Petrous internal carotid artery aneurysm rupture induced by Eustachian tube catheterisation: case report.

BACKGROUND: Petrous internal carotid artery aneurysms are very rare vascular lesions, which may present with otalgia and life-threatening massive otorrhoea. CASE REPORT: An 84-year-old woman presented at a local otolaryngology clinic with progressive otalgia due to an acute exacerbation of chronic otitis media. She was referred with left-sided massive otorrhoea following Eustachian tube catheterisation. She suffered another massive otorrhoea with epistaxis during left-sided ear cleaning at a clinic visit. Contrast-enhanced computed tomography and computed tomography angiography revealed a left-sided aneurysm and adjacent stenosis at the left internal carotid artery. Coil embolisation of the petrous internal carotid artery aneurysm was performed with percutaneous transluminal angioplasty followed by dilatation of the stenosis. CONCLUSION: Computed tomography angiography should be performed immediately when a patient reports massive otorrhoea. Endovascular occlusion is a treatment option as it avoids complications of open surgical ligation procedures.

[Clinical application of prefabricated super-thin perforator flaps after expansion in the reconstruction of facial and cervical scar].

OBJECTIVE: To explore a combined application of tissue expansion, perforator flaps and super-thin flaps in reconstruction of extensive face and neck scars. METHODS: In the first stage, the position and course of the perforators were confirmed with the multi-detector computed tomography ( MDCT) and color Doppler ultrasound. The expanders were implanted between subdermal vascular plexus and superficial fascia. In the second stage, the expanded super-thin perforator flaps were transferred to resurface the extensive defects and deformities in the face and neck. RESULTS: 26 cases with extensive facial and cervical scars were included in this study. Except for one case with necrosis at the distal end, the other 25 flaps survived completely. The maximum flap size was 35 cm x 10 cm with a pedicle of 8 cm x 4 cm. Long-term follow-up showed that this combined application provided thinner flap than the conventional pre-expanded flap, thus avoiding secondary flap debulking and revisions. All the patients got improvement in contours, facial features and emotional expression. CONCLUSIONS: The combined application of tissue expansion, perforator flaps and super-thin flaps is a practical method which has advantages in feature recontouring and recovery of delicate emotions in reconstruction of extensive face and neck scars.

Propeller flaps: classification and clinical applications.

Propeller flaps feature a highly reliable reconstructive method, based on a perforator vessel. Since their introduction in 1991, a great variety of propeller flaps have been described, according to their shape and their potential of coverage. Indeed, these flaps have progressively been refined and modified, concerning their vascularity and space design. The authors present a classification of propeller flaps. This anatomical classification is necessary to understand the dissection procedure and the differences between the numerous types of propeller flaps nowadays described. It is the international classification, which should be used for the description and conception of these flaps.

Infantile hemangiopericytoma--case report and literature review.

Infantile hemangiopericytoma is a rare soft tissue neoplasm of pericytic origin and is almost always benign, despite its worrisome pathologic features. We describe a 2-month-old male infant with a soft tissue mass on his right thigh. Histologically, the lesion showed a characteristic hemangiopericytoma-like vascular pattern, multilobulation, and moderate mitotic activity. These morphologic features were prediagnosed as infantile hemangiopericytoma. However, immunohistochemical and ultrastructural studies revealed a heterogeneous cellular composition, primarily pericytes and endothelial cells, similar to that observed in infantile myofibromatosis.

Flap-in-flap method for enhancing the advancement of a V-Y flap.

The V-Y principal is used in a number of flap reconstruction techniques. V-Y flaps suffer from design problems of the advancing edge, which is usually concave, trying to match another concave edge on the opposite side of the defect. The flap-in-flap technique uses a second V-Y flap at the advancing edge of the main flap to overcome this mismatch, and also improves the amount of advancement possible. The technique has been used in three patients, demonstrating reliability and a further advantage, which is the ability of the second flap to rotate at an angle to the main flap to aid in reconstructing a complex defect such as the alar base of the nose. Further experience with this technique should widen its applications.

Penis reconstruction using three different operative methods.

To identify the relative success rates, including aesthetic success, of three penis reconstruction techniques, we reviewed 44 cases of penis reconstruction carried out over the past 12 years. The three operative methods we surveyed involved: lower abdominal pedicled fascia flaps; paraumbilical island flaps; and free forearm flaps. Reconstructions survived in only half of the patients receiving lower abdominal pedicled fascia flaps, but 100% success rates were obtained with paraumbilical island flaps and free forearm flaps. The paraumbilical island flap is safe in terms of its blood supply, and the operative procedure is relatively simple in that it does not require microsurgery. Although, the flap is thicker than the forearm skin flap, its shape is satisfactory in slim patients; furthermore, it can be defatted secondarily. The free forearm skin flap provides the best shape, but skilled microsurgery is necessary to carry out the procedure, and damage is likely to the forearm. In conclusion, the best methods to repair defects in the penis in our experience are the paraumbilical island flap and free forearm flap. Lower abdominal pedicled fascia flaps are unsuitable for penile reconstruction and should be used less often.

A rare case of intracranial metastatic amelanotic melanoma with cyst.

A rare case of intracranial metastatic amelanotic melanoma with cyst is presented. The patient was a 51 year old woman with a malignant melanoma arising on her right chest. Two years after a wide excision, skin and brain metastasis occurred. Brain magnetic resonance images demonstrated a tumour with a cyst in the left occipital lobe. Because the tumour showed low intensity on T1 weighted images and high intensity on T2 weighted images, the metastatic melanoma was identified as an amelanotic melanoma. Intracranial amelanotic melanoma is very rare, and there have been few reports of melanoma with cyst.

An anatomical and clinical study of the dorsal intercostal cutaneous perforators, and application to free microvascular augmented subdermal vascular network (ma-SVN) flaps.

We report a two-part anatomical and clinical study whose aim was to map the dominant dorsal intercostal cutaneous perforators (DICPs), which are useful for microvascular augmentation of flaps raised from the skin of the back called subdermal vascular network (SVN) flaps, and to test their reliability in the clinical setting. In the anatomical arm of the study, using preserved cadavers, we macroscopically confirmed the location of DICPs, and performed micro-angiography of the dorsal skin to find each dominant DICP. In the clinical arm of the study, we confirmed the location of the dominant DICP during microvascular augmented SVN flap transfer. Postoperatively, posteroanterior radiographs of the chest were taken to locate vessel clips used to ligate the DICPs. The combined study results showed that the dominant DICP is the sixth or seventh in most instances, but there are some anatomical variations. If no dominant DICP is found in the sixth or seventh spaces, at least one DICP that is of sufficient calibre for microvascular augmentation can usually be found in the general vicinity, such as the fifth, eighth or ninth spaces. The clinical application of microvascular augmented SVN flaps, both pedicled and free, is presented.

The microvascular augmented subdermal vascular network (ma-SVN) flap: its variations and recent development in using intercostal perforators.

In 1994 we reported the use of the microvascular augmented occipito-cervico-dorsal 'super-thin' flap for reconstruction of the cervical region in three cases. Since this preliminary report, we have performed a further 17 flaps, and the usefulness of the flap in the treatment of anterior cervical scar contractures in extensively burned patients has become apparent. Moreover, we have devised flaps with not only a narrow skin pedicle but also myocutaneous or island vascular pedicles. Various augmentation vessels, including myocutaneous perforators of the intercostal spaces in the back and chest, have also been used successfully. Here, we describe the microvascular augmented subdermal vascular network flaps that we have devised.

An elderly patient with gastric carcinoma developing multiple metastasis in skeletal muscle.

We present a 70-year-old man with gastric carcinoma developing multiple metastasis in skeletal muscle. He had a right supraclavicular lymph node swelling. Brain, chest and abdomen CT scans revealed metastatic lesions in the brain, lung, liver and bilateral adrenal glands. Further, CT showed a ring enhanced soft-tissue mass in the left lumbar muscle. Needle aspirate of the mass in both the left lumbar muscle and the right enlarged supraclavicular lymph node revealed cells suggestive of poorly differentiated adenocarcinoma. Upper gastrointestinal endoscopic evaluation demonstrated an advanced gastric carcinoma. Two months after admission, the tumor in the left lumbar muscle had grown and some new lesions in the left iliopsoas muscles appeared. Intramuscular metastasis from gastric carcinoma is an extremely rare phenomenon.

Scrotal reconstruction with a thinned flap based on both inferior epigastric arteries. Case report.

A 62-year-old man presented with an extensive defect of the scrotum caused by Fournier's gangrene. We reconstructed the scrotum using a thinned flap based on both inferior epigastric arteries one month after the first debridement. This method has the advantage of achieving adequate mobility of the reconstructed scrotum. The results were satisfactory both functionally and cosmetically, although we had to repair a hernia at the donor site a year later.

Immediate reaugmentation of the breasts using bilaterally divided TRAM flaps after removing injected silicone gel and granulomas.

The authors present eight cases of reconstruction of the breasts using bilaterally divided TRAM flaps after removing the injected silicone gel and granulomas. In Japan, we have the opportunity to examine many patients who have had foreign substance injections to the breasts for purposes of augmentation however, most of them are now suffering from delayed complications. Until now we have reconstructed breasts such cases by use of silicone bag prostheses after removal of granulomas; however, now it is difficult to obtain silicone prostheses. Thus, we have decided to reconstruct by the use of autogenous cutaneous and adipose tissue flaps as presented by us in this article.

Treatment of nevus of Ota by Q-switched ruby laser.

The effectiveness of the Q-switched ruby laser was investigated in 38 patients with nevus of Ota at more than 10 months after the first irradiation. In 14 patients who were followed-up for a mean of 25.2 months after the first treatment, the effectiveness was evaluated as "excellent" in eight patients (57%), "good" in four patients (28%), and "fair" in two patients (14%). The mean number of irradiation treatments was 7.3 in the "excellent" group, 4.2 in the "good" group, and 3.0 in the "fair" group. In 24 patients who were followed-up for a mean of 13.6 months after the first treatment, the effectiveness was evaluated as "excellent" in eight patients (33%), "good" in 12 patients (50%), and "fair" in four patients (16%). The mean number of irradiation treatment was 5.7 in the "excellent" group, 5.2 in the "good" group, and 2.5 in the "fair" group. Even after repetitive irradiations, good results without scarring were noted in all cases except one where a slight inverted scar was developed. The effective rate tended to be higher in patients who underwent more irradiation treatments and were observed for a longer period of time. Satisfactory cosmetic results were achieved after Q-switched ruby laser therapy for nevus of Ota.

Experimental study of allogeneically vascularized prefabricated flaps.

The authors fashioned vascularized island flaps using cryopreserved allogeneic vascular bundles as the vascular pedicles in rabbits. Auricular vessels of 8 cm in length were harvested and cryopreserved in liquid nitrogen for 30 days. The allovascular bundles were anastomosed into the recipients' native auricular vessels. Dorsal flaps (6 x 6 cm) in the recipient were raised on the implanted allovascular bundle. Eight days later, the flaps were elevated as vascular island flaps nourished by the allovascular bundle. Computed microangiography demonstrated the anastomoses between the vasculatures of the implanted vessels and the recipient sites 8 days after vascular implantation in the dorsal flap. Flap survival estimation, which was done 1 week after flap elevation, showed flap viability. Allogeneic vascular bundles proved their potential utility as vascular pedicles of autologous tissue transfer.

The "super-thin" flap.

The so-called "super-thin" flap was devised in China and these flaps have been in general use since about 1982. However, detailed descriptions of the flaps have rarely appeared in English Language journals. In this paper, we present the development of our use of these flaps in clinical cases, and discuss some factors which seem to contribute to the increase of the survival area of the distal portion of these so-called "super-thin" flaps.

Microvascular augmentation of the super-thin occipito-cervico-dorsal flap.

The super-thin flap technique was first devised in China. Flaps thinned by this technique are especially useful in the neck, face or hands of patients with extensive burn scarring, where the combination of thinness and suppleness is needed. However, some of these radically thinned flaps may suffer from superficial or full thickness necrosis due to the unpredictability of survival of the super-thinned area. In this paper, we present a technique of microvascular augmentation of the blood supply of the thinned flap, an example of so-called "supercharging".

Heel coverage with a T-shaped distally based sural island fasciocutaneous flap.

Two cases of heel damage that were reconstructed with a T-shaped distally based island fasciocutaneous flap in the sural area are presented. This flap is vascularized by the distal sural arterial network. The advantages of this flap are: (1) It does not sacrifice any major arteries of the leg. (2) It covers the whole calcaneal area with a one-stage operation. (3) It can be elevated without losing any nerve sensitization in the leg. (4) The donor site can be closed with primary sutures when the flap is small enough. We conclude that our procedure is suitable for reconstructing soft tissue defects of the calcaneal area.