How to reconstruct a natural and deep umbilicus: three methods of umbilicoplasty for five types of umbilical deformities.

UNLABELLED: Conventional methods of umbilicoplasty using V-Y advancement flap often result in unnatural wide or shallow umbilical depressions facing upward or downward. Moreover, although the umbilical deformities have many variations, no report has described the selection of an umbilicoplasty method for types of umbilical deformity. To resolve these problems, we devised 3 methods of umbilicoplasty. In this report, we classified all kinds of umbilical deformities into 5 types, and studied the most suitable method for each type of umbilical deformity. METHOD: The umbilical deformities are classified into Type 0: the defect of umbilicus; Type I, the low-grade protrusion; Type II, the high-grade protrusion with wide base; Type III, the high-grade protrusion with narrow base; and Type IV, the protrusion in depression. The most suitable method among our 3 methods was adapted to each type. Method 1 with a S-shaped skin incision was adapted to Type 0 and I, Method 2 with fan-style flaps was adapted to Type II, and Method 3 with dividing the umbilical protrusion was adapted to Type III and IV. RESULTS: Sixty-three patients (10 cases of Type 0, 31 cases of Type I, 10 cases of Type II, 5 cases of Type III, and 7 cases of Type IV) underwent umbilicoplasty using the suitable method, and all were well corrected. CONCLUSIONS: Using the best choice among our 3 methods, it is easy to create a natural, vertically long and deep umbilical depression without conspicuous scars in all types of umbilical deformities.

Repair of a huge vesicocutaneous fistula with the rectus femoris musculocutaneous flap and VAC.

Adequate drainage is a prerequisite for closing a vesicocutaneous fistula, but the continued exposure to urine makes this impossible. Here, VAC was successfully used as a preoperative therapy before flap transplantation.

Microsurgeons are superstitious? A statistical survey by questionnaire.

In Japan, many people believe in superstitions or omens. Microsurgery results, however, are scientific and thus considered to be black or white. Even if the operator is a proficient master, the possibility of flap necrosis is inevitable. It can be said that microsurgeons live in a world of uncertainty where "might" rules. How do they prepare themselves for an operation? We administered a questionnaire to front-line Japanese microsurgeons and thereby attempted to examine the mental side of these experts. We constructed a detailed questionnaire regarding several factors, including the annual number of microsurgeries, the consciousness of daily life, the physician before and after the operation, and even concerning superstition, habits for good luck, or other beliefs. We sent the survey to the front-line Japanese microsurgeons in our country by e-mail and 20 replies were returned. Many of the surgeons prepare themselves before the operation, from the day before until just before the operation. These surgeons can be divided into three types: type A, microsurgeons who prepare themselves on a daily basis and do not believe in a charm or a jinx; type B, those who do not prepare themselves especially in daily life, but have some charm or jinx; and type C, surgeons who do not have special daily preparation or belief in a superstition. The type C group included a significant number of experienced microsurgeons. Experienced microsurgeons as leaders or trainers of young microsurgeons tend to be natural and not mystic in daily life and thus tend not to be superstitious.

Intracerebral foreign body granuloma caused by a resorbable plate with passive intraosseous translocation after cranioplasty.

Numerous reports have demonstrated the usefulness of bioresorbable materials, but few have described severe complications caused by delayed degradation. The authors present the case of an intracranial foreign body granuloma caused by plates made of unsintered hydroxyapatite (uHA) particles and poly-l-lactide (PLLA; Super Fixsorb MX, Takiron) after cranioplasty. This 1-month-old boy presented to the authors' department with Pfeiffer syndrome. He had multiple-suture synostosis causing turribrachycephaly, Chiari malformation Type 1, and obstructive sleep apnea syndrome. At 6 months old, the child was treated with multidirectional cranial distraction osteogenesis. The uHA-PLLA plates were applied as base stones to reinforce the pins. After 16 days of distraction and 3 weeks of consolidation, the pins were removed. Seventeen months postoperatively, the plate on the right temporal bone showed passive intraosseous translocation (PIT), and by 2 years postoperatively, the plate was completely left behind in the cerebrum. At 3.5 years postoperatively, MRI disclosed a contrast-enhanced mass with surrounding brain edema at the site of the plate. The lesion was resected. The clinical history and histological specimens led to a diagnosis of foreign body granuloma surrounding the nonabsorbed resorbable plate in the dura mater. Resorbable plates are clearly useful resources in cases in which delayed absorption will not prove problematic, but careful application and follow-up is required when dealing with the growing skull given the possibility of intracranial displacement after PIT.

The versatile perifascial areolar tissue graft: adaptability to a variety of defects.

Reconstruction using flaps with good blood circulation is appropriate for covering an intractable ulcer or a fistula in which tendon or bones are exposed. A non-vascularised perifascial areolar tissue (PAT) graft can also survive in such an area. This study reports the versatile application of a PAT graft for use as a non-vascularised graft material. A total of 32 patients were treated between April 2004 and December 2010 (16 men and 16 women). The donor sites were the inguinal region in 20, the thigh in 11, and the subclavian region in one. There were 13 inlay grafts to the dead space after tumour resection, eight closures for cerebrospinal fluid leakage, seven skin ulcers with exposed bones and tendons, three fistulas, and one vascular leak of the common carotid artery. The total survival rate of the grafts was 91%. The complications associated with this procedure included infection in 9% and seroma in the donor site in 19%. However, all cases improved after conservative treatment. The PAT is a pliable loose areolar tissue with a rich vascular plexus, and the harvesting technique is quite simple and minimally invasive. The PAT graft could therefore represent an alternative for flaps that are used as a free graft material for the reconstruction of such defects as intractable skin ulcers, fistulas or dead spaces that usually require reconstruction with vascularised flaps.

Mandible reconstruction using the calcium-sulphate three-dimensional model and rubber stick: a new method, 'mould technique', for more accurate, efficient and simplified fabrication.

BACKGROUND: Osteocutaneous flaps are one of the best options for one-stage mandible reconstruction. However, the challenge remains to achieve optimal functional and cosmetic results. A new novel approach involving the preoperative prefabrication of a reconstructive plate through a calcium-sulphate three-dimensional (3D) model facilitates the contouring of vascularised bone grafts. We herein report our preparations and results using this technique. METHODS: A total of 17 mandibular defects were reconstructed by this novel approach. A calcium-sulphate 3D model was constructed from computed tomography (CT) data. After the oncologist designed the cut line on the model, the mandibular arc was ground to the neo-mandible shape, which consisted of several linear planes according to the osteotomy of the bone graft. The reconstruction plate was shaped to fit this. After tumour resection, the prefabricated plate was placed to the remaining mandible and revealed the defect to be reconstructed, just as a mould. Rubber sticks were used as a template to shape the bone graft. The preoperative information, and functional and aesthetic results were retrospectively analysed. RESULTS: As many as 12 fibular and 5 scapular flaps were applied. Postoperative complications included two salivary fistulae, one abscess and one partial skin loss, all of which were resolved after conservative treatment. Postoperatively, all patients could speak clearly, 12 had a normal diet and 12 had excellent cosmetic results. CONCLUSIONS: This is the first report using models made by calcium-sulphate. The largest advantage of this model is that the neo-mandible shape can be demonstrated preoperatively. The refinement of mandible reconstruction after tumour ablative surgery can be achieved with a prefabricated plate through the use of a calcium-sulphate 3D model. It enables more accurate, faster and simplified fabrication of reconstruction plates, thus leading to satisfactory functional and cosmetic results.

Surgical repair of transverse facial cleft: oblique vermilion-mucosa incision.

Various surgical techniques have been reported for the repair of the transverse facial cleft using a straight-line closure, Z- or W-plasty, local flaps, etc. However, several problems remain such as deviation, distortion and scars in the commissure and cheek. To resolve these problems, we studied the anatomy of the commissure again and devised the most reasonable method for repair of the transverse facial cleft. In our new method, oblique vermilion and mucosa incision lines, 45 degrees to the vermilion-cutaneous junction, were designed. After mucosal closure, the orbicularis muscle was reconstructed by cross-overlap joining the upper muscular bundle over the lower muscular bundle at an angle of 90 degrees. The skin was sutured using horizontal straight-line closure with a small Z-plasty lateral to the nasolabial fold. We performed the new method on seven macrostomias. The patient cohort consisted of four girls and three boys, and their ages ranged from 4 months to 3 years. Symmetrical commissure and natural oral movement was obtained in the past five cases. The scar around the commissure and cheek was inconspicuous in all cases. The new method used the oblique vermilion-mucosa incision and straight-line closure, the cross-overlap joining of the muscular bundles at an angle of 90 degrees , and the horizontal straight-line skin closure with a small Z-plasty lateral to the nasolabial fold. This method, which is anatomically reasonable, can construct a symmetrical and natural commissure without conspicuous scars.

Aesthetic repair for syndactyly of the toes using a plantar rectangular flap.

BACKGROUND: Use of a dorsal rectangular flap is the most common method of creating a deep interdigital space for syndactyly of the toes. However, the pigmented skin grafts exposed to the dorsal side are conspicuous. To resolve this problem, several methods have been reported. However, the local flap methods could be adapted only in mild syndactylies, and plantar skin flaps exposed to the dorsal side are too whitish. Meanwhile, in the methods using skin grafts from the inframalleolar region, the marginal scars of the skin grafts are still conspicuous on the dorsal side. To resolve these problems, the authors devised a new surgical method using a plantar rectangular flap. METHODS: In this method, the authors designed a rectangular flap on the plantar side. Only a small triangular flap and a slight zigzag skin-incision line were designed on the dorsal side. The plantar rectangular flap was put down into the bottom of the interdigital space and was sutured with the dorsal triangular flap. Full-thickness skin was grafted to the raw surface at the sides of the divided toes. RESULTS: The authors performed this method on 18 syndactylies of 12 patients. In all cases, the corrected toes showed a deep and natural interdigital space without exposure of skin grafts or conspicuous scars. CONCLUSIONS: The authors devised the plantar rectangular flap to avoid extra skin defects on the dorsal side. Using this method, the authors can create a deep interdigital space without any exposure of skin grafts or whitish plantar skin flaps on the dorsal side. This method is not appropriate for syndactyly of the fingers but is an ideal method for syndactyly of the toes.

Three-step orbitofacial reconstruction after extended total maxillectomy using free RAM flap and expanded cervicofacial flap with cartilage grafts.

Facial defect after an extended total maxillectomy is one of the most difficult deformities to reconstruct aesthetically, because the defect is not only large but also three-dimensional. Although free-flap reconstruction is useful, the patchwork-like scar, bad colour match and poor texture match are major problems. The contracture and displacement of the reconstructed eyelids and eye socket are also serious matters. To resolve these problems, we have performed a three-step reconstruction using a free rectus abdominis myocutaneous (RAM) flap and an expanded cervicofacial flap with cartilage grafts. In the first step, a free RAM flap was transplanted to the defect after extended total maxillectomy. In the second step, tissue expanders were placed under the skin of the cheek and neck a year after the RAM flap transplantation. After expansion of the cheek and neck skin, the third step was performed. The inferior part of the external skin island of the RAM flap was raised and sutured to the superior margin of the skin island to create a pouch for the eye socket. Costal cartilage was grafted to reconstruct the orbital floor and malar prominence, and auricular cartilage was grafted to reconstruct the tarsal plates. Finally, the expanded cervicofacial flap was rotated to cover this construct. Two weeks after reconstruction, the neo-eyelids were divided to form the lid fissure. We performed the three-step reconstruction on six cases after extended total maxillectomy. In all cases, a deep and stable eye socket was reconstructed. The reconstructed eyelids and cheek were natural in appearance with good colour and texture match without conspicuous scars. To obtain symmetry and natural appearance in the orbitomaxillary reconstruction, there are five points that should be formed; the eye socket, the groundwork of the eye socket, the orbital floor and malar prominence, the tarsal plates and the surface of the eyelids and cheek. We do not reconstruct the palate to set prosthetic dentures and to clean the surface of the skin island in the nasal cavity. To reconstruct the indispensable five points and achieve satisfying results, we propose this three-step reconstruction.

Combined sliding flap using a single perforator enables simple closure of the donor site: a case report.

We report the case of a 39-year-old man with a dermatofibrosarcoma protuberans (DFSP) on the right shoulder. A wide surgical excision of the tumour was performed, creating a 12-cm-wide defect. An anterolateral thigh flap created from two semicircular skin paddles was harvested and the two skin paddles were slid towards each other to cover the circular defect. The sliding technique is a useful design that preserves the suprafascial plexus and enables a single perforator to supply two split-skin paddles. Using this design, the donor site can be closed primarily without requiring a skin graft. This technique can be applied to other free flaps to reconstruct wide defects after the resection of cancers.

Salvage of infected tissue expanders using a new continuous irrigation method with intermittent aspiration.

When tissue expander sites are infected, it often results in removal of the expander. To salvage the infected expander and achieve full expansion, we devised a new continuous irrigation method with intermittent aspiration. In this method, the continuous irrigation of the tissue expander pocket was performed without removal of the expander. Saline was continuously infused at 50 ml h(-1) via the IVH catheter and intermittent aspiration was done at 10 cm H(2)O negative pressure via the suction drainage tube for 3 min per hour until the infection was under control. We performed this method on two cases of infection of tissue expander sites and salvaged both expanders. After controlling the infection, reconstructions were successfully performed with enough skin expansion. In this method, the expander left in the pocket acts not only in maintaining the expanded pocket but also helps in irrigating the inner surface of the skin pocket. This method can perform effective irrigation with a relatively small amount of saline (1200 ml per day) and salvage the tissue expander.

Breast reconstruction using tissue expander and TRAM flap with vascular enhancement procedures.

The transverse rectus abdominis myocutaneous (TRAM) flap can create a good breast shape, however, the patchwork-like scar obviously shows that the breast has been reconstructed. To reconstruct a breast without the patchwork-like appearance, we used a two-stage procedure using a tissue expander before transplanting a de-epithelialised TRAM flap. In addition, to avoid fat necrosis and resorption in a large TRAM flap, we performed two vascular enhancement procedures, surgical delay and supercharging microvascular anastomosis. The surgical delay, which consisted of an extended skin island delay and a vascular delay, was performed when the tissue expander was placed under the breast skin in the first stage. As the extended skin island delay, zones 3 and 4 of the TRAM flap were elevated and silicone sheets were laid under the flaps. As the vascular delay, the deep inferior epigastric vessels (DIEV) on the pedicle side were ligated. In the second stage, the de-epithelialised TRAM flap was transferred into the expanded breast skin pocket. The flap was double pedicled with supercharging microvascular anastomosis between DIEV on the contra-pedicle side of the flap and the thoracodorsal vessels of the recipient site. This surgery was performed on 20 post modified radical mastectomy patients to reconstruct large breasts without patchwork-like scars, and every TRAM flap survived perfectly without fat necrosis or resorption. All patients were satisfied with the reconstructed breasts and the abdominal contour without abdominal wall hernia or any other complications.