BACKGROUND:A Divided eyelid nevus is a rare congenital condition that poses complex reconstructive challenges. This study reports our experience with single split-flaps for medium and large-sized lesions, complemented by a systematic review of flap-based techniques. METHODS:We retrospectively analyzed 26 patients treated between 2005 and 2024. Eleven patients with broad foreheads underwent reconstruction using superficial temporal artery frontal branch (STA-Fbr)-based flaps, and fifteen underwent reconstruction using distally based brachial artery perforator (dBAP) flaps. Intraoperative indocyanine green angiography (ICGA) was used for vessel mapping, flap splitting, and perfusion assessment. Depending on medial canthus involvement, the flaps were split distally in a fish-mouth or window pattern to enable simultaneous reconstruction of both eyelids. A systematic review was conducted on August 12, 2024, across four major databases. RESULTS:Six medium and five large lesions were reconstructed using STA-Fbr-based flaps, whereas six medium and nine large lesions were reconstructed using dBAP flaps. The mean tissue expansion periods were 5 and 6 months, respectively. ICGA accurately guided flap splitting and confirmed adequate perfusion. All STA-Fbr-based and 12 dBAP flaps were split in a fish-mouth pattern, while the remaining dBAP flaps were split in a window pattern. All flaps survived without venous congestion or necrosis. The systematic review identified 27 studies supporting the reliability of pre-expanded forehead and medial arm flaps for large lesions. CONCLUSIONS:The single split-flap technique using pre-expanded STA-Fbr-based or dBAP flaps under ICGA guidance is a reliable approach for the simultaneous reconstruction of both eyelids in medium and large lesions, achieving favorable functional and aesthetic outcomes.

Impaired wound healing and pathological scarring remain major clinical challenges, with immune cell dysregulation being a key driver of disease progression. Conventional in vitro models fail to recapitulate human immune responses, limiting their translational relevance. In recent years, advances in tissue engineering and microfluidic technologies have driven growing efforts to incorporate immune cells into in vitro models, thereby improving their ability to mimic pathological microenvironments. Among these, organ-on-a-chip technology stands out for its capacity to replicate dynamic perfusion, mechanical stimulation, and multicellular crosstalk-features critical for modeling immune-mediated wound repair. This review systematically summarizes recent progress in immune cell-integrated models of aberrant wound healing, including two-dimensional co-cultures, three-dimensional static cultures, organoid systems, and organ-on-a-chip platforms. We highlight core strategies for immune cell integration and their roles in recapitulating key pathological processes such as inflammation and fibrosis. Despite ongoing challenges in cell source stability, model standardization, and long-term culture viability, emerging strategies (e.g., organ-on-a-chip combined with three-dimensional bioprinting or modular design) offer new opportunities for creating biomimetic, high-throughput platforms for wound research. This review aims to facilitate the adoption of immune-integrated in vitro models in wound healing research, deepen mechanistic understanding of immune-driven pathology, and accelerate the development of precision therapeutics.

The retention rate after autologous fat grafting is unpredictable and often suboptimal. Tranexamic acid (TXA) is widely used for its hemostatic effects and its ability to attenuate edema and inflammation. However, the effects of TXA on fat graft outcome remain unclear. In this study, TXA-treated fat grafts were transplanted into C57BL/6 mice to evaluate the effects of TXA on graft retention and quality. A total of 24 mice were included. Inguinal fat pads were harvested and pretreated with different concentrations of TXA (0 mg/mL [phosphate-buffered saline control], 4 mg/mL, 10 mg/mL, and 50 mg/mL) before subcutaneous transplantation into the same mice. Samples were collected at 10 weeks. Weight retention was measured, and histological analyses were performed using hematoxylin and eosin staining, along with immunohistochemical staining for perilipin and CD31. The effects of TXA pretreatment on fat graft retention and quality, along with its potential underlying mechanisms, were evaluated. At 10 weeks, the weight retention rates were 45.2 ± 5.0 www.springer.com/00266 .

BACKGROUND:The latissimus dorsi myocutaneous flap (LDMF) is a well-established workhorse flap for soft-tissue reconstruction. However, harvesting large LDMFs is limited by the challenge of achieving reliable donor-site closure. Although various techniques have been proposed, a broadly applicable strategy to achieve primary closure of large LDMF donor-site defects remains lacking. Thus, in this study, we aimed to present the use of circumflex scapular artery (CSA)-based flaps as a reliable approach for primary donor-site closure following large LDMF harvest. METHODS:We retrospectively reviewed patients who underwent reconstruction of LDMF donor-site defects using CSA-based flaps between April 2009 and March 2025. Demographic characteristics, reconstructive indications, flap characteristics, postoperative complications, and follow-up outcomes were analyzed. Subgroup analyses were performed comparing patients who underwent reconstruction with pre-expanded versus nonexpanded CSA-based flaps. RESULTS:All LDMF donor-site defects were primarily closed using CSA-based flaps. Ascending scapular flaps were used in 17 patients (68.0%) and scapular flaps in 8 (32.0%). LDMF pre-expansion was performed in 14 patients (56.0%), and CSA-based flap pre-expansion was performed in 7 (28.0%). Postoperative complications occurred in 2 patients: distal partial flap necrosis in one patient and hypertrophic widening of the scar in another patient. Subgroup analysis showed no significant difference in complication rates between pre-expanded and nonexpanded CSA-based flaps for LDMF donor-site reconstruction (14.3% vs. 5.6%; P =0.490). CONCLUSIONS:CSA-based flaps provide a reliable option for primary donor-site closure following large LDMF harvest, supported by consistent anatomic characteristics. When indicated, simultaneous pre-expansion of both the LDMF and CSA-based flap may further enhance reconstructive capacity without increasing complication rates. This approach represents a practical and reproducible strategy for LDMF donor-site management.

Skin wound healing remains a major clinical challenge due to impaired regeneration and incomplete restoration of dermal architecture, creating the need for biomaterials that reconstruct the human extracellular matrix (ECM) microenvironment, especially the collagen-rich structural network. Current strategies to obtain human-relevant collagen primarily include genetically engineered recombinant collagen and ECM directly produced by human cells. Although recombinant collagen has been extensively developed, it represents a simplified surrogate of native human collagen, and the biosynthesis of fully mature human collagen remains technically challenging. Therefore, we developed an engineered and scalable strategy to fabricate human cell-derived engineered ECM (HE-ECM) from human fibroblasts and systematically compared it with commercial recombinant collagen. Physicochemical analyses demonstrated that HE-ECM preserved native-like porous matrix architecture, collagen triple-helical integrity, enhanced thermal stability, and a more complex protein composition. HE-ECM significantly enhanced fibroblast viability, proliferation, and migration in vitro and accelerated wound closure with improved tissue organization in a rat full-thickness skin defect model. Overall, this controllable and donor-independent fabrication strategy enables scalable production of human collagen-rich HE-ECM that more faithfully recapitulates the native skin microenvironment than recombinant collagen, thereby suggesting its potential as a biomimetic platform for tissue regeneration.

Background: Evidence regarding the association between indocyanine green angiography (ICGA) use and flap necrosis remains inconsistent. This inconsistency may partly reflect differences in how studies define comparison groups, particularly whether classification is based on ICGA use or on whether ICGA findings informed the final intraoperative decision. We therefore compared flap necrosis primarily according to the basis for the final decision and secondarily according to ICGA use. Methods: This single-center retrospective comparative cohort study included 108 pre-expanded extended lower trapezius myocutaneous (e-LTMC) flaps in 101 patients between 2012 and 2022. Flaps were classified into the clinical-assessment group (Group A, n = 49) and the ICGA-guided group (Group B, n = 59) according to the basis for the final decision. Outcomes were overall and severe flap necrosis. Firth penalized logistic regression was the primary inferential method. Results: Overall necrosis occurred in 4/59 flaps (6.8%) in Group B and 14/49 (28.6%) in Group A (adjusted odds ratio [OR] 0.223, 95% confidence interval [CI] 0.063-0.661, p = 0.006). Severe flap necrosis occurred in 1/59 flaps (1.7%) and 11/49 (22.4%), respectively (adjusted OR 0.097, 95% CI 0.010-0.436, p = 0.001). Comparisons based on ICGA use alone showed no clear difference in either outcome (p = 0.422 and p = 0.750). Excluding the 11 retained hypoperfused flaps attenuated the difference in overall necrosis (p = 0.056), whereas the difference in severe necrosis remained significant (p = 0.033). Conclusions: In pre-expanded e-LTMC flap reconstruction, a management pathway in which ICGA findings informed or confirmed the final intraoperative decision was associated with lower observed rates and lower adjusted odds of overall and severe flap necrosis. The observed association reflects the management pathway, including perfusion status and the feasibility of modification, rather than ICGA alone. ICGA is therefore best incorporated into intraoperative decision-making alongside clinical assessment.

OBJECTIVE:The lower trapezius musculocutaneous flap (LTMF) is a workhorse flap for the reconstruction of soft-tissue defects of the head and neck. However, when harvesting a large LTMF to repair massive defects, primary closure of the donor site may be challenging. This study aimed to evaluate the feasibility and safety of using a perforator propeller flap (PPF) for primary closure of LTMF donor sites and to analyze the buddy flap donor-site closure strategies through a comprehensive literature review. METHODS:We retrospectively reviewed data from patients who underwent LTMF donor-site defect reconstruction using PPF between January 2015 and October 2025. Data on patient demographics, defect features, flap characteristics, postoperative complications, and outcomes were collected and analyzed. In addition, a comprehensive literature search was conducted in PubMed, Embase, Scopus, and Web of Science to identify studies published before October 9, 2025, describing the use of an additional flap to close the donor site of a primary flap. RESULTS:Seventeen patients underwent donor-site reconstruction of LTMFs using PPFs. The harvested LTMFs measured an average of 29.8 × 11.5 cm. The PPFs measured an average of 15.7 cm in length and 5.9 cm in width. All donor sites were closed primarily, and all PPFs survived completely. Complications occurred in three cases, including two cases of distal partial necrosis of the LTMF and one wound dehiscence at the LTMF donor site. The distal necroses were managed with debridement followed by secondary local flap reconstruction, whereas the wound dehiscence healed after conservative treatment. In the literature review, 43 studies comprising 547 cases were identified. Three reconstructive categories were established: Type 1 (locoregional flap), Type 2 (distant pedicled flap), and Type 3 (free flap) donor-site closures. Primary closure was achieved in 97.1% of patients, with an overall complication rate of 15.4%. Commonly adopted donor-site closure techniques for harvesting large flaps from different anatomical regions were summarized, providing a comprehensive overview of region-specific reconstructive strategies and their clinical outcomes. CONCLUSIONS:The PPF provides a safe and effective option for achieving primary closure of large LTMF donor sites. Using one flap to reconstruct the donor site of another large flap represents a reliable and versatile approach that facilitates primary closure while minimizing donor-site morbidity and adhering to the "like-with-like reconstruction" principle.

BACKGROUND:Extensive upper extremity soft-tissue defects with exposed vital structures present a significant reconstructive challenge, particularly when microsurgical options are unavailable. Traditional distant pedicled abdominal flaps require a wide skin tube to protect the vascular pedicle, resulting in substantial donor-site morbidity and risks of pedicle compression. This study introduces a modified technique utilizing a hybrid combination of artificial dermis and local skin flap to create a hybrid-enveloped pedicle, aiming to minimize donor-site sacrifice and improve postoperative management. METHODS:Between 2019 and 2025, 5 patients with extensive proximal or mid-forearm defects underwent reconstruction using a paraumbilical perforator-based pedicled abdominal flap. The vascular pedicle was protected using a conduit constructed from a combination of a small skin flap and artificial dermis, forming a flexible tube. A retrospective review assessed flap survival, complications, donor-site outcomes, and functional recovery. RESULTS:All 5 flaps survived. The length of the pedicle segment enclosed by the hybrid envelope ranged from 4 to 7 cm. No pedicle compression, infection, or vascular crisis occurred. One patient developed distal flap-tip necrosis, which healed with conservative management. All flaps demonstrated satisfactory contour, texture, and integration with surrounding tissues. Upper-extremity joint motion recovered well in all cases, and all patients reported high satisfaction with the reconstructive outcome. CONCLUSIONS:The artificial dermis-assisted hybrid pedicle technique offers a safe, reliable, and tissue-sparing alternative to the conventional skin-tube method for distant abdominal flap transfer. It effectively reduces donor-site morbidity, minimizes compression risk, enhances postoperative monitoring, and facilitates earlier rehabilitation. This refined approach represents a practical and accessible reconstructive solution for complex upper extremity defects in settings where free tissue transfer is contraindicated or unavailable.

Keloids are characterized by fibrosis and chronic inflammation, but links between mitochondrial dysfunction and keloid pathogenesis remain unclear. This study examined whether impaired PINK1/Parkin-dependent mitophagy is associated with mitochondrial DNA (mtDNA)-mediated innate immune activation and fibrosis in keloids, and evaluated mitochondrial transplantation as a potential therapeutic strategy. Primary keloid fibroblasts (KFs), normal skin fibroblasts (NFs), adipose-derived stem cells (ADSCs), human keloid tissues, and human keloid xenografts in immunodeficient BALB/c nude mice were analyzed using ultrastructural, molecular, and functional approaches. Freshly isolated NF-derived mitochondria (nMito) and ADSC-derived mitochondria (aMito) were compared at protein-equivalent doses. KFs exhibited mitochondrial abnormalities, impaired oxidative phosphorylation, increased reactive oxygen species, mtDNA leakage, and cGAS/STING pathway activation. Elevated PINK1 expression, reduced Parkin expression and p62 accumulation were consistent with impaired downstream mitophagic clearance. Both nMito and aMito were associated with improved mitochondrial function, changes in mitophagy-related markers, reduced cytosolic mtDNA and cGAS/STING signaling, and attenuated fibroblast activation, with greater aMito-associated changes in selected endpoints. In xenografts, intralesional administration of either mitochondria improved collagen organization and reduced fibrotic and inflammatory signaling. Together, these findings link altered PINK1/Parkin-dependent mitophagy to mtDNA-driven inflammation and fibrosis and support mitochondrial transplantation as a potential organelle-based therapeutic approach.

The emotional and psychological complexities experienced by patients who will undergo plastic surgery are profound. This study aims to explore the origins of preoperative emotional challenges and their associated risk factors among these individuals. Utilizing a cross-sectional study design, we administered questionnaires to patients prior to their procedures. The survey assessed their preoperative concerns and demographic factors that may influence their concerns. Multivariant logistic regression analysis was used to identify risk factors associated with patients’ concerns regarding plastic surgery. A total of 122 patients were enrolled and analyzed. Over 90 www.springer.com/00266 .

Reconstruction of central facial regions, particularly the lower eyelid and lateral nasal areas, continues to pose significant challenges for plastic surgeons. These regions encompass multiple esthetic subunits, necessitating meticulous consideration of texture compatibility and tension-free closure within each unit. Although various perforator flaps—such as those based on the facial artery or supraorbital artery—have been employed for mid-cheek reconstruction, achieving optimal contour and esthetic integration of the periorbital and nasal subunits remains difficult. In this study, we investigate the application of an infraorbital artery (IOA) perforator flap for the reconstruction of the lower eyelid and lateral nasal region, aiming to improve postoperative esthetic outcomes. This study provides an anatomical description and its clinical applications. In a cadaveric study, eight hemifaces were used to illustrate the precise location of the IOA, and the flap and artery pedicle were dissected to confirm surgical feasibility. Between August 2022 and May 2024, four patients underwent surgery with IOA perforator flaps to repair their lower eyelid or nose. Anatomical Study: In anatomical dissections, the mean distance between the infraorbital artery (IOA) and the infraorbital rim was 10.12 ± 1.10 mm, while the mean diameter of the IOA at its origin from the infraorbital foramen measured 1.50 ± 1.09 mm. During the dissection of the IOAP and its accompanying nerves, the mean diameter of the perforating vessels was approximately 0.5 mm. The length of the vascular pedicle that could be mobilized ranged from 2 to 4 cm. Clinical Study: In the clinical series, four patients underwent reconstruction with an IOA perforator flap. All flaps survived without signs of necrosis or vascular compromise, indicating excellent flap viability and reliable perfusion. According to the FACE-Q assessment scale, patients showed significant improvements in both esthetic appearance and functional outcomes. The infraorbital artery perforator flap represents a feasible and effective option for the reconstruction of defects involving the nose and lower eyelid, offering superior contour restoration of the periorbital and nasal regions compared to alternative techniques. 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 .

BACKGROUND:Lower trapezius myocutaneous flap (LTMF) is widely used for reconstructing head and neck defects. However, a single LTMF, even after pre-transfer tissue expansion, is often insufficient to cover defects involving the bilateral neck and chest wall. This study presents our experience with the use of bilateral pre-expanded LTMFs for repairing extensive cervicothoracic defects. METHODS:A retrospective study was conducted of patients who underwent bilateral pre-expanded LTMF reconstruction between March 2013 and August 2024. Patient demographics, defect features, flap characteristics, and surgical outcome were recorded to assess the efficacy and safety of the procedure. RESULTS:Ten patients underwent reconstruction of bilateral pre-expanded LTMF reconstruction. The median age was 18 years (range, 5-41 years). The median defect size was 222.5 cm 2 on the left (range, 85-390 cm 2 ) and 246 cm 2 on the right (range, 80-490 cm 2 ). Tissue expansion lasted 3.5-9.5 months. The median flap size was 420 cm 2 on the left (range, 150-660 cm 2 ) and 477 cm 2 on the right (range, 260-645 cm 2 ). Fourteen flaps were transferred through subcutaneous tunnels, while 6 were transferred through an open wound between donor and recipient sites in a propeller fashion. The donor sites were closed primarily in all patients. Complete flap survival was achieved in 9 patients, while 1 patient experienced flap tip necrosis. CONCLUSIONS:Bilateral pre-expanded LTMFs represent a reliable reconstructive option for cervicothoracic defects, providing satisfactory functional and aesthetic outcomes.

Reconstructing severe cervical scar contractures (SCSC) remains a considerable challenge. This study presents a novel approach to SCSC reconstruction using a combination of pre-expanded bipedicled forehead and lower trapezius musculocutaneous flaps. A retrospective analysis was conducted on 25 patients who underwent this procedure between April 2004 and July 2020. Sixteen patients received a forehead flap combined with a unilateral lower trapezius musculocutaneous flap; in contrast, 9 patients underwent reconstruction using bilateral lower trapezius musculocutaneous flaps. The surgery was performed in 4 stages. First, tissue expanders were inserted into the forehead and back. After sufficient expansion, the lower trapezius musculocutaneous flap(s) were transferred to repair cervicothoracic contractures in the second stage. In the third stage, the pre-expanded bipedicled forehead flaps were elevated to reconstruct lower facial and submental defects. Finally, the forehead flap pedicle was divided after 3 weeks. Patient demographics and surgical outcomes were collected and analyzed. All flaps survived without perfusion-related complications. Postoperatively, improvements were observed in neck range of motion, inferior mandibular border definition, and subhyoid depression. The cervicomental angle reduced considerably from 177.08±1.28 degrees to 106.6±1.18 degrees. In addition, the color and texture of the reconstructed flaps matched the adjacent skin. No scar contracture recurrence was reported during follow-up, which ranged from 4 months to 8 years. The technique, combining pre-expanded bipedicled forehead and lower trapezius musculocutaneous flaps, provides excellent functional and aesthetic outcomes for SCSC reconstruction. It effectively restores the cervicomental angle, inferior mandibular borders, and subhyoid depressions.

BACKGROUND:Repairing large forehead defects presents significant challenges due to the risk of asymmetry, inconsistent skin color, texture, thickness, or scarring. This study aimed to introduce a method utilizing preexpanded brachial artery perforator (BAP) flaps to reconstruct large forehead defects. METHODS:A retrospective case series was conducted on 17 patients who underwent forehead reconstruction using preexpanded BAP flaps between 2012 and 2024. The etiologies included nevus, scars, neurofibromas, and wounds with titanium mesh exposure. The surgery was performed in 3 stages. An expander was inserted into the medial arm. After achieving adequate inflation, the distally based BAP flap was elevated and transferred to reconstruct the forehead defect. The distal portion of the flap covered the defect, while the proximal portion was rolled into a tube. The pedicle was divided 3 weeks later, and the remaining flaps were reimplanted at the forehead and donor site. RESULTS:All flaps survived without any perfusion-related complications. The defect location included the unilateral forehead in 13 patients, the central forehead in 3, and the total forehead in one. Defect sizes ranged from 8×5 to 15×7 cm 2 . Flap sizes ranged from 17×6 to 30×10 cm 2 , with an average length-to-width ratio of 2.45. Eight patients underwent secondary scar revision, flap debulking, or eyebrow-lifting surgery. No expander-related complications, titanium exposure, wound infections, or shoulder function compromise were observed. After 6 to 80 months of follow-up, flap color, texture, and thickness closely matched the native forehead skin, and the donor-site scar was well concealed within the medial arm. All patients and their families were satisfied with the outcomes. CONCLUSIONS:The distally based BAP flap is an alternative option for reconstructing large or complex forehead defects, providing favorable functional and esthetic outcomes. Future research should explore the survival mechanism of extended BAP flaps.

Divided eyelid nevus is a rare congenital anomaly leading to functional and aesthetic issues, with a potential risk of malignant transformation. The aim of reconstruction is to provide tissue that closely matches the eyelid skin in color, texture, and thickness while minimizing donor-site morbidity. This study evaluated the efficacy of the pre-expanded brachial artery perforator (BAP) flap in reconstructing defects following resection of a divided eyelid nevus. There are fifteen patients who underwent eyelid reconstruction procedures involving tissue expansion, flap transfer, and pedicle division between December 2014 and December 2024. Patient demographics, flap characteristics, postoperative flap survival, and aesthetic outcomes were assessed. All 15 pre-expanded BAP flaps, ranging in size from 15 × 7 cm to 20 × 13 cm (mean 17.6 × 8.7 cm), survived without complications. The size of the expanders ranged from 100 to 200 mL (mean 146.7 mL), with an expansion duration of 4–9 months (mean 6.2 m onths). The defect dimensions ranged from 5 × 3 cm to 15 × 8 cm (mean 8.8 × 6.2 cm). Donor sites were primarily closed in seven patients, while eight patients required reconstruction using a pre-expanded latissimus dorsi myocutaneous flap. No secondary deformities were noted. All patients were satisfied with the aesthetic outcomes of the reconstructed eyelids and donor sites. The pre-expanded BAP flap can be used to reconstruct defects following resection of divided eyelid nevus, providing consistent functional and aesthetic outcomes. 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 https://www.springer.com/00266 .

BACKGROUND:Tranexamic acid (TXA) has gained increasing recognition for its efficacy in minimizing blood loss, ecchymosis, and edema. METHODS:This study investigates whether local infiltration of TXA during tissue expander insertion safely reduces postoperative drainage. A single-surgeon retrospective cohort study was performed to analyze patients undergoing tissue expander insertion between 2021 and 2023. Following expander insertion, patients in the intervention group received 5 mL of TXA (0.25 g in NaCl 0.9 %) infiltrated into the dissection area, whereas the historical controls did not. Patient demographics, drainage volume and duration, surgical complications, and adverse events were examined. The impact of various factors on the drainage volume and duration was evaluated by multiple linear regression analysis. Using inverse probability weighting (IPW), a statistical method that applies weights to account for confounding factors in observational studies, the drainage volume and duration between the two groups were compared. RESULTS:A total of 127 expander insertion procedures were reviewed, with 42 receiving TXA and 85 not. Complications were similar between the groups, and no severe adverse effects of TXA were observed. Regression analysis indicated that the use of TXA and limb location were negatively correlated with postoperative drainage duration and drainage volume unit area of the first postoperative day. Due to the imbalance in the layer of expander insertion between the two groups, IPW was applied. After IPW, the TXA group had significantly reduced drainage duration (P = 0.002) and drainage volume on the first postoperative day (P = 0.008) compared to the no-TXA group. CONCLUSIONS:Local infiltration of TXA during expander insertion is associated with reduced drainage.

Owing to the prevalence of congenital single eyelids among Asians, methods are needed to create a double-eyelid fold. Incisional blepharoplasty is considered an ideal method for this purpose. The classical approach tends to create a stable but less dynamic fold. Subsequent refinements aim to achieve a balance between stability and dynamism. However, there are many procedural variations due to anatomical differences, which may account for the varying surgical outcomes. This systematic review explored the current techniques used in Asian blepharoplasty and focuses on the efforts to balance stability and dynamism in double-eyelid-fold creation. A literature search was conducted across PubMed and EMBASE databases. We analyzed the effect of different surgical procedures on fold formation in Asians on the basis of anatomical features. We identified the essential steps of blepharoplasty: debulking the upper eyelid tissue (removing skin, orbicularis, retro-orbicularis oculi fat, and orbital fat), preparing the dynamic system by adjusting the aponeurosis and surrounding structures for proper corneal coverage, and establishing a connection between the anterior and posterior lamellae for a double-eyelid fold. However, debates are still ongoing on the best approach to achieve an ideal balance between stability and dynamism. Research interest in the identification of methodologies for optimizing the effects of incisional blepharoplasty has increased substantially. Further studies should aim to develop surgical strategies tailored to patients’ anatomical characteristics. 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 .

The expanded forehead flap based on the frontal branch of the superficial temporal artery (STA-Fbr) is a versatile technique for reconstructing cervicofacial defects. The aim of this study was to summarize STA-Fbr forehead flap harvesting patterns. Between July 2003 and July 2023, 66 patients (43 males) underwent face and neck defect reconstruction using STA-Fbr-based forehead flaps. These were divided into pattern I (vascular-pedicled) and pattern II (cutaneous-pedicled) flaps. Pattern II was subdivided into unilateral (IIa) and bilateral (IIb) cutaneous-pedicled flaps. Pattern IIa flaps were categorized as traditional or scarless based on pedicle location. Of the 66 flaps, 62 survived without perfusion-related complications. There were 10 Pattern I and 56 pattern II flaps (11 traditional IIa, 19 scarless IIa, and 26 IIb). Venous congestion occurred in 3 pattern I and 1 scarless IIa flap. After conservative management, 3 flaps survived; 1 pattern I flap developed distal necrosis. Defects were located in the temporal region, eyebrow, eyelid, nose, cheek, ear, mentum, and neck. Expanders ranged from 50 to 400 mL (average: 236 mL), with expansion times of 3 to 16 months (average: 5.9 mo). Defect dimensions ranged from 3 × 2 cm to 27 × 8 cm (average: 10.8 × 5.3 cm), and flap dimensions ranged from 4 × 3 cm to 30 × 9 cm (average: 16.3 × 6.6 cm). The STA-Fbr-based forehead flap remains a reliable and effective option for cervicofacial defect reconstruction, delivering functional and aesthetic outcomes. Successful surgery requires thorough anatomical knowledge, meticulous flap design, and in-depth patient communication.