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Background: As an exposure region, the face is susceptible to burn injuries, which often lead to physical and psychological problems. For facial scar reconstruction, the subclavicular region has the advantages of matched color, similar texture, and thin and pliable tissue supply. The island or pedicled subclavicular flap, which is nourished by the thoracic branch of supraclavicular artery (TBSA) had been reported to cover cervical facial defects and achieved good outcomes. However, the main restriction is the limitation of the pedicle length. Therefore, the authors applied preexpanded TBSA free flap transplantation for treatments of upper and contralateral facial scars to overcome the pedicle limitation., Methods: Three patients were treated with preexpanded TBSA flaps to repair the facial defects after scar resections. Two of them were combined with forearm or deltopectoral flaps according to different purposes. The patients were followed up for 2 to 7 years. The clinical data and surgical techniques were recorded and analyzed. The scars were scored by Vancouver Scar Scale., Results: Two of the TBSA flaps survived well without complication. Partial flap necrosis in the distal end was healed by dressing changes, and mild contracture in the left medial canthus was corrected by Z plasty in case 1. The scars around transferred flaps and donor sites were scored 3 to 4 by Vancouver Scar Scale. The patients were satisfied with the outcomes. All the donor sites were closed primarily., Conclusion: A preexpanded TBSA-free flap could overcome the restriction of pedicle length for reconstruction procedures. The method is a feasible alternative of thoracic flaps to repair facial defects beyond pedicle limitation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Although the incidence of scalp avulsion has decreased in recent years, it remains a major concern among plastic surgeons. We therefore aimed to introduce an improved free flap technique for repairing scalp avulsion with less tissue from the donor site. This method can achieve maximum primary closure of the donor site and improve its appearance and function as well as reduce the donor-site morbidity by ensuring that a smaller free flap can completely cover the scalp defect. Eight patients with scalp avulsion who had undergone staggered placement of the free flaps were evaluated. Data on the age, cause of scalp avulsion, scalp defect size, degree of avulsion, postoperative complications, and follow-up duration were analyzed. The postoperative evaluation criteria were donor-site sensation, latissimus dorsi muscle strength, upper extremity function, and quality of life. Patients' mean age was 38.7 years. The main cause of scalp avulsion was occupation-related accidents. The mean scalp defect size and postoperative follow-up duration were 26 cm × 20.4 cm and 41.5 months, respectively. One patient developed flap congestion postoperatively. The wounds at the recipient site healed well in all patients. There was no significant difference in the sensation between the surgical and nonsurgical sides. However, the latissimus dorsi muscle strength significantly differed between both sides. The mental component score, which was used to assess quality of life, did not significantly differ between the patients and healthy population, whereas the physical component score significantly differed between the two groups. None of the included patients had severe upper extremity functional limitation. Staggered placement of free flaps achieved maximum primary closure of the donor site and greater scalp avulsion defect coverage with less tissue excised from the donor site. Importantly, donor-site appearance improved and some donor-site functions were preserved postoperatively., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: Auricular reconstruction is a great challenge for surgeons to achieve good aesthetic outcomes when adjacent tissues were burned. Compared with pedicle flap therapies, there are some advantages of pre-expanded free flaps for ear rebuilding, such as thinner layer tissues for aesthetic requirements of delicate auricular structures and less donor site deformity. In this study, the authors introduced 6 sequential surgical procedures for total auricular reconstruction with severe ipsilateral facial scar., Methods: Pre-expanded deltopectoral flap was used to release periauricular contracture and repair facial scar. The injured ear was restored by expanded forearm flap including autologous cartilage framework. The surgical procedures were lasted more than 2 years. An 8 and half year's follow-up was performed from November 2012 to April 2021. The clinical data and surgical techniques were recorded and analyzed., Results: The patient was satisfied with the aesthetic outcomes of the new ear. The skin texture and color of the grafts were approximately matched to the recipient sites. Facial expression was not affected severely. Sensations of the transferred flap and new ear had partially recovered. The donor sites were recovered without severe complication., Conclusions: The pre-expanded free forearm flap is a feasible method for total ear reconstruction when local flap therapies could not be applied. Repair of ipsilateral facial scar is beneficial for auricular procedures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Double eyelid surgery is popular worldwide, especially in East Asia. Although double eyelid surgery seems simple, it comes with numerous complications. These complications can be divided into disordered complications and esthetic complications. Plastic surgeons pay more attention to the esthetic aspect. In our long-term clinical work, we have repeatedly observed that many patients with overactive facial muscles (frontalis muscle or corrugator supercilii muscle) often develop esthetic complications after surgery. These patients present with an appearance of a double eyelid fold that is either too high, too low, or absent. However, some plastic surgeons have not realized this, and most of them believe that esthetic complications are caused by improper techniques during surgery. Therefore, it is necessary for us to share our experience in this field with our peers., Competing Interests: None

Background: Trauma can cause large defects in the weight-bearing foot sole. The reconstruction of such defects poses a major challenge in providing a flap that is durable, sensate, and stable. The pedicled medial plantar flap has been commonly used for reconstructing heel and plantar forefoot defects; however, the ipsilateral instep region is usually compromised by trauma. The purpose of this article was to report the use of contralateral free medial plantar flaps for the coverage of weight-bearing plantar defects and to compare these with distant free flaps., Methods: Between 2005 and 2019, 15 patients (10 men and 5 women) with weight-bearing foot plantar defects were treated with a contralateral medial plantar flap, 11 (7 men and 4 women) with either a latissimus dorsi flap or a scapular flap. The average age was 18.07 ± 10.14 years (range, 4-34 years) and 26.55 ± 13.05 years (range, 13-56 years), respectively. Surgery was performed as a primary or secondary reconstruction after a trauma by the same surgical team., Results: The mean size of defects was 9.73 ± 3.55 × 6.43 ± 2.8 cm in the contralateral free medial plantar flap group and 17.14 ± 6.84 × 11.41 ± 4.29 cm in the free dorsal flap group. All flaps survived in both groups. In the instep flap group, the appearance was satisfactory, the flap was durable, and tactile sensation was preserved in all patients, and none required a revision procedure. Two patients experienced delayed union of the donor-site grafted skin. In the dorsal flap group, 5 patients complained of a partial necrosis or delayed union at the recipient site, and 9 developed recurrent ulcerations over the weight-\bearing area. Five patients achieved only partial sensation in the flap., Conclusions: The contralateral medial plantar flap provides superior appearance, duration, and sensation over distant muscle flaps, without recurrent ulcerations. However, dorsal myocutaneous flaps may be used as a substitute when the defects are beyond the maximum boundaries of the instep area or are combined with bone loss.

The scars of face and scalp caused by burning often show as 1 large facial-scalp scar. The deltopectoral flap was recognized as one of the first choices for the facial scar reconstruction. However, this flap cannot cross the level of zygomatic arch traditionally when it was transferred with pedicle. When the flap reconstructed the facial-scalp scars with expanded random scalp flap, another flap was often needed to reconstruct the remaining temple and forehead scars. The authors reviewed 24 patients of large facial-scalp scars reconstructed by expanded pedicled deltopectoral flap and scalp flap with several technique improvements. The seaming scar between the deltopectoral flap and scalp flap in the temple region formed the new hairline. The technique improvements included ligation of the perforating branches of the transverse cervical artery and thoracoacromial artery when dissecting the pocket, the partial bolster compressive dressing to the distal part of the flap and dividing the pedicle partly as a delaying procedure before dividing the pedicle completely. Good skin compliance, normal contours, and emotional expression were noted. There were complications including expander exposure in 3 patients, stretch marks in 5 patients, flap tip necrosis in 2 patients, and mild postoperative hypertrophic scars in 3 patients. In conclusion, the expanded pedicled deltopectoral flap can enlarge the reconstructive territory in face successfully with the technique improvements. The combination of the expanded pedicled deltopectoral flap and scalp flap is a reliable and excellent reconstructive option for large postburn facial-scalp scars.

Background: The anterior chest is an excellent donor site for cervicofacial reconstruction. Studies of chest flaps began as early as 1988 at our institution. We identified a new branch of the supraclavicular artery that nourishes the anterior chest, and on the basis of this finding, we created a new flap called the subclavicular flap. Unlike the supraclavicular flap, which is pedicled by the deltoid branch, this flap is primarily pedicled by the thoracic branch, and it shares similar vascular territory with the deltopectoral flap. In China, this flap has been widely used for neck reconstruction since our first publications on it in 1993. However, reports of its application are limited. To popularize the use of this flap, we present our experiences with pre-expanded subclavicular island flaps for the repair of facial scars., Methods: Fifteen patients with facial scars underwent reconstruction with these flaps. All flaps underwent pre-expansion before being transferred to the face through a subcutaneous tunnel. The pivot point was in the supraclavicular region and allowed the flap to reach the mid-face without compulsive positioning. Donor sites were closed primarily., Results: Flaps sizes ranged from 4 cm × 5 cm-10 cm × 17 cm. Fourteen flaps survived completely with satisfactory colour and texture. Total flap loss occurred in one patient, who was then treated by harvesting a skin graft from the dying flap. One patient experienced venous congestion, and the flap was successfully salvaged by pure vein anastomosis., Conclusion: Pre-expanded subclavicular island flaps have similar benefits to supraclavicular and deltopectoral flaps, and they may emerge as one of the best choices for cervicofacial reconstruction globally., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Bulky appearance is a major shortcoming after surface coverage using free muscle flaps. The one-stage thinning procedure at the time of transfer can improve the appearance and avoid additional debulking surgery. We present our experiences in the reconstruction of complex lower extremity defects using thinned free muscle flaps., Methods: Latissimus dorsi muscle flaps (LDMs) and rectus abdominis muscle flaps (RAMs), which have vessel pedicles running deep in the muscles, were raised and the superficial tissue layers were removed to thin the flaps. These thinned muscle flaps were then used to resurface the wounds on lower extremities followed by coverage of skin autografts on the muscle surfaces., Results: Fourteen LDMs and four RAMs were thinned used for resurfacing eight, five, and three defects on feet, ankles, and pretibial regions, respectively, with wounds that ranged from 6 × 4 cm(2) to 23 × 9 cm(2). All muscle flaps survived the tangential thinning procedures uneventfully. High take rates were observed for most skin grafts, except that a partial skin loss was found in one case. During the 1-20 months follow-up, the skin surface contours over the thinned muscle flaps matched well with adjacent areas., Conclusions: Intraoperative immediate thinning of LDMs and RAMs can be safely accomplished during the primary reconstruction procedure and may provide an alternative for coverage of complex lower extremity defects., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. 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 .

Repair of extensive foot defects requires both adequate tissues for wound coverage and special tissues for functional reconstruction. To maximize its function reconstruction, fabricated chimeric flaps consisting of multiple separate flaps were designed to reconstruct such defects. Five patients suffered extensive foot defects with sizes ranging from 23 × 12 cm to 38 × 14 cm(2) in multiple regions including heel, forefoot, dorsum, ankle, anterior leg, and even toes. Causes included crushing injuries, avulsion injuries, and scar excision. Most areas of the defects except heel were first covered by latissimus dorsi muscle flap or anterolateral thigh flap and their pedicles were anastomosed with recipient vessels. Then free medial plantar flaps were transferred for heel reconstruction and their pedicles were further attached to either side branches of the main source vessel or to its distal continuation. All chimeric flaps survived uneventfully and all patients were able to walk in normal footwear during the 1.5- to 4-years follow-up. None of the flaps developed ulcer and flap breakdown. The assessment by Maryland Foot Score showed that four of the five patients gained a "good" recovery and one patient showed moderate improvement of foot functions. Appearances of reconstructed heels were near-normal. The results indicate that fabricated chimeric flap has good design flexibility and may provide an option for functional reconstruction of extensive foot defects. © 2015 Wiley Periodicals, Inc. Microsurgery 36:303-309, 2016., (© 2015 Wiley Periodicals, Inc.)

Background: Parry-Romberg syndrome is an infrequent, acquired disorder characterized by progressive facial atrophy of the skin and soft tissue of the face and, in some cases, results in atrophy of muscles, cartilage, and the underlying bony structures. We investigated dorsal thoracic adipofascial free flap and concurrent lipoinjection as a reconstructive option for Parry-Romberg syndrome., Methods: Thirteen patients with hemifacial atrophy caused by Parry-Romberg syndrome underwent surgical correction after their deformitiesreached a stable stage. All patients were classified as having severe atrophy; they had either atrophy of the skin and subcutaneous tissues observable in all 3 sensory branches of the trigeminal nerve or bone involvement. In all cases, we applied dorsal thoracic adipofascial free flap and concurrent lipoinjection followed by secondary revision with debulking or lipoinjection., Results: The adipofascial flaps survived after the initial operation in all 13 patients. After the second-stage operation, 11 of 13 patients had achieved a natural appearance without any sagging or insufficient filling in the upper face., Conclusions: For patients with severe hemifacial atrophy with little or no bone involvement, dorsal thoracic adipofascial free flap and concurrent lipoinjection was a feasible and reliable reconstructive option.

Background: Facial scars caused by burns and trauma severely affect patients' function and appearance. The expanded deltopectoral flap to local shift is the traditional method of repair, but for patients with the compulsive position after pedicle transfer, the therapeutic outcome is not satisfactory. The authors explored the surgical procedures for repairing facial scars by using the free expanded deltopectoral flap, which can reduce patient suffering and ensure a satisfactory outcome., Methods: Eighteen patients with large facial scars underwent repair using free expanded deltopectoral flaps. After expansion, the flaps were transplanted to repair facial scars by vascular anastomosis. If the contour was not good and the pedicle was clumsy, another operation to thin the flaps was performed to perfect the repair., Results: The 18 patients achieved satisfactory results. All of the flaps survived and the skin color, texture, and contour were well matched to those of the peripheral tissue. Six months postoperatively, the flaps had partially recovered sensation, and no adverse effect on facial expression was detected. One patient experienced venous congestion but the flap was successfully salvaged; another patient experienced expander exposure because of infection during saline injection. The asymmetric position of the nipples during the early phase improved gradually over time., Conclusion: After expansion and free transplantation, the deltopectoral flap has proved to be more effective than flaps used traditionally and will become one of the best choices for the treatment of facial scars., Clinical Question/level of Evidence: Therapeutic, V.