Objective To detect the msr gene which confers resistance to erythromycin, and ana-lyze its distributing difference between the two biovars of Ureaplasma urealyticum. Methods Broth dilution method was used to determine the minimum inhibitory concentrations (MIC) to erythromycin among 72 U. urealyticum clinical isolates. The msrA, msrB, msrC and msrD genes detection and biotyping of U. urea-lyticum were conducted using PCR. Results The MICs of 72 U. urealyticum isolates to erythromycin ranged from ≤0. 125 μg/ml to ≥128 μg/ml. MIC_(50) was 32 μg/ml and MIC_(50) was ≥128 μg/ml. Biotyping showed that biovar Parvo had 51 strains (51/72, 70.83%) and biovar T960 had 21 (21/72, 29.17%) strains.The msrA, msrB, msrC and msrD genes were obtained in 1, 12, 0 and 24 strains, respectively, with five strains carrying the msrB and msrD genes, and one strain carrying the msrA, msrB and msrD genes. There was no resistance difference to erythromycin between the two biovars when the MIC≥8 μg/ml was considered resistance to eryt hromycin. But the msrB gene was predominantly detected in biovar T960. Conclusion U. urealyticum clinical isolates harbeur the msrA, msrB and msrD genes, and the predominantly detected msrB gene is of biovar T960.

Objective To study the relationship between erythromyein sensitivity and ermB gene in 143 Ureaplasma urealyticum (Uu) clinical isolates. Methods We detected the minimum inhabit concen-trations (MICs) of Uu to erythromycin by broth dilution method and MIC≥8 μg/ml was used as standard concentration of resistance to erythromycin. Polymerase chain reaction was used to detect the ermB gene and biotype Uu with primers based on multi-band antigen gene. Results The MICs, MIC50 MIC90 of Uu to erythromycin were ≤0. 125 μg/ml to ≥128 μg/ml, 16 μg/ml, and ≥128 μg/ml, respectively, with a high resistance rate of 64.38%. ermB gene, which was mainly detected in Uu with MIC≥8 μg/ml, was positively detected in 40 out of 143 Uu strains (27.97%). No significant differences of the resistance to erythromycin and positive rate of ermB gene were found between the two biovars in the study . Conclusion ermB gene may probably be one of the important genes conferring resistance to erythromycin in Uu. Further studies are needed to discover the difference of resistance and mechanism of erythromycin between the two bi-ovars.

Objective To study the resistance mechanism of Ureaplasma urealyticum (Uu) to erythromycin.Methods The susceptibility of 73 clinical isolates of Uu to erythromycin was evaluated by using broth dilution techniques. PCR and DNA sequencing were carried out to screen hot spot mutations at the variable region of 23S ribosomal RNA in erythromycin-resistant strains of Uu. Moreover, erythromycin resistance methylase genes (ermA, ermB, ermC) and efflux pump genes (mefA/E, msrA/B, mreA) were screened by using PCR with specific primers. Results There were 35 (47.95%) resistant Uu strains out of the 73 isolates, and the minimal inhibitory concentration varied from 8 to 32 mg/L among these resistant strains. The ermB gene was detected in 19 (54.29%) resistant strains, and msrA/B gene in 9 (25.71%) resistant strains. Two resistant strains harbored both ermB gene and msrA/B gene. No mutation at 23S ribosomal RNA or amplification of resistance-associated genes was noted in sensitive or reference strains of Uu. Conclusion The ermB and msrA/B genes may be responsible for the erythromycin resistance of Uu.

Objective: To investigate the feasibility and technical tips of repairing facial defects with pre-expanded propeller flap based on the perforators of the supratrochlear artery or the supraorbital artery. Methods: In the first-stage operation, a tissue expander was buried underneath the frontalis muscle. The second-stage operation was conducted using pre-expanded supratrochlear artery or the supraorbital artery based propeller flap to repair facial defect. Results: From July 2010 to July 2016, this method was used in 8 patients. 5 flaps were based on the supratrochlear artery, and 3 flaps based on the supraorbital artery. Expander size was ranged from 150 ml to 300 ml. The size of propeller flaps was from 10 cm × 6 cm to 15 cm × 13 cm. All the flaps survived without any major complications. Follow-up period ranged from 3 to 36 months. Eyebrow replacement, flap thinning and scar revision were performed in 6 cases. All patients were satisfied with the final aesthetic result. Conclusions The pre-expanded propeller flap based on the supratrochlear artery or the supraorbital artery is an alternative option to repair the facial defect in appropriate cases.

Objective: To explore the feasibility and technical tips of defect reconstruction using the pre-expanded perforator propeller (PEPP) flap. Methods: From July 2009 to December 2017, 56 patients underwent defect reconstruction using the PEPP flap. During the first-stage operation, an expander with appropriate size was buried within a soft-tissue pocket. Three strategies were used for expander placement, including placement of the expander underneath the muscle, at a distance from the emergence point of the perforator when the perforator location is relatively fixed, and following the criteria when a free-style perforator flap is designed. At the second-stage operation, a PEPP flap was raised and rotated a certain number of degrees to reconstruct the defect. Results: 56 flaps were elevated. The expanders were buried according to the strategy Ⅰ in 2 cases, the strategy Ⅱ in 42 cases, and the strategy Ⅲ in 12 cases. The flap size ranged from 7-13 cm to 14-32 cm with the average size of 9.38 cm × 21.22 cm. The pedicle length ranged from 2.5 cm to 10 cm and the mean length was 5.03 cm. The rotation angle was 180 degrees in 44 cases, 150 and 120 degrees in 6 cases respectively. The perforators that were previously explored were all identified during the second-stage operation. 53 flaps survived completely. Venous congestion of the distal portion of the flap was observed after the surgery in two cases. Necrosis of small area of the flap occurred and free skin grafting was used to resurface the defect after debridement. All patients were followed up for 3 months to 4 years and the average follow-up time was 13.4 months. Conclusions The PEPP flap can not only ensure primary closure of the donor site, but also provide more extra tissue for defect reconstruction. For selected patients, it could be an alternative option for soft-tissue defect reconstruction.

Objective: To propose a classification method and explore the indications and technical tips of the pedicled deep inferior epigastric artery perforator (DIEAP) flap. Methods: From July 2005 to December 2017, 18 patients underwent soft-tissue defect repairment using the pedicled DIEAP flap. The defect locations included abdomen (n=6), iliolumbar region (n=2), perineum (n=4), and proximal thigh (n=6). The flaps were divided into two types. The type Ⅰ flap were further subdivided into two subtypes. The type Ⅰa flap was solely based on the DIEAP. The type Ⅰb flap was also based on the DIEAP, however, the main trunk of the deep inferior epigastric vessels needs to be divided to further improve the pedicle length. The type Ⅱ flap was the traditional pedicled DIEAP flap. Results: Twenty flaps were included in this series. The mean flap size and pedicle length of the 4 flaps in type Ⅰa were 19.0 cm× 6.5 cm and 2.88 cm respectively. The rotation angles were 60 degrees (n=1), 120 degrees (n=1), and 180 degrees (n=2). The 3 flaps of type Ⅰb was 26 cm × 6 cm, 20 cm × 5 cm and 24 cm × 7 cm in size, and the pedicle lengths of them were 6 cm, 7 cm and 7 cm, respectively. All flaps in this subtype were rotated by 180 degrees. The mean flap size and pedicle length of the 13 type Ⅱ flaps were 21.46 cm × 9.38 cm and 11.08 cm. 17 flaps completely survived postoperatively. Small-sized necrosis of the distal portion of the flap occurred in 3 flaps. All patients were followed up for 6 months to 5 years, with the averaged 11 months follow-up time. All patients were satisfied with the final outcomes. Tumor recurrence was not noticed for the oncological patients. Conclusions The pedicled DIEAP flap has remarkable versatility in the defect repairment for the regions including abdomen, iliolumbar region, proximal thigh, and perineal region. Combining with the " propeller flap" concept, the clinical application of pedicled DIEAP flap could be further expanded. The pedicled DIEAP flap is a reliable reconstructive method for defect repairment in abdominal and iliolumbar regions.

Objective: To explore the clinical effects of scapular region flaps pedicled with circumflex scapular artery in the reconstruction of axillary burn scar contractures. Methods: From December 2008 to December 2018, 21 patients with axillary burn scar contractures were admitted to our department. There were 12 male patients and 9 female patients, aged 2-48 years, with an average of 17.4 years. According to the characteristics of axillary scar contractures, the patients were divided into type Ⅰ of 5 patients, type Ⅱ of 2 patients, type Ⅲ of 5 patients, and type Ⅳ of 9 patients. The preoperative abduction ranges of shoulder joint were 20-150°, with an average of 68.33°. The wound areas after resection and release of scar contractures ranged from 12 cm×4 cm to 33 cm×11 cm, with an average of 18.13 cm×5.41 cm, and the wounds were repaired with scapular region flaps pedicled with circumflex scapular artery in the areas of 14 cm×5 cm-35 cm×14 cm, with an average of 20.19 cm×7.71 cm. The donor sites of 5 patients were expanded prior to flap repair operation, and the other 16 patients were repaired by direct transfer of flaps. The donor sites were closed directly. The type, number, and transfer way of scapular region flaps were calculated, and the improvement of abduction angle of shoulder joint and condition of the flaps were observed during follow-up after operation. Results: There were 5 ascending scapular flaps, 13 scapular flaps, and 3 parascapular flaps. The flaps were transferred through open wounds in 18 cases, subcutaneous tunnel in 1 case, and trilateral foramia in the remaining 2 cases. All the flaps survived after operation. During follow-up of 3 months to 5 years, with an average of 19.4 months, the abduction angles of shoulder joints were 90-180°, with an average of 137.62°, which showed that the abduction function of shoulder joint improved obviously. The texture of flap was soft, and the color of the flap was close to the surrounding skin. The patients and/or their family members were satisfied with the operation results. Conclusions The scapular region flap pedicled with circumflex scapular artery has a lot of advantages, including a long vascular pedicle, simple technique for flap harvest, a hidden donor site, and flexible and diverse transfer mode of flap. It is an effective option for clinical reconstruction of severe axillary burn scar contracture.

Objective: To explore the feasibility and technical points of soft tissue defect reconstruction using the pedicled anterolateral thigh flap based on perforating vessels from the lateral circumflex femoral artery oblique branch. Methods: Between November 2009 and April 2019, 27 pedicled anterolateral thigh flaps were performed to repair the wound of trunk and lower extremity, based on perforating vessels from the lateral circumflex femoral artery oblique branch. 16 flaps were proximally based and 11 were distally based. Results: The proximally based flap ranged from 15 cm×8 cm to 32 cm×12 cm. The mean length of the pedicle was 8.2 cm. The distally based flap ranged from 9 cm×7 cm to 24 cm×8 cm. The mean length of the pedicle was 18.6 cm. All flaps survived after surgery. Venous congestion occurred in one flap and relieved in five days. Conclusions With oblique branch as the pedicle, the vascular dissection was easy and donor site morbidity was minimized while harvesting the proximally based anterolateral thigh flaps; long pedicle could be obtained, and the reconstructive sphere was extended when using the distally based anterolateral thigh flaps.

A large number of innovative and new technologies and method in the field of perforator flap were proposed with the hard work of many experts and surgeons. This paper briefly reviewed the following items including the discovery of the perforator flap and its enlightenment to us, three-dimensional visualized anatomy, angiosome and perforasome theories, pre-operative perforator detection techniques, techniques for evaluation of the flap vascular perfusion, the concept of freestyle perforator flap, chimeric flap, flow-through flap technique, new designs of pedicle perforator flap, particularly the propeller and keystone flaps, supramicrosurgery, superthin flap, microdissected thin perforator flap, and microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. These new technologies and method have greatly improved our understanding of flap surgery and promote the development of the reconstructive surgery. The traditional research focused on investigating the anatomic features of a single flap and strategies for the reconstruction of different defects and organs. Nowadays, the treatment scope of reconstructive surgery is more extensive and has developed to repair various refractory wounds following trauma and oncological resection, nerve injuries, and to reconstruct defect and organ by using the vascularized composite allotransplantation. Researches on the upper limb lymphedema after breast cancer surgery have been highly valued recently. It can be expected that the direction of reconstructive surgery would be transformed from the improvement of theraputic modalities to concentrating on the treatment of diseases, and this undoubtedly conforms to the essence of medicine. The research of perforator flaps will be directed to more precise, minimally invasive, and individualized according to the requirements of evidence-based medicine.

Objective: To explore the flap design and clinical applications of the propeller flaps based on perforators from different branches of the lateral circumflex femoral artery in defect reconstruction. Methods: Between September 2009 and December 2018, 27 patients with soft tissue defects from lower extremities were involved in this study, including 15 males and 12 females, with an average age of 34.6 years old (range, 3 to 73 years old). Before surgery, the type of the flap to be used was designed preliminarily by evaluating the location, size and shape of the lesion or defect. The perforators of the lateral circumflex femoral artery were explored using an ultrasound Doppler probe, marked on skin. The computed tomographic angiography was also used to get more information of the branches of the lateral circumflex femoral artery when possible. The propeller flaps were divided into typeⅠ, Ⅱ, Ⅲ, and Ⅳ according to the perforators that originated from the transverse, descending, oblique, and rectus femoris branches of the lateral circumflex femoral artery, respectively. The type Ⅱ flap was subdivided into type Ⅱa and type Ⅱb flaps that were based on antegrade and reverse flow from the descending branch. The defects were reconstructed using the perforator propeller flap. Results: Twenty-seven patients underwent reconstruction of defects using the propeller flaps based on perforators from different branches of the lateral circumflex femoral artery including 3 type Ⅰ flap, 12 type Ⅱa, 2 type Ⅱb, 10 type Ⅲ and 3 type Ⅳ. The size, pedicle length and rotation angle of the flaps were 12 cm×6 cm to 30 cm×15 cm, 4 cm to 15 cm, and 60 to 180 degrees, respectively. Total necrosis occurred in one flap and small-sized distal necrosis in another one. Minor complications occurred in two flaps and the remaining propeller flaps survived completely. All patients were followed up from one to 25 months and mean follow-up time was 9.9 months. Tumor recurrence was noticed in one patient. All patients were satisfied with the final functional and aesthetic outcomes. Conclusions For appropriate cases, reconstruction of defects from the groin to the knee could be achieved by using the propeller flaps based on perforators from different branches of the lateral circumflex femoral artery, with advantages of easy-to-operate and minor donor-site morbidity.