Multiple Lymphaticovenular Anastomoses for Chyluria in Klippel-Trenaunay Syndrome.

ABSTRACT: Klippel-Trenaunay syndrome (KTS) is characterized by port-wine stains, mixed vascular malformations, and soft tissue and bone hypertrophy. Klippel-Trenaunay syndrome is occasionally complicated by chyluria, for which there is no effective treatment currently. We report a case of KTS complicated by intractable chyluria and hematuria due to a lymphatic-ureteral fistula. The patient was successfully treated with multiple lymphaticovenular anastomoses (LVAs).A 66-year-old woman with an enlarged left lower extremity since childhood was diagnosed with KTS. At 60 years of age, she developed chyluria (urine albumin, 2224 µg/mL) and hematuria. Lymphoscintigraphy showed a lymphatic-ureteral fistula near the ureterovesical junction. Conservative treatment was ineffective. She also developed left lower extremity lymphedema, which gradually worsened. Leg cellulitis and purulent pericarditis developed because of hypoalbuminemia (minimum serum albumin level, 1.3 g/dL).We performed 14 LVAs in 2 surgeries to reduce lymphatic fluid flow through the lymphatic-ureteral fistula. The chyluria and hematuria resolved soon after the second operation, and the urine albumin level decreased (3 µg/mL). After 28 months, she had no chyluria or hematuria recurrence and her serum albumin level improved (3.9 g/dL). Multiple LVAs can definitively treat chyluria caused by a lymphatic-ureteral fistula in patients with KTS.

Rapid Forehead Ossification due to a Subperiosteal Hematoma in a Patient With Neurofibromatosis Type 1.

Rapid ossification due to a subperiosteal hematoma in extremities has occasionally been documented in patients with neurofibromatosis type 1, but it has not been reported in the maxillofacial region. The authors present the first case of a subperiosteal hematoma in the forehead. A 36-year-old man presented with a rapidly swelling firm, fixed, 8×10 cm forehead mass. It became evident shortly after a fine-needle aspiration biopsy. Computed tomography imaging 2 months after the biopsy showed a hematoma that was encapsulated by a surrounding layer of ossification. Magnetic resonance imaging displayed a fluid-fluid level under the ossified area. These characteristic images led us to diagnose this rare lesion as a subperiosteal hematoma with ossification. Rapid ossification is a characteristic imaging finding of subperiosteal hematoma, which makes definitive diagnosis easy. It becomes imperative to underscore the potential risks of fine-needle aspiration in proximity to the periosteum in patients with neurofibromatosis type 1.

Lymphaticovenular anastomosis for lymph vessel injury in the pelvis and groin.

BACKGROUND: Lymphatic diseases due to lymph vessel injuries in the pelvis and groin require immediate clinical attention when conventional treatments fail. We aimed to clarify the effectiveness of and indications for lymphaticovenular anastomosis (LVA) to treat these lymphatic diseases. METHODS: We retrospectively evaluated six patients who underwent LVA for lymphatic diseases due to lymph vessel injuries in the pelvis and groin. Specific pathologies included groin lymphorrhea (N = 3), chylous ascites (N = 2), and retroperitoneal lymphocele (N = 1). The maximum lymphatic fluid leakage volume was 150-2600 mL daily. Conventional treatments (compression, drainage, fasting, somatostatin administration, negative pressure wound therapy, or lymph vessel ligation) had failed to control leakage in all cases. We performed lower extremity LVAs after confirming the site of lymph vessel injury using lymphoscintigraphy. We preferentially placed LVAs in thigh sites that showed a linear pattern by indocyanine green lymphography. Postoperative lymphatic fluid leakage volume reduction was evaluated, and leakage cessation was recorded when the drainage volume approached 0 mL. RESULTS: LVA was performed at an average of 4.3 sites (range, 3-6 sites) in the thigh and 2.7 sites (range, 0-6 sites) in the lower leg. Lymphatic fluid leakage ceased in all cases after a mean of 6 days (range, 1-11 days) postoperatively. No recurrence of symptoms was observed during an average follow-up of 2.9 (range, 0.5-5.5) years. CONCLUSIONS: LVA demonstrates excellent and rapid effects. We recommend lower extremity LVA for the treatment of lymphatic diseases due to lymph vessel injuries in the pelvis and groin.

Use of negative pressure wound therapy to treat a cochlear implant infection around the auricle: a case report.

Although negative pressure wound therapy (NPWT) is widely used, its application to the head and neck region remains challenging due to anatomical complexities. This report presents the case of a female patient presenting with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes, uncontrolled diabetes and severe bilateral sensorineural hearing loss. The patient had undergone cochlear implant surgery and five months later the wound was infected with methicillin-resistant Staphylococcus aureus (MRSA). NPWT was started shortly after removing the internal receiver and was stopped 11 days later. NPWT helped in controlling infection and led to a successful wound closure. In this case, NPWT was effective in treating infectious wounds around the auricle after cochlear implant surgery. Declaration of interest: The authors have no financial support for this article and no conflict of interest directly relevant to the content of this article.

Toxic Shock Syndrome Caused by Staphylococcal Infection After Breast Implant Surgery: A Case Report and Literature Review.

Toxic shock syndrome is a rare but life-threatening complication after breast implant surgery. We describe a 77-year-old woman who developed toxic shock syndrome caused by methicillin-resistant Staphylococcus aureus after breast implant reconstruction. Despite a high fever and markedly increased white blood cell count, suggesting severe infection, she initially had no symptoms of local findings, such as wound swelling and redness of the breast. Soon after diagnosis of toxic shock syndrome and removal of her breast implant, she was recovered from the shock state. To date, 16 cases of toxic shock syndrome have been reported, including this case, and they were related to breast implants or tissue expander surgery. The common and noteworthy characteristic of these cases was the lack of local findings, such as swelling or redness, which suggests infection. Therefore, early diagnosis is generally difficult, and the initiation of proper treatment can be delayed without knowledge of this characteristic. Toxic shock syndrome requires early diagnosis and treatment. If the patient has a deteriorated vital sign after breast implant surgery or tissue expander breast reconstruction, toxic shock syndrome should be suspected, even if there are no local signs of infection, and removal of the artifact should be considered as soon as possible.

Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: A case report.

Fournier's gangrene is lethal necrotizing fasciitis that involves the perineum and external genitalia. We describe the case of a 52-year-old man with Fournier's gangrene who underwent reconstruction of an extensive perineoscrotal defect using three pedicled perforator flaps. Three debridement procedures resulted in a skin and soft tissue defect of 36 × 18 cm involving the perineum, scrotum, groin, medial thigh, buttocks, and circumferential perianal area and left the perforating arteries originating from these locations unavailable for reconstruction. We repaired the defect using left deep inferior epigastric artery perforator (DIEP) (29 × 8 cm) and bilateral anterolateral thigh perforator (ALT) flaps (35 × 8 cm and 22 × 7 cm). The flaps reached the defect without tension, and the defect was successfully covered without a skin graft. No postoperative complications occurred except for epidermal necrosis involving a tiny part of the DIEP flap tip. Nine months postoperatively, the patient experienced no impairment of bowel function or hip joint movement. There was also no avulsion or ulceration of the reconstructed perineal skin, and the cosmetic appearances of the healed wound and donor site were satisfactory. The combination of these three perforator flaps enabled us to achieve a satisfactory outcome while avoiding skin grafts.

Securing split-thickness skin grafts using negative-pressure wound therapy without suture fixation.

OBJECTIVE: Negative-pressure wound therapy (NPWT) is generally applied as a bolster for split-thickness skin grafts (STSG) after the graft has been secured with sutures or skin staples. In this study, NPWT was applied to secure STSGs without any sutures or staples. Surgical outcomes of using NPWT without sutures was compared with a control group. METHODS: Patients with STSGs were divided into two groups: a 'no suture' group using only NPWT, and a control group using conventional fixings. In the no suture group, the grafts were covered with meshed wound dressing and ointment. The NPWT foam was placed over the STSG and negative pressure applied. In the control group, grafts were fixed in place using tie-over bolster, securing with fibrin glue, or NPWT after sutures. RESULTS: A total of 30 patients with 35 graft sites participated in the study. The mean rate of graft take in the no suture group was 95.1%, compared with 93.3% in the control group, with no significant difference between them. No graft shearing occurred in the no suture group. Although the difference did not reach statistical significance, mean surgical time in the no suture group (31.5 minutes) tended to be shorter than that in the control group (55.7 minutes). CONCLUSION: By eliminating sutures, the operation time tended to be shorter, suturing was avoided and suture removal was not required meaning that patients could avoid the pain associated with this procedure. Furthermore, the potential for staple retention and its associated complications was avoided, making this method potentially beneficial for both medical staff and patients.

Omental and deep inferior epigastric artery perforator flap coverage after heart transplantation to manage wide left ventricular assist device exposure with pocket infection.

Infection is a serious potential complication after left ventricular assist device (LVAD) implantation. In general, infection of the device pocket, with device exposure, should be managed by early device removal and heart transplantation. However, because of the small number of donors in Japan, accelerating access to heart transplantation is often difficult and the LVAD can be widely exposed during the waiting period. We report our experience of successful heart transplantation in a patient with a widely exposed LVAD with pocket infection. A 48-year-old man suffered from heart failure due to idiopathic dilated cardiomyopathy. An LVAD was implanted, but postoperative infection led to blood pump exposure. Heart transplantation was performed 4 months after LVAD exposure, at which time the epigastric skin defect measured 14 × 8 cm. The skin defect could not be closed after heart transplantation, so it was covered by an omental flap with split-thickness skin grafts. 7 days postoperatively, the peritoneal suture broke and the intestinal tract prolapsed outside the body. Reintroduction of the prolapsed intestinal tract and deep inferior epigastric artery perforator (DIEP) flap coverage of the omental flap were performed. The postoperative course was uneventful. There have been no reports of the management of wide skin defects in the presence of infection when heart transplantation is performed. Omental flap placement was useful for controlling long-lasting infection. An omental flap placed in a patient with a wide epigastric skin defect should be covered by durable skin flap, such as a DIEP flap, to avoid intestinal prolapse.

Extensor Hallucis Brevis Tendon Transfer for the Correction of Drop Toe Deformity After Dorsalis Pedis Tendocutaneous Free Flap Harvest.

The dorsalis pedis tendocutaneous (DPTC) free flap is an ideal option for the reconstruction of the combined defect of the dorsal hand skin and multiple extensor tendons, whereas it possess not only soft tissue problems, but also symptomatic drop toe deformity in the donor site. We have corrected this drop toe deformity with a tendon transfer technique, using the extensor hallucis brevis muscle, which was preserved during the DPTC free flap harvest. The donor site exposing the transferred tendons was covered with another thin free flap. Two cases that underwent this technique exhibited satisfactory alignment and active extension of the toes. This tendon transfer technique combined with free flap coverage overcomes almost all the problems in the donor site of the DPTC free flap, achieving excellent contours of both the dorsal hand and the foot.

Infrahyoid myofascial flap transfer for the prevention of concave deformity and gustatory sweating after parotidectomy.

OBJECTIVE: Concave deformities and gustatory sweating are the most common complications that cause substantial patient dissatisfaction after parotidectomy. Various surgical methods to prevent these complications have been described. However, effective techniques have not been established, especially in patients with medium- to large-sized parotidectomy defects. We evaluated the utility of infrahyoid myofascial flap reconstruction of parotidectomy defects for the prevention of these complications. METHODS: We conducted a retrospective case series study in patients with a benign or malignant parotid tumor measuring over 4 cm who underwent immediate pedicle infrahyoid myofascial flap reconstruction after total or subtotal parotidectomy or total resection of either the superficial or deep parotid gland at our hospital. Subjective analyses of facial symmetry, postoperative concave deformities of the anterior neck, gustatory sweating, voice disorders, odynophagia, neck scarring in the parotid and anterior neck areas, sensory disorders, pain, and neck stiffness were performed using patient interview data. Objective evaluations of facial symmetry were made by the first or second author. Both analyses were performed after a follow-up of more than six months. Additionally, patient demographic data, clinicopathological factors, parotidectomy and skin incision types, flap survival, and postoperative complications were evaluated. RESULTS: We included eight patients (male, n=5; mean age, 69.3 years [range, 37-93 years]). Procedures included total or subtotal parotidectomy (n=4), superficial lobe parotidectomy (n=2), and deep lobe parotidectomy with partial superficial lobe parotidectomy (n=2). Infrahyoid myofascial flaps reached the cranial tip of the parotid defect without tension, and their volume sufficiently filled the parotidectomy defect in all patients. There were no local signs of insufficient blood flow within the transferred flaps. Objective and subjective assessments were made after a mean duration of 1.2 years (range, 0.6-1.8). Postoperatively, no patient subjectively reported facial asymmetry. Objectively, facial symmetry was "good" in four patients and "fair" in four patients. No distinctly visible concave deformity in the parotid or anterior neck area occurred in any patient. Gustatory sweating occurred in one patient; this individual had the largest parotidectomy defect. Only one patient experienced donor site morbidity (mild anterior neck stiffness) related to infrahyoid myofascial flap elevation. CONCLUSION: Although complete prevention of gustatory sweating was unsuccessful, infrahyoid myofascial flap reconstruction of medium- to large-sized parotidectomy defects led to postoperative facial symmetry with minimal donor site morbidity.

Videofluorographic Analysis of Swallowing Function after Total Glossolaryngectomy.

SUMMARY: Surgeons have traditionally believed that swallowing is mainly dependent on gravity after total glossolaryngectomy. However, swallowing function after total glossolaryngectomy varies widely among patients, and a thorough analysis is lacking. The authors aimed to clarify the swallowing function after total glossolaryngectomy and determine whether it is primarily dependent on gravity. The authors retrospectively analyzed videofluorographic examinations of patients who underwent total glossolaryngectomy and free or pedicle flap reconstruction. The authors enrolled 20 patients (12 male; mean age, 61 years; age range, 43 to 89 years). All patients demonstrated constriction of the reconstructed pharynx to some degree, and no patient's ability to swallow was dependent on gravity alone. Videofluorography showed excellent barium clearance in eight patients and poor clearance in 12. All patients with excellent clearance showed strong constriction of the posterior pharyngeal wall, whereas only 8.3 percent of the patients with poor clearance showed adequate constriction, which was significantly different ( p = 0.0007). Velopharyngeal closure and lip closure also contributed significantly to excellent clearance ( p = 0.041). The shape of the reconstructed pharynx (depressed, flat, protuberant) showed no statistically significant association with excellent clearance. Contrary to previous understanding, constriction of the remnant posterior pharyngeal wall played an important role in swallowing after total glossolaryngectomy, and gravity played a secondary role. Dynamic posterior pharyngeal wall movement might result from the increased power of the pharyngeal constrictor muscle and compensate for the immobility of the transferred flap. A well-functioning pharyngeal constrictor muscle and complete velopharyngeal and lip closures can contribute to excellent barium clearance in patients after total glossolaryngectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Selective epithelial ischemia of transferred free jejunum after late loss of its vascular pedicle.

Free flaps are considered to revascularize from the surrounding tissue and survive without their original pedicle flow after a certain period postoperatively. We report 2 patients who developed mucosal ischemia of the transferred jejunum by ligation of its vascular pedicle 10 and 25 months after microvascular free jejunal transfer. Both patients had a history of heavy smoking, and had undergone definitive radiotherapy and previous surgery to the recipient bed. Both were treated conservatively; however, a stenotic change of the transferred jejunum remained in 1 patient. If poorly revascularized flaps, such as jejunal flaps, were transferred to the irradiated and scarred recipient bed, revascularization might never reach completion. If pedicle division is required in such cases, reanastomosis of the pedicle would be ideal regardless of the time after the transfer.

Volumetric changes of transferred free anterolateral thigh flaps in head and neck lesions.

OBJECTIVE: The purpose of this study was to clarify sequential volumetric changes of anterolateral thigh (ALT) flaps transferred to head and neck lesions. PATIENTS AND METHODS: We retrospectively analyzed volumetric changes in fat and muscle of 22 ALT flaps. We assessed "true" flap volume using the water-displacement method intraoperatively. Postoperative flap volume was assessed using three-dimensional volume-calculating software. RESULTS: The average duration until the entire flap volume decreased to its minimal size was 8.7 months. After 8.7 months, entire flap volume decreased to 47.4% of its initial intraoperative volume. The fat volume decreased to 62.5%, and the muscle volume decreased to 30.2%. The rate of muscle volume decrease was significantly larger than that of fat volume decrease (p<0.005). The only significant factor which affected entire flap volume decrease was the recipient site where the ALT flap was transferred (oral and pharyngeal lesions) (p=0.001), and the factor that affected fat volume decrease was postoperative body-weight loss (p=0.046). CONCLUSION: To minimize the influence of postoperative ALT flap volume decrease, an ALT flap should mainly comprise fatty tissue, and its size should be 1.6-times larger (100/62.5) than the ideal volume intraoperatively. Maintaining the body weight is crucial to avoid ALT flap volume decrease.

A Double-Barreled Fibular Graft for the Reconstruction of Both Forearm Bones and Humeroradial Joint after a Tumor Resection.

A double-barreled fibular graft was used to reconstruct both forearm bones and the humeroradial joint after tumor resection. The patient had a tumor of radius that invaded the ulna and extensor groups. After a wide tumor resection, vascularized fibular autograft and soft tissue reconstruction was performed. A fibular graft were placed as a double barrel in the proximal ulnar and radial defects including the radial head and fixed using two locking plates. Simultaneously, reconstruction of the humeroradial joint and wrist dorsiflexion was performed. Two years postoperatively, the patient is satisfied with his elbow function while performing activities of daily living. Although amputation was one of the options considered during the preoperative planning in this case, the affected limb could be preserved by grafting a double-barreled fibula and tendon transfer, which could maintain the function of his upper left limb.

Successful Management of a Severe Sacral Pressure Injury Penetrating to the Retroperitoneum.

INTRODUCTION: Reports of retroperitoneal infection related to a sacral pressure injury (PI) are rare, and none of the reports described the direct spread of infection through the sacrum to the retroperitoneum. The authors present, to their knowledge, the first report of a severely infected PI that showed full-thickness sacral destruction and direct retroperitoneal penetration. CASE REPORT: A 63-year-old female was referred for management of a stage 4 sacral PI complicated by a retroperitoneal abscess. The patient's comorbidities were diabetes mellitus and pemphigus foliaceus with steroid therapy-induced immunosuppression. Upon admission, the patient presented with a sacral PI producing copious purulent discharge that measured 5 cm × 3 cm. Magnetic resonance imaging revealed full-thickness sacral bone destruction and a massive retroperitoneal abscess, suggesting the sacral PI directly penetrated to the retroperitoneal space. Antibiotics were administered, and surgical debridement and sequestrectomy were performed. Negative pressure wound therapy (NPWT) with continuous saline irrigation was initiated. The patient's mesorectum was exposed within the retroperitoneal space. Therefore, a nonadhesive wound dressing was applied before placing the irrigation tube to avoid perforating the rectum. Because the patient had fragile skin secondary to long-standing pemphigus foliaceus and steroid treatment, a liquid skin protectant and hydrocolloid wound dressing were applied. The infection was successfully controlled with NPWT with saline irrigation. The patient experienced no rectal injury or skin rupture, and surgical closure was performed after 75 days. Although partial wound dehiscence occurred because of the poor condition of the skin, the resultant open wound was managed conservatively. The patient showed no retroperitoneal abscess recurrence 6 months later. CONCLUSIONS: A rare case of an intractable sacral PI complicated by retroperitoneal abscess was successfully managed in an immunocompromised patient. Notably, NPWT with saline irrigation was useful in controlling the patient's severe retroperitoneal infection.

Relative level of thymidylate synthase mRNA expression in primary tumors and normal tissues predicts survival of patients with oral tongue squamous cell carcinoma.

Thymidylate synthase (TS) is a major target of 5-fluorouracil (5-FU) and dihydropyrimidine dehydrogenase (DPD) is a rate-limiting enzyme in the degradation of 5-FU. There are no studies investigating the comparison of TS and DPD mRNA expressions in oral tongue SCC (OSCC) and nontumor tissues obtained from the same patients. In addition, increased interest has been focused on the biological roles of TS and DPD as the independent prognostic factors as well as responsive determinants for cancer patients with 5-FU based therapy. We determined the expression levels of TS and DPD in tumor (T) and nontumor squamous epithelial tissues (N) of OSCC using real-time reverse transcription-polymerase chain reaction and evaluated whether the T/N ratio would correlate with clinicopathological factors. The mRNA expressions of TS and DPD were significantly higher in tumor areas than in nontumor areas. No correlation was found between the T/N ratio of each mRNA expression and gender, clinical stage, T classification, N classification or differentiation. The T/N ratio of TS in patients that died of disease was significantly higher than in patients with free of disease, whereas there were no relationships between The T/N ratio of DPD and disease status. Clinical follow-up data showed shorter overall survival periods for cases with high T/N ratio of TS than for cases with low T/N ratio of TS with the statistically significant. Our study showed that TS but not DPD seems to have prognostic value in OSCC. These findings suggest that the assessment of TS activity may be useful both in the management and in the treatment of OSCC.

Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation.

BACKGROUND: Various surgical treatments have been advocated for stump pain and phantom limb pain after limb amputation but the most effective is unknown. We report a case of intractable stump pain and phantom limb pain of the upper limb, which was successfully treated by end-to-end coaptation of the cutaneous nerves after multimodal treatment failures. CASE DESCRIPTION: A 39-year-old man was referred to our department with a history of severe stump neuroma-related pain and phantom limb pain of his right upper limb. He had undergone multiple treatments over 26 years including medication, nerve blocks, and repeated surgeries. None had been successful for relief of pain. The clinical assessment showed a point of marked tenderness around the medial stump of the upper arm. Ultrasound-guided peripheral infiltration of local anaesthetic around the medial stump produced significant relief of his pain. Exploration around the medial limb stump revealed two stump neuromas of the medial cutaneous nerves of the forearm. Both stump neuromas were resected, and their stumps were coapted to each other. After 4 years, he was completely relieved of his pain and without any sensory deficit. CONCLUSION: Successful nerve coaptations for painful stump neuromas of the upper limb are reported rarely. This case suggests this method can be helpful. The patient burden was minimal because it involved the resection and coaptation of the two neuromas. This method should be encouraged for cases of intractable stump-related pain in the upper limb. HOW TO CITE THIS ARTICLE: Kadota H, Ishida K. Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation. Strategies Trauma Limb Reconstr 2020;15(1):50-53.

Perforator Branch Flaps.

BACKGROUND: Modern microsurgical reconstruction aims to achieve functional and satisfactory esthetic outcome and the primary thinning procedure results in one-stage reconstruction. However, current techniques are lacking preoperative knowledge of the peripheral perforator in the adipose layer. We hypothesized that the combination of the knowledge of microvasculature and visualization of such small vessels in the adipose layer by Color Doppler ultrasonography (CDU) will make the dissection of these vessels with simultaneous flap thinning of the perforator branch flap technique feasible and provide consistent results in variety of flaps. METHODS: Retrospective chart review of consecutive cases in which perforator branch flap technique was used from 2011 to 2019 was conducted. Entire course of branch of the perforator in the adipose layer were traced up to the dermis by CDU, and marked on the skin surface. Based on CDU finding, perforator branches were dissected in the adipose layer simultaneously with the primary thinning of the skin flap. RESULTS: Thirty perforator branch flaps in 28 cases were elevated. Courses of the perforator branches detected by CDU accurately corresponded to surgical findings in all cases. There was no total flap loss in any of the cases and partial necrosis in one case. In five flaps, a secondary debulking procedure was needed. CONCLUSIONS: The combination of knowledge of microvasculature with CDU guidance has made the perforator branch technique possible and allowed to safely transfer the skin flap from various body areas to the defect, thereby, achieving "like with like" reconstruction in one-stage.

Successful local use of heparin calcium for congested fingertip replants.

BACKGROUND: Conventional methods of external bleeding for congested fingertip replants exhibit notable problems, including uncontrollable bleeding and unpredictable survival of the replant. We have added a local injection of heparin calcium to the routine use of systemic heparinization for inducing external bleeding. We retrospectively examined patients who underwent external bleeding using our method. METHODS: Local subcutaneous injections of heparin calcium were made in 15 congested replants in addition to systemic heparinization. Each injection ranged from 500 to 5,000 U. The average duration of the injections was 4.1 days. Surgical outcomes were analyzed and compared with a control group of patients who underwent external bleeding without heparin calcium. RESULTS: The overall survival rate was 93.3%, which was higher than that of the control group (83.3%), but the difference was not statistically significant (P=0.569). The survival rate for subzones I and II by the Ishikawa subzone classification was 100%, whereas it was 87.5% in subzones III and IV. No statistically significant difference was observed. The rate of partial necrosis was 0% in subzones I and II, whereas it was significantly higher (66.7%) in subzones III and IV (P=0.015). The mean total blood loss via external bleeding was 588 g in 10 fingers. No patients required blood transfusion. CONCLUSIONS: Congestion of a replanted fingertip can be successfully managed without blood transfusion by our method. Although complete relief from congestion in replants in subzones I and II is achievable, there is a higher risk of partial necrosis in subzones III and IV.