We also found a wide variance in FPE (22.4-77.2%; mean ± SD 50.4 ± 19.1) that is reflected in the variability of plasma insulin (48.1 ± 30.9 pmol/L) and SI (9.4 ± 5.8 × 104 dL · kg-1 · min-1 · [pmol/L]-1). FPE could be the nexus of regulation of both plasma insulin and SI.

Head and neck reconstruction with free flaps based on the thoracodorsal system.

The advent or micro-vascular free tissue transfer has facilitated the reconstruction of increasingly complex head and neck defects. There are multiple donor sites available, each with its' own advantages and disadvantages. However, the subscapular system, including the thoracodorsal system, provides the widest array of soft tissue and osseous flaps, as well as chimeric options. Its advantages include a long pedicle, independently mobile tissue components, relative sparing from atherosclerosis, and minimal donor site morbidity. The soft tissue flaps available from the thoracodorsal system include the Latissimus Dorsi, and Thoracodorsal Artery Perforator flaps, while the Tip of Scapula provides the osseous component. This review paper outlines the anatomical basis for these flaps, as well as describing their utility in head and neck reconstruction.

Stacked Thoracodorsal Artery Perforator Flaps for Unilateral Breast Reconstruction.

The thoracodorsal artery perforator flap is reliable and safe for breast reconstruction, but stacking bilateral thoracodorsal artery perforator flaps for unilateral reconstruction to achieve greater volumes has not been reported. To create a stacked thoracodorsal artery perforator flap, the ipsilateral flap is transferred as an island, and the contralateral flap is transferred as a microvascular free flap. In this article, the authors present their 8-year 14- patient experience with stacked thoracodorsal artery perforator flaps for unilateral breast reconstruction. Patients' ages ranged from 33 to 72 years (mean, 52.6 years). Mean follow-up time was 48.1 months (range, 1 to 98 months). Flaps measured between 22 × 6 cm and 32 × 8 cm and weighed between 110 and 550 g. Two of the island flaps had steatofibrosis of the distal 3 cm, which was resected and closed directly. The rest of the island flaps and all 14 free flaps healed uneventfully. At the time of follow-up, all flaps appeared healthy, and the reconstructed breast had a similar appearance and volume as the contralateral side. The donor areas had almost no functional deficit, and the final scar was aesthetically acceptable, especially when the ascending oblique design was used. This represents the first description of stacked thoracodorsal artery perforator flaps for unilateral breast reconstruction. This novel addition to the reconstructive surgeon's selection of methods is a safe and reliable option for large-volume unilateral breast reconstruction. It allows for symmetry without requiring prostheses or reduction of the contralateral side.

Comprehensive Analysis of Donor-Site Morbidity following Free Thoracodorsal Artery Perforator Flap Harvest.

BACKGROUND: The authors evaluated donor-site morbidity following free thoracodorsal artery perforator flap harvest comprehensively and investigated patient-and operation-related factors that might contribute to adverse outcomes. METHODS: A retrospective analysis was conducted for all cases of free thoracodorsal artery perforator flap reconstruction performed between January of 2002 and December of 2014. Donor-site morbidity was evaluated in three aspects: postoperative complications, scar-related problems, and functional impairment. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was administered postoperatively to assess donor-site function. RESULTS: A total of 293 patients were analyzed. The median follow-up period was 19.0 months. Donor-site complications developed in 33 patients (11.3 percent). Wound dehiscence (7.4 percent) and seroma (3.0 percent) were the most common complications. Harvesting thoracodorsal artery perforator flaps on multiple perforators or segmental latissimus dorsi muscle-chimeric flaps increased the rate of seroma formation but did not affect other donor-site morbidities significantly. Patient American Society of Anesthesiologists classification was a significant predictor of wound dehiscence and overall donor-site complications. Thirty-one patients (10.6 percent) had scar-related problems, including 18 hypertrophic and 13 widened scars. A transverse skin paddle design had a significant protective effect on developing scar-related problems, compared with the nontransverse design. The mean Quick-Disabilities of the Arm, Shoulder and Hand questionnaire score was 2.68 (range, 0 to 18.2), and 90 percent of patients scored less than 10. Flap dimensions were positively correlated with the questionnaire score. CONCLUSIONS: The present study suggests that the free thoracodorsal artery perforator flap is associated with low donor-site morbidity and minimal dysfunction. Careful consideration of patient condition and thoughtful planning could further minimize donor-site morbidity. CLINICAL QUESTION/LEVEVL OF EVIDENCE: Therapeutic, IV.

[THREE DIMENSIONAL VISUAL RESEARCH OF THORACIC DORSAL ARTERY BASED ON CT ANGIOGRAPHY].

OBJECTIVE: To study the digital anatomy and application value of the thoracic dorsal artery based on CT angiography (CTA). METHODS: Between September 2012 and June 2014, aorta CTA images were chosen from 10 cases (20 sides) undergoing aorta CTA. By using Mimics 17.0 software for three dimensional (3D) reconstruction of image post-processing, the digital vascular anatomical information were obtained after observing and measuring the origin of the thoracic dorsal artery, the number of perforators, type, inner diameter, and pedicle length; and the body surface location of perforator vessel was determined, and then the thoracic dorsal artery perforators tissue flap harvesting was simulated. RESULTS: 3D reconstruction images showed that the thoracic dorsal artery originated from subscapular artery, 76 perforator vessels were found, including 32 perforators (42.1%) from the medial branch of the thoracic dorsal artery and 44 perforators (57.9%) from the lateral branch of the thoracic dorsal artery, of which 69 were intramuscular perforators (90.8%) and 7 were direct skin artery (9.2%). The inner diameter of the thoracic dorsal artery was (1.69 ± 0.23) mm, and its pedicle length was (2.12 ± 0.64) cm. The first lateral perforator of the thoracic dorsal artery located at (1.65 ± 0.42) cm above the horizontal line of the inferior angle of scapula and at (1.68 ± 0.31) cm lateral to vertical line of the inferior angle of scapula. The first medial perforator located at (1.43 ± 0.28) cm above the horizontal line of the inferior angle of scapula and at (1.41 ± 0.28) cm lateral to vertical line of the inferior angle of scapula. The thoracic dorsal artery perforators flap harvesting was successfully simulated. CONCLUSION: CTA is a more intuitive method to study the thoracic dorsal artery in vivo, it can clearly display 3D information of the main blood supply artery course and distribution after flap reconstruction, so it can effectively and accurately guide the design of the flap.

Does type 1 diabetes alter post-exercise thermoregulatory and cardiovascular function in young adults?

Recent data demonstrated that individuals with type 1 diabetes mellitus (T1DM) exhibit impaired sweating and increased rectal temperature (i.e., heat storage) during exercise compared with healthy controls. Our purpose in this study was to investigate the consequences of T1DM on post-exercise thermal homeostasis. Sixteen participants (eight controls matched with eight T1DM) performed 90 min of cycling followed by 60 min of seated recovery. Esophageal and rectal temperatures, sweating (forearm, chest, and upper back), skin blood flow [forearm and upper back, presented as cutaneous vascular conductance (CVC)], and blood pressure [mean arterial pressure (MAP)] were measured at baseline and throughout recovery. Esophageal temperature was similar during baseline and recovery between groups (P = 0.88). However, rectal temperature was elevated in our T1DM group throughout recovery (P = 0.05). Sweating and CVC were similar between groups at all sites from 10-min post-exercise until the end of recovery (P ≥ 0.16). While absolute MAP was similar between groups (P = 0.43), the overall decrease in MAP post-exercise was greater in controls from 20 min (T1DM: - 8 ± 5 vs control: - 13 ± 6 mmHg, P = 0.03) until the end of recovery. We conclude that despite increased heat storage during exercise, individuals with T1DM exhibit a suppression in heat loss similar to their healthy counterparts during recovery.

Reconstruction of the external auditory canal using the random flap technique and laser Doppler evaluation.

BACKGROUND: The external auditory canal is one of the most difficult sites to reconstruct after tumor resection. In general, fascia transplantation is used to reconstruct defects of the external auditory canal, but this method is associated with scar formation and prolonged wound healing. Scar tissue might cause stenosis in the external auditory canal and hypoacusis, and wound healing is further delayed by radiation and chemotherapy. OBJECTIVE: To examine the safety of a random flap for reconstruction of an external auditory canal based on blood flow evaluation using a laser Doppler system. METHODS: Ten healthy volunteers were enrolled in this study to compare blood flow in the face, back, and behind the ear using a laser Doppler system. Two cases of external auditory canal reconstruction are presented. RESULTS: Blood flow behind the ear was abundant compared with that in the back. Blood flow in the face was higher than that behind the ear or on the back. CONCLUSION: Blood flow in the random flap was easily evaluated using the laser Doppler method. Based on our findings, we propose the random flap to reconstruct the external auditory canal after tumor resection.

Relaxing on a bed of nails: an exploratory study of the effects on the autonomic, cardiovascular, and respiratory systems, and saliva cortisol.

OBJECTIVES: This study investigated subjective and physiologic responses of lying on a bed of nails (BN) called the Shakti-mat and of listening to relaxing instructions and music. The BN has 6210 sharp-edge 5-mm plastic nails about 5 mm apart. DESIGN: Thirty-two (32) healthy participants went through four conditions in randomized orders combining BN and relaxing instructions. RESULTS: The subjective pain ratings on the BN increased immediately and reached a peak within 30 seconds. The pain then subsided gradually, indicating a habituation effect. Self-rated relaxation increased over time in all conditions. Systolic and diastolic blood pressures were higher, heart rate was slower, and there was more high-frequency power heart rate variability (HRV), and signs of increasing circulation in the back on the BN. The relaxation instruction especially affected breathing and the HRV-indices standard deviations of normal interbeat intervals and low-frequency power, both known to be responsive to slow breathing. There were no differences in saliva cortisol. CONCLUSIONS: Healthy participants habituated to the induced pain on the BN and were able to subjectively relax. When on a BN, signs of both sympathetic and parasympathetic nervous system activity were observed. The pain may hypothetically have triggered a parasympathetic response.

[Intravital observation technology of dorsal microcirculatory chamber and its application].

Observation of microcirculation plays an important role on the basic research and clinical diagnosis. However, an observation as such on the anesthetized patient will cause stress reaction, thus it will affect normal physiological state and interfere experimental results. At present, a method adopting dorsal microcirculatory chamber (DMC) to do in vivo observation in an unanesthetized state can eliminate the influence of anesthesia. Based on the research reports and practical applications of this method abroad, we summarize, in here, the configuration, function, observation techniques; the application of DMC; and the research states of microcirculation observation.

Therapeutic massage of the neck and shoulders produces changes in peripheral blood flow when assessed with dynamic infrared thermography.

OBJECTIVE: This study's objective was to determine the effect of therapeutic massage on peripheral blood flow utilizing dynamic infrared thermography in a constant temperature/humidity thermal chamber to assess noncontact skin temperature. DESIGN: The design was a repeated-measures crossover experimental design; the independent variable was treatment condition (massage, light touch, control). SETTING: The study setting was a university research laboratory. SUBJECTS: Seventeen (17) healthy volunteers (8 males/9 females; age = 23.29 +/- 3.06) took part in the study. INTERVENTIONS: One (1) 20-minute neck and shoulder therapeutic massage treatment was performed for each of the three treatment conditions. OUTCOME MEASURES: The dependent variable was noncontact, mean skin temperature in 15 regions measured at 6 time points (pretest and 15, 25, 35, 45, and 60 minutes post-test) for each treatment condition. RESULTS: The massage treatment produced significant elevations in temperature in five regions: anterior upper chest (p = 0.04), posterior neck (p = 0.0006), upper back (p = 0.0005), posterior right arm (p = 0.03), and middle back (p = 0.02). Massage therapy produced significant increases in temperature over time, compared to the other conditions, in the anterior upper chest, and posterior neck, upper back, right arm, and the middle back. Additionally, the temperatures remained above baseline levels after 60 minutes. Interestingly, the massage treatment produced significant temperature elevations in two nonmassaged areas posterior right arm and middle back. CONCLUSIONS: These changes in temperature suggest corresponding changes in peripheral blood flow in the treated areas as well as in adjacent not-massaged areas. Moreover, the results suggest dynamic infrared thermography as a useful tool to measure noninvasive, noncontact changes in peripheral blood flow for massage therapy research.

Thrombospondin-1-CD47 blockade and exogenous nitrite enhance ischemic tissue survival, blood flow and angiogenesis via coupled NO-cGMP pathway activation.

Tissue ischemia and ischemia-reperfusion (I/R) remain sources of cell and tissue death. Inability to restore blood flow and limit reperfusion injury represents a challenge in surgical tissue repair and transplantation. Nitric oxide (NO) is a central regulator of blood flow, reperfusion signaling and angiogenesis. De novo NO synthesis requires oxygen and is limited in ischemic vascular territories. Nitrite (NO(2-)) has been discovered to convert to NO via heme-based reduction during hypoxia, providing a NO synthase independent and oxygen-independent NO source. Furthermore, blockade of the matrix protein thrombospondin-1 (TSP1) or its receptor CD47 has been shown to promote downstream NO signaling via soluble guanylate cyclase (sGC) and cGMP-dependant kinase. We hypothesized that nitrite would provide an ischemic NO source that could be potentiated by TSP1-CD47 blockade enhancing ischemic tissue survival, blood flow and angiogenesis. Both low dose nitrite and direct blockade of TSP1-CD47 interaction using antibodies or gene silencing increased acute blood flow and late tissue survival in ischemic full thickness flaps. Nitrite and TSP1 blockade both enhanced in vitro and in vivo angiogenic responses. The nitrite effect could be abolished by inhibition of sGC and cGMP signaling. Potential therapeutic synergy was tested in a more severe ischemic flap model. We found that combined therapy with nitrite and TSP1-CD47 blockade enhanced flap perfusion, survival and angiogenesis to a greater extent than either agent alone, providing approximately 100% flap survival. These data provide a new therapeutic paradigm for hypoxic NO signaling through enhanced cGMP mediated by TSP1-CD47 blockade and nitrite delivery.

[Clinical application of thoracodorsal artery perforator flaps].

OBJECTIVE: To analyses the clinical application of thoracodorsal artery perforator flaps (TAP). METHODS: We used free or pedicled TAP flaps in 7 patients from Aug 2006 to April 2007, The age ranged from 7 to 42 years old, the perforator arteries was detected and labeled with a hand held Doppler flowmeter, the size of flaps ranged from 6 cm x 9 cm - 12 cm x 16 cm, the flaps designed with perforator artery included, all the flaps are based on the first perforator artery. RESULTS: All the flaps survived well, no complication occurred with lowest donor site morbidity. CONCLUSIONS: The thoracodorsal artery flap with latissimus dorsal muscle saved is a thin and reliable flaps with robust of blood supply, the flap can reduce significantly donor site morbidity and is a good choice for reconstructive surgery.

Skin perforators of back region: anatomical study and clinical applications.

BACKGROUND: Despite widespread studies that have been commonly performed recently on skin perforators and perforator flaps of various regions of the body, investigations on the back region of the body are still insufficient. This study investigates the anatomical characteristics and clinical applications of perforating vessels in the back region. MATERIALS AND METHODS: The skin on the back region between the right and left, 7th to 11th thoracic vertebrae of 10 fresh cadavers were raised as flaps. Perforating vessels perfusing the skin with pedicle diameters of over 1 mm were included in the study. The anatomical localization, diameter, pedicle size, and the supplying vessels of these pedicles were determined. Utilizing this information, the defects of 8 patients with large meningomyeloceles included in the study were closed with prepared intercostal artery perforating flap. RESULTS: Perforators of the back region were seen to originate from the posterior intercostal vessels. There were a higher number of perforators on the right side of the body. The most commonly observed perforators were the 7th and 9th posterior intercostal perforators, and their diameters were larger. All flaps were viable following perforator flap closure for defects in 8 patients with large meningomyelocele included in the clinical study. No problems were encountered in the postoperative 3-month follow-up of cases. CONCLUSION: Owing to the low donor area morbidity and wide motion capabilities, the perforator flap is a new choice of flap for the back region. Perforator pedicle flaps supplied by the posterior intercostal vessels may be safely used in congenital tissue defects, such as meningomyelocele, tumors, and traumatic defects.

Circumferential lower truncal dermatolipectomy.

Obesity and overweight in the general population have increased significantly over the last several years. Such increases have stimulated many approaches to treat this condition from a clinical perspective, with improved surgical and conservative measures that have become available for controlling overweight. The present article examines both established procedures for performing body lift procedures and innovative approaches that are now available, as well as their potential complications. The problems and solutions discussed in this article derive from the authors' own experiences collected over the last 10 years at the Department of Plastic and Reconstructive Surgery at the Dreifaltigkeits-Hospital in Wesseling, Germany. These surgical procedures are the operations with the largest treated body surface area with manageable risks when the planning and operation are performed meticulously and conscientiously.

[The thoracodorsal artery musculocutaneous perforator flap: anatomic study and clinical significance].

OBJECTIVE: To investigate the feasibility of clinical application of the thoracodorsal artery musculocutaneous perforator flap (TAMPF). METHODS: (1) The morphosis and blood supply of TAP flap on 15 formalized adult cadavers(30 sides) were examined by microsurgery anatomy. (2) An imitative operation of the TAMP flap and latissimus dorsi flap on 1 formalized adult cadavers (2 sides) was conducted. RESULTS: (1) A total of 102 musculocutaneous perforators larger than 0.5 mm were found in 16 specimens(32 sides). 56 perforators (55%) were originated from the medial branch and 46 (45%) originated from the lateral branch. The biggest perforator is (0.82 +/- 0.11) mm (0.68 - 1.08 mm). There was an average of 1.9 perforators (range, 1 - 3 perforators) of the medial branch and an average of 1.8 perforators (range, 1 - 3 perforators) of the lateral branch. Additionally, there were 24 perforators samller than 0.5 mm, and 76 perforators originated from intercostal artery and lumbar artery. (2) Musculocutaneous perforators over 0.5 mm were found only in proximity of the medial and lateral branches within a distance of 8.5 cm (6.4 cm - 9.2 cm) distal to the neurovascular hilus. CONCLUSIONS: With the characteristics of constant position, large caliber, long pedicle, the thoracodorsal artery musculocutaneous perforator was suitable to be musclocutaneous perforator flaps and "fan-shaped" flaps.

The anatomy of the thoracodorsal artery in perforator flap for resurfacing shallow defect.

OBJECTIVE: To systematically determine the location and number of cutaneous perforators greater than 0. 5 mm in diameter of the lateral branch of the thoracodorsal artery perforator flap for resurfacing shallow defect. MATERIAL AND METHOD: Sixty dissections of the thoracodorsal arterial system were carried out in 30 preserved cadavers. The location and number of cutaneous perforators greater than 0.5 mm in diameter of the lateral branch of the thoracodorsal artery perforator flap were studied and measured. RESULTS: Seventy-six perforators were found in 60 flaps (1.3 perforators per flap). The first perforator was exited in all dissections. It emerged from the latissimus dorsi muscle 9.8 cm below the dome of the axilla. In 21.67% of the cases, the second perforator of the thoracodorsal artery arose 3.4 cm distal to the origin of the first perforator The third perforator was found in 5% of dissections, and originated 3.0 cm away from the origin of the second perforator In addition, most perforators penetrated the muscle within 7.0-14. 0 cm below the dome of the axilla. CONCLUSION: The center of the flap designed should be placed between 7 to 14 cm from the dome of the axilla.

Cross-sectional internal diameters of radial, thoracodorsal, and dorsalis pedis arteries in children: relationship to subject sex, age, and body size.

The purpose of this study was to determine the average diameter of the radial, thoracodorsal, and dorsalis pedis arteries in a pediatric population and to evaluate the relationship of these measurements to the subject's age, sex, height, weight, and body mass index (BMI). The internal diameters of the radial, thoracodorsal, and dorsalis pedis arteries were non-invasively studied in 45 normotensive, presumed normal children of various ages (4 to 14 years) with the use of a Doppler system. The average diameters of the radial, thoracodorsal, and dorsalis pedis arteries in females and males were as follows: radial artery 1.39 (SD +/- 0.18) mm and 1.57 (SD +/- 0.18) mm; thoracodorsal artery 1.27 (SD +/- 0.11) mm and 1.36 (SD +/- 0.2) mm; and dorsalis pedis artery 1.22 (SD +/- 0.08) mm and 1.34 (SD +/- 0.12) mm. These were correlated with the age, height, weight, and BMI. Gender had a strong influence on the diameter of these arteries. In a linear regression model, weight was found to be statistically the best independent variable for predicting radial and dorsalis pedis diameters, whereas age was the best predictor for the diameter of the thoracodorsal artery. The diameters of these three arteries in an age group of 4 to 14 years ranged between 1 to 2 mm. The age and weight of the children predicted the diameters of the peripheral arteries.