Polypropylene Mesh Infection From Surgical Site Infections Caused by Mycobacterium fortuitum.

This report highlights two cases of surgical site infections (SSIs) caused by Mycobacterium fortuitum (Mf) following abdominal mesh implantation. The first case involved an 83-year-old male experiencing non-healing erythema and wounds post-operation, which persisted despite multiple treatments, until effective management was achieved with targeted antibiotics after Mf identification. The second case concerned a female patient with a gynecological postoperative hernia, where Mf was quickly detected following SSI onset three weeks after surgery. Prompt mesh removal and appropriate antibiotic treatment led to a rapid and full recovery. These cases emphasize the importance of early detection and intervention in managing Mf infections effectively, illustrating how the timing of diagnosis can significantly influence treatment outcomes.

Early Predictors of Fistula Formation Following Head and Neck Reconstruction.

BACKGROUND: Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation. METHODS: We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula. RESULTS: In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value. CONCLUSION: CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.

A Clinical Study of Histopathological and Clinical Image Changes After Sclerotherapy of Lip Venous Malformations.

Venous malformations (VMs) are histopathologically benign but can greatly impair patients' quality of life. Screlothprapy is known to be effective in improving symptoms without a scar, but surgical resection of residual lesions is sometimes necessary due to inadequate reduction. However, there is no consensus on what criteria should be used to consider switching to surgical treatment, and individualized decisions must be made for each case. To investigate the factors that contribute to the lack of efficacy of sclerotherapy in reducing lesions and how to predict this, the authors performed a retrospective clinical imaging and histopathological study of 6 cases of labial vein malformations treated with sclerotherapy and 3 cases without sclerotherapy. Clinical image investigations are based on magnetic resonance imaging before and after sclerotherapy. The authors found a significant decrease in the percentage of cystic components in the total lesion of VMs after sclerotherapy. Histopathological investigations are based on resected VMs with or without sclerotherapy. Elastica van Gieson stains suggested a significant increase in fibrotic tissue inside VMs treated with sclerotherapy compared with those without. In conclusion, magnetic resonance imaging signal changes inside the VMs after sclerotherapy was observed, and it may reflect fibrosis of the tissue. These changes in the VMs after sclerotherapy may reduce the effect of sclerotherapy on tissue reduction should be considered.

The superficial branch of the radial nerve and sensory disturbance in the radial forearm flap donor-site.

Introduction: Sensory disturbance due to injury of the superficial branch of the radial nerve (SBRN) is a donor-site morbidity of the radial forearm (RF) flap. The relationship between the SBRN preservation method and the post-operative sensation at the flap donor-site was retrospectively investigated. Methods: We included 39 patients who underwent head and neck reconstruction with a free RF flap at Hyogo Cancer Center between April 2014 and March 2018. The patients were classified into the following three groups according to the SBRN preservation method: group 1, zero preservation, excision of the entire SBRN; group 2, main trunk preservation, excision of all branches except the main trunk of the SBRN; and group 3, complete preservation, preservation of the entire SBRN. Objective sensations and subjective symptoms at the flap donor-site were analyzed. Results: The mean objective sensory scores were 3.18, 2.97, and 1.78 in groups 1, 2, and 3, respectively. Differences between groups 1 and 3 and between groups 2 and 3 were significant (p = 0.0035 and p = 0.037, respectively). The mean subjective symptom scores were 2.40, 1.33, and 1.40 in groups 1, 2, and 3, respectively. Differences between groups 1 and 2, and between groups 1 and 3 were significant (p = 0.032 and p = 0.019, respectively). Conclusions: Zero preservation method had a higher risk of subjective symptoms and objective hypoesthesia development at the flap donor-site than the complete preservation method. Despite inevitable objective hypoesthesia, the main trunk preservation prevented the development of subjective symptoms. Complete preservation is optimal for RF flap harvest; however, in case of perforator crossing, main trunk preservation is another option.

Absorbable Barbed Continuous versus Nonabsorbable Nonbarbed Interrupted Suturing Methods for Donor-site Closure of the Rectus Abdominis Myocutaneous Flap.

Abdominal incisional hernia is a complication of the rectus abdominis myocutaneous (RAMC) flap harvest. This study aimed to compare the incidence of abdominal incisional hernia and donor-site closure time between absorbable barbed continuous (ABC) and non-absorbable non-barbed interrupted (nAnBI) methods. Methods: This study included 145 patients who underwent free RAMC flap reconstruction after head and neck cancer surgery at Kobe University Hospital between January 2012 and March 2020. The nAnBI method was selected between January 2012 and August 2016, and the ABC method was selected between September 2016 and March 2020. The incidence of abdominal incisional hernia and the average time required for donor-site closure were compared between the two groups. Results: Of the 145 patients surveyed, 116 (57 and 59 in the nAnBI and ABC groups, respectively) were followed-up for at least 90 days after the surgery. The incidence rates of abdominal incisional hernia were 0% and 5.1% (n = 3) in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.244). The average donor-site closure times were 127.6 and 111.3 minutes in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.122). Conclusions: No significant differences in the incidence of abdominal incisional hernia and donor-site closure time were observed between the nAnBI and ABC groups. However, there was a tendency for increased hernia occurrence and shorter wound closure time in the ABC group. A randomized prospective multicenter study is warranted to validate our findings of the ABC method.

Salvage surgery for mesenteric lymph node metastasis by resection of the first jejunal flap and reconstruction with the second jejunal flap.

We report a case of a second free jejunal transfer to treat metastasis in the mesenteric lymph node of the first jejunal flap. A 73-year-old man underwent total pharyngolaryngectomy, bilateral neck dissection, and free jejunal transfer for recurrent hypopharyngeal cancer [left pyriform sinus, pT2N0, moderately differentiated squamous cell carcinoma (SCC)] after radiotherapy. Seven years post-surgery, he underwent transoral videolaryngoscopic surgery for oropharyngeal cancer (soft palate, pT1N0, well-differentiated SCC). Ten years after the first jejunal transfer, metastasis was found in the mesenteric lymph node surrounding the jejunal flap's vascular pedicle. Under general anesthesia, resection of the first jejunum including the affected lymph node, and second jejunal transfer were performed. Lymph node pathological examination revealed poorly differentiated SCC, compatible with pharyngeal cancer metastasis. After neck dissection and jejunal flap transfer, lymphatic collateral pathways toward the flap's mesenteric lymph node might form. Possibly, hypopharyngeal or oropharyngeal cancer metastasized via this pathway.

A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection.

Introduction: Post-sternotomy surgical site infection (SSI) is a serious complication of cardiovascular surgery. Here, we proposed a new clinical classification and reconstructive strategy for this condition. Methods: A retrospective study based on medical records was performed on 100 consecutive cases requiring wound management by plastic surgeons for post-sternotomy SSI at Kobe University Hospital between January 2009 and December 2021. We classified 100 cases into four categories according to the anatomical invasiveness of the infection (type 1, superficial SSI; type 2, sternal osteomyelitis; type 3, mediastinitis; and type 4, aortic graft infection). The standard treatment plan comprised initial debridement, negative pressure wound therapy with continuous irrigation, and reconstructive surgery. Reconstructive methods and their outcomes (in-hospital mortality rate, follow-up period, and infection recurrence rate) were investigated for each SSI category. Results: There were nine SSI cases in type 1, 28 in type 2, 25 in type 3, and 38 in type 4. The pectoralis major (PM) muscle advancement flap was mainly selected in types 1 and 2 (100 and 70.4%, respectively), while the omental flap or latissimus dorsi (LD) myocutaneous flaps were mainly selected in types 3 and 4 (77.3 and 81.8%, respectively) for reconstructive surgery. The in-hospital mortality rates for types 1, 2, 3, 4 were 44.4, 3.6, 12.0, and 15.8%, respectively. The mean follow-up periods for types 1, 2, 3, 4 were 542.8, 1514.5, 1154.5, and 831.1 days, respectively. Infection recurrence rates for types 1, 2, 3, 4 were 0, 11.5, 13.3, and 19.2%, respectively. All of these recurrent cases, except for 4 cases of type 4 that required surgical intervention, were treated with conservative wound management. Conclusion: A volume-rich flap (omental or LD flap) was required to fill the dead space after debridement in mediastinitis (type 3) or aortic graft infection (type 4), whereas superficial SSI (type 1) or sternal osteomyelitis (type 2) received a less-invasive flap (PM muscle advancement flap). Our new classification method was based on the anatomical invasiveness of the infection, providing both a simple and easy diagnosis and definitive treatment strategy.

Palliative Free Flap Surgery for Plantar Sarcoma: A Case Report and Literature Review.

We report a case of palliative surgery in a 73-year-old patient with metastatic plantar sarcoma. The patient underwent resection and irradiation of an undifferentiated spindle cell sarcoma in the right plantar region. The wound was not closed and systemic metastases were observed. The chief complaint of the patient on his first visit to our department was difficulty walking due to pain in the right plantar region. Since we were unsuccessful in relieving the pain with conservative treatment, we decided to perform a palliative free tissue transfer to the right plantar. The surgery was successful, the skin ulcer healed, and the pain was relieved after the surgery. When performing palliative surgery, more detailed preoperative management and planning are necessary to achieve a successful outcome. The selection of the flaps according to the local lesion and metastatic lesions and changes in the local hemodynamics should be considered when planning.

Analysis of Orbital Blowout Fracture Location and Hess Area Ratio.

ABSTRACT: This study aimed to analyze the Hess area ratio (HAR%) in cases of blowout fracture treated in our department and clarify the outline of eye movement disorders in blowout fractures. Patients who underwent surgery for orbital blowout fractures in our department were included. Fracture locations were classified into 5 types (A, outside floor; B, C, anterior and posterior floor; and D, E, anterior and posterior medial wall). The HAR% was compared before and after surgery in eligible cases. The relationship between the fracture location and preoperative HAR% was investigated using multiple regression analysis. The study involved 85 patients. Hess area ratio was higher postoperatively than preoperatively (70.75 ±â€Š18.26 versus 90.06 ±â€Š13.99, P  < 0.01). The postoperative HAR% tended to be higher when the iliac bones were compared to other materials; however, this difference was not significant (90.73 ±â€Š12.91 versus 80.30 ±â€Š17.81, P = 0.178). Fracture locations C and E significantly contributed to the prediction of HAR% as negative regression coefficients (P = 0.024 and 0.013, respectively). The posterior fracture area on both the orbital floor and medial wall contributed to the decrease in preoperative HAR%. This observation indicates that the reconstruction of the posterior region is extremely crucial.

Simple and Easily Interpretable Flap Monitoring Method Using a Commercial Pulse Oximeter and a Widely Used Bedside Patient Monitor.

Background  Various methods for monitoring after free flap surgery have been reported in the literature. Among them, pulse oximetry shows a sensitive reaction to vascular issues, and it is easy to interpret visually. However, previous reports used special equipment that was less commonly used and difficult to generalize. In this study, we used a commercial pulse oximeter and a widely used bedside patient monitor to monitor transplanted free tissue and lower extremities of healthy subjects with impaired circulation. Methods  A reflectance pulse oximeter sensor was attached on the flap after free tissue transplantation. The sensor was connected to a bedside patient monitor, and the flap oxygen saturation (SpO2) levels and arterial waveforms were continuously monitored. Additionally, blood circulation disorder was induced in the lower limbs of healthy volunteers using pressure cuff inflation on the thigh, and the waveform and SpO2 levels on the pulse oximeter attached to the lower leg were monitored. Results  Twenty-two patients were included in this study. No postoperative vascular issues were observed in any case. Pulse oximeters showed normal rhythmic wavelengths, and the flap SpO2 level ranged approximately >90%. The pulse oximeter waveform rapidly disappeared during arterial occlusion in the thigh pressure cuff inflation test, and the waveform flattened and the SpO2 level decreased slightly during venous congestion. Conclusion  Flap monitoring using a commercially available pulse oximeter and a bedside patient monitor is a versatile, easy-to-interpret, and useful method. Changes in waveform and SpO2 levels appear during arterial and venous circulation disorders, and these changes can be differentiated.

Peripheral facial nerve schwannoma at the inferior mandibular margin: a case report.

Schwannomas commonly occur in the head and neck region as acoustic neuromas. Facial nerve schwannomas are rare and usually occur in the temporal region. A 57-year-old woman presented with a mass at the right mandibular margin. Magnetic resonance imaging revealed a schwannoma located immediately caudal to the mental foramen. We were initially uncertain whether it arose from the trigeminal nerve or the facial nerve. Excision was performed under general anesthesia. The mass was encapsulated and easily detached from the surrounding tissue. The nerve of origin was identified proximal to the tumor. A facial nerve origin was confirmed as the muscles supplied by the marginal mandibular branch of the facial nerve moved on nerve stimulation. Nerve fibers were not found distal to the tumor, possibly because they had been cut during excision. We believe that this is the first report of a schwannoma arising from the peripheral facial nerve.

Closing an Intractable Tracheoesophageal Fistula Caused by a Tracheoesophageal Shunt Using a Myocutaneous Flap and a Hinged Flap With Skin Graft in a Two-Step Procedure.

Total laryngectomy involves removal of the vocal cords resulting in the loss of vocal function. After laryngectomy, the patient's vocal function can be restored in several ways, including the insertion of a tracheoesophageal (TE) shunt. A TE shunt is considered an effective means of restoring speech due to its high efficacy, low requirement for training, and no need for any equipment while speaking. However, complications such as saliva inflow into the trachea, caused by the widening of the shunt opening, have also been reported. Moreover, the optimal treatment for an enlarged fistula has not yet been established. A fistula may also form at sites of hypopharyngeal reconstruction with free jejunal transplantation. Following its formation, the influx of saliva, infections, and pressure exerted by the act of swallowing make a fistula resistant to closure, and most patients require closure surgery using myocutaneous flaps. We encountered a case where an intractable TE fistula formed due to a TE shunt after the patient underwent total pharyngolaryngeal resection for hypopharyngeal cancer and hypopharyngeal reconstruction with a free jejunum flap. Since the optimal method for the TE fistula closure remains uncertain, we attempted to close the fistula according to the fistula closure of the free jejunal transplantation. Failure to close a TE fistula using a myocutaneous flap necessitates a re-closure procedure. However, because the surgical field around the trachea can be limited in such patients, creating an additional myocutaneous flap may not be feasible. In addition to the myocutaneous flap, ventilation control using a conventional intubation tube may further narrow the surgical field during the re-closure surgery. Based on our experience and existing literature, in this article, we summarize several ways of managing TE fistula when the surgical field around the trachea is limited.

Congenital Cheek Fistula: A Rare Case of Developmental Abnormality in the Buccal Area.

A congenital cheek fistula is a rare malformation in the buccal area. Here, we report the case of a congenital cheek fistula in a 50-year-old woman who visited our clinic with complaints of swelling and pain in her left cheek. Physical examination revealed a small hole in the left corner of the mouth present since birth. She had no other congenital malformations in the maxillofacial region such as an accessory ear and cleft lip. Manual compression of the cheek mass induced serous discharge from the hole. Magnetic resonance imaging (MRI) showed a cystic lesion in the left cheek and a fistula within the orbicularis oris muscle that opened into the small hole. After immediate incision and drainage of the cyst, both the cyst and fistula were surgically resected. The cystic lesion was completely delineated from the boundary of the parotid gland. The orbicularis oris muscle was partially incised to remove the fistula and the surrounding scar tissue. Histopathological examination of the resected specimen revealed a cavity consisting of epithelium inside the fistula. The postoperative course was insignificant. No recurrence of the cyst was observed six months postoperatively. The operative and pathological findings demonstrated that the ectoderm-derived epithelial tissue was enclosed by the mesoderm-derived muscle tissue. The mixture of different germ layer-derived tissues suggested that the fistula was a type of congenital transverse facial cleft induced by malfusion of the mandibular and maxillary prominences during embryonic development. The differential diagnoses of the congenital cheek fistula included orocutaneous fistulas and salivary fistulas. MRI was useful in delineating the border between the lesion and the surrounding tissue.

Perineal reconstruction with pedicled rectus abdominis myocutaneous flap after posterior pelvic exenteration -A 3D model study.

INTRODUCTION: Limited literature exists regarding the positional relationship between the pedicled-rectus abdominis myocutaneous (p-RAMC) flap and residual pelvic organs post posterior pelvic exenteration (PPE). PRESENTATION OF CASE: Four patients underwent PPE and reconstruction with a p-RAMC flap. After harvesting the p-RAMC flap with the deep inferior epigastric artery and veins as the vascular pedicle, the intra-pelvic shortest pathway of the flap was created. We dissected the subcutaneous tissues of the flap donor site toward the perineal defect along the inner wall of the pelvis. The pubic origin of the rectus abdominis muscle was preserved. A three-dimensional model was constructed using an image processing software. The vascular pedicle ran almost linearly along the inner wall of the pelvis. The muscle belly was placed on the pelvic floor through the posterior wall of the urinary bladder which filled the dead space of the resected area. All flaps survived without significant complications. DISCUSSION: Assigning the cranial side of the flap to the perineum and caudal side to the pelvic floor could reduce postoperative intrapelvic complications. By preserving the pubic origin of the rectus abdominis muscle, a shock absorber of the pedicle of the flap was created, preventing over-traction of the flap while passing through the intrapelvic pathway. CONCLUSION: A p-RAMC flap via intra-pelvic shortest pathway is an ideal reconstructive method for large skin defect in perineal area after PPE.

BNCT for primary synovial sarcoma.

Synovial sarcoma is a rare tumor requiring new treatment methods. A 46-year-old woman with primary monophasic synovial sarcoma in the left thigh involving the sciatic nerve, declining surgery because of potential dysfunction of the affected limbs, received two courses of BNCT. The tumor thus reduced was completely resected with no subsequent recurrence. The patient is now able to walk unassisted, and no local recurrence has been observed, demonstrating the applicability of BNCT as adjuvant therapy for synovial sarcoma. Further study and analysis with more experience accumulation are needed to confirm the real impact of BNCT efficacy for its application to synovial sarcoma.

Wire Myography for Continuous Estimation of the Optimal Concentration of Topical Lidocaine as a Vasodilator in Microsurgery.

BACKGROUND: Intraoperative vasospasm during reconstructive microvascular surgery is often unpredictable and may lead to devastating flap loss. Therefore, various vasodilators are used in reconstructive microsurgery to prevent and relieve vasospasm. Lidocaine is a vasodilator commonly used in microvascular surgery. Although many reports have described its in vitro and in vivo concentration-dependent vasodilatory effects, limited studies have examined the pharmacological effects of lidocaine on blood vessels in terms of persistence and titer. METHODS: In this study, the vasodilatory effect of lidocaine was examined by using the wire myograph system. Abdominal aortas were harvested from female rats, sliced into rings of 1-mm thickness, and mounted in the wire myograph system. Next, 10, 5, 2, and 1% lidocaine solutions were applied to the artery, and the change in vasodilation force, persistence of the force, and time required to reach equilibrium were measured. RESULTS: The vasodilatory effect was confirmed in all groups following lidocaine treatment. Although strong vasodilation was observed in the 10% lidocaine group, it was accompanied by irreversible degeneration of the artery. Vasodilation in the 1% lidocaine group was weaker than that in the other groups 500 seconds after lidocaine addition (p < 0.05). Between the 5 and 2% lidocaine groups, 5% lidocaine showed a stronger vasodilatory effect 400 to 600 seconds after lidocaine addition (p < 0.01); however, there was no significant difference in these groups after 700 seconds. Additionally, there was no difference in the time required for the relaxation force to reach equilibrium among the 5, 2, and 1% lidocaine groups. CONCLUSION: Although our study confirmed the dose-dependent vasodilatory effect of lidocaine, 5% lidocaine showed the best vasodilatory effect and continuity with minimal irreversible changes in the arterial tissue.

Effect of size difference between hemiglossectomy and reconstruction flap on oral functions: A retrospective cohort study.

BACKGROUND AND OBJECTIVE: Forearm free flaps are used after hemiglossectomy. However, no investigation has been performed on whether oral functions are better preserved when sizes of the resection and reconstruction flap are exact matches, or whether the size of the resection should be changed. We aimed to retrospectively examine whether size differences between the resection and reconstruction flap affect speech and swallowing functions postoperatively, and to determine whether there are more favorable flap size ratios. METHODS: This is a retrospective cohort study of patients undergoing hemiglossectomy using a forearm free flap between 2006 and 2016 at Kobe University Hospital, Japan. The effect of size difference between the resection and reconstruction flap on maintained oral function was assessed. Speech and swallowing functions were assessed, and their correlation with the ratio of the flap size to that of the resected area was determined. With these data, distribution maps of the relationship between the functional level and reconstructed dimension ratio were prepared. The more suitable reconstructed dimension ratio was examined and evaluated. The Fisher exact test, Kruskal-Wallis test, and Scheffe test were used in statistical analyses. RESULTS: Eighty-eight patients underwent hemiglossectomy using a forearm free flap during a 10-year period. Of these cases, 66 patients were included in this study, while 22 were excluded. The ratio of the area of the reconstruction flap to that of the resection site was 0.59-2.79 (median: 1.61). Sixty patients had flaps greater than the resection area, whereas 6 had smaller flaps. Significant differences were found in speech intelligibility and swallowing function when the reconstructed dimension ratio was categorized as follows: ≤1.3, 1.3-1.8, and ≥1.8. CONCLUSION: Our findings suggest that postoperative deterioration of oral functions after hemiglossectomy could be reduced if reconstruction is performed using a forearm free flap with a surface area 1.3 to 1.8 times greater than that of the resection area.

Long-Term Effects on Volume Change in Musculocutaneous Flaps after Head and Neck Reconstruction.

OBJECTIVE: Musculocutaneous flap reconstruction surgery is one of the standard procedures following head and neck cancer resection. However, no previous studies have classified flaps in terms of muscle and fat or examined them after long-term follow-up. The purpose of this study was to estimate the fat and muscle volume changes in musculocutaneous flaps during long-term follow-up. METHODS: We conducted a retrospective analysis of 35 patients after musculocutaneous flap reconstruction. The total, fat, and muscle volumes of the musculocutaneous flaps were measured using 3-dimensional images. Changes in flap volumes over time (1 month, 1 year [POY1], and 5 years [POY5] postoperatively) were assessed. Flap persistence was calculated using flap volumes at 1 month after reconstruction for reference. RESULTS: Flap persistence at POY5 was 42.0% in total, 64.1% in fat, and 25.4% in muscle. Muscle persistence was significantly decreased (p < 0.0001). In a multiple regression analysis, decreased body mass index (BMI) of ≥ 5% influenced fat persistence less than muscle persistence at POY1; however, there was no significant difference at POY5. Postoperative radiation therapy was associated with a significant decrease in total flap persistence at POY1 (p = 0.046) and POY5 (p = 0.0097). Muscle persistence significantly decreased at POY5 (p = 0.0108). Age significantly influenced muscle volume at POY1 (p = 0.0072). CONCLUSION: Reconstruction flaps are well-preserved with high fat-to-muscle ratios. Recommendations for weight maintenance are necessary for patients less than 2 years after surgery due to the influence of BMI on fat persistence. Radiation therapy is necessary for some patients based on their disease state. Intensity-modulated radiation therapy can be offered to reduce scattering irradiation to normal tissues.

Post-sternotomy deep wound infection following aortic surgery: wound care strategies to prevent prosthetic graft replacement†.

OBJECTIVES: The aim of this study was to evaluate the early and long-term outcomes of our multidisciplinary strategy for treating deep sternal wound infection after aortic grafting, which consisted of debridement by a plastic surgeon, negative pressure wound therapy with continuous irrigation and chest wall reconstruction. METHODS: We performed a retrospective analysis of 18 patients who had a deep sternal wound infection following aortic grafting through a median sternotomy between January 2009 and December 2017. All patients had organisms cultured from mediastinal tissue within 2 months from the initial aortic surgery. The prosthetic grafts were exposed in 15 patients during resternotomy. Our protocol involved repeat debridement and negative pressure wound therapy with continuous irrigation twice a week until the results of the culture were negative and chest wall reconstruction was complete. RESULTS: The mean duration from primary aortic surgery to resternotomy was 23.7 ± 15.9 days. Except for 1 patient, 17 patients underwent chest wall reconstruction. The mean duration from resternotomy to chest wall reconstruction was 31.1 ± 28.0 days. The hospital mortality rate was 16.7% (3 patients), although no patients died of wound-related causes. The mean follow-up period was 2.9 ± 2.5 years. Overall survival was 69.6 ± 11.4% at 1 year and 54.2 ± 13.3% at 5 years. Freedom from reoperation for reinfection was 94.4 ± 5.4% at 5 years. CONCLUSIONS: Our wound care strategy achieved acceptable early and late survival in patients who had deep sternal wound infection following aortic grafting. This strategy may benefit those who experience this devastating complication.

Effect of local application of transcutaneous carbon dioxide on survival of random-pattern skin flaps.

INTRODUCTION: Skin flap procedures are widely used to reconstruct skin and soft tissue defects. Skin flap necrosis is a serious postoperative complication. Many researchers have introduced pharmacological agents to improve flap ischemia in experimental studies. However, outcomes of these studies remain controversial. We previously demonstrated that transcutaneous CO2 application improves hypoxia in fracture repair. In this study, we hypothesized that improving hypoxia by transcutaneous CO2 application can improve the blood flow in skin flaps and increase angiogenesis. We investigated whether transcutaneous CO2 application can increase the survival of random-pattern skin flaps. MATERIALS AND METHODS: Six-week-old male Sprague-Dawley rats were divided into two equal groups: the control group (n = 6) and CO2 group (n = 6). A random-pattern skin flap was constructed in these rats. Topical CO2 was applied using a hydrogel every day for 5 days in the CO2 group. The flap survival area was measured on postoperative days 1, 3, and 5. The vessel density and expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and hypoxia-inducible factor-1α (HIF-1α) were evaluated on postoperative day 5. RESULTS: A statistically significant difference was found in the percentage of the flap survival area between the two groups on postoperative days 3 and 5 (p < 0.05). Furthermore, the expression of VEGF and bFGF was significantly higher and that of HIF-1α was significantly lower in the CO2 than in the control group (p < 0.05). CONCLUSIONS: Transcutaneous CO2 application can improve the blood flow in skin flaps and increase angiogenesis, thus increasing the survival of random-pattern skin flaps.