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Ming-Wei Yu,1,2,* Min Wang,1,* Qian Wang,1Yong Chen,1Si-Ming Yuan11Department of Plastic Surgery, Jinling Hospital, Nanjing, Jiangsu, 210002, People’s Republic of China; 2Department of Plastic Surgery, Wuhan Third Hospital, Wuhan, Hubei, 430000, People’s Republic of China*These authors contributed equally to this workCorrespondence: Si-Ming Yuan, Department of Plastic Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210002, People’s Republic of China, Email yuansm@163.comObjective: The latissimus dorsi (LD) flap has generally been considered a workhorse flap in clinics. However, the impairment of shoulder function and the dramatic appearance in the donor site are the major problems associated with traditional latissimus dorsi myocutaneous flap (LDMF). Here, we analyzed the reliability of three types of LD flaps in repairing deep soft tissue defects in the upper limbs, shoulder, back, and chest wall.Methods: From December 2016 to December 2020, 21 patients from our center underwent reconstruction of deep soft tissue defects using different types of LD flaps. The distribution of the thoracodorsal artery and the location of its branches were confirmed by imaging examination. Based on the defects, traditional LDMF, thoracodorsal artery perforator flap with capillary perforators (TAPcp), or low-skin-paddle pedicled LDMF was selected and specifically designed for each patient. The appearance satisfaction and shoulder functional of daily life recovery were evaluated.Results: A total of 12 traditional LDMF, 4 TAPcp, and 5 low-skin-paddle pedicled LDMFs were used. All flaps survived well. The donor site was sutured directly with satisfactory appearance (n = 7) or repaired using skin grafts (n = 14). Compared to traditional LDMF, TAPcp and low-skin-paddle pedicled LDMF have faster shoulder function of daily life recovery.Conclusion: Based on the characteristics of defects, personalized design of different types of LD flaps is a reliable option to repair different defects.Keywords: latissimus dorsi myocutaneous flap, thoracodorsal artery perforator flap with capillary perforators, low-skin-paddle pedicled flap, shoulder function

Venous malformations (VMs) and sclerotherapy may disrupt the normal systemic coagulation profile in individuals. This study investigated a correlation between the clinical efficacy of sclerotherapy in the treatment of VMs and the changes in coagulation indexes to provide data that will inform the future application of this therapy.From September 2019 to September 2020, 61 patients were enrolled in this study to receive sclerotherapy with absolute alcohol. The clinical outcomes and the coagulation profile were assessed.Sclerotherapy induced increasing fibrin (original) degradation products (FDP) and D-dimer (D-D) levels. The changes in FDP and D-D level pretreatment and posttreatment were positively correlated with treatment outcomes. Moreover, a repeated treatment with absolute alcohol may restore normal levels of FDP and D-D.Upregulation of FDP and D-D levels after sclerotherapy results in good therapeutic outcomes. Therefore, monitoring changes in FDP and D-D levels in patients with VMs undergoing sclerotherapy may reflect the effects of sclerotherapy.

Qian Wang,1 Chen Yong,1 Min Wang,1 Lei Cui,1 Si-Ming Yuan1,2 1Department of Plastic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, People’s Republic of China; 2Department of Plastic Surgery, Jinling Hospital, Nanjing School of Clinical Medicine, Southern Medical University, Nanjing, 210002, People’s Republic of ChinaCorrespondence: Si-Ming Yuan, Department of Plastic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, People’s Republic of China, Email yuansm@163.comObjective: Refractory port-wine stain (PWS) usually contains hypertrophic, nodular lesions or severe scars due to improper treatment, making surgical treatment a necessity. This study aims to introduce our experiences in surgical management of refractory PWSs in the scalp and face.Methods: From January of 2013 to September of 2018, 25 patients with refractory PWSs in the scalp and face received surgeries in our department. Clinical manifestation of the disease, the surgical procedures and postoperative complications were reviewed. A Visual Analog Scale (VAS) was applied to evaluate the outcomes.Results: In this study, surgical procedures included serial resection (4 cases), complete resection followed by local flap transplantation (6 cases) or skin grafting (7 cases), and two-staged surgeries using expanded flaps (5 cases) or expanded prefabricated flap (3 cases). All the skin grafts and flaps survived well. Follow-up evaluation with VAS showed that most patients were satisfied with the surgery.Conclusion: The surgical procedures should depend on the site, area and type of the lesions and patients’ personal requirement. Individualized surgical treatment of refractory PWSs achieved satisfactory results in re-establishing symmetric facial contour and improving the overall appearance.Keywords: port-wine stain, surgery strategy, scalp and face

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF.

Objective Head and neck are the predilection sites of arteriovenous malformations (AVMs). Although embolization is the first-line treatment for AVMs, complete surgical removal of the lesion still has its value due to the best outcome with low recurrence rate. Here, the authors made a retrospective analysis on the surgical treatment of AVMs in the head and neck. Methods From January 2006 to December 2019, a total of 18 patients with AVMs in the head and neck were enrolled in this study, including 10 males. The Schobinger clinical staging, Yakes' angioarchitecture type, and surgical treatment were analyzed. The follow-up data were collected. Then, individual treatment strategies were summarized. Results According to Schobinger clinical classification system, 6 patients were at stage I, 7 patients at stage II, and 5 patients at stage III. According to Yakes' AVM classification system, 3 Type I, 4 Type II, 5 Type III, and 3 Type IV were confirmed. 3 patients cannot be confirmed due to lacking of arteriographic data. Surgical treatments included simple surgical excision (8 patients), dilator therapy (6 patients), and skin grafting after surgical excision (4 patients). In the follow-up period, 2 patients had recurrence and accepted operation again. All patients were satisfied with the appearance. Conclusions Individual surgical treatment based on the clinical stage and angioarchitecture type can achieve satisfactory results in AVMs in the head and neck.

The reverse medial plantar flap (RMPF) raised from the nonweight-bearing region of the plantar foot represents a viable option for the soft tissue defect in planter forefoot. The anatomical basis of RMPF is the complex anastomotic branches between medial plantar artery (MPA) and deep plantar arch. Those anastomotic branches have high variation rate and may be damaged by trauma such as electric injury. Therefore, it is very important to know whether those anastomotic branches are present and intact before harvesting RMPF. Five patients with soft tissue defect in planter forefoot were enrolled into the study. The digital subtraction angiography (DSA) was performed to evaluate the plantar hemodynamics in the ipsilateral foot. The RMPF was harvested only after the anastomotic connections between MPA and deep plantar arch was confirmed. Anastomosis between superficial branch of MPA and deep plantar arch was observed in all DSA examinations. All 5 patients received the repair of soft tissue defect in plantar forefoot with RMPF. All flaps survived completely. The DSA can effectively evaluate the blood supply basis of RMPF and provide imaging evidence for the design and harvest of the flap. The main anatomical basis of RMPF is the anastomotic connections between superficial branch of MPA and deep plantar arch.

Introduction Using meta-analysis to evaluate the efficacy of absolute ethanol and polidocanol in the treatment of venous malformations. Materials and methods A systematic search of the English literature was conducted in April 2019 including PubMed, Embase and Web of Science. Article selection was based on preset criteria. The included literature was scored on the MINORS scale, and the meta-analysis and the forest plot were made using the R 3.5.1 software for efficiency. Results Ten articles were included in the meta-analysis. Absolute ethanol response rate ranged between 79% and 92% with a pooled rate of 85%, and polidocanol response rate ranged between 63% and 94% with a pooled rate of 77%. Discussion Although sclerotherapy is effective in most studies, a large number of randomized controlled trials are still needed to confirm the best treatment options at different sites.

Background and objective Craniofacial malignant tumors require not only extended resection but also appropriate reconstruction to restore appearance, which remains a major challenge. Here the authors introduced the application of superficial temporal artery (STA) flap in wound repairing after the resection of craniofacial malignant tumors. Methods From January 2015 to December 2018, 16 patients with craniofacial malignant tumors were enrolled into the study, including squamous cell carcinoma (n = 6), basal cell carcinoma (n = 3), melanoma (n = 4), neuroendocrine carcinoma (n = 2), and dermatofibrosarcoma protuberance (n = 1). All of the tumors underwent extended resection. The defects formed were repaired by flaps pedicled with superior or frontal branch of STA. Donor sites were repaired with skin grafts. Patients were followed up for 6 months to 3 years to monitor the recurrence of tumor. Results All the flaps survived well. Venous congestion occurred in two cases but resolved after blood-letting and application of drugs promoting venous draining. During the follow-up, no recurrence of tumors was observed and the appearance of flaps was satisfying. But flap donor sites suffered from relatively poor appearance or alopecia deformity. Conclusions The STA flap is reliable for wound repairing after resection of craniofacial malignant tumors. The STA parietal branch flap is preferred for repairing scalp defects, while the STA frontal branch flap is preferred for repairing facial defects. However, the STA flap should be used prudently due to its disadvantage of the deformity in scalp donor sites.

Meng-Nan Xu,1,* Qian Wang,1,* Min Wang,1 Yuan Xu,1 Si-Ming Yuan1,2 1Department of Plastic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, 210002, People’s Republic of China; 2Department of Plastic Surgery, Jinling Hospital, Nanjing School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu, 210002, People’s Republic of China*These authors contributed equally to this workCorrespondence: Si-Ming Yuan, Department of Plastic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, 210002, People’s Republic of China, Email yuansm@163.comBackground: Port wine stain (PWS) is a congenital skin lesion involving capillary malformations. Most PWS lesions will gradually become hypertrophic and appear nodular in contour. Current research shows that rapamycin, an mTOR inhibitor, is probably a promising adjunctive therapy for PWS, which suggests that the mTOR signaling pathway may play an important role in its pathological process.Methods: From January 2013 to January 2019, 13 samples were obtained during the surgical excision. Each sample was divided into 3 parts according to the type of lesion, namely, the flat, hypertrophic and nodular lesions. Pathologic structures of each type were observed under the microscope after HE staining. The expression of mTORC1, p70S6, p-p70S6, eIF4EBP1 and p-eIF4EBP1 was examined by immunohistochemical staining and western blotting. The location of the expression of mTORC1, p-p70S6 and p-elF4EBP1 was further detected by immunofluorescence staining.Results: Large amounts of dilated and malformed vessels were observed in all types of PWS lesions. Abundant hyperplastic hair follicles/glands were shown in the hypertrophic or nodular lesions. Phosphorylation level of p70S6 and elF4EBP1 in PWS was significantly higher than those in normal skin and increased accordingly in the progression of PWS. Activated molecules in mTOR signaling pathway were mostly located in the endothelium of malformed vessels. They were also located in the hyperplastic hair follicles/glands of hypertrophic and nodular lesions.Conclusion: The mTOR signaling pathway was increasingly activated during the progression of PWS. Enhanced activation of mTOR signaling pathway may contribute to the hypertrophy and nodularity of PWS. The results provide preliminary evidence for treating PWS and related syndromes by inhibiting mTOR signaling pathway.Keywords: port wine stain, mTOR signaling pathway

Background: Cutaneous melanoma is a highly malignant tumor which tends to metastasize in the early stage and leads to poor prognosis. Hematogenous and lymphatic metastasis are common in the dissemination of melanoma. Rapamycin, an mTOR inhibitor, was reported to have anti-angiogenic and anti-lymphangiogenic properties. Aim: The aim of this study was to investigate if rapamycin can inhibit the formation of blood vessels and lymphatic vessels in melanoma. Methods: A melanoma xenograft model was generated by subcutaneously transplanting A375 human melanoma cells into the back of immunodeficient mice. Two weeks after cell transplantation, rapamycin was injected intraperitoneally every other day seven times. Then, tumors were harvested. Hematoxylin-eosin (H-E) staining, immunohistochemical staining, Western blot, and quantitative PCR were performed to observe the pathological structure of the tumor, the distribution of blood vessels and lymphatic vessels, and the expression of mTOR signal pathway, VEGF-A/VEGFR-2, and VEGF-C/VEGFR-3. Results: The results showed that CD34(+) blood vessels and LYVE-1(+) lymphatic vessels decreased in the peritumor and intratumor region in rapamycin-treated tumors. Expression of p-4EBP1 and p-S6K1 proteins was downregulated. Expression of both proteins and mRNAs of VEGF-A/VEGFR-2 and VEGF-C/VEGFR-3 was downregulated. Conclusion: In conclusion, rapamycin suppresses angiogenesis and lymphangiogenesis in melanoma by blocking the mTOR signal pathway and subsequently downregulating the expression of VEGF-A/VEGFR-2 and VEGF-C/VEGFR-3. Therefore, targeted therapy via mTOR signal pathway may control the hematogenous and lymphatic metastasis of melanoma, and even prolong patients' survival time.

Background and objective Defects resulted from the removal of large scars, benign tumors, severe pigmentation abnormalities, and vascular malformations, etc., in the scalp and face need to be repaired to restore the appearance. Here, the authors introduced the application of various expanded superficial temporal artery (STA) flaps in the repair of above defects. Methods From Jan. 2015 to Dec. 2018, 19 patients with craniofacial secondary defects received the repair with expanded STA flaps in our clinic. The defects were resulted from the removal of scalp scar (n = 6), neurofibroma (n = 4), sebaceous nevus (n = 3), arteriovenous malformation (n = 2), facial scar (n = 2), and port-wine stain (n = 2). The expanded STA flaps included 14 cases of flaps pedicled by parietal branch of STA, 2 cases of flaps pedicled by parietal branch of STA combined with laser hair removal, 1 case of flaps pedicled by frontal branch of STA, and 2 cases of prefabricated expanded skin flap with the superficial temporal fascia in the neck. Results The two-stage operation and water-filling expansion were accomplished in all patients. All flaps survived well, except one flap with venous congestion, which resolved after blood-letting and application of drugs promoting venous draining. In the three to six months follow-up, the flaps' color, texture, and thickness were satisfying. Conclusions Individual application of different types of expanded STA flaps could achieve ideal results in repairing craniofacial secondary defects.

Under the general trend of mobile Internet, more and more industries began to change from traditional business model to e-commerce, which made the scale of e-commerce in China expand rapidly. E-commerce recommendation system provides users with commodity information and suggestions on the basis of understanding and learning customers’ needs and preferences, recommends products that may be of interest to users, and helps users complete the purchase process. Collaborative filtering is the most widely used and successful recommendation technology in the recommendation system. However, with the increase of the number of users and commodities in the e-commerce system, the time spent searching the nearest neighbor of the target user in the whole user space also increases sharply, which leads to the decline of system performance. In this paper, a cooperative recommendation implementation method based on user clustering is proposed. Users are clustered based on their scores of commodity categories, and only users’ nearest neighbors are searched in the categories to which they belong, so as to search as many nearest neighbors as possible in as little user space as possible.

Venous malformations (VMs) are common slow-flow vascular malformations, which affect almost anywhere of the body. From January 2010 to October 2019, 126 patients with VMs who had complete imaging and follow-up data were enrolled into this study, including 75 males. The initial treatment age ranged from 5 to 72 years. The role of imaging results on the choice of treatment measures and the application were summarized. In this study, we retrospectively analyzed the imaging examinations, treatment measures, and follow-up results of the patients with VMs in our clinic. In this series, imaging examinations included ultrasound, magnetic resonance imaging, computed tomography (CT) scan and enhanced scan, percutaneous sinus angiography and three-dimensional CT imaging, plain film, CT venography, CT angiography, and digital subtraction angiography. Treatment measures included surgical excision (n = 20), sclerotherapy (n = 86, including absolute ethanol [n = 75], polidocanol [n = 8], and pingyangmycin [n = 3]), and combination treatment with intralesional copper wire retention and sclerotherapy(n = 20). After treatment, most of the lesions shrunk obviously or disappeared, and the symptoms were largely relieved. Comprehensive and accurate imaging assessment of VMs is necessary for selecting appropriate treatment. Individual strategy and sequential treatment can achieve effective results and avoid potential complications.

Venous malformation is one of the slow-flow vascular malformations. Dysfunction of coagulation often occurs in most venous malformations, especially the diffuse and multifocal lesions, referred to as localized intravascular coagulopathy. It is characterized by the elevation of D-dimers and fibrin degradation products, low levels of fibrinogen, FV, FVIII, FXIII, and antithrombin III, and sometimes minor-to-moderate thrombocytopenia. Here we reviewed the clinical manifestations, pathogenesis, diagnosis, and treatment of localized intravascular coagulopathy in venous malformations.

Objective Infantile hemangiomas (IHs) are the most common benign tumor in infancy. Periorbital IHs may lead to visual dysplasia so prompt and effective treatment should be adopted. In this study, we retrospectively analyzed the diagnosis and treatment of periorbital IHs treated in our clinic and give the strategy for clinical practice. Methods From Jan. 2006 to Dec. 2018, 35 patients with periorbital IHs were enrolled into this study, including 13 males. The initial age of treatment ranged from 0.6 to 7 months. The clinical manifestations, imaging examination results, treatment measures and follow-up results were analyzed. Then diagnosis and treatment strategy were summarized. Results All patients were examined by ultrasound to confirm the depth of tumor, evaluate the effect of treatment and provide the evidence for drug withdrawal. For patients with deep hemangiomas, enhanced CT were added. Intralesional injection of glucocorticoids and oral propranolol were applied. All patients achieved good results. Ocular symptoms were avoided in most of the patients. Conclusion Periorbital IHs have special growth features and can be diagnosed by the appearance, ultrasound, CT scan, and propranolol experimental therapy if necessary. In consideration of potential complications, oral propranolol is the first treatment option for periorbital IHs.

Infantile hemangioma can grow dramatically or typically locate on the face, which may lead to functional impairment, cosmetically disfiguring and exhibiting complications such as ulceration, bleeding, or infection. Early intervention is necessary. In this study, the authors chose individual treatment for different patients. From January 2012 to December 2016, 185 patients with hemangioma were enrolled into this study. Lesion area ranged from 0.5 cm × 0.5 cm to 9 cm × 12 cm. The initial treatment age ranged from 1 to 7 months with an average age of 3.9 months. Thirty-five children achieved the treatment of Intralesional Compound Betamethasone, 134 children achieved the treatment of oral propranolol, and 16 children achieved the treatment of topical carteolol. In the follow-up, the treatment could be repeated or switched to oral propranolol if the tumor tended to grow again. At the end of follow-up, 89% of the patients' tumors shrinked or involuted completely, 5 patients switched to oral propranolol. The adverse effects included soft tissue atrophy, moon face, diarrhea, heart rate reduction, and liver enzyme abnormalities. All of the patients recovered in a short period. Early treatment for hemangioma can achieve good results and avoid functional impairment. For different patients, the authors suggest individualized treatment according to the tumors' size and location.

// Si-Ming Yuan 1, * , Yao Guo 1, * , Qian Wang 1 , Yuan Xu 1 , Min Wang 1 , Hai-Ni Chen 2 and Wei-Min Shen 2 1 Department of Plastic Surgery and Vascular Biology Lab, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, China 2 Department of Plastic Surgery, Children’s Hospital, Nanjing, Jiangsu 210008, China * These authors have contributed equally to this work Correspondence to: Si-Ming Yuan, email: yuansm@163.com Keywords: infantile hemangioma; involution; mesenchymal stem cell; PPAR-γ; adipogenesis Received: August 08, 2017 Accepted: December 05, 2017 Published: December 26, 2017 ABSTRACT Background: Most of infantile hemangiomas involute into fibrofatty tissue in childhood, which indicates adipogenesis during this period. Mesenchymal stem cells (MSCs) contribute to the adipogenesis in IH. In this study, we investigated the effects of overexpression of PPAR-γ2 gene on the adipogenic differentiation of Hemangioma-derived MSCs (Hem-MSCs), and discussed the possibility of targeted therapy via PPAR-γ pathway. Methods: MSCs were isolated from proliferating hemangioma by their selective adhesion to plastic culture dishes. Recombinant lentivirus with PPAR-γ2 gene were prepared, and used to transfect Hem-MSCs. Transfected cells were cultured in adipogenic medium to observe the differentiation in vitro . And the cells were mixed with Matrigel, then subcutaneously injected into the back of nude mice to observe the differentiation in vivo . Results: In the in vitro tests, Hem-MSCs with overexpression of PPAR-γ2 gene showed enhanced adipogenic differentiation with increased expression of adipogenic-related genes, including PPAR-γ2, ADD1, LPL, and CEBPA genes. In the in vivo tests, Hem-MSCs/Matrigel plugs with overexpression of PPAR-γ2 gene also showed accelerated adipogenesis and time-phased changes of above genes. Conclusions: Overexpression of PPAR-γ2 gene enhances and accelerates the adipogenic differentiation of Hem-MSCs in vitro and in vivo . The results may provide the preliminary evidences for the targeted therapy of IH via PPAR-γ signal pathway.

Purpose This time series experiments aimed to investigate the dynamic change of gut microbiomes after severe burn and its association with enteral nutrition (EN). Materials and methods Seven severely burned patients who suffered from a severe metal dust explosion injury were recruited in this study. The dynamic changes of gut microbiome of fecal samples at six time points (1–3 days, 2, 3, 4, 5 and 6 weeks after severe burn) were detected using 16S ribosomal RNA pyrosequencing technology. Results Following the post-burn temporal order, gut microbiota dysbiosis was detected in the gut microbiome after severe burn, then it was gradually resolved. The bio-diversity of gut bacteria was initially decreased, and then returned to normal level. In addition, at the early stage (from 2 to 4 weeks), the majority of those patients' gut microbiome were opportunistic pathogen genus, Enterococcus and Escherichia; while at the end of this study, the majority was a beneficial genus, Bacteroides. EN can promote the recovery of gut microbiota, especially in EN well-tolerated patients. Conclusions Severe burn injury can cause a dramatic dysbiosis of gut microbiota. A trend of enriched beneficial bacteria and diminished opportunistic pathogen bacteria may serve as prognosis microbiome biomarkers of severe burn patients.

Objectives Intermuscular venous malformations are common vascular malformation, do not have typical symptoms, and are difficult to diagnose. This article is a retrospective analysis of the diagnostic and therapeutic measures of intermuscular venous malformations. Methods From January 2013 to June 2018, 21 patients were included in this study. The clinical presentations, managements, and follow-up results were retrospectively analyzed. The indications and potential risks of different treatments were summarized. Results The complaints of patients with intermuscular venous malformations included local pain, swelling, discomfort, or aggravation after activity. Ultrasound, phlebography, magnetic resonance imaging, percutaneous sinus angiography, and three-dimensional computed tomography imaging were performed. The patients received surgical excision, sclerotherapy, or the combinational therapy of intralesional copper wires retention and ethanol injection and were followed for six months to five years. All patients’ symptoms were relieved largely. The lesions evaluated by magnetic resonance imaging decreased apparently or disappeared. Conclusions Imaging examinations are necessary in the diagnosis of intermuscular venous malformations and can guide the choice of treatment. Individualized treatment for intermuscular venous malformations should be made to achieve good effect and avoid adverse effects.

Soft tissue reconstruction of the distal lower leg and foot sole is a challenge for surgeons. In this article, we describe our experience and outcomes with distal lower leg and foot sole reconstruction using the medial plantar flap. From January 2007 to December 2017, 29 consecutive patients from our department underwent reconstruction of soft tissue defects over the distal lower leg, heel and plantar forefoot using medial plantar flaps. Of the 29 patients, the defects were located in the distal lower leg (

BACKGROUND AND OBJECTIVES Large scars formed after burns injury can seriously hamper appearance and function in children. Surgical resection of scars and secondary skin or flap grafting often brings severe damages to donor sites, which may lead to physiological and psychological development disorders in children. Here, we introduce the use of artificial dermis and skin grafts from scalps to treat large scars in children to minimize the donor site morbidity. METHODS A retrospective char review was performed including 7 children with large scars between January 2016 and December 2017. First, the scars were resected, and artificial dermis was applied to the secondary wounds. Twelve days later, outer silicone membrane was removed. Another 2 days later, scalp skin grafts of 0.3 mm were transplanted to the wounds. Manchester Scar Scale and Visual Analog Scale were used to evaluate scar appearance before and after the treatment respectively. One special patient with extensive scars was treated twice at an interval of 1 year. The first therapy was performed with both conventional method of resection and skin grafting and the new method described above. In the second therapy, 4 samples were taken from 4 different sites-the normal skin, scars, the skin where artificial dermis and scalp skin grafting were performed, and the skin where only scalp skin grafting was performed. H-E staining, Masson staining, Aldehyde fuchsin staining, and scanning electron microscopy were used for histological observation. RESULTS All skin grafts survived well. The Manchester Scar Scale score of the graft area was significantly reduced (P

Cutaneous melanoma is a highly malignant skin tumor, and in China, the planta pedis is a commonly involved site. The sites of plantar melanomas are a challenge to reconstruct after wide excision. Our experience with surgical management of melanomas was based on the 4 different anatomic subunits of the planta pedis. From January 1, 2002 to December 31, 2016, 35 patients who had had plantar melanoma had undergone surgical treatment in our clinic. The tumor locations were as follows: the toe in 6, the ball of the foot in 5, the arch in 15, and the heel in 9. Surgical management involved extended resection of the tumor, repair of defects with skin grafts or flaps, and inguinal lymphadenectomy. The skin flaps included a residual toe flap, an anterograde or retrograde medial plantar flap, and a retrograde sural neurocutaneous vascular flap. Of the 35 cases of flaps and skin grafts, 33 (94.29%) survived, and the wounds had healed by first intention. After a follow-up period of 6 months to 7 years, 24 patients (68.57%) were free of local and systemic disease and 30 patients (85.71%) were ambulatory using shoes, and all the flaps and skin grafts showed a good appearance. The personalized surgical treatments we used for melanoma in the planta pedis resulted in overall satisfactory outcomes and adequate disease clearance, and allowed the patients to resume normal lives. The function of the foot was maintained or restored to the greatest possible degree, and the patients' quality of life improved postoperatively.

Objective: Severe trauma to the hand or forearm often results in the deep soft tissue defect with the exposure of tendon or bone, which needs to be repaired by skin flaps. In this study, we introduced the use of paraumbilical perforator flap in the repair of such defects, and discussed its advantages and disadvantages. Methods: From Jan. 2006 to Dec. 2016, 14 patients with deep soft tissue defects in the hand and forearm were admitted into our clinic. The defects were caused by hot-crush injury (n=2), electrical injury (n=4), severe burn (n=2), crush injury (n=3), and avulsion injury (n=3). After admission, the patients underwent the debridement, vacuum suction, and skin graft to repair partial wound. The deep defects with the exposure of tendon and bone were repaired by paraumbilical perforator flap finally. Methods: From Jan. 2006 to Dec. 2016, 14 patients with deep soft tissue defects in the hand and forearm were admitted into our clinic. The defects were caused by hot-crush injury (n=2), electrical injury (n=4), severe burn (n=2), crush injury (n=3), and avulsion injury (n=3). After admission, the patients underwent the debridement, vacuum suction, and skin graft to repair partial wound. The deep defects with the exposure of tendon and bone were repaired by paraumbilical perforator flap finally. Conclusions: The paraumbilical perforator flap has reliable blood supply, good texture, sufficient area, and is convenient to transfer. It's an ideal choice for the repair of the deep soft tissue defect in the hand and forearm.

Objective Venous malformation (VM) is a common vascular malformation in soft tissue. Its morphological and draining features, relationship with main vein, and hemodynamics in the lesion are not completely clear till now. Above information is important for choice of treatment. Methods From January 2012 to December 2013, 23 patients were enrolled into this study. Percutaneous puncture into the lesion was made and contrast media was injected into venous sinus. Immediately after that CT scan was performed, and repeated several minutes later. Then three-dimensional imaging was performed to show the morphology and draining veins of VMs, and the relevant main veins. The hemodynamics in the lesion was also evaluated. Results All patients underwent successful examination. Three-dimensional imaging showed an irregular shape of VM. Based on the draining features, VMs were classified into three types: (1) Type I (7/23): malformation without visible draining vein; (2) Type II (10/23): malformation with normal draining vein; (3) Type III (6/23): malformation with abnormal dilated draining vein. The flow in type I VMs was slow. Contrast media retained in the lesion for more than 1 day. The flow in type III VMs was fast. Contrast media flowed away rapidly. The flow of type II VMs was between type I and type III. According to above information and adjacent anatomy, all patients received suitable treatment, including sclerotherapy with absolute ethanol and bleomycin A5, intralesional copper wires retention, surgical removal, and combinational therapy of the above methods. Conclusions This procedure can clearly show the morphological and draining features of VM and its relationship with main vein, and further evaluate the hemodynamics in the lesion, which are helpful for the choice of treatment.

Objectives Neurofibroma, a common benign tumor in soft tissue, continues to grow, so it often appears to be giant. Surgical management of giant neurofibroma is a challenge due to the risk of excessive bleeding. Embolization of tumor's nutrient artery may reduce the blood loss in operation. This study introduces the surgical management of giant scalp neurofibroma with preoperative ultra-selective embolization of nutrient artery. Methods From January 2006 to December 2013, 9 patients with giant scalp neurofibroma were enrolled into the study. Digital subtraction angiography (DSA) showed tumor's nutrient artery. Ultra-catheter was inserted into the nutrient artery and its branches as close as possible to the tumor. Then ultra-selective embolization was performed with gelatin sponge particles. Surgical removal of tumor was performed in 3 days after embolization. The wound was repaired by skin graft. Results All of the 9 patients underwent successful DSA and ultra-selective embolization. Among them, occipital artery was embolized in 3 patients (left side in 1 patient and right side in 2 patients). Both occipital artery and superficial temporal artery were embolized in 6 patients (left side in 2 patients, right side in 3 patients, and both side in 1 patient). No complications, such as ectopic embolism, occurred in the patients. All of the tumors were resected completely without blood transfusion. The skin graft survived very well on the wounds. Conclusions Preoperative ultra-selective embolization of nutrient artery is a feasible, safe, and effective method to reduce the blood loss in operation and facilitate the surgical management of giant scalp neurofibroma.

Kaposiform hemangioendothelioma (KHE), a borderline tumor of endothelial origin, is associated with Kasabach-Merritt phenomenon, characterized by profound thrombocytopenia and consumptive coagulopathy resulting from the localized intravascular coagulation (LIC) in the tumor. Previous studies have suggested that the trapping of blood components, including platelets, may underlie the LIC in KHE. However, more evidence is needed to support this hypothesis. In this study, one case of a Chinese infant with a KHE in the left arm was complicated by Kasabach-Merritt phenomenon. The tumor was partially resected and the sample was used for ultrastructural observation and immunohistochemistry staining of Glut-1. Ultrastructural observation found the trapping of erythrocytes, platelets, macrophages, and lymphocytes in the slit-like channels of the tumor nodules, and phagocytic vesicles in the cytoplasm of neoplastic cells. Immunohistochemistry staining further showed numerous Glut-1(+) erythrocytes in the channels. In conclusion, our results provided compelling morphological evidence of the trapping of blood components in KHE, which may interpret the LIC in the tumor and subsequent consumptive coagulopathy.

Objectives: Complex venous malformations (VMs) may extensively involve the soft tissue. The treatment remains a challenge till now. Here we introduce a combinational therapy of copper wires and pingyangmycin (bleomycin A5, PYM). Methods: Copper wires were retained in VMs by repeated penetration with a straight needle. Subsequently, PYM solution was injected into the lesion. Eight to 10 days later, copper wires were removed. The dressing was changed every day until the puncture pores healed. Magnetic resonance imaging scanning was performed to observe the change of VMs. Results: From January 2001 to December 2011,56 patients were treated. During the follow-up period, most of the VMs shrunk obviously. The symptoms were relieved or disappeared. The complications included local pain, temporary paraesthesia and moderate fever, which disappeared quickly after the removal of copper wires. Conclusions: This combinational therapy is a safe and effective approach for the complex VMs in soft tissue.

Background Venous malformation (VM) is a common vascular malformation in soft tissue. Surgical management plays an important role in its treatment. The location, extent, and adjacent anatomy of the lesion are crucial information for the safety of operation. This study introduces the application of magnetic resonance imaging and percutaneous sinus angiography/three-dimensional computed tomography imaging in gathering above information. Methods A retrospective analysis was made in the patients with venous malformation from January 2012 to June 2014 in our clinic. All patients underwent magnetic resonance imaging and percutaneous sinus angiography/three-dimensional computed tomography imaging. The location, extent of the lesion, its draining veins, and the relationship with around tissues were showed. Surgical management was carried out in the lesions which were well defined, located in the superficial fascia without important vessels and nerves across it. The wound was repaired by skin flap or skin graft. Results A total of 13 patients underwent complete surgical removal of the lesions, including five type I venous malformations and eight type II venous malformations. Ten lesions were removed by undermining dissection, and the wound was repaired by the undermined flap. Three superficial lesions were removed together with the skin over it, and the wound was repaired by the skin graft. In the six months to two years of follow-up period, none of the recurrence of the lesion was observed. Conclusion Magnetic resonance imaging and percutaneous sinus angiography/three-dimensional computed tomography imaging can display abundant morphological details of venous malformation, which are helpful for the surgical management.

Kasabach-Merritt phenomenon (KMP) is life-threatening, charactered by the profound thrombocytopenia and consumptive coagulopathy associated with vascular tumors. The therapy of KMP still remains challenging. In this study, we retrospectively analyzed the clinical data of KMP treated in Nanjing Children’s Hospital and Jinling Hospital, China, and brief reviewed the literature on KMP. From Jan. 2005 to Dec. 2014, a total of 19 cases of KMP were enrolled into this study. Laboratory results showed that seven patients had typical disseminated intravascular coagulation (DIC), and others were atypical DIC. CT scanning showed the low-density tumor with obvious intensification in enhanced scanning, and the large distorted arteries in association with the tumor. After the admission, the patients received the infusion of platelets and the applying of dipyridamole, steroids, and other necessary drugs. Eight patients underwent complete surgical removal of the tumor, or partial removal with subsequent chemotherapy of vincristine. Three patients underwent only the chemotherapy of vincristine. Eight patients underwent the intralesional injection of absolute ethanol. Pathological examination showed eighteen samples were kaposiform hemangioendothelioma, and one tufted agioma. In our cases, six patients died from extensive hemorrhage and subsequent multiple organ failure. The others survived. In conclusion, KMP in Chinese children has typical symptoms. Kaposiform hemangioendothelioma is the most frequent vascular tumor associated with KMP. The individual treatments with surgical management, chemotherapy with vincristine, and intralesional injection of absolute ethanol can achieve good results in most of the patients with KMP.

To investigate the role of the expression of PPAR-gamma gene in the adipogenesis in hemangioma evolution.Routine immunohistochemistry staining of Perilipin A, the marker antigen of adipocytes, was performed to observe the adipogenesis in hemangioma. Immunofluorescence staining of PPAR-gamma, the important transcription factor in promoting adipogenesis, was carried out to observe its location in hemangioma tissue, with the co-staining of alpha-SMA and CD31. And RT-PCR was used to examine the expression of PPAR-gamma gene in hemangioma in different stages.In the evolution of hemangioma, the number of adipocytes increased continuously. And the tumor was replaced by fibrofatty tissue finally. PPAR-gamma was located in the nuclei of perivascular cell in hemangioma tissue. The expression of PPAR-gamma gene in hemangioma increased in the evolution of hemangioma, but still was lower than that in normal fat tissue from children.The expression of PPAR-gamma in the perivascular cells suggests that they may contribute to the adipogenesis in hemangioma involution.

Infantile hemangioma grows quickly in the first year of life and regresses slowly to fibrofatty tissue during childhood; mesenchymal stem cells (MSCs) have been reported to contribute to this adipogenesis. Recent studies have shown the perivascular origin of MSCs in multiple organs. We hypothesized that MSCs in hemangioma might also reside in the perivascular region. We isolated MSCs from proliferating hemangioma by their selective adhesion to plastic culture dishes. Mesenchymal stem cells from bone marrow (BM-MSCs) and foreskin-derived fibroblasts were used as controls. Flow cytometry and immunofluorescence staining were used to examine their antigen profiles; in vitro induction of multi-lineage differentiation was performed to test their pluripotency. Platelet-derived growth factor R-β (PDGFR-β), CD133, and peroxisome-proliferator-activated receptor gamma (PPAR-γ) were selected as the markers to observe MSCs in hemangioma by immunohistochemistry staining, with costaining of CD31 and alpha-smooth muscle actin (α-SMA). Hemangioma-derived MSCs (Hem-MSCs) had fibroblast-like morphology; they expressed the MSC markers CD105, CD90, CD29, and vimentin and did not express the hematopoietic/endothelial markers CD45, CD34, CD31, and flt-1; Hem-MSCs also expressed CD133 and PPAR-γ. Most Hem-MSCs expressed PDGFR-β and α-SMA; in contrast, the expression of PDGFR-β and α-SMA in BM-MSCs was very weak. The Hem-MSCs differentiated into adipocytes, osteoblasts, and chondroblasts in vitro. This confirmed their pluripotency. Immunohistochemistry showed the colocalization of PDGFR-β/α-SMA, CD133/α-SMA, and PPAR-γ/α-SMA in the perivascular region. MSCs were successfully obtained from proliferating hemangioma, revealing the perivascular origin of MSCs in hemangioma.

To evaluate the therapeutic effect of retained copper wires combined with pingyangmycin (PYM) injection for complicated cavernous venous malformation.The location of venous malformation was detected by physical examination and MRI. The copper wires in 0.2 mm width were used to puncture the lesion repeatedly and retained in the lesion to form a net. After that, 8 mg PYM was injected into the residue malformed veins. 8-10 days later, the copper wires were taken out and necrotic tissue was squeezed out. The wounds of punctual holes healed through dressing. The patients received postoperative MRI to evaluate the therapeutic effect.From Jan. 2002 to Dec. 2008, 45 cases were treated. The patients were followed up for 1-3 years. 51.1% (23/45) of the lesions shrinked markedly or even disappeared. 42.2% (19/45) of the lesions reduced. 6.67% (3/45) of the lesions didn't change. There was no complication like invasive infection.It is very effective to treat complicated cavernous venous malformation with retained copper wires combined with pingyangmycin injection.

To investigate the therapeutic effect of central wedge resection and asymmetric Z-plasty for minor labia reduction.Based on the Giraldo procedure, the incision was designed and the redudent tissue was resected quantitatively. The Z-plasty was modified to rectangle flap with deviated incision. The incisions at the two surface of minor labia were designed in an opposited direction. The two rectangle flaps were inserted to form the free edge of minor labia.11 cases of minor labia hypertrophy were treated with good results.The modified procedure is easily performed with precise design. It is suitable for all kinds of minor labia hypertrophy.

To investigate the distribution, phenotype and development of pericytes in infantile hemangioma.Fifty-two infantile hemangioma samples were included in our study. alpha-SMA was used as the marker antigen to observe the distribution of pericytes. Transmission electron microscope and TUNEL method were used to analyze the apoptosis of pericytes.In the early and middle proliferating stage, there existed many pericytes in hemangioma; Pericytes together with endothelial cells generated vasculogenesis. In the late proliferating stage, many pericytes became apoptotic. In the early involuting stage, there were only a few of pericytes around the microvessels; After that, the microvessels became obstruction progressively and pericytes disappeared finally.The pericyte is one of the major constitutive cells of hemangioma. The vasculogenesis, development and disappearance of microvessels undertaken by pericytes and endothelial cells lead to the pathologic evolution of infantile hemangioma.

To investigate the expression and role of glucose transporter-1 (Glut1) in infantile hemangioma.Fifty-two samples from infantile hemangioma, 25 in cavernous venous malformation, 9 in arteriovenous malformation, 2 in capillary malformation and 5 in normal skin samples were involved in this study. The EnVision immunohistochemical stain was used to investigate the expression of Glut1 protein in these samples.In the early proliferating stage, a number of endothelial cells expressed Glut1. In the middle proliferating stage, most of vascular endothelial cells and scattered endothelial cells expressed Glut1. In the late proliferating stage, the expression of Glut1 decreased quickly. In the involuting stage, all hemangioma samples didn't express Glut1. All of the samples from the cavernous venous malformations, arteriovenous malformations, capillary malformations and normal skin had no expression of Glut1.Glut1 may be one of the phenotypes of infantile hemangioma endothelial cells in their development, rather than the inherent character. The expression of Glut1 changes according to the metabolic need of infantile hemangioma cells.

To investigate the polymorphic distribution of short tandem repeat (STR) sequences D21S1433, D21S1442, D21S1444, D21S2051 in Guangdong Han nationality in China.Using quantitative fluorescens PCR technology, the authors analyzed 200 unrelated samples to acknowledge the allele frequency, heterozygosity and other genetic information.D21S1433, D21S1442, D21S1444, D21S2051 were tested in 200 samples, which were tested to be statistical according to Hardy-Weinberg equilibrium (P0.05), 9, 10, 9 and 5 alleles were detected separately in each STRs. The heterozygosity of each STR was 0.818, 0.820, 0.770, and 0.261. The polymorphic information content0.7 in D21S1433, D21S1442, D21S1444, while D21S2051 owned only 0.247 polymorphic information.D21S1433, D21S1442, D21S1444 are found to have high heterozygosity and polymorphic information content, and they could provide useful markers for genetic purposes, while D21S2051 is not informative in Guangdong Han nationality in China.

To investigate the expression of Fas/FasL in infantile hemangiomas and discuss the role of Fas/FasL in the pathologic evolution of infantile hemangioma.The EnVision immunohistochemical stain and RT-PCR technique was used to examine the expression of Fas/FasL protein and mRNA in the infantile hemangiomas.(1) In the early and middle proliferating stage, a number of infantile hemangioma cells expressed Fas. In the late proliferating stage, the number of positive cells increased obviously and the expression of Fas mRNA was reaching the strongest level. In the early regressing stage the Fas still existed in some cells and after that the expression decreased quickly. (2) Up to the middle proliferating stage, there were a few of FasL(+) cells foound. In the late proliferating stage, the number of FasL(+) cells increased significantly. From the early regressing stage, the number of FasL(+) cells decreased rapidly and disappeared.There may exist significant correlation between the expression of Fas/FasL and the development of the infantile hemangioma cells. The apoptosis of the infantile hemangioma cells mediated by Fas/ FasL may be the major reason of the spontaneous involution of infantile hemangioma.

To investigate the clinical pathology of cavernous venous malformations of the body surface.Tissue samples of cavernous venous malformations from 42 cases were stained with hematoxylin and eosin to observe the pathologic structure. The clinical manifestations and case history were summarized accordingly.There was no distribution difference of the malformation in sex and body sides, but with obvious difference in anatomic sites. The malformation occurred most frequently at the head and neck, more frequently at extremities and least frequently at the trunk. According to pathologic structure, cavernous venous malformations of the body surface can be divided into three types: the cellular, the canaliform and the mixed.The cause of distribution difference in anatomic sites remains unclear. Internal hemorrhage and infection may account for the increased growth and ache of the lesion. The different pathologic structure of the malformation may cause different clinical manifestations.

To investigate the role of releasing the fibrous bundles across the levator muscle between the medial canthus and lateral canthsus near the top of tarsus in the correction of the congenital blepharoptosis.Twenty-seven patients with 40 eyes of blepharoptosis were undergoing the treatment. It was performed by releasing the fibrous bundles across the levator muscle between the medial canthus and lateral canthsus near the top of tarsus to correct the mild and moderate blepharoptosis. A further procedure can also be added to by folding the levator aponeurosis if necessary. In the severe blepharoptosis, the frontalis aponeurose flap may be applied for the suspension as well during the operation.Of the 40 eyes in 27 cases with mild, moderate and severe blepharoptosis were treated by using this method, with 38 eyes corrected satisfactorily and 2 eyes corrected mostly in the following-ups from 3 months to 1 year.The above mentioned technique may be a good, simple and effect method to corret congenital blepharoptosis.

To study the expression and significance of structural proteins, VEGF and Ang-1 in cavernous venous malformations of the body surface.Tissue samples came from 25 cases of cavernous venous malformations, 12 cases of normal moderate veins and 12 cases of normal small veins. Envision immunohistochemical stain was used to investigate the expression of IV collagen, fibronectin, laminin, VEGF and Ang-1. The results were analyzed semi-quantitatively.The distribution of structural proteins in cavernous venous malformations is similar to moderate and small veins, but the expression in venous malformations is less obviously. VEGF expression in cavernous venous malformations and small veins is stronger obviously than moderate veins. Ang-1 expression in small veins is stronger remarkably than cavernous venous malformations and moderate veins.The abnormal expression of structural proteins may be an important factor in etiopathology and progress of cavernous venous malformations. There is disturbance of blood vessel remodelling in the sinusoid of cavernous venous malformations, with which the less expression of Ang-1 may be related.