Salvage of Ear Framework Exposure Following Autologous Microtia Reconstruction: Repair Strategy for Each Location of Exposure.

One of the most common complications of total auricular reconstruction is exposure of the ear framework. Various reconstruction methods have been reported depending on the location and size of exposed cartilage. This report describes a safe reconstruction method for each exposed part of the grafted ear framework. From January 2019 to August 2021, 2 cases (4 areas) of framework exposure were observed following autologous microtia reconstruction. The first case developed 2 small areas of skin necrosis on the anterior helix and lower antihelix to concha. The former was reconstructed with a temporal fascia flap and the latter with a local transposition flap. The second case also developed 2 small areas of skin necrosis on the posterior helix and lower antihelix to concha. The former was sutured directly and the latter with a local transposition flap. However, both wounds recurred due to flap necrosis and the cartilage was exposed again. The 3rd operation was performed by covering both wounds with a posterior auricular turnover flap and skin graft. In both cases, the exposed framework was completely covered with the flaps, and the reconstructed ears showed well-defined convolutions. Covering exposed cartilage with a local flap with a random pattern of blood circulation is convenient because no additional skin grafts are required. However, the blood circulation of the flaps is inadequate when an elongated flap is required; consequently, flap necrosis may occur. On the other hand, a temporal fascia flap and posterior auricular flap, which have axillary pattern blood circulation, are considered to be safer. We believe that it is safe to use a temporal fascia flap for cartilage exposure in the upper half of the auricle, and a posterior auricular turnover flap for the lower half.

Additional superdrainage reduces anastomotic fistula and stenosis after gastric tube reconstruction with cervical anastomosis for esophageal cancer.

Objective: Gastric pull-up is a common procedure to reconstruct the continuity of the upper digestive tract after esophagectomy. However, this technique sometimes causes postoperative anastomotic leakage or stricture, resulting from congestion of the gastric tube. We performed additional microvascular venous anastomoses to solve this problem. The purpose of this study was to compare postoperative anastomotic leaks and strictures in cases with or without additional venous superdrainage after gastric tube reconstruction. Methods: A total of 117 consecutive patients with cervical and thoracic esophageal cancer who underwent thoracoscopic esophagectomy with gastric tube reconstruction in the National Nagasaki Medical Center between 2011 and 2021 were analyzed retrospectively. Of these patients, 46 did not undergo additional venous anastomoses (standard group), and 71 who underwent gastric pull-up surgery after November 2014 have added this surgical procedure to their routine (superdrainage group). We compared the frequency of postsurgical leakage and stricture in the 2 groups retrospectively. Results: Fifteen patients (32.6%) developed postoperative leakage in the standard group and 6 (8.5%) did so in the superdrainage group. Twelve patients (26.1%) showed postoperative anastomotic stricture in the standard group and 7 (9.9%) did so in the superdrainage group. Patients who did not undergo additional venous superdrainage were significantly more likely to develop postsurgical leakage (χ2 test P < .01) and anastomotic stricture (χ2 test P < .05). The mean time taken to perform additional venous anastomoses was 54.2 minutes. Conclusions: Our study revealed that performing additional venous anastomosis for as little as 1 hour can significantly reduce the incidence of postoperative leakage and stenosis. This procedure is of merit to perform after total esophagectomy with gastric tube reconstruction.

The Efficacy of Salvage Intervention with Emergency Transient External Arterial Bypass for Traumatic Artery Occlusion of Main Extremities.

Even if the vascular repair is successful, the frequency of limb loss is still high when popliteal artery injury is associated with postischemic syndrome due to blunt trauma or a prolonged ischemic time. Because prolonged ischemia interferes with an injured foot rescue, shortening of the ischemic time is a major aim of surgeons. We present two types of transient external arterial bypass and two cases of ischemic extremities due to main arterial injury. Even though the injured extremities had no circulation for more than 6 h, a transient external arterial bypass supplied circulation immediately, and they were reconstructed successfully. Although transient external arterial bypass is a dated technique, it is a recommended option, especially in the management of acute traumatic ischemia of the extremities to shorten the ischemic time and provide immediate reperfusion, which will bring the opportunity to save the ischemic limbs.

Fournier's Gangrene With Subcutaneous Emphysema of the Thigh Caused by Air Inflow Associated With a Rectovaginal Fistula: A Case Report of Pseudo-gas Gangrene.

INTRODUCTION: Rectovaginal fistulas (RVFs) are abnormal connections between the rectum and vagina. CASE REPORT: A 61-year-old female patient was admitted to the authors' hospital with swelling, extending from the left thigh to the left lower abdomen and crepitus. An axial computed tomography scan showed air in the soft tissue of the left thigh, left buttock, perineal region, and left lower abdomen. Gas gangrene was suspected. Accordingly, the patient was administered meropenem, clindamycin, and vancomycin and underwent emergency debridement. An intraoperative examination revealed necrotizing fasciitis in the left buttock but no inflammatory signs in the thigh. On postoperative day 8, fecal matter was discharged from the patient's vagina, and an RVF was detected by colon fiberscopy. The patient underwent resurfacing surgery with a free skin graft, and a colon stoma was fashioned 15 days after the primary surgery. The patient was discharged on day 14 following surgery with wound healing. CONCLUSION: The existence of free air in subcutaneous tissue combined with an infection, particularly in the extremities, is generally suggestive of gas gangrene. In the present case, subcutaneous gas was not caused by gas gangrene but rather by air inflow from an RVF. Appropriate treatment of the RVF was necessary to avoid the exacerbation of Fournier's gangrene and prevent necrosis spreading to the thigh.

Eccrine Porocarcinoma on the Lateral Nose Wall: A Rare Case Report.

Eccrine porocarcinoma (EPC) is an uncommon malignant tumor derived from the eccrine sweat glands. We present a case of EPC on the lateral nose wall, in which the tumor was excised, and the resultant defect was reconstructed using a nasolabial flap. A 66-year-old female was referred to the Department of Plastic and Reconstructive Surgery to receive treatment for a cutaneous tumor on her right lateral nose wall, which had been growing rapidly for 3 months. Histological analysis of a biopsy specimen of the tumor suggested that it was a squamous cell carcinoma. Surgical excision was performed with a 3-mm margin. The tumor was histologically diagnosed as an EPC. EPC exhibits various pathological features; therefore, it is often confused with other malignant cutaneous tumors. We consider that histologically examining surgical specimens obtained via total resection, rather than incisional biopsy specimens, is important for correctly diagnosing EPC.

Sacral Pressure Ulcer-induced Fournier's Gangrene Extending to the Retroperitoneum: A Case Report.

INTRODUCTION: Fournier's gangrene (FG) is a type of necrotizing fasciitis of the perineum and scrotum that is characterized by very rapid progression. Sacral pressure ulcers are one of the causes of FG. CASE REPORT: An 85-year-old man was referred to the National Hospital Organization Nagasaki Medical Center (Ohmura City, Japan) with a diagnosis of FG extending to the retroperitoneum caused by a sacral pressure ulcer. Immediate debridement was performed; however, it was not possible to remove all necrotic tissue from the pelvis. The wound was cleansed with continuous irrigation combined with negative pressure wound therapy, which brought the infection under control. The exposed rectum was resurfaced with a gracilis musculocutaneous flap, and the remaining wound in the sacral region was covered with a gluteal artery perforator flap. CONCLUSIONS: The authors consider continuous irrigation combined with negative pressure wound therapy as extremely useful for patients with FG in whom sufficient debridement cannot be performed.

Risk Factors for Postoperative Complications among the Elderly after Plastic Surgery Procedures Performed under General Anesthesia.

BACKGROUND: The frequency of surgery involving elderly patients has been increasing. The use of free tissue transfers in the elderly has been examined previously (Howard et al., 2005, Hwang et al., 2016, Grammatica et al., 2015, Serletti et al., 2000, and Sierakowski et al., 2017), whereas there have not been any such studies of plastic surgery procedures. We evaluated the risk factors for complications after plastic surgery procedures performed under general anesthesia in patients aged ≥75 years. METHODS: The cases of patients aged ≥75 years who underwent plastic surgery procedures under general anesthesia at the Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, between 2009 and 2016 were reviewed retrospectively. Multiple logistic regression analysis was used to identify the risk factors for postoperative complications. RESULTS: Two hundred and sixty-three cases were reviewed. Complications were seen in 137 patients. Age was not predictive of complications. The risk factors included a serum albumin level of <2.8 g/dl (odds ratio (OR): 2.96), an operative time of ≥120 min (OR: 6.22), and an American Society of Anesthesiologists performance status of ≥3 (OR: 2.39). CONCLUSIONS: Age is not contraindication for surgery in the elderly. It is important to assess comorbidities and perform surgical procedures as soon as possible to shorten the surgical period.

Reconstruction of Abdominal Wall Defects Using a Pedicled Anterolateral Thigh Flap including the Vastus Lateralis Muscle: A Report of Two Cases.

The purpose of abdominal wall reconstruction is to prevent hernias and protect the abdominal viscera. In cases involving full-thickness defects of the rectus abdominis muscle, the muscle layer should be repaired. We present 2 cases in which full-thickness lower rectus abdominis muscle defects were reconstructed using vastus lateralis-anterolateral thigh flaps. The pedicled vastus lateralis-anterolateral thigh flap provides skin, fascia, and muscle tissue. Furthermore, it has a long neurovascular pedicle and can reach up to the periumbilical area and cover large defects. We consider that this muscle flap is a good option for repairing full-thickness lower abdominal defects.