Salvage surgery for a locally persistent or recurrent tumour in maxillary cancer patients who have undergone radiotherapy and concomitant intra-arterial cisplatin: implications for surgical margin assessment.

Limited information about salvage surgery is available for locally persistent and recurrent maxillary sinus cancers after the completion of chemoradiation therapy. Seventy-six maxillary sinus cancer patients who had undergone chemoradioselection using initial radiotherapy and concomitant intra-arterial cisplatin were screened retrospectively. Twenty-four of these patients who had a locally persistent or recurrent tumour were investigated. The 2-year overall survival rate of patients with maxillary sinus cancer of all types was 39.0% for those who underwent salvage surgery and 10.0% for those who did not. The 2-year overall survival rate of patients with maxillary sinus squamous cell carcinoma was 45.8% for those who underwent salvage surgery and 11.1% for those who did not. Furthermore, the 2-year local control and overall survival rates of patients with positive and negative surgical margins were 14.3% and 83.3% and 14.3% and 66.7%, respectively. There were significant differences in local control (P=0.004) and overall survival (P=0.005) regarding surgical margin status. Although salvage surgery for a locally persistent or recurrent maxillary sinus cancer is a feasible treatment, patients with positive surgical margins are more prone to local relapse. Therefore, surgical safety margins should be assessed thoroughly.

[Vacuum-assisted wound closure in the management of deep sternal wound infection].

We herein present a case who underwent vacuum-assisted wound closure (VAC) therapy for post-sternotomy mediastinitis. A 71-year-old female with chronic renal failure on dialysis underwent a graft replacement of the ascending aortic aorta for the treatment of an acute aortic dissection. After she was discharged from the hospital, a purulent discharge was noted to occur from the median sternal wound. The wound was therefore reopened and all sternal wires were removed. Thereafter, polyurethane foam which was shaped to fit the defect was placed within the cavity. The area was covered with adhesive drape and suction drainage was carried out at -100 mmHg. The polyurethane foam was replaced every few days. The wound was finally closed using a muscle flap at 49 days after surgery. VAC therapy is therefore considered to be a useful treatment modality for deep sternal wound infections.

Long-term viability of cryopreserved cultured epithelial grafts.

Human cultured epithelial grafts are frozen for long-term preservation. To assess the viability of these stored grafts, their cell survival rate and colony-forming efficiency of grafts cryopreserved at -135 degrees C and at -80 degrees C were followed over time. Flow cytometry showed that the cell survival rate of the grafts cryopreserved at -135 degrees C for 1 month, 6 months and 1 year averaged 89.3%, 61.7% and 61.6%. Cryopreservation at -80 degrees C maintained cell survival rate as well for 1 month, but after 6 months of cryopreservation survival was reduced at -80 degrees C (35.2%) compared with that of -135 degrees C. In histological examination, the cell structure and basal layer were very well preserved after 6 months of storage at -135 degrees C, but not at -80 degrees C. Cell survival rate at -135 degrees C was also assessed by colony-forming efficiency. Colony-forming efficiency of the grafts cryopreserved for 1 month, 6 months and 1 year averaged 66.1%, 58.5% and 55.1% of control (noncryopreserved) grafts. These findings suggest that, even when cultured epithelial grafts are subjected to long-term cryopreservation, cell viability remains sufficient, reculturing is possible, and that graft banking could be used for clinical applications.

Cryopreserved cultured epidermal allografts achieved early closure of wounds and reduced scar formation in deep partial-thickness burn wounds (DDB) and split-thickness skin donor sites of pediatric patients.

Burn treatment in children is associated with several difficulties, e.g. available skin replacement is small, donor area could expand, and subsequent hypertrophic scar and contracture could become larger along with their physical growth. In order to have better clinical results, the authors prepared cryopreserved cultured epidermal allografts from excess epidermal cells of other patients, and applied the epidermal allografts to 55 children, i.e. 43 cases of deep partial-thickness burn wounds (DDB) due to scald burn and 12 cases with split-thickness skin donor sites. In the 43 DDB patients, epithelialization was confirmed 9.1+/-3.6 days (mean+/-S.D.) after treatment. In 10 of the 43 patients, epithelialization was comparable between the area which received the epidermal allografts (grafted area) and the area which did not receive the epidermal allografts but was covered with usual wound dressing (non-grafted area). As a result, epithelialization day was 7.9+/-1.7 in grafted areas and 20.5+/-2.3 in non-grafted areas. In the 12 patients with split-thickness skin donor sites, epithelialization was confirmed 6.3+/-0.9 days after treatment. Epithelialization of the grafted and non-grafted areas was comparable in 8 of the 12 patients, and it was 6.5+/-1.1 days and 14.1+/-1.6 days, respectively. In these 10 DDB patients and 8 split-thickness skin donor site patients, redness and scar formation were also milder in the grafted area. The 55 patients have been followed up for 1-8 years (mean, 4.75 years), and scar formation was suppressed in both DDB and split-thickness skin donor sites. These findings showed that cryopreserved cultured epidermal allografts achieve early closure of the wounds and good functional outcomes.

Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage.

In reconstruction of the nipple-aerola complex, it is important to maintain nipple projection. The conventional methods of reconstructing the nipple using local skin flaps maintain the feature for a certain period postoperatively, but the height of the nipple eventually flattens as the scars soften over time. Considering that sustaining the feature of the nipple is most important for achieving and maintaining nipple projection, we have therefore devised a new operative technique. Rolled auricular cartilage is placed in the center of the bridge of the dermal base and is wrapped with bilobed dermal-fat flaps. This technique has the following advantages: The cartilage produces and sustains a good form of the feature without subcutaneous depression because the cartilage is supported by the bridge of the dermal base. Since the dermal base forms a bridge, the method is safe, maintains good circulation, and does not lead to any necrosis in the flap. This method also was compared with a method in which the rolled auricular cartilage is wrapped with a trilobed dermal fat flap.

Reconstruction for palmar skin defects of the digits and hand using plantar dermal grafting.

The plantar skin is considered suitable for skin grafting onto the volar aspect of the digits and hand. However, this method is not widely used because it is associated with problems at the donor site. To solve these problems, a new method was developed in which two different layers of the plantar skin are harvested from the same site. In this method, a split-thickness skin graft of the upper layer including the corneal layer of epidermis and a dermal graft of the lower layer are harvested from the same plantar skin. The split-thickness skin graft is returned to the original donor site, whereas the dermal graft is used for the palmar skin defects on the digits and hand. To prevent drying, the dermal graft was covered with a wound-covering material to achieve good graft takes. Reconstruction was performed for 17 patients using this method, involving digit-only reconstruction in 8 patients, and wider reconstruction in the other 9. Excellent color and texture match of the graft and donor sites were obtained with no noticeable marginal scarring, and the durability of the skin was satisfactory. This method was useful for skin grafting to the digits and palms with minimal sacrifice to the donor site.

An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction.

A conventional single pedicled TRAM (transverse rectus abdominis myocutaneous) flap is a musculocutaneous flap widely used for breast reconstruction. However, complications such as partial flap necrosis, fat necrosis, and fatty induration may occur as a result of unstable blood flow circulation to the flap. One major factor is venous congestion in the flap. In an effort to obtain more stable TRAM flap blood circulation, we anastomosed the ipsilateral deep inferior epigastric vein of a pedicled TRAM flap to the thoracodorsal vein. This procedure provides superdrainage by means of enhanced venous perfusion. This flap with superdrainage augmentation is referred to as a superdrainaged TRAM flap (12 patients). Changes in cutaneous blood flow were also assessed by measurement of cutaneous blood flow in zone IV using a laser blood flow meter (8 patients). The patients who underwent breast reconstructive surgery using this technique showed no evidence of postoperative complications such as flap necrosis, fat necrosis, or fatty induration. Satisfactory results were obtained during breast reconstruction in patients who had previously undergone a radical mastectomy with resultant large areas of tissue defects. In addition, the two patient groups, 12 patients with superdrainaged TRAM flap and 20 patients with single pedicled TRAM flap, were compared to assess differences in complications. The incidence of partial flap necrosis, fat necrosis, and fatty induration was lower among patients with superdrainaged flap than those with single pedicled flap.

Take percentage and conditions of cultured epithelium were improved when basement membrane of the graft was maintained and anchoring mesh was added.

To achieve a higher take rate for epithelial grafts, this study investigated grafting techniques. Seventy-seven nude mice received flap grafting in which cultured human epithelium was grafted inside the flap, and 55 nude rats received transplantation of epithelium to a full-thickness skin defect. In each group, four models were studied, including model 1, in which epithelium was cultured with the conventional method; model 2, in which epithelium was cultured with fibrin gel to avoid sheet damage, then absorptive mesh was incorporated into the epithelium for anchoring to the graft bed; model 3, in which epithelium was cultured with fibrin gel and combined with absorptive mesh and artificial dermis containing fibroblasts; and model 4, in which the model 2 epithelium was grafted after artificial dermis was transplanted. The take for these models was evaluated grossly and histologically. The results show that the take percentage of models 2 and 3 was significantly higher than that of model 1 (conventional epithelium) and that there was no significant difference between model 3 (simultaneous grafting) and model 4 (two-step grafting). The difference in the take percentages of the grafts to the flap and to the full-thickness skin defect was also insignificant. In immunohistochemistry, human keratin appeared in all epidermis layers and diversification of the layer was observed in models 2, 3, and 4. In these three models, type IV collagen appeared in the basal layer and the formation of basal membrane was confirmed. These findings suggest that epithelia cultured on fibrin gel and combined with absorptive mesh could be used in a new technique for better, more stable take.

A retrospective study of 66 esophageal reconstructions using microvascular anastomoses: problems and our methods for atypical cases.

We have studied 66 patients who underwent esophageal reconstruction using microvascular anastomoses. This series comprises 28 patients with reconstruction using a free jejunal interposition between the pharynx and the cervical esophagus following pharyngolaryngoesophagectomy for hypopharyngeal carcinoma and 38 atypical patients in whom other methods of reconstruction were used. Successful transfer was achieved in 98.5 percent (65 of 66). Issues concerning atypical reconstruction and our procedures in these cases are discussed. In order to obtain adequate tension in the jejunum on the anal side, in particular, since the anastomosis is located in a deep or narrow space, autosuture instruments were used. The anastomotic leakage rate was 2.8 percent (1 of 36); the stenosis rate was 2.8 percent (1 of 36). To prevent necrosis in the trachea, a greater omentum flap was used in three patients, a mesenterium flap in two, and a pectoralis major musculocutaneous flap in one. There were no significant complications. In patients with a short gastric pedicle or in those in whom a double cancer occurred in the hypopharynx and thoracic esophagus, a gastric pedicle and a free jejunum flap were used together. As a result of this method, the incidence of any reflux of digestive juice was reduced to 0 percent (0 of 6). To reduce the possibility of an ischemic complication at the oral end of the colonic pedicle, we added a microvascular anastomosis of the colonic pedicle, thereby reducing both leakage [0 percent (0 of 9)] and necrosis [0 percent (0 of 9)]. These procedures involving microvascular anastomoses have reduced the incidence of complications in esophageal reconstructions.

Functional reconstruction of swallowing and articulation after total glossectomy without laryngectomy: money pouch-like reconstruction method using rectus abdominis myocutaneous flap.

When a total glossectomy is performed without a laryngectomy, the functional recovery of swallowing and articulation is extremely important in maintaining the patient's quality of life. The authors established a money pouch-like reconstruction method in which a round and raised tongue is rebuilt using a rectus abdominis myocutaneous flap. In this method, the skin island of the rectus abdominis myocutaneous flap is created about 20 percent larger than the defect in both width and length. The skin island is sutured to the defect such that the excess skin folds into the shape of a money pouch. This allows the tongue to be reconstructed with its tip and dorsum touching the hard palate and its base bulging in the dorsal and posterior directions. Misswallowing was not detected in the three patients who had this surgery, and each of them had improved articulation sufficient to carry out daily conversations.

A surgical method for treating anterior skull base injuries.

Skull base surgery was performed on 18 patients with anterior skull base injuries. The operative technique consisted of opening the operative field in the anterior skull base via a coronal incision and a frontal craniotomy, debridement of the anterior skull base including the injured dura mater, performing drainage from the anterior skull base to the nasal cavity by ethmoidectomy, and reconstructing the resulting dural and anterior skull base defect using bilateral temporal musculo-pericranial flaps and a bone graft. Seventeen of the 18 patients recovered without any complications, although epidural abscesses in the anterior skull base had been present in four patients at the time of the operation. Only one patient developed an epidural abscess in the anterior skull base after the operation. None of the patients developed any other complications including meningitis, recurrent liquorrhoea or cerebral herniation. Satisfactory aesthetic results were achieved in 16 of the 18 patients. In one patient, uneven deformity of the forehead, which was caused by the partial sequestration of the frontal bone due to postoperative infection, was observed. In another patient, a depressed deformity of the forehead, which was caused by the partial loss of the frontalis muscle following the use of the frontal musculo-pericranial flap instead of a temporal musculo-pericranial flap, was observed. Anterior skull base reconstruction using bilateral temporal musculo-pericranial flaps provides excellent results in terms of patient recovery and aesthetics.

Cranioplasty with split lateral skull plate segments for reconstruction of skull defects.

This paper reports the use of cranioplasty using segments of split lateral skull plate to correct large skull defects (larger than 8 x 8 cm). The subjects consisted of 10 patients with head trauma who had undergone decompression surgery, and two patients who had undergone tumour resection. Bone grafts were obtained by cutting approximately 2 cm wide strips from the lateral skull plate using a bone saw that was inserted from a free margin of the bone defects. By cutting strips laterally from the bone defect, the necessary amount of split lateral skull plate can be obtained without performing craniotomy. The pieces of split lateral skull plate are then fixed to the defect using wire or titanium mini-plates. At this point, the selection of bone grafts that match the curvature of the dura mater is important, so that no dead spaces are created between the dura mater and the bone grafts. Infection was not detected in any of the 12 patients, and all bone grafts took completely. One of the 12 patients suffered from a pathological fracture and bone resorption 6 months after surgery. The fracture occurred because the use of basket-shaped reconstruction plates resulted in large spaces between the plate segments, and in addition the intracranial pressure was kept low by a V-P shunt, thus rendering the patient more vulnerable to atmospheric pressure.

A method that preserves circulation during preparation of the pectoralis major myocutaneous flap in head and neck reconstruction.

The present article describes a method that preserves circulation during the preparation of the pectoralis major myocutaneous flap used in head and neck reconstruction. The major disadvantage of this flap is its poor circulation and consequent partial necrosis. To solve this problem, we analyzed the circulation and hemodynamics of the pectoralis major myocutaneous flap (the perforator of the anterior intercostal branch located about 1 to 2 cm medial to the areola in the fourth intercostal space is important), evaluated the safe donor sites in the chest wall for a skin island (the perforator is included on the skin island's central axis), improved the surgical procedure for elevating flaps (for preventing perforator injuries), and devised a means to transfer flaps, thereby increasing the range of the flaps (the transfer route is under the clavicle). Using this technique, head and neck reconstruction was performed on 62 patients. The diagnosis included oral cancer (21), oropharyngeal carcinoma (10), parotid carcinoma (10), hypopharyngeal carcinoma (9), and other head and neck malignant tumors (12). Of these, partial or marginal necrosis of the flap caused by circulatory problems was detected in three patients (5 percent). Using our method, the problems associated with inadequate circulation in the pectoralis major myocutaneous flap were greatly alleviated, thus reconfirming the usefulness of this flap in head and neck reconstruction.

Posterior glottis. Morphological study in excised human larynges.

Two sets of investigations were conducted with excised human larynges. The glottis was closely observed and photographed from above and below in three conditions: neutral, adduction, and abduction. The structure surrounding the posterior glottis was histologically investigated in the same three conditions. The results are as follows. The structure surrounding the posterior glottis consists of three portions: the posterior wall of the glottis, the lateral wall of the posterior glottis, and the cartilaginous portion of the vocal fold. During vocal fold adduction, the posterior part of the larynx closes completely not at the glottis but at the supraglottis, resulting in formation of a conic space in the posterior glottis that can be viewed only from below. The posterior glottis accounts for approximately 35% to 45% of the entire glottic length and 50% to 65% of the entire glottic area. The mucosa of the posterior glottis has ciliated epithelium. The lamina propria consists of two layers. The posterior glottis can be regarded as a respiratory glottis.

Distribution of elastic cartilage in the arytenoids and its physiologic significance.

An investigation of the distribution of the elastic cartilage in the arytenoids was performed on excised human adult and newborn larynges. The distribution of elastic cartilage in the arytenoids was investigated histologically in two serial sections: horizontal and coronal. The behavior of the elastic cartilage portion of the arytenoids was investigated histologically under the conditions of adduction and abduction. The results are summarized as follows. 1) Elastic cartilage is found not only at the tip of the vocal process but at the superior portion of the arytenoid cartilage from the vocal process to the apex. 2) This phenomenon is observed at birth. 3) The vocal process bends at the elastic cartilage portion during adduction and abduction. The sides of the arytenoids come into contact mainly at the elastic cartilage portion. 4) Elastic cartilage appears to play an important role in the physiologic functioning of the arytenoid.

Reduction cranioplasty for macrocephaly. Two case reports.

Multi-stage reduction cranioplasty was performed on two children with severe macrocephaly secondary to hydrocephalus. One patient underwent a four-stage operation, and the other underwent a two-stage operation. The postoperative course of both patients was uneventful. Reduction cranioplasty improved quality of life for both patients, and good cosmetic results were achieved. Reduction cranioplasty is effective for the treatment of macrocephaly, and multi-stage surgery can reduce the associated risks.

Stanford type A acute dissection developing acute myocardial infarction.

A 75-year-old female, exhibiting epigastric pain and vomiting, underwent treatment for acute gastritis. She also experienced incontinence of urine and chest pain. A diagnosis of acute myocardial infarction was made upon examination of electrocardiographic findings and the patient was transferred to our hospital. Diffuse infarction of the left ventricle and acute aortic dissection (Stanford type A) were diagnosed by electrocardiographic and echo-cardiography. An emergency operation was performed. After induction of anesthesia, elevation of pulmonary artery pressure and fall of pulse pressure were observed, indicating acute cardiac tamponade. Transesophageal ultrasonography disclosed the entry of dissection in the descending aorta. Dissection of the aorta extended proximally up to the annulus of the aortic valve and the right and left coronary arteries were compressed by its aneurysm. As aortic insufficiency was mild, only reconstruction of the ascending aorta was carried out. The patient was discharged in fair condition one month after operation under use of postoperative long-term administration of catecholamines.

Thoracic aortic aneurysm complicated with severe coronary arterial occlusive disease.

The patient was a 77-year-old female who had been treated medically for angina pectoris since 5 years ago. Expanded aneurysms in the distal aortic arch and in the descending thoracic aorta were seen during follow-up. She presented continuous back-pain at rest along with increasing size of the aneurysms despite antihypertensive therapies after admission. First, two saphenous vein grafts were anastomosed to the left anterior descending artery and obtuse marginal artery under beating heart. Next, the proximal portion of the left subclavian artery was clamped and divided. To this graft, the proximal ends of the coronary bypassed vein grafts were anastomosed and coronary perfusion was established and maintained until this artery was anastomosed to the aortic graft. Then, the aneurysms in the distal arch and descending thoracic aorta were excised and the aorta and its two pairs of intercostal arteries were reconstructed. The Postoperative course was uneventful with favorable cardiac function.

Evaluation of an internal thoracic artery as a coronary artery bypass graft by intercostal duplex scanning ultrasonography.

OBJECTIVES: Although angiography is often used to determine whether the internal thoracic artery is appropriate as a coronary bypass graft, but use of duplex scanning ultrasonography for this purpose is not yet widespread. METHODS: The internal diameter and flow of the internal thoracic artery were measured using intercostal duplex scanning in 100 patients during April 1995. The ultrasonographic device (sonos 2000, Hewlett Packard) used had a linear probe delivering a frequency of 7.5 MHz. Bilateral internal thoracic arteries and their blood flow were imaged clearly in all subjects. Diameter was compared by angiography and duplex scanning ultrasonography in 20 patients. RESULTS: The average internal diameter of internal thoracic artery was 2.19 +/- 0.46 mm (right) or 2.13 +/- 0.32 mm (left) in men and 2.05 +/- 0.44 mm (right) or 2.09 +/- 0.42 mm (left) in women. The gender difference was statistically significant (p = 0.05). The maximum systolic blood flow velocity through the internal thoracic artery was 0.85 +/- 0.34 m/s (right) or 0.84 +/- 0.36 m/s (left) in men and 0.87 +/- 0.28 m/s (right) or 0.82 +/- 0.28 m/s (left) in women. The average internal thoracic arterial blood flow (F) was 54.6 +/- 29.0 ml/min (right) or 50.9 +/- 28.8 ml/min (left) in men and 56.8 +/- 38.2 ml/min (right) or 58.2 +/- 33.4 ml/min (left) in women. Duplex scanning ultrasonography using an intercostal approach enables easy imaging of bilateral internal thoracic arteries and visualizes entire internal thoracic artery structure by simply changing the probe position. CONCLUSION: Intercostal duplex scanning ultrasonography is thus recommended for reliable evaluation of the internal diameter and blood flow of the internal thoracic artery.

Efficacy of temporal musculopericranial flap for reconstruction of the anterior base of the skull.

Since March 1988 the temporal musculopericranial (TMP) flap has been used as our flap of choice to reconstruct defects of the anterior base of the skull that are larger than 2 x 3 cm, including the dura mater, in 33 patients. The primary diseases were malignant head and neck tumours (n = 16), trauma (n = 15), meningioma (n = 1), and teratoma (n = 1). The dura mater was reconstructed with a unilateral TMP flap, after which the cranial and nasal cavities were closed with the opposite TMP flap. In addition, bone was grafted by sandwiching the bone between the two flaps and fixing it to the surrounding residual bone. When a large area was resected, making it impossible to use a TMP flap, a frontal musculopericranial (FMP) flap or a free flap (usually the rectus abdominis myocutaneous flap) was used to close the cranial and nasal cavities. Thirty of the 33 patients recovered with no postoperative complications. Two patients developed extradural abscesses in the anterior base of the skull and one developed mild meningitis, but they were successfully treated conservatively. When bilateral TMP flaps were used for the reconstruction, no patient had aesthetic problems in the forehead region. The TMP flap is extremely effective for the reconstruction of the anterior base of the skull because it is minimally invasive and causes few aesthetic problems in the forehead region.