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Object: Age-related morphological changes in the human hyoid bone were investigated radiographically and histologically. Materials and Methods: Thirty-two measurements were performed on radiographs of 238 hyoid bones from autopsy cases of known age and sex. Thirty-one hyoid bones that were studied by radiography were also examined histologically in horizontal sections. Results: Analysis of the length and width of the hyoid bone revealed significant increases in the body and the anterior part of the greater cornu and a significant decrease in the posterior part of the greater cornu with aging. Most measurements of the body and the greater cornu revealed differences between male and female hyoid bones. The outer margins of the body and the greater cornu were situated further outside in older males compared with females. The breadth of the joint space showed a significant age-related decrease, and the degree of fusion showed a significant age-related increase. Histological findings showed ossified or calcified fusion, with osteoclasts in the marginal area of the joint space. Conclusions: Increasing age induces fusion of the body and the greater cornu. The morphometric changes in the shape of the hyoid bone may represent functional adaptation to articulation fixation.

Background: Reconstruction of recalcitrant pressure ulcers is very challenging because all available local tissues have been exhausted. Although occasionally suggested as reconstructive options in some reports, free flaps are still not favored for pressure ulcers because of the less available recipient vessels in buttock area and the need for position change. Here, we describe our experience with latissimus dorsi muscle-splitting free flaps harvested in prone position for recalcitrant pressure ulcers.Methods: Between January 2012 and January 2020, 10 patients of recalcitrant pressure ulcers underwent reconstruction using latissimus dorsi muscle-splitting free flaps. To harvest flaps in the prone position, the curvilinear incision was made along the line connecting the lateral border of the scapula and the midaxillary line of the armpit and the latissimus dorsi muscle was split just below the skin incision. Only the required amount of muscle was harvested including the 5 Â 3 cm sized muscle cuff around bifurcation points of the transverse and descending branches.Results: Flap size ranged from 16 Â 9 to 24 Â 14 cm and the gluteal vessels were mainly used as recipients. The mean operation time was 170 mins. All the flaps survived but two patients suffered wound disruption and partial flap loss, respectively.During the mean follow-up periods of 2.45 years, there were no recurrences at the reconstruction site, and no patient complained of donor site morbidity.Conclusions: Based on the results obtained from this consecutive series of patients, latissimus dorsi muscle-splitting free flaps are valuable option for recalcitrant pressure ulcer reconstruction.

Background For successful microsurgical reconstruction using free tissue transfer, healthy recipient vessels must be obtained from outside the zone of injury. Securing an appropriate length pedicle length is also essential, and various techniques for lengthening a vascular pedicle have been developed. Herein, we present our experience using the descending branch (DB) of the lateral circumflex femoral vessels (LCFVs) with a thigh flap as an extender graft for consecutive second flap. Methods We reconstructed the complex and vessel‐depleted defects of nine patients. The mean age was 47.6 years. The defects were located in the lower leg in four patients, in the perineum in two patients and in the forearm in three patients. The two patients who suffered from Fournier's gangrene underwent a pedicled anteromedial thigh (pAMT) flap with the DB of the LCFVs and seven patients, five who suffered high‐energy trauma and two who had scar contracture, underwent a free anterolateral thigh (ALT) flap with the distal run‐off DB of the LCFVs. In all patients, second consecutive free latissimus dorsi or thoracodorsal artery perforator flaps were prepared and the thoracodorsal vessels of the second flap were anastomosed to the distal DB of the LCFVs. Results The total length of the thigh flap pedicles measured from both ends of the DB of the LCFVs varied from 15 to 20 cm, which was sufficient for use as a vascular conduit. Of the 18 flaps, 17 survived completely without any complications and 1 pAMT flap showed partial necrosis, which was covered with a perineal perforator‐based island flap. The mean follow‐up period was 16.7 months. Unfortunately, one patient, who suffered a total amputation below the knee and had replantation surgery, underwent amputation due to venous congestion in the distal leg. However, the previous two flaps survived and were used for coverage of the stump. Conclusions Using a thigh flap as a vascular extender graft for second flap may be an alternative option in vessel‐depleted reconstructions.

IntroductionAround the knee reconstruction is challenging for reconstructive surgeons. Several methods have been proposed, including perforator and muscle flaps; however, all have advantages and disadvantages. As the success rate of free‐flap surgery increases, reconstruction around the knee using this method is becoming increasingly popular. Nevertheless, there are no large‐scale case reports in the previous literature using either a thoracodorsal artery perforator flap (latissimus dorsi (LD) perforator flap) or a muscle‐sparing latissimus dorsi (msLD) flap for reconstruction around the knee. In this retrospective report, we describe our clinical experiences and present an algorithm regarding recipient vessel choice in free‐flap reconstructive surgery of around the knee defects.Patient and MethodsFifty‐six cases in which a flap from the lateral thoracic area was used to reconstruct an around the knee defect between January 2016 and March 2022 were reviewed. The patients were aged 18–87 years (mean, 52.13 years), and of the 56 patients, 36 were male and 20 were female. Injuries were caused by trauma, contracture, rheumatoid vasculitis, tumor, infection, burns, sunken deformity, and pressure sores. The 56 cases included 22 with a defect including the knee, 14 with a defect below the knee (7 of the primary below‐knee amputation [BKA] and 7 of the secondary BKA), 9 involving the distal medial thigh, 8 involving the distal lateral thigh, 2 involving the popliteal area, and 1 involving the middle thigh. Most cases were reconstructed using a single LD perforator flap or msLD flap. Chimeric or supplementary flaps were used when extensive coverage or dead space obliteration was required. The average size of the defect area was 253.6 cm2 (range: 5 × 6–21 × 39 cm2).ResultsIn the cases, the recipient artery used included the following: descending genicular artery (23), superficial femoral artery (14), descending branch of the lateral circumflex femoral artery (14), anterior tibial artery (2), popliteal artery (2), and posterior tibial artery (1). The recipient vein included the greater saphenous vein (24), descending branch of the lateral circumflex femoral vein (14), superficial femoral vein (7), descending genicular vein (6), anterior tibial vein (2), popliteal vein (2), and posterior tibial vein (1). The average flap size was 281.8 cm2 (range: 4 × 8–35 × 19 cm2). All flaps survived; however, seven complications occurred, including 2 partial flap losses, 1 arterial insufficiency, 1 hematoma, 1 minor dehiscence, 1 donor‐site graft loss, and 1 short BKA. Normal knee range of motion (121–140°) was observed in 34 patients and 16 showed varying degrees of limited range of motion. Motion was not observed in four patients who underwent knee fusion and could not be evaluated in two patients who underwent above‐knee amputation. The mean follow‐up duration was 24.6 months (range: 4–72 months).ConclusionThe LD perforator flap is ideal for the reconstruction of around the knee defects because it enables a long pedicle, large flap, and chimeric design. The msLD flap is ideal because it enables strong stump support, dead‐space obliteration, and infection control. Moreover, since the two flaps are distant from the knee, this method is advantageous in terms of postoperative rehabilitation and there is minimal donor‐site morbidity due to the thin nature of the LD muscle. In addition, the flap can be elevated in three positions and the operation can be completed without positional changes in various recipient vessel locations. Based on our experience, we conclude that the LD flap has the potential to be used as widely as or in preference to the anterolateral thigh flap in the reconstruction of around the knee defects.