Transmalar Kirshner Wire Fixation Under Ultrasound Scanning is Useful for Unstable Zygomatic Arch Fracture Combined With Zygomatic Body Fracture.

Plate fixation to zygomatic arch fractures carries the risk of facial nerve palsy and scarring of the cheek; however, without plate fixation, bone deviation or displacement may reoccur after surgery. Furthermore, zygomatic arch fractures combined with zygomatic body fractures are more postoperatively unstable than single zygomatic arch fractures. Few reports have focused on this combined fracture type, and no consensus has been reached regarding treatment. Because plate fixation for slight deviation of the zygomatic body has little advantage for stabilization, the authors, usually opt for transmalar pinning alone instead of plate fixation at the hospital. This study is a retrospective case series of 7 patients, among 100 zygomatic fractures excluding isolated zygomatic arch fractures, treated using transmalar pinning under ultrasound scanning. The reduction was performed through the oral and temporal incision as a surgical procedure. Under ultrasound observation, a Kirshner wire was inserted into the zygomatic body from the unaffected side while maintaining the reduced position. The wire was removed at an outpatient visit 2 to 3 months following surgery. In all cases, the zygomatic body was of the laterally rotated type, and postoperative morphologic evaluation showed improvement without postoperative complications. Scores were higher in middle-aged and older than in young people. Correction of zygomatic rotation also scored higher than zygomatic arch morphology. Transmalar Kirshner wire fixation under ultrasound observation is a simple and minimally invasive method for zygomatic arch fractures, which avoids the possible complications related to plate fixation.

Treatment for Lateral Ray Polydactyly with Brachydactyly of the Foot.

Surgical methods for lateral ray polydactyly with brachydactyly of the foot include simple toe ablation and toe lengthening. However, there are few reports on comparative studies, and there is no standard treatment. We retrospectively investigated cases of lateral ray polydactyly with brachydactyly treated at our department and related facilities. In our study, the prevalence of Hirai-Togashi classification type IV was 8.8% (13/147 toes). Five patients did not request toe lengthening and underwent simple ablation, resulting in a shortened remaining toe in these 5 patients. The surgical methods for toe lengthening were pedicle bone grafting in 2 cases and on-top formation in 6 cases. Good results can be obtained in the most common phalangeal type cases, but care must be taken in cases with block-shaped metatarsal heads to avoid poor toe alignment.

Therapeutic Potential of Adipose-Derived Stem Cell-Conditioned Medium and Extracellular Vesicles in an In Vitro Radiation-Induced Skin Injury Model.

Radiotherapy (RT) is one of three major treatments for malignant tumors, and one of its most common side effects is skin and soft tissue injury. However, the treatment of these remains challenging. Several studies have shown that mesenchymal stem cell (MSC) treatment enhances skin wound healing. In this study, we extracted human dermal fibroblasts (HDFs) and adipose-derived stem cells (ADSCs) from patients and generated an in vitro radiation-induced skin injury model with HDFs to verify the effect of conditioned medium derived from adipose-derived stem cells (ADSC-CM) and extracellular vesicles derived from adipose-derived stem cells (ADSC-EVs) on the healing of radiation-induced skin injury. The results showed that collagen synthesis was significantly increased in wounds treated with ADSC-CM or ADSC-EVs compared with the control group, which promoted the expression of collagen-related genes and suppressed the expression of inflammation-related genes. These findings indicated that treatment with ADSC-CM or ADSC-EVs suppressed inflammation and promoted extracellular matrix deposition; treatment with ADSC-EVs also promoted fibroblast proliferation. In conclusion, these results demonstrate the effectiveness of ADSC-CM and ADSC-EVs in the healing of radiation-induced skin injury.

Quantitative Evaluation and Midterm Progress of Reconstructed Toe Thickness in Lateral Ray Polydactyly of the Foot.

In lateral ray polydactyly, the reconstructed toe often tends to become thicker, but no standard evaluation criteria for this thickness are available. 57 patients (68 toes) with Hirai-Togashi classification type II, III, or IV whom we were able to follow-up for more than 6 months after the operation were underwent measurement of the "Reconstructed toe width to Third toe width ratio." In addition, 16 patients who could be followed up for 3 years through the mid-term course were evaluated for mid-term progress. At 6 months after surgery, the mean R/T ratio was 1.246. In patients who could be followed up for 3 years after surgery, the mean R/T ratios at 6 months after surgery and at 3 years were significantly decreased. This result suggests that the thickness of the reconstructed toe may become relatively thin in the long term.

A Novel Model of Perifascial Areolar Tissue Transplant in Rats.

Background Perifascial areolar tissue (PAT) transplant is a method of transplanting loose connective tissue harvested in a sheet form from above the fascia to the wound bed and is effective for wounds with exposed ischemic tissue. However, the engraftment mechanism is unknown, and no animal models of PAT transplant for wound healing exist. Methods In this study, we harvested connective tissue from the backs of Wistar rats in a sheet form to simulate a human PAT transplant. The PAT was affixed to exposed bone of the head. Results In the PAT(+) group, the wound areas gradually decreased due to epithelialization and contraction. The wound area of the PAT(+) group was significantly smaller than that of the PAT(-) group. Conclusions This clinically relevant rat model is useful for elucidating the mechanism of the PAT transplant and establishing a reliable surgical method.

Delayed primary fascia closure of Björck grade 4 open abdomen with enteroatmospheric fistulas after repeated surgery for adhesive small bowel obstruction: a case report.

BACKGROUND: An open abdomen with frozen adherent bowels is classified as grade 4 in Björck's open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management. CASE PRESENTATION: A 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy. CONCLUSIONS: Primary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.

Squamous cell carcinoma arising from an ischial pressure ulcer initially suspected to be necrotizing soft tissue infection: A case report.

BACKGROUND: Pressure ulcers are the most common complications in bedridden patients or those with spinal cord injuries. Marjolin's ulcer refers to a malignant transformation arising from burn scars or chronic nonhealing wounds-such as pressure ulcers-over many years. Squamous cell carcinoma is the major histopathologic type of Marjolin's ulcer, and the gold standard for diagnosis is tissue biopsy. Medical professionals may have difficulty distinguishing pressure ulcers from Marjolin's ulcer, especially when the latter presents with invasive infections. Thus, malignant transformations arising from pressure ulcers are frequently overlooked. Herein, we describe a case of squamous cell carcinoma arising from pressure ulcers on the left ischium, which was initially identified as a necrotizing soft tissue infection. CASE REPORT: A 59-year-old paraplegic patient presented with stage 3 left ischial pressure ulcer, which involves full-thickness skin loss and extends into deep subcutaneous tissue, and arrived at our hospital with suspected sepsis. Upon physical examination, the patient presented with fever and shivering. Initial examination and imaging findings revealed the presence of necrotizing soft tissue infections. Three weeks later, rapid increase in granulation in the deep part of the ulcer was observed. Samples from multiples ulcer sites were collected for tissue biopsy. Finally, histological examination revealed well-differentiated squamous cell carcinoma. The patient received radiation therapy and chemotherapy and died 11 months after the diagnosis. CONCLUSION: Malignant transformations arising from pressure ulcers may closely resemble pressure ulcer infections. In these cases, tissue biopsies should be performed during primary care for the infection to exclude malignant transformations.

Free-flap reconstruction for full-thickness oral defects involving the oral commissure combined with oral modiolus reconstruction using a fascial sling.

BACKGROUND: Oral modiolus reconstruction is important in unilateral oral commissure removal including the modiolus. However, the proper procedure is not yet established. We performed free-flap reconstruction for full-thickness oral defects involving the oral commissure combined with oral modiolus reconstruction using a fascial sling. PATIENTS AND METHODS: From 2008 to 2018, six oral carcinoma patients, aged 65 to 86 years, underwent free-flap modiolus reconstruction after tumor resection. The resulting lip defects of 10% to 80% were labial (two patients), buccal (two patients), and mixed (two patients). RESULTS: Five anterolateral thigh flaps including one perforator and one radial forearm flap were performed. The oral defects were covered with folded flaps (size, 11 × 6-18 × 7.5 cm2 ). The orbicularis oris stumps were connected to the masseter with a fascia lata or palmaris longus tendon (length, 15-20 cm), arranged in a Y-shape in four patients and a V-shape in two patients. All the flaps survived without complications. Almost all the patients achieved good oral static effects (lip deviation and drooping) and dynamic effects (mouth opening, oral commissure narrowing, and diet) in the 6 to 65 months' follow-up. CONCLUSION: Free-flap reconstruction combined with oral modiolus reconstruction using a fascial sling achieves good oral static and dynamic effects for full-thickness oral reconstruction involving the oral commissure.

End-to-Side Venous Anastomosis to a Ligated Vein Stump for Free Flap Transfer in Head and Neck Reconstruction.

INTRODUCTION: In head and neck reconstruction, use of a free flap paired with end-to-side anastomosis to a preserved vein is generally performed. However, it is frequently difficult to select the recipient vein after a neck dissection in which there is only a ligated internal jugular vein/external jugular vein (IJV/EJV). Here, a new anastomosis technique using a ligated IJV/EJV stump is described. PATIENTS AND METHODS: End-to-side anastomoses to ligated vein stump surgeries for free flap transfer in head and neck reconstruction were performed at the Department of Plastic and Reconstructive Surgery, University of Tsukuba, from 2009 to 2016. RESULTS: The subject pool comprised 6 patients. All patients received a free flap transfer after head and neck tumor excision. The free flaps used were 1 free radial forearm flap, 1 free tensor fascia lata muscle perforator flap, and 4 free rectus abdominis musculocutaneous flaps. The cervical vessels used were 3 IJVs and 3 EJVs. All veins of the free flaps could be anastomosed end-to-side to ligated vein stumps without vein grafting. All flaps survived completely without complications. CONCLUSIONS: The end-to-side venous anastomosis to a ligated vein stump procedures were easy to perform and not dependent on the vessel diameters of the free flaps. No complications were observed in any patient owing to differences in vessel diameter, ease of anastomosis, and safety. Results suggest that this new technique is a simple and very useful option in head and neck reconstruction where the IJV/EJV cannot be preserved.

Linear Separation of Toe Syndactyly With Preserved Subcutaneous Vascular Network Skin Grafts.

BACKGROUND: Conventional surgery of toe syndactyly is accomplished using a zig-zag incision and full thickness or split thickness skin grafting. However, this method has an aesthetic problem with a prominent scar on the dorsal side of the foot. The aim of the article was to investigate the efficacy of a cosmetically conscious operation for syndactylies performed using a single technique. METHODS: A retrospective analysis was performed involving 66 patients with 88 syndactylic toes who presented to the department of plastic and reconstructive surgery at 1 of 3 major institutions during a 16-year period (1998-2014). Syndactylies were classified according to the affected interdigital spaces (IDSs). All cases were treated using the same method: linear skin incisions to divide the digits, triangular flaps on the dorsal and plantar sides of the foot, and preserved subcutaneous vascular network skin grafts from the medial inframalleolar region. RESULTS: The most frequent type of toe syndactyly was IDS-2 (union of the second/third toes), which accounted for 59.1% (39/66) of the cases. The rates of familial anomalies were significantly different between bilateral IDS-2 (4/13) and unilateral IDS-2 (0/24) (P < 0.05, Fisher exact test). There were no severe postoperative complications, including scar contracture or keloid formation. All patients obtained sufficiently deep IDSs, and none required repeat surgery. CONCLUSIONS: A straight incision minimizes the scar observed from the visible side, and preserved subcutaneous vascular network skin grafts prevent postoperative contracture of linear scar.

A simple, novel technique for fixing Penrose drains in minor surgeries, with advantages for remote outpatient clinics: a retrospective comparison with conventional drain fixation in North Ibaraki, Japan.

INTRODUCTON: In rural areas with few doctors, Penrose drains in minor surgeries for soft tissue trauma or small subcutaneous tumors are sometimes avoided, even though the drain would prevent hematoma, because of the limited availability of professional postsurgical care. The authors developed a simple fixation method for Penrose drains that can be used even in remote areas where a doctor is not present to remove the drain. A retrospective study was conducted to compare this new method of fixing Penrose drains with instances in which the Penrose drain was fixed to skin by conventional suturing. METHODS: The medical records of patients who underwent minor surgeries using Penrose drains were reviewed. The surgeries were performed from April 2012 to March 2015 in remote outpatient clinics in Ibaraki Prefecture, Japan. The cases were divided into two groups: those using the new method, in which the Penrose drains were sewn onto the wound dressings and could be automatically removed while changing the dressing, and those in which the Penrose drains were conventionally fixed to the skin and removed one or several days after surgery by another doctor at the outpatient clinic. The rates of drain-related complications and of automatic drain removal (ie removal without a doctor's assistance) between the two groups were compared. RESULTS: A total of 54 Penrose drains used for 48 lesions in 44 patients (25 men, 19 women) in the new-method group, and 36 Penrose drains for 25 lesions in 21 patients (12 men, 9 women) in the conventional-method (control) group were analyzed. All 54 Penrose drains in the new-method group were removed automatically, while none of the 36 drains in the control group were removed automatically. There were no drain-related complications, such as massive hematoma, retrograde infection, seroma, or drain breakage or straying, in any of the new-method or control cases. CONCLUSIONS: This new Penrose-drain fixation method is safe and is particularly suitable for minor surgeries in rural areas where there are no resident doctors. The wide use of this method for appropriate minor surgeries in doctorless rural areas has the potential to reduce surgical complications and the time burden for both patients and surgeons.

Long-term results of orbicularis oris muscle reconstruction in primary cleft lip repair using the "basket-weave method".

The basket-weave method is an orbicularis oris muscle reconstruction method used in primary unilateral cleft lip repair. We compared the long-term results of the basket-weave method with those of a conventional method. For primary unilateral cleft lip repair, we compared the long-term results of 7 cases in which the orbicularis oris muscle was reconstructed by use of the basket-weave method, and of 7 cases in which the reconstruction was performed by use of the conventional method. The average postoperative follow-up period was 12 years and 7 months for the basket-weave method, and 11 years and 9 months for the conventional method. Using photographs of the front and elevation angle views, we evaluated the results as good if the philtrum ridge was formed on the fissure side and was almost symmetrical in height; as fair if the philtrum ridge was lower than the normal side; and as poor if the philtrum ridge had disappeared. For the basket-weave method, the results were good in 6 cases (85.7%), fair in 1 case (14.3%), and poor in 0 cases. For the conventional method, the results were good in 2 cases (28.6%), fair in 4 cases (57.1%), and poor in 1 case (14.3%). A significant difference was found between the 2 groups (Mann-Whitney U test, P = 0.0417). The philtrum ridge shape could be reconstructed by use of the basket-weave method, which gave better results in the long-term than did the conventional method for orbicularis oris muscle reconstruction in primary unilateral cleft lip repair.

Presurgical orthopedic treatment ameliorates postoperative nasal deformity after cheiloplasty.

We assessed the postoperative nasal form and symmetry after presurgical use of a Hotz plate (HP) in patients with unilateral complete cleft lip and palate (UCLP). The subjects were 28 infants with UCLP who underwent cheiloplasty. Of these subjects, 14 underwent presurgical orthopedic treatment using the HP (HP group) and 14 underwent the same treatment without the HP (non-HP group). Photographic records were obtained 1 and 6 months after cheiloplasty, and the results of anthropometric analysis were compared between the 2 groups. The nasal inclination and the ratio of the width of the nasal base to the total width of the nose were significantly improved in the HP group compared with the non-HP group at both postoperative time points. Thus, presurgical use of the HP significantly improved the nasal asymmetry and deformity in UCLP patients after primary cheiloplasty and nasal repair.

Perifascial Areolar Tissue Transplantation for Covering Exposed Proximal Interphalangeal Joint After Electric Burn.

Soft tissue damage in electric burn injuries is often deep and may expose tendons, bones, or joints in the hand. Here, we present the case of a 76-year-old man treated using perifascial areolar tissue (PAT) transplantation for covering the proximal interphalangeal joint of the middle finger, which had been exposed because of an electric burn. Following ointment therapy, surgery was performed on day 34 postinjury when a deep ulcer with opening of the proximal interphalangeal joint was observed on the dorsum of the right middle finger. After resecting the cartilage of the proximal interphalangeal articular surface, two Kirschner wires were inserted, and arthrodesis was performed. PAT was harvested from the left inguinal region and applied to the joint exposed wound of the middle finger. Full-thickness skin graft was applied over it. Three months after surgery, the preserved middle finger could be used as a functional finger. PAT transplantation does not require microsurgery techniques, is simple and minimally invasive, and has a short treatment period, so it may be an effective option for treating wounds in which exposed ischemic tissue is present. Soft tissue damage in electric burn injuries is often deep and may expose tendons, bones, and joints in the hand, which is the most common affected site. Here, we report a case treated using perifascial areolar tissue (PAT) transplantation for covering the proximal interphalangeal joint of the middle finger, which had been exposed because of an electric burn.

Combining a Bilateral Bipedicle Flap and Artificial Dermis for Extensive Coverage in Meningomyelocele Surgery.

Myelomeningoceles with soft tissue defects are often difficult to close primarily and require reconstructive surgery. Furthermore, cases with large skin defects or cases with kyphosis of the spine require a large area to be covered, making reconstruction even more difficult. We performed closure of soft tissue defects using a bilateral bipedicle flap and application of artificial dermis to the flap donor area in three cases in which surgery was difficult. The bilateral bipedicle flap was able to easily and reliably close the soft tissue defect even in highly difficult emergency myelomeningocele surgery. We believe that applying artificial dermis to the flap donor area is a useful method that avoids autologous skin grafting and facilitates wound management. There have been no cases of major donor wound contracture. The healing period of the flap donor area may be predicted to some extent by the width immediately after surgery.

Hydrocolloid wound dressing for sealing periwound with poor normal skin: negative pressure wound therapy for deep limb burns with extensive burns.

BACKGROUND: Negative pressure wound therapy (NPWT) is effective for wounds with exposed bones and tendons, but when the wound is accompanied by extensive burns, sealing is difficult. We performed sealing with a hydrocolloid wound dressing on limb burns. CASE REPORT: A 61-year-old woman was burned in a fire at her home. Split-thickness skin grafting was performed 14 and 35 days post injury, but exposure of the right patella and patellar tendon became apparent. The hydrocolloid wound dressing was wrapped around the proximal and distal aspects of a deep wound. The limb was sandwiched from the front and back surfaces and sealed with 2 film dressings, including the hydrocolloid, according to the sandwich method. Using this method, NPWT could be performed without leakage, the exposed tendons and bones were covered with granulation, and skin grafts were performed on day 88 after injury. CONCLUSION: Our method allows NPWT to be easily and effectively performed for deep limb burns with poor normal skin periwound area.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan.

BACKGROUND: There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction. METHODS: This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence. RESULTS: Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15. CONCLUSION: The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The role of collagen arrangement change during tendon healing demonstrated by scanning electron microscopy.

The dry weight of tendon tissue is accounted for mainly by collagen fibers. Accordingly, the tendon-healing process primarily involves repair of collagen fibers. During the remodeling phase of tendon healing, newly proliferating collagen fibers are transformed into a mature repaired tendon. Despite the importance of this phenomenon, the details of fibrous rebuilding have not been reported previously. The aim of this study was to visualize the ultrastructural changes and to obtain a clear understanding of the reorganization of the collagen fibers in the tendon repair site, using rat Achilles tendons. We used scanning electron microscopy (SEM) with cell maceration as the main method of analysis. Pretreatment with cell maceration removed the cellular components successfully. This allowed precise visualization of each collagen fiber and the three-dimensional network of the fibers. This study was the first to apply the cell-maceration/SEM method to observe tendon tissue. Seven days after surgery, new collagen fibers grew extensively in the repair site in a random arrangement. Fourteen days after surgery, the collagen fibers began to form an axial arrangement. Near the tendon stump, this change progressed from the outer layer to the core region. On the other hand, in the middle of the repair site, it progressed from the core to the outer layer. Change in the axial arrangement of collagen fibers contributes to the connection between the repair site and the tendon stump and to the separation of the repair site from the paratenon.

Presurgical nasoalveolar molding orthopedic treatment improves the outcome of primary cheiloplasty of unilateral complete cleft lip and palate, as assessed by naris morphology and cleft gap.

We evaluated the effects of presurgical nasoalveolar molding (NAM) with an orthopedic appliance and compared them with a passive orthopedic method (Hotz plate, HP), focusing on the naris morphology and width of the alveolar and palate cleft gap. The subjects were 28 unilateral complete cleft lip and palate patients treated with primary cheiloplasty at Tsukuba University Hospital from 2004 to 2011. Thirteen patients were treated preoperatively with NAM (NAM group), and 15 with HP (HP group). The surgical outcome was assessed according to left-right naris symmetry, as measured by the area ratio, perimeter ratio, aspect a/u ratio (aspect ratio of the affected side/aspect ratio of the unaffected side), and Hausdorff distance. In addition, the alveolar and palate cleft width was measured at the times of orthopedic plate setting and primary cheiloplasty. The aspect ratio was significantly smaller in the NAM group than in the HP group before the operation. In both groups, the aspect ratio, perimeter ratio, and Hausdorff distance were significantly smaller after the operation than before. The width of the alveolar and palate cleft gap was significantly narrowed in the NAM group, and the cleft gap at the initiation of NAM correlated significantly with the Hausdorff distance after cheiloplasty. We found that NAM improved the form of the naris after primary cheiloplasty and decreased the palate cleft gap more effectively than HP and that the width of the palate cleft gap was correlated with the surgical outcome of the naris.