Identification of peroneal artery perforators using non-contrast-enhanced T2prep multi-shot gradient echo planar imaging MRA.

The purpose of this study was to investigate the spatial resolution of non-contrast-enhanced (CE) T2prep multi-shot gradient echo planar imaging (MSG-EPI) magnetic resonance angiography (MRA) required to identify peroneal artery perforators and demonstrate its effectiveness in preoperative simulation. Twenty-six legs of 13 volunteers were scanned using non-CE T2prep MSG-EPI-MRA at three spatial resolutions: 1.0-, 0.8-, and 0.6-mm isotropic voxels. The location and number of peroneal artery perforators that could be candidates for free fibula flaps were identified by consensus among three plastic surgeons. Surgeons distinguished between septocutaneous and musculocutaneous perforators using MRA, and confirmed the accuracy of their presence and identification using ultrasonography (US). The ability to detect hypoplasia or stenosis of the anterior tibial, posterior tibial, and peroneal arteries was evaluated by confirming the consistency between the MRA and US results. The number of cutaneous perforators identified using MRA and confirmed using US was 39, 51, and 52 at each respective resolution. The discrimination accuracies between septocutaneous and musculocutaneous perforators were 92.3%, 96.1%, and 96.2%. The number of identified septocutaneous perforators was 1.3 ± 0.6, 1.6 ± 0.8, and 1.7 ± 0.8 at 1.0-, 0.8-, and 0.6-mm data, respectively. All the MRA results, including hypoplasia and stenosis, were consistent with the US results. Non-CE T2prep MSG-EPI-MRA with a spatial resolution of 0.8 mm or less shows promise for identifying septocutaneous perforators of the peroneal artery, suggesting its potential as an alternative to conventional imaging methods for the preoperative planning of free fibula osteocutaneous flap transfers.

Early Predictors of Fistula Formation Following Head and Neck Reconstruction.

BACKGROUND: Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation. METHODS: We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula. RESULTS: In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value. CONCLUSION: CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.

The superficial branch of the radial nerve and sensory disturbance in the radial forearm flap donor-site.

Introduction: Sensory disturbance due to injury of the superficial branch of the radial nerve (SBRN) is a donor-site morbidity of the radial forearm (RF) flap. The relationship between the SBRN preservation method and the post-operative sensation at the flap donor-site was retrospectively investigated. Methods: We included 39 patients who underwent head and neck reconstruction with a free RF flap at Hyogo Cancer Center between April 2014 and March 2018. The patients were classified into the following three groups according to the SBRN preservation method: group 1, zero preservation, excision of the entire SBRN; group 2, main trunk preservation, excision of all branches except the main trunk of the SBRN; and group 3, complete preservation, preservation of the entire SBRN. Objective sensations and subjective symptoms at the flap donor-site were analyzed. Results: The mean objective sensory scores were 3.18, 2.97, and 1.78 in groups 1, 2, and 3, respectively. Differences between groups 1 and 3 and between groups 2 and 3 were significant (p = 0.0035 and p = 0.037, respectively). The mean subjective symptom scores were 2.40, 1.33, and 1.40 in groups 1, 2, and 3, respectively. Differences between groups 1 and 2, and between groups 1 and 3 were significant (p = 0.032 and p = 0.019, respectively). Conclusions: Zero preservation method had a higher risk of subjective symptoms and objective hypoesthesia development at the flap donor-site than the complete preservation method. Despite inevitable objective hypoesthesia, the main trunk preservation prevented the development of subjective symptoms. Complete preservation is optimal for RF flap harvest; however, in case of perforator crossing, main trunk preservation is another option.

Commissuroplasty Using Split Dry Lips: A Case Report.

Commissuroplasty is a procedure that is performed to correct deformities at the corner of the mouth or oral commissure. Herein, we report a case of postoperative microstomia treated with commissuroplasty using split dry lips. In a surgical procedure, the dry lip was divided into orbicularis oris muscle cutaneous flaps and transpositioned into the cleft formed. The deformation of the corners of the mouth improved, and mouth opening improved enough to wear dentures. We believe that this method enables commissuroplasty that combines aesthetics with function.

Analysis of Orbital Blowout Fracture Location and Hess Area Ratio.

ABSTRACT: This study aimed to analyze the Hess area ratio (HAR%) in cases of blowout fracture treated in our department and clarify the outline of eye movement disorders in blowout fractures. Patients who underwent surgery for orbital blowout fractures in our department were included. Fracture locations were classified into 5 types (A, outside floor; B, C, anterior and posterior floor; and D, E, anterior and posterior medial wall). The HAR% was compared before and after surgery in eligible cases. The relationship between the fracture location and preoperative HAR% was investigated using multiple regression analysis. The study involved 85 patients. Hess area ratio was higher postoperatively than preoperatively (70.75 ±â€Š18.26 versus 90.06 ±â€Š13.99, P  < 0.01). The postoperative HAR% tended to be higher when the iliac bones were compared to other materials; however, this difference was not significant (90.73 ±â€Š12.91 versus 80.30 ±â€Š17.81, P = 0.178). Fracture locations C and E significantly contributed to the prediction of HAR% as negative regression coefficients (P = 0.024 and 0.013, respectively). The posterior fracture area on both the orbital floor and medial wall contributed to the decrease in preoperative HAR%. This observation indicates that the reconstruction of the posterior region is extremely crucial.

Combined treatment using cross-leg free flap and the Masquelet technique: a report of two cases.

We introduce a treatment that combines the cross-leg free flap with the Masquelet technique and describe two cases using this method for bone and soft tissue reconstruction. Both patients were successfully treated and ambulatory. This novel method can be safely performed using the delay technique, indocyanine-green angiography and near-infrared spectroscopy.

An Ideal Choice for Closure of Large Free Radial Forearm Flap Donor Site Using a Local Full-Thickness Skin Graft.

ABSTRACT: The local full-thickness skin graft (FTSG) method based on the V-Y closure is reported to be the most convenient and reliable technique for free radial forearm flap (FRFF) donor site closure. The spindle-shaped FTSG was the most common local closure method in free osteofasciocutaneous fibula flaps but not FRFF reconstructions, despite being conveniently applicable to FRFF donor sites. The authors devised a spindle-shaped FTSG harvested from the ipsilateral radial forearm as a new concept in repairing the FRFF donor site. This procedure was performed on 4 patients and the average flap defect size was 5.0 × 8.3 cm (41.3 cm 2 ). The spindle-shaped FTSG is more likely to adapt to longer FRFFs, while a V-Y closure is more likely to adapt to wider ones. It is desirable to use both FTSGs properly depending on the large FRFF shape.

Simple and Easily Interpretable Flap Monitoring Method Using a Commercial Pulse Oximeter and a Widely Used Bedside Patient Monitor.

Background  Various methods for monitoring after free flap surgery have been reported in the literature. Among them, pulse oximetry shows a sensitive reaction to vascular issues, and it is easy to interpret visually. However, previous reports used special equipment that was less commonly used and difficult to generalize. In this study, we used a commercial pulse oximeter and a widely used bedside patient monitor to monitor transplanted free tissue and lower extremities of healthy subjects with impaired circulation. Methods  A reflectance pulse oximeter sensor was attached on the flap after free tissue transplantation. The sensor was connected to a bedside patient monitor, and the flap oxygen saturation (SpO2) levels and arterial waveforms were continuously monitored. Additionally, blood circulation disorder was induced in the lower limbs of healthy volunteers using pressure cuff inflation on the thigh, and the waveform and SpO2 levels on the pulse oximeter attached to the lower leg were monitored. Results  Twenty-two patients were included in this study. No postoperative vascular issues were observed in any case. Pulse oximeters showed normal rhythmic wavelengths, and the flap SpO2 level ranged approximately >90%. The pulse oximeter waveform rapidly disappeared during arterial occlusion in the thigh pressure cuff inflation test, and the waveform flattened and the SpO2 level decreased slightly during venous congestion. Conclusion  Flap monitoring using a commercially available pulse oximeter and a bedside patient monitor is a versatile, easy-to-interpret, and useful method. Changes in waveform and SpO2 levels appear during arterial and venous circulation disorders, and these changes can be differentiated.

Extra-Anatomical Bypass Grafting and Latissimus Dorsi Myocutaneous Flap Reconstruction for Post-sternotomy Mediastinitis With Prosthetic Aortic Graft Infection.

Extra-anatomical bypass grafting is a surgical method used to remove an infected aortic graft and promote revascularization with a new graft in the non-infected area. Here, we report a case of intractable post-sternotomy mediastinitis (PSM) with aortic graft infection which was treated with extra-anatomical bypass grafting. A 56-year-old woman with a history of multiple aortic dissection and prosthetic graft replacement in the thoracoabdominal area developed PSM with aortic arch graft infection. Bacterial culture of the exposed prosthetic graft tissue yielded multidrug-resistant Pseudomonas aeruginosa. Meticulous debridement of the wound and management by negative pressure wound therapy with continuous irrigation was performed. However, the infection of the prosthetic graft could not be controlled. Extra-anatomical bypass was performed between the left common carotid artery and right subclavian artery via the right common carotid artery. Then, the infected graft was removed. After the resolution of infection, the mediastinal wound was reconstructed with a pedicled latissimus dorsi myocutaneous flap, which was harvested from the right dorsum. No recurrence of infection occurred in the nine-month follow-up period. Debridement and removal of exposed artificial graft are considered the gold standard for treating wound infection. In situ replacement of infected aortic grafts carries a risk of re-infection due to residual bacterial contamination of the periprosthetic tissue. Extra-anatomical bypass would be a useful option for reducing the risk of re-infection in patients with intractable PSM and prosthetic aortic graft infection. Further studies are warranted to evaluate the risks and benefits of this operative method.

Experimental study on the efficacy of a hybrid artificial nerve: The hot dog method.

INTRODUCTION: We hypothesized that hybrid artificial nerves might overcome the limitations of a nerve conduit by isolating nerve fascicles from autologous nerves. Nerve sacrifice during harvest, a drawback of conventional autologous nerve transplantation, may be reduced by the hot dog method. The hot dog method (based on the morphology of hybrid artificial nerves) adds nerve conduits to autologous nerve fascicles. METHODS: Forty-eight rats with a 10-mm sciatic nerve defect were divided into six groups (n = 8 per group) according to the neural reconstruction method: autologous nerve transplantation, the hot dog method, nerve conduit, nerve fascicle transplantation, sham control, and nerve fascicle isolation were classified as Groups I, II, III, IV, V, and VI, respectively. The sciatic nerve function was assessed in these groups, a histological evaluation was performed, and statistical analyses were conducted based on these data. RESULTS: Group III (nerve conduit) and Group IV (nerve fascicle transplantation) showed the lowest functional and axonal regenerative effects, followed by Group II (hot dog method) and Group I (autologous nerve transplantation). Group VI (nerve fascicle isolation) tended to achieve better recovery in motor function and axonal regeneration than Group I (autologous nerve transplantation). CONCLUSIONS: The hot dog method is simple, safe, and easy to execute. This method can serve as a new neural reconstruction method that uses artificial nerves.

Perineal reconstruction with pedicled rectus abdominis myocutaneous flap after posterior pelvic exenteration -A 3D model study.

INTRODUCTION: Limited literature exists regarding the positional relationship between the pedicled-rectus abdominis myocutaneous (p-RAMC) flap and residual pelvic organs post posterior pelvic exenteration (PPE). PRESENTATION OF CASE: Four patients underwent PPE and reconstruction with a p-RAMC flap. After harvesting the p-RAMC flap with the deep inferior epigastric artery and veins as the vascular pedicle, the intra-pelvic shortest pathway of the flap was created. We dissected the subcutaneous tissues of the flap donor site toward the perineal defect along the inner wall of the pelvis. The pubic origin of the rectus abdominis muscle was preserved. A three-dimensional model was constructed using an image processing software. The vascular pedicle ran almost linearly along the inner wall of the pelvis. The muscle belly was placed on the pelvic floor through the posterior wall of the urinary bladder which filled the dead space of the resected area. All flaps survived without significant complications. DISCUSSION: Assigning the cranial side of the flap to the perineum and caudal side to the pelvic floor could reduce postoperative intrapelvic complications. By preserving the pubic origin of the rectus abdominis muscle, a shock absorber of the pedicle of the flap was created, preventing over-traction of the flap while passing through the intrapelvic pathway. CONCLUSION: A p-RAMC flap via intra-pelvic shortest pathway is an ideal reconstructive method for large skin defect in perineal area after PPE.

Treatment of orbital blowout fracture using a customized rigid carrier.

PURPOSE: This study aimed to examine the usefulness of treating orbital blowout fracture using a customized rigid carrier. MATERIAL AND METHODS: Patients who underwent surgery for orbital blowout fractures in our department from April 2016 to March 2019 were recruited in the study. We molded a rigid thermoplastic material into the same shape as the reconstruction material according to the 3D model and transplanted it into the orbital space along with the reconstruction material. We assessed Hertel exophthalmometry, awareness of diplopia, and the Hess area ratio (HAR%). RESULTS: We performed this procedure in 15 patients with blowout fractures. Reconstruction materials used were iliac bone, absorbable plates, and titanium mesh in 12, 2, and 1 patient, respectively. None of the patients showed a difference of more than 2 mm on Hertel exophthalmometry. Only one patient had diplopia after surgery. The average preoperative and postoperative HAR% were 83.1 and 90.6, respectively. HAR% was more than 85% in 6 of 7 postoperative cases. CONCLUSIONS: This method can be applied for surgery using various reconstructive materials and can be a useful method, especially in patients with a wide range of orbital bone defects.

Analysis of Orbital Morphology and its Relationship With Eyelid Morphology.

Correct anatomical reconstruction of the orbital wall for function and cosmesis is important; however, this is difficult because of the structure's complexity. The authors aimed to analyze and classify orbital morphology from computed tomography (CT) images and examine the relationship between orbital morphology and eyelid morphology in the Japanese population. CT images of 60 men (right side, 29; left side, 31) and 44 women (each side, 22) were included. The lengths of the orbital medial wall and floor in the coronal plane at the anterior, middle, and posterior planes of the orbit; angle between them; simotic index; and the thickness of upper eyelid were measured. Additionally, the presence or absence of double eyelids was evaluated. Non-paired Student's t test and Pearson correlation coefficient test were used for analysis. Orbital morphology was symmetrical on both sides, and men had a larger orbit than women. Orbital morphology was classified into 2 groups according to the posterior angle, and there was a difference between the groups in the simotic index. The difference between groups may represent a genetic difference between the Jomon and Yayoi people and not only provide a new classification for the orbit of the population but also be useful in orbital reconstruction.

Reverse vascular pedicle digital island flap with preservation of the dorsal branch of the digital nerve.

A reverse vascular pedicle digital island flap is a useful treatment option for reconstruction in fingertip amputation. We describe a surgical procedure to preserve the dorsal branch of the digital nerve in the middle phalanx during elevation of this flap with favourable outcomes.

Two cases of debulking surgery for lower limb diffuse plexiform neurofibroma with transcatheter arterial embolisation.

INTRODUCTION: Diffuse plexiform neurofibroma (DPN) in patients with neurofibromatosis type 1 (NF1) causes motility dysfunction in severe cases. Transcatheter arterial embolisation (TAE) is an effective haemorrhage control method in vascular tumour surgery. PRESENTATION OF CASE: We performed debulking surgery for DPN in the buttock and posterior thigh of two NF1 patients. Preoperative TAE with gelatine particles to tumour feeder vessels was conducted in both cases. Operative bleeding volumes were 500 and 4970 mL, respectively. In the latter case, the resection area extended to the upper poles of the buttocks, and the tumour invaded deeply into the surrounding tissues. Massive haemorrhage occurred, and internal iliac arterial balloon was inflated temporarily to further suppress the bleeding. Delayed wound healing due to TAE occurred; debridement and wound closure were required. Motor function improvement was confirmed in both patients. DISCUSSION: Bleeding volumes varied because of highly developed collateral pathways and tumour invasiveness. As the upper pole of the buttock was perfused by the superior gluteal artery and its numerous collateral vessels, complete haemostasis was difficult despite adequate TAE. Because delineating the tumour border from the normal tissue was impossible due to the high tumour invasiveness, cutting into the hypervascular tumour was inevitable. As gelatine particles were absorbed but remained within the vessels, prolonged wound ischaemia and delayed healing occurred. CONCLUSION: Although TAE with gelatine particles and balloon occlusion were reliable haemorrhage control methods in debulking surgery for lower limb DPN, optimal haemorrhage control technique, compatible with haemostasis and wound healing, was desired.

Ultrasonography-guided Cannula Method for Hyaluronic Acid Filler Injection with Evaluation using Laser Speckle Flowgraphy.

Hyaluronic acid (HA) is present in the connective tissues of the skin and decreases with age. HA fillers are popular as facial rejuvenation treatments. They are generally considered safe; however, complications, such as cutaneous necrosis and blindness due to vascular embolism, sometimes occur. Because vascular embolisms are likely associated with the deep placement of HA fillers, a strategy that involves injection into superficial regions (the conventional method) is commonly used to reduce risks. However, deep injections to achieve revolumization are becoming common, even in high-risk areas for intravascular infusion. We aimed to study the usefulness of the ultrasonography-guided cannula method for preventing intravascular infusion of HA fillers. An HA filler was injected into the region just under the dermis on the left side of the face of a 38-year-old man using the conventional method, and another HA filler was injected into the periosteum on the right side using the ultrasonography-guided cannula method. The skin blood flow on both sides was compared using laser speckle flowgraphy (LSFG). The ultrasonography-guided method was successful in detecting the cannula and the blood vessel, and the HA filler was safely injected into a deep region. Using LSFG, a difference in skin blood flow between the 2 methods was detected. The ultrasonography-guided cannula method was effective in aiding the safe injection of an HA filler in a deep high-risk area and maintained skin blood flow. LSFG may be adopted to evaluate skin blood flow after HA filler injections.

A Novel Method of Noninvasive Monitoring of Free Flaps With Near-Infrared Spectroscopy.

Objective: Thrombosis of a site of anastomosis in microsurgical free tissue transfer can result in tissue necrosis. To salvage potentially failing free flap, various methods of monitoring the viability of tissue have been described. We report a novel method of monitoring free flaps using near-infrared spectroscopy. Methods: After microsurgical operation, we monitored the regional oxygen saturation of the flap with using the In-Vivo Optical Spectroscopy. A total of 57 patients participated in this study. Results: Of 57 cases, arterial insufficiency was detected in 1 case and venous insufficiency was detected in 3 cases. Regional oxygen saturation decreased before the flap color changed to a pale or congestive color. We could salvage these 4 patients by re-exploration. Conclusions: The postoperative monitoring with the In-Vivo Optical Spectroscopy is noninvasive, continuous, reliable, and reproducible. This technique could be one of the best methods for monitoring microsurgical free tissue transfers.

Simple and easy surgical technique for infantile hemangiomas: intralesional excision and primary closure.

OBJECTIVE: Infantile hemangioma (IH) is a benign vascular tumor that gradually shrinks over several years. Involuting or involuted IHs usually retain their shape, however, and result in redundant skin or conspicuous scarring due to ulceration in the proliferating phase. We present a case series of 12 patients who underwent intralesional excision and primary closure for treatment of involuting or involuted IH. METHODS: Twelve patients (5 boys, 7 girls) underwent our treatment method for involuting or involuted IH. A blinded assessor evaluated clinical result of each patient. RESULTS: Surgical results were excellent in 4 patients, good in 6, and fair in 2. A small dog ear was prominent in 1 patient; nevertheless, all parents were satisfied with the results. CONCLUSIONS: Intralesional excision and primary closure for treatment of involuting or involuted IH is an easy and simple procedure that does not result in dog-ear formation or elongated residual scarring.