Long-term survival of the Sister Mary Joseph nodule originating from breast cancer: A case report.

BACKGROUND: A Sister Mary Joseph nodule (SMJN) is an uncommon cutaneous metastasis found in the umbilicus, indicating an advanced malignancy. SMJNs typically originate from intra-abdominal sources, rarely from breast cancer. Diagnosis suggests a poor prognosis with a median survival of approximately 8 mo after detection. Managing patients with SMJNs is challenging, as most receive limited palliative care only. The optimal strategy for long-term survival of these patients remains unclear. CASE SUMMARY: A 58-year-old female, previously diagnosed with right breast cancer 17 years ago and underwent breast-conserving surgery, adjuvant radiotherapy, and endocrine therapy, presented with a 2-cm umbilical nodule. Thirteen years previously, metastases were detected in the right supraclavicular, infraclavicular, hilar, and mediastinal lymph nodes. An umbilical nodule emerged four years before the date of presentation, confirmed as a skin metastasis of primary breast cancer upon excisional biopsy. Despite initial removal, the nodule recurred and grew, leading to her referral to our hospital. The patient underwent extensive excision of the umbilical tumor and immediate abdominal wall reconstruction. Endocrine therapy was continued postoperatively. Five years later, no local recurrence was observed, and the patient continued to work full-time, achieving over 9 years of survival following SMJN diagnosis. CONCLUSION: This case study aimed to identify the optimal strategy for achieving extended survival outcomes in patients with SMJN through comprehensive treatment. We presented a case of the longest survival in a patient after undergoing a multidisciplinary treatment regimen. Our findings underscore the significance of adopting a multimodal treatment approach comprising timely and wide excision along with adjunctive therapy. This approach can control the disease, prolong survival, and improve the quality of life in patients with SMJN.

Ultrafast sensitivity-controlled and specific detection of extracellular vesicles using optical force with antibody-modified microparticles in a microflow system.

Extracellular vesicles (EVs), including nanoscale exosomes and ectosomes, hold promise as biomarkers that provide information about the cell of origin through their cargo of nucleic acids and proteins, both on their surface and within. Here, we develop a detection method of EVs based on light-induced acceleration of specific binding between their surface and antibody-modified microparticles, using a controlled microflow with three-dimensional analysis by confocal microscopy. Our method successfully detected 103-104 nanoscale EVs in liquid samples as small as a 500 nanoliters within 5 minutes, with the ability to distinguish multiple membrane proteins. Remarkably, we achieved the specific detection of EVs secreted from living cancer cell lines with high linearity, without the need for a time-consuming ultracentrifugation process that can take several hours. Furthermore, the detection range can be controlled by adjusting the action range of optical force using a defocused laser, consistent with the theoretical calculations. These findings demonstrate an ultrafast, sensitive, and quantitative approach for measuring biological nanoparticles, enabling innovative analyses of cell-to-cell communication and early diagnosis of various diseases, including cancer.

Light-Induced Condensation of Biofunctional Molecules around Targeted Living Cells to Accelerate Cytosolic Delivery.

The light-induced force and convection can be enhanced by the collective effect of electrons (superradiance and red shift) in high-density metallic nanoparticles, leading to macroscopic assembly of target molecules. We here demonstrate application of the light-induced assembly for drug delivery system with enhancement of cell membrane accumulation and penetration of biofunctional molecules including cell-penetrating peptides (CPPs) with superradiance-mediated photothermal convection. For induction of photothermal assembly around targeted living cells in cell culture medium, infrared continuous-wave laser light was focused onto high-density gold-particle-bound glass bottom dishes exhibiting plasmonic superradiance or thin gold-film-coated glass bottom dishes. In this system, the biofunctional molecules can be concentrated around the targeted living cells and internalized into them only by 100 s laser irradiation. Using this simple approach, we successfully achieved enhanced cytosolic release of the CPPs and apoptosis induction using a pro-apoptotic domain with a very low peptide concentration (nM level) by light-induced condensation.

Attogram-level light-induced antigen-antibody binding confined in microflow.

The analysis of trace amounts of proteins based on immunoassays and other methods is essential for the early diagnosis of various diseases such as cancer, dementia, and microbial infections. Here, we propose a light-induced acceleration of antigen-antibody reaction of attogram-level proteins at the solid-liquid interface by tuning the laser irradiation area comparable to the microscale confinement geometry for enhancing the collisional probability of target molecules and probe particles with optical force and fluidic pressure. This principle was applied to achieve a 102-fold higher sensitivity and ultrafast specific detection in comparison with conventional protein detection methods (a few hours) by omitting any pretreatment procedures; 47-750 ag of target proteins were detected in 300 nL of sample after 3 minutes of laser irradiation. Our findings can promote the development of proteomics and innovative platforms for high-throughput bio-analyses under the control of a variety of biochemical reactions.

Wearable, wireless, multi-sensor device for monitoring tissue circulation after free-tissue transplantation: a multicentre clinical trial.

Wearable sensors have seen remarkable recent technological developments, and their role in healthcare is expected to expand. Specifically, monitoring tissue circulation in patients who have undergone reconstructive surgery is critical because blood flow deficiencies must be rescued within hours or the transplant will fail due to thrombosis/haematoma within the artery or vein. We design a wearable, wireless, continuous, multipoint sensor to monitor tissue circulation. The system measures pulse waves, skin colour, and tissue temperature to reproduce physician assessment. Data are analysed in real time for patient risk using an algorithm. This multicentre clinical trial involved 73 patients who underwent transplant surgery and had their tissue circulation monitored until postoperative day 7. Herein, we show that the overall agreement rate between physician and sensor findings is 99.2%. In addition, the patient questionnaire results indicate that the device is easy to wear. The sensor demonstrates non-invasive, real-time, continuous, multi-point, wireless, and reliable monitoring for postoperative care. This wearable system can improve the success rate of reconstructive surgeries.

Microsurgical Lymphovenous Anastomosis for Pelvic Lymphoceles after Gynecological Cancer Surgery.

BACKGROUND: Pelvic lymphoceles are the most common complications after pelvic lymphadenectomy. Microsurgical procedures have attracted attention as an alternative treatment for lymphoceles. Here, we report six cases of refractory lymphoceles that were successfully treated using lymphovenous anastomosis (LVA). METHODS: Six patients underwent surgery for gynecological cancers and developed pelvic lymphoceles, which did not respond to conventional treatment. We mainly performed LVA on the ipsilateral lower limbs, although some procedures were also performed on the contralateral limbs. The change in the lymphocele volume after LVA was examined using computed tomography and compared using the Wilcoxon test. RESULTS: Five of the six refractory lymphocele cases were successfully treated using LVA, and the remaining case exhibited an 87% reduction in lymphocele volume. The average numbers of anastomoses were 6.7 on the ipsilateral side and 2.8 on the contralateral side (the median numbers: 6 [range: 5-9] vs. 3 [range: 1-4], P = 0.034). The average lymphocele volume decreased significantly from 414.0 mL preoperatively to 8.0 mL postoperatively (the median lymphocele volume: 255.8 [range: 61.5-1,329.2] vs. 0 [range: 0-47.7], P = 0.0313). CONCLUSION: We found that microsurgical treatment was potentially effective for lymphoceles that did not respond to conventional treatment.

Lymphatic-venous anastomosis for the treatment of refractory lymphatic ascites following radiation therapy: A case report.

Radical treatments for intra-abdominal malignancies disturb physiological lymphatic drainage and predispose the patients to lymphatic complications such as lymphatic ascites. Despite its infrequent occurrence, lymphatic ascites is a morbid complication, and a definitive treatment protocol for refractory cases has not been established. Surgical treatments are opted depending on the etiology, symptoms, and facility equipment. Lymphatic-venous anastomosis (LVA) bypasses the proximal lymphatic blockages and provides an alternative route for lymphatic fluid recirculation into the venous system, thereby improving the lymphatic congestion. Herein, we report the utility of LVA surgery in the treatment of refractory serous lymphatic ascites that developed after radiation therapy for cervical cancer in a 77-year-old woman. The patient had massive ascites and suffered from abdominal distention and anorexia for 1 year. The ascites was unresponsive to conservative treatment. Under local anesthesia, eight incisions were made in the lower extremities just above the lymphatic channels that were identified by indocyanine green lymphography, and a total of 14 LVAs were created. The postoperative course was uneventful, and the ascites improved significantly. The patient remained free from the recurrence of ascites during 3.5 years of postoperative follow-up. LVA surgery was effective for the improvement and long-term control of lymphatic ascites. This procedure may be a viable option for the management of lymphatic ascites.

Sacral defect reconstruction using a sensate superior gluteal artery perforator flap based on the superior cluneal nerves: A report of two cases.

The superior gluteal artery perforator (SGAP) flap is a widely used flap for sacral reconstruction. However, it is non-sensate flap and sensory loss is one of the most important risk factors for pressure ulcer development and recurrence; therefore, a sensate SGAP flap would be ideal for the reconstruction. Because the upper buttock is innervated by the superior cluneal nerves (SCNs) which originate from Th11 to L4, a sensate SGAP flap based on SCNs is anatomically possible. Herein, we present a novel sensate SGAP flap based on SCNs for reconstruction of sacral defects. Two patients with a sacral defect underwent reconstruction using a sensate SGAP flap (53 and 56 years old, both men). Diagnoses were sacral spindle cell sarcoma and sacral pressure ulcer. The defect sizes were 16 × 13 and 12 × 11 cm. The flap was designed based on the locations of SCNs which are commonly located at 6-8 cm lateral from the midline at the iliac crest. Flap sizes were 16 × 9 and 15 × 13 cm, respectively. The flaps survived completely in both cases. Flap sensation was observed immediately after surgery except in flap margins. However, sensory recovery occurred in these areas as well several months postoperatively. None of the patients developed postoperative pressure ulcers during the follow-up period of 37 and 13 months. This method may preserve flap sensation and therefore can contribute to reducing the risk of postoperative pressure ulcers and could be a useful option for sacral reconstruction.

Superficial Circumflex Iliac Perforator-Osteocutaneous Flap for Reconstruction of Extensive Composite Defects in the Forefoot.

Although the great toe plays important roles in walking, loading, and maintaining balance when compared with other toes, there are few reports on great toe reconstruction, including the reconstruction of distal phalanx. This report aims to describe the use of a superficial circumflex iliac artery perforator (SCIP)-osteocutaneous flap for reconstructing a complex tissue defect of the great toe. A 62-year-old man presented with a crush injury to the forefoot. Because the great toe was severely crushed, the defect distal to the proximal phalanx of the great toe was reconstructed using a SCIP-osteocutaneous flap. The immediate postoperative course was uneventful; however, surgical revision was necessary. Signs of osseous union could be observed on radiographic images taken 2 months after the initial surgery. Twenty-four months after surgery, the patient could freely walk without resorption of the transferred bone. We demonstrated that SCIP-osteocutaneous flaps may be promising free flaps in complex tissue defect reconstruction of the great toe.

Superthin Thoracodorsal Artery Perforator Flap for the Reconstruction of Palmar Burn Contracture.

Treating burn scar contractures is challenging. Although free flap transfer is an effective tool for hand reconstruction, free flaps are often bulky, causing functional disturbance and poor cosmetic appearance. Secondary debulking operations are required, resulting in a prolonged total treatment period and delayed return to daily life and work for the patient. Therefore, 1-stage reconstruction using a thin and pliable flap is ideal. In this report, we present the superthin TDAP flap as an option for the reconstruction of postburn palmar contracture. During TDAP flap elevation, the thoracodorsal artery perforator was identified and traced distally until its penetration into the dermis. Subsequently, the subdermal tissue was removed and a uniformly superthin TDAP flap was elevated. Postoperatively, early functional recovery was achieved with excellent palmar contour and texture. No revision surgery was required and no recurrence of contractures occurred during the 6-month follow-up. This procedure is useful in elevating a superthin TDAP flap and is a feasible option for the reconstruction of working surfaces, such as the palm.

Effective Secondary Reconstruction of Refractory Urethrocutaneous Fistula after Metoidioplasty Using Folded Superficial Circumflex Iliac Artery Perforator Flap.

One of the primary goals of penile reconstruction for female-to-male transsexuals is to enable voiding while standing. Metoidioplasty represents a viable option, but it is associated with a high rate of postoperative fistula formation and recurrence, which affects the aesthetic and functional outcomes. Subsequent surgical repair using scarred and inadequate local tissue may contribute to fistula recurrence. The folded superficial circumflex iliac artery perforator (SCIP) island flap offers sufficient well-vascularized tissue and skin envelope for the reconstruction of the urethra and outer skin after failed metoidioplasty. The SCIP flap can be elevated as a hairless thin flap, making it useful in urethral reconstruction even when it is folded. We describe a case of a 44-year-old female-to-male transsexual patient who developed a refractory urethrocutaneous fistula after metoidioplasty. Surgical repairs were attempted using local tissue 4 times without success. The patient presented to our hospital, and we performed urethral reconstruction using a folded, pedicled SCIP flap for both urethra and skin augmentation. The postoperative course was uneventful, with satisfactory functional results and low donor-site morbidity. No fistula recurrence was observed during the 2 years of follow-up. This novel procedure offers a viable alternative technique for refractory urethrocutaneous fistula repair.

Resection and Reconstruction of Giant Abdominoscrotal Arteriovenous Malformation.

Genital arteriovenous malformations are rare and present unique surgical challenges in preserving urogenital function, abdominal wall integrity, and lower limb perfusion. A 32-year-old man with a giant abdominoscrotal arteriovenous malformation presented with recurrent heavy bleeding. Due to the high risk of rebleeding and fatal hemorrhage, surgery with curative intent was proposed and the patient was counseled on the risks of ischemia to the lower limb, testes, and penis. Preoperative embolization of the feeding vessels was performed. Three days later, surgical excision of the mass with the affected scrotum, left rectus muscle, sheath, and overlying abdominal skin followed. The testes were dissected from the malformation and preserved along with the right internal pudendal artery. The left thigh skin was advanced to the scrotal remnants and a neoscrotum created. The resulting large abdominal wall defect was reconstructed in layers with a pedicled anterolateral thigh flap, including innervated vastus lateralis muscle, to prevent herniation. Recovery was uneventful, and a 4-year follow-up revealed no significant clinical or radiological recurrence with recovery of flap sensation, retained erectile function, and no herniation. We report this case due to rarity of giant abdominoscrotal arteriovenous malformations and present preoperative embolization, surgical resection, and functional anterolateral thigh flap reconstruction as a valuable treatment option of this life-threatening illness.

Two-stage Reconstruction Using a Free Jejunum/Ileum Flap After Total Esophagectomy.

BACKGROUND: Reconstruction after esophagectomy is conventionally performed with a gastric conduit. However, in cases where a gastric conduit is unavailable, reconstructive procedures vary in terms of flap type, operative timing, and conduit route. Single-stage surgery is associated with a long operation time and high surgical stress, resulting in perioperative mortality. Recent advances in reconstructive microsurgery have made free intestinal flap transfer safe and reliable. Therefore, to overcome the shortcomings with previous methods, we performed 2-stage surgery involving free jejunum/ileum transfer for reconstruction after esophagectomy. PATIENTS AND METHODS: From 2010 to 2018, 42 free jejunum/ileum flaps were transferred for reconstruction after esophagectomy in 41 patients. The diagnosis was esophageal cancer in 38 patients. All operations were performed in 2 stages. In most cases, total esophagectomy was performed in the first operation. The cervical stump of the esophagus was sutured to the cervical skin, creating an esophagostomy in the left neck. About 4 to 7 weeks after the first operation, the second operation was performed. The free jejunum/ileum flap was transferred through the subcutaneous route. Microvascular anastomosis was performed with the internal mammary artery and internal mammary vein, transverse cervical artery, internal and external jugular veins (internal jugular vein and EJV, respectively), and cephalic vein. The mean follow-up duration was 20 months. RESULTS: Free jejunum/ileum transfer was performed as the first operation in 4 cases and as the second operation in 38 cases. A free jejunal flap was used in 36 cases and free ileal flap was used in 6 cases. The recipient arteries were the internal mammary artery in 38 cases and transverse cervical artery in 4 cases. The recipient veins were the internal mammary vein in 15 cases, cephalic vein in 13 cases, EJV in 10 cases, and internal jugular vein in 10 cases. The flaps survived in all cases, except 1 case (41/42, 97.6%). The complications were anastomotic leakage of the flap in 9 cases, respiratory complications in 10 cases, and ileus in 2 cases. Perioperative mortality was not noted. CONCLUSIONS: Two-stage surgery using free jejunum/ileum flap transfer is a safe and reliable option for esophageal reconstruction in cases where gastric pull-up is unavailable.

Use of the transverse branch of the superficial circumflex iliac artery as a landmark facilitating identification and dissection of the deep branch of the superficial circumflex iliac artery for free flap pedicle: Anatomical study and clinical applications.

BACKGROUND: The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the "transverse branch" of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications. METHODS: Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient. RESULTS: In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5-50 mm). The average dimension of the flap was 13.1 × 5.9 cm2 . All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow-up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results. CONCLUSIONS: The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

Additional venous anastomosis in free profunda artery perforator flap transfer using the posterior accessory saphenous vein.

BACKGROUND: The profunda artery perforator (PAP) flap has recently been widely used for head and neck as well as breast reconstruction. Although this flap has various advantages, its vascular pedicle is relatively smaller and shorter than that of other workhorse flaps such as the anterolateral thigh flap. The posterior accessory saphenous vein (pASV) is a branch of the great saphenous vein, which runs in the posteromedial aspect of the thigh and can be included in the PAP flap. Here, we present the anatomical characteristics of the pASV and feasibility of its use in PAP flap transfers. PATIENTS AND METHODS: An anatomical study of the pASV was conducted in nine lower extremities of five patients using ultrasonography. Several landmarks such as point A (the point where the pASV crosses the posterior border of the adductor longus muscle), point B (the point where the pASV merges with the great saphenous vein) and the inguinal crease, were marked. Distribution of the pASV was plotted, and several distances were measured. On the basis of the anatomical study, nine free PAP flap transfers were performed. RESULTS: In the anatomical study, the mean diameter of the pASV was 3.4 and 4.9 mm at points A and B, respectively. The mean available length of the pASV was 9.4 cm. In clinical cases, all flaps completely survived. No flap-related complication was observed. The pASV was included in the PAP flap in eight cases. The mean length of the harvested pASV was 8.6 cm, and the mean diameter was 3.3 mm. Indocyanine green angiography showed effective drainage using the pASV alone. CONCLUSIONS: The use of the pASV can be an effective option, particularly for head and neck reconstruction, and its application in various types of reconstructive surgery can be widened.

A Simple Skin Incision Design for Pediatric Superficial Branch of Superficial Circumflex Iliac Artery.

BACKGROUND: Superficial circumflex iliac artery (SCIA) perforator flap is one of the demanding flaps. However, little is known about SCIA anatomy, which is crucial for successful SCIA perforator flap elevation, in children. We assessed the efficacy of our incision design to detect the superficial branch of the SCIA in vivo. METHODS: Eleven consecutive pediatric patients who required harvesting (eg, skin grafts or vascularized lymph node transfer) were assessed. All possible congenital vascular malformation cases were excluded. To reduce potential bias, all groin procedures were performed on the contralateral side of malformations. After inguinal area mapping, 1.5-cm skin incision was made. From the window opened by the skin incision, tiny perforation to the skin surface was detected for further dissection. Following the tiny branch, the main trunk of the superficial circumflex vascular bundle was dissected. The whole vascular bundle, artery, and major vein from the bundle were dissected and their sizes were measured. RESULTS: Of the 11 patients, 4 were boys; the age range was 5 months to 14 years (mean age: 3.2 years). Vessel bundle size was 0.7-1.5 (mean: 1.1 mm). In all cases, the bundle was detected within 5 min (1-5, mean: 2.5 min). No vascular damage was observed, and all arteries pulsated well, without requiring additional skin incision. The superficial branch of the SCIA was mainly detected right below the initial skin incision. CONCLUSIONS: Our skin incision design can effectively detect the SCIA in pediatric patients and may be used in adult patients.

Use of the Distal Facial Artery (Angular Artery) for Supermicrosurgical Midface Reconstruction.

BACKGROUND: In free-flap reconstruction of the midface, options for the recipient artery are quite limited; the superficial temporal artery and the facial artery are the most commonly used arteries. We report our approach for the use of the angular artery (the terminal branch of the facial artery) as the recipient artery in free-flap reconstruction of the midface. METHODS: Nine patients with midface defects underwent free-flap reconstructions using the angular artery as the recipient artery. Identification and marking of the facial artery were performed preoperatively using handheld Doppler ultrasound. The angular artery was located through an incision made on the side of the nose. When present, a vena comitans of the facial artery or any subcutaneous vein in the vicinity of the defect was used as the recipient vein. In other cases, the facial vein in the submandibular region was chosen as the recipient vein, using a vein graft. RESULTS: The average diameter of the angular artery was 0.9 mm (range, 0.7-1.0 mm). In all cases, arterial anastomosis was performed in an end-to-end fashion, and flaps survived completely. In 4 cases, a vein graft was used to bridge the pedicle vein and the facial vein. CONCLUSIONS: Although supermicrosurgical skills may be required for its anastomosis, the angular artery is an anatomically consistent artery, which is suitable for use as the recipient artery in free-flap reconstruction of the midface. Use of the angular artery as the recipient artery allows shorter flap pedicles and decreases the number of vein grafts necessary.

Treating Pulsatile Exophthalmos in Child with Minimally Invasive Approach and Custom-made Titanium Mesh Plate.

Orbital roof fracture is a relatively rare trauma. In most cases, surgical intervention is not needed since the fracture is slight. However, invasive surgical procedures are inevitable once pulsatile exophthalmos occurs if vision impairment is to be avoided. We report our rare experience of orbital roof fracture in a child with pulsatile exophthalmos. Good reconstruction of the anterior cranial base was achieved using a custom-made titanium mesh and a minimally invasive approach. A 3-year-old girl who had been diagnosed with subdural hematoma, brain contusion, and fracture of the right orbital roof caused by facial bruising underwent emergent external decompression by coronal skin incision and a transcranial approach on the same day as the trauma. Cranioplasty using autologous frozen bone in the same approach was performed 103 days posttrauma, but this was followed by pulsatile exophthalmos. After recovering from critical stage, the girl was brought to our department for reconstruction of the anterior base. Risk of vision impairment was also one reason for reconstruction, but the neurosurgeon hesitated to approach the region using a coronal approach considering the possibility of infection in the frozen autologous bone. Through cross-team discussion, reconstruction using a subeyebrow incision was performed with a custom-made titanium mesh plate. Pulsatile exophthalmos completely disappeared. Pulsatile exophthalmos is a very rare but serious complication that carries a risk of vision impairment. By applying a custom-made titanium mesh plate, precise reconstruction was enabled with minimal invasiveness and low risk.