Morphological Changes and Durability of Skin and Mucosal Flaps in Intraoral and Pharyngeal Reconstructions: Long-term Follow-up and Literature Review for Potential Second Carcinomas.

The long-term changes in tissues implanted in the oral cavity and pharynx after head and neck reconstruction have not been fully evaluated. This study aimed to clarify the morphological changes, long-term durability, and potential for secondary carcinogenesis in such tissues. In our single-center study, the rough morphological changes in 54 cases of intraoral and pharyngeal skin and mucosal flaps were evaluated more than 10 years after flap transfer. In addition, the literature on the development of second carcinomas from skin flaps was reviewed. The mean follow-up period for transferred flaps was 148 months. The reconstruction areas and the probability of morphological changes were significantly correlated (p=0.006), especially in cases with tongue, lower gingiva, and buccal mucosal reconstruction. Free jejunal flap surfaces were well maintained, whereas tubed skin flaps showed severe morphological changes in cases with pharyngeal reconstruction. None of the flaps in our series developed second primary carcinomas. Skin flaps generally had good durability for > 10 years in intraoral environments, while mucosal flaps had better durability for pharyngeal reconstruction. Second squamous carcinomas arising from skin flaps are extremely rare; however, surgeons should take this possibility into consideration and conduct meticulous and long-term follow-up.

Recurrent branch of anterior interosseous artery perforator-based propeller flap for distal forearm injuries: Report of 2 cases.

Despite various options for the reconstruction of soft tissue defects in the distal forearm, perforator-based propeller flap is rarely used. Here, we presented 2 cases of distal forearm injuries that were repaired using the recurrent branch of anterior interosseous artery perforator-based propeller flap. Patients in these cases were 57 and 67 years of age. Wounds resulting from farming machine injury and pyogenic extensor tenosynovitis following cat bite wounds were localized to the distal forearm and dorsum of the hand. Defect dimensions were 5 cm × 10 cm and 5 cm × 8 cm. The 12 cm × 7 cm and 21 cm × 4 cm sized recurrent branch of anterior interosseous artery perforator-based propeller flap was designed adjacent to the wounds. In the latter case, the absence of the posterior interosseous artery in the distal forearm was observed. One perforator from the recurrent branch of the anterior interosseous artery emerged through the septum between the extensor digiti minimi and extensor carpi ulnaris 7.5 cm and 6.0 cm proximal to the ulnar head in cases 1 and 2, respectively. Perforators were identified using multidetector computed tomographic angiography and handheld Doppler. Extending to two-thirds or almost the full length of the forearm, the flaps were raised and rotated by 90° and 120° to cover the defect. The donor sites were closed using free skin graft. Both flaps survived. Except for minor wound dehiscence and hemarthrosis, no other postoperative complications occurred. Patients returned to work or daily activities at 3- and 4-month follow-up after surgery.

Analysis of 10-Year Training Results of Medical Students Using the Microvascular Research Center Training Program.

Background In this article, we reviewed the training results of medical students using the Microvascular Research Center Training Program (MRCP), and proposed an ideal microsurgical training program for all individuals by analyzing the training results of medical students who did not have any surgical experience. Methods As of 2015, a total of 29 medical students completed the MRCP. In the most recent 12 medical students, the number of trials performed for each training stage and the number of rats needed to complete the training were recorded. Additionally, we measured the operating time upon finishing stage 5 for the recent six medical students after it became a current program. Results The average operating time upon finishing stage 5 for the recent six medical students was 120 minutes ± 11 minutes (standard deviation [SD]). The average vascular anastomosis time (for the artery and vein) was 52 minutes ± 2 minutes (SD). For the most recent 12 medical students, there was a negative correlation between the number of trials performed in the non-rat stages (stages 1-3) and the number of rats used in the rat stages (stages 4-5). Conclusion Analysis of the training results of medical students suggests that performing microsurgery first on silicon tubes and chicken wings saves animals' lives later during the training program. We believe that any person can learn the technique of microsurgery by performing 7 to 8 hours of training per day over a period of 15 days within this program setting.

Secondary head and neck reconstruction using free flap to improve the postoperative function or appearance of cancer survivors.

BACKGROUND: Secondary reconstructive operations are needed when patients with head and neck cancers have complications such as tumor recurrence after initial treatment. These reconstructive procedures are also performed to improve the function and appearance of the head and neck region for many cancer survivors. We reviewed the patients who underwent secondary head and neck reconstruction to improve function and appearance and considered the significance of this procedure for cancer survivors, as well as its associated problems. METHODS: Among the secondary reconstruction patients, 20 patients underwent reconstruction to improve their function and/or appearance. The goal of reconstruction for the patients was functional improvement in eight cases, appearance improvement in ten cases, and both function and appearance in two cases. Chi-square analyses were performed between the secondary and primary reconstructive groups with regard to the incidence of postoperative complications. RESULTS: All transferred flaps survived completely. We performed a small postoperative modification procedure in four cases. Minor complications not requiring surgical correction occurred in 2 of 20 patients. Additional operations were required owing to major postoperative complications in 2 of 20 patients. No significant associations were identified between the secondary and primary reconstructive groups with regard to postoperative complications. CONCLUSION: The outcomes of the present report suggest that secondary reconstructive surgery is a relatively safe procedure. The decision to perform adaptation operations depends on various factors after sufficient discussion with patients.

Effects of radiation therapy on postoperative complications and adverse events in patients with head and neck reconstruction with flaps.

BACKGROUND: Radiation therapy is an essential treatment for head and neck cancer. However, the condition of the operative field is entirely altered after radiation therapy. This study aimed to examine the effects of preoperative radiation therapy on complications in patients who underwent head and neck reconstruction with flaps. METHODS: We retrospectively reviewed 252 instances of head and neck reconstruction with flaps in 240 patients between October 2000 and May 2011 at Okayama University Hospital. Of the participants, 51 had preoperative radiation exposure (21.3%) and 189 had no radiation exposure (78.7%). Postoperative complications were divided into three categories: minor complications that healed with conservative medical treatment within 4 weeks without a need for surgery; major complications requiring reoperation within 1 week after surgery (reoperation); and major complications needing additional operation later than 1 week after surgery (additional operation). RESULTS: Preoperative radiation therapy was only associated with major complications requiring reoperation later than 1 week after surgery (P < 0.001), open cervical wounds (P = 0.0030), and skin grafting for cervical skin necrosis (P = 0.0031) when compared to no radiation exposure. The results of flap failure were not significantly different between both groups (P = 0.3820). CONCLUSIONS: Minor complications and reoperation in the early postoperative period were not influenced by radiation exposure. The complications of radiation tend to be protracted and associated with additional operation later than 1 week after the initial surgery. It was thought that shortening of the duration of treatment was successful when we needed to perform early additional operations.

Erratum: Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunum Transfer: Erratum.

[This corrects the article DOI: 10.1097/GOX.0000000000002663.].

Vaginoplasty with a pudendal-thigh flap in intersexuals.

We treated 2 different types of intersexual patients who underwent a vaginoplasty with the pudendal-thigh flap. One was a female with testicular feminization syndrome for whom we reconstructed the total vagina with a pudendal-thigh flap, and the other was a female with an adrenogenital syndrome for whom we enlarged the introitus of the vagina with the same approach. There were no complications such as a flap necrosis. In addition, there was no stricture of the neo-vagina and no urinary problem.

Phantom erectile penis after sex reassignment surgery.

Between January 2001 and December 2007, we performed vaginoplasty as sex reassignment surgery in a total of 14 male-to-female transsexual (MTFTS) patients [1]. Several complications occurred such as partial flap necrosis, rectovaginal fistula formation and hypersensitivity of the neoclitoris. Just after the operation, some patients feel that their penises still exist, but by several weeks postoperatively, this sensation has disappeared. Herein we report a case of MTFTS in whom the sensation of a phantom erectile penis persisted for much longer.

Vaginoplasty with an M-shaped perineo- scrotal flap in a male-to-female transsexual.

To date, many techniques have been reported for vaginoplasty in male-to-female trans-sexual (MTFTS) patients, such as the use of a rectum transfer, a penile-scrotal flap and a reversed penile flap. However, none of these procedures is without its disadvantages. We developed a newly kind of flap for vaginoplasty, the M-shaped perineo-scrotal flap (M-shaped flap), using skin from both sides of the scrotum, shorn of hair by preoperative laser treatment. We applied this new type of flap in 7 MTFTS patients between January 2006 and January 2007. None of the flaps developed necrosis, and the patients could engage in sexual activity within 3 months of the operation. The M-shaped flap has numerous advantages: it can be elevated safely while retaining good vascularity, it provides for the construction of a sufficient deep vagina without a skin graft, the size of the flap is not influenced entirely by the length of the penis, and it utilizes skin from both sides of the scrotal area, which is usually excised.

Risk factors for wound complications in head and neck reconstruction: 773 free jejunal reconstruction procedures after total pharyngolaryngoesophagectomy.

BACKGROUND: Most studies that examined risk factors for wound complications after head and neck reconstruction analyzed various complications collectively. Moreover, they included a wide variety of resection areas and reconstruction materials. To overcome these limitations, both the resection area and reconstruction method were constrained in the present study. METHODS: Patients who underwent free jejunal graft reconstruction after pharyngolaryngoesophagectomy for hypopharyngeal cancer were enrolled. The outcomes of interest were abscesses, fistulas, and cervical skin flap necrosis. RESULTS: Abscesses, fistulas, and cervical skin flap necrosis developed in 19.3%, 11.3%, and 8.2% of 773 patients, respectively. A significant relationship was found between use of an open drain and abscess formation and between a longer operation time and cervical skin flap necrosis. CONCLUSION: Our findings suggest that use of an open drain, cardiovascular disease, and a longer operation time are significant risk factors for abscess formation, fistula formation, and cervical skin flap necrosis, respectively.

Unilateral lower limb lymphedema resulting from a heart surgery performed 50 years prior.

INTRODUCTION: Lymphedema is classified into two main types: secondary lymphedema accompanied by lymph node excision surgery or radiotherapy; and idiopathic lymphedema. Here we experienced a very rare case of lymphatic edema resulting from cardiac surgery that the patient underwent 50 years previously. PRESENTATION OF CASE: A 62-year-old woman experienced progressive unilateral lower leg lymphedema for recent years. After undergoing cardiac surgery at another hospital at the age of 12 years, she gradually developed left lower leg edema. The cause of the edema was unclear and it remained untreated. Her edema symptoms gradually worsened in recent years, so she consulted the plastic surgery division of our hospital. DISCUSSSION: Perhaps the lymphatic structures of affected individuals differ prior to disease onset. If the mechanism of lymphatic edema outbreak is elucidated, patients needing conservative and surgical therapy might be more easily identified. Knowing the outbreak mechanism of lymphatic edema would definitely ease the investigation of an unconventional case like this one. Conservative treatments for lymphedema, such as self-massage and compression therapy using garments, were immediately started. With these treatments, the leg volume and edema symptoms reduced. CONCLUSION: The research on the cause of this case may be important step for elucidating the source of secondary lymphatic edema.

Risk factors of thrombosis in a single method of microsurgical head and neck reconstruction: A multi-institutional study of 773 reconstructions with a free jejunal graft after total pharyngolaryngoesophagectomy for hypopharyngeal cancer.

BACKGROUND: The risk factors for thrombus formation in anastomotic vessels in free-flap head and neck reconstruction have been previously reported. However, the evidence is inconsistent. METHODS: In total, 773 patients who underwent free jejunal graft reconstruction after pharyngolaryngoesophagectomy for hypopharyngeal cancer were enrolled at 12 institutions in Japan from 1995 to 2006. Both the resection area and the applied reconstruction method were constrained to overcome the limitations of previous studies. After the exclusion of recurrent cases, odds ratios (ORs) and 95% confidence intervals (CIs) for thrombosis were calculated in a multivariate logistic regression analysis. RESULTS: Postoperative anastomotic thrombosis developed in 23 patients (3.0%). In the multivariate analysis, the OR for thrombosis per 100-mL increase in blood loss was 1.24 (95% CI = 1.02-1.51), even after controlling for other risk factors. CONCLUSION: Our results show that the blood loss volume is an independent risk factor for thrombosis in free tissue grafts. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Histologic Evaluation of Lymphaticovenular Anastomosis Outcomes in the Rat Experimental Model: Comparison of Cases with Patency and Obstruction.

BACKGROUND: Lymphaticovenular anastomosis plays an important role in the surgical treatment of lymphedema. The outcomes of lymphaticovenular anastomosis are evaluated based on changes in edema; however, isolated assessment of the anastomosis itself is difficult. The authors used an animal experimental model to conduct a detailed examination of histologic changes associated with lymphaticovenular anastomosis and determined the factors important for success. METHODS: The experimental lymphaticovenular anastomosis model was created using lumbar lymph ducts and iliolumbar veins of Wistar rats. The authors performed anastomosis under a microscope and reviewed postoperative histologic changes using optical and electron microscopy. In addition, electron microscopy and histology were used for detailed examination of the area in the vicinity of the anastomotic region in cases with patency and obstruction. RESULTS: The patency rates immediately after, 1 week after, and 1 month after lymphaticovenular anastomosis were 100 percent (20 of 20), 70 percent (14 of 20), and 65 percent, respectively. A detailed examination of the anastomotic region with electron microscopy revealed that, in cases with patency, there was no notable transformation of the endothelial cells, which formed a smooth layer. In contrast, in obstruction cases, the corresponding region of the endothelium was irregular in structure. CONCLUSIONS: Vessel obstruction after lymphaticovenular anastomosis may be associated with irregular arrangement of the endothelial layer, leading to exposure of subendothelial tissues and platelet formation. One part of the postoperative changes after anastomosis and a cause of obstruction were elucidated in this study. The authors' results may enable improvements in lymphaticovenular anastomosis by translating back to real clinical operations.

Evaluation of the microvascular research center training program for assessing microsurgical skills in trainee surgeons.

BACKGROUND: We established the Microvascular Research Center Training Program (MRCP) to help trainee surgeons acquire and develop microsurgical skills. Medical students were recruited to undergo the MRCP to assess the effectiveness of the MRCP for trainee surgeons. METHODS: Twenty-two medical students with no prior microsurgical experience, who completed the course from 2005 to 2012, were included. The MRCP comprises 5 stages of training, each with specific passing requirements. Stages 1 and 2 involve anastomosing silicone tubes and blood vessels of chicken carcasses, respectively, within 20 minutes. Stage 3 involves anastomosing the femoral artery and vein of live rats with a 1-day patency rate of >80%. Stage 4 requires replantation of free superficial inferior epigastric artery flaps in rats with a 7-day success rate of >80%. Stage 5 involves successful completion of one case of rat replantation/transplantation. We calculated the passing rate for each stage and recorded the number of anastomoses required to pass stages 3 and 4. RESULTS: The passing rates were 100% (22/22) for stages 1 and 2, 86.4% (19/22) for stage 3, 59.1% (13/22) for stage 4, and 55.0% (11/20) for stage 5. The number of anastomoses performed was 17.2±12.2 in stage 3 and 11.3±8.1 in stage 4. CONCLUSIONS: Majority of the medical students who undertook the MRCP acquired basic microsurgical skills. Thus, we conclude that the MRCP is an effective microsurgery training program for trainee surgeons.

Surgical management of axillary necrotizing fasciitis: a case report.

Axillary necrotizing fasciitis (NF) is quite rare and requires special management with respect to debridement and delayed surgical reconstruction. A 76-year-old man presented to our emergency department with a 2-day history of high fever, severe left axillary pain and redness. A few hours later, he developed discoloration and hemorrhagic bulla in the axilla, and the redness enlarged on the trunk. Emergency surgical debridement was performed. The blackish necrosis in the axilla was completely excised and the erythematous areas in the chest wall were cut down to the level of the fascia. Split-thickness skin grafts were applied during the second debridement on the 30th day of hospitalization and negative pressure wound therapy was used. Although the grafts took partially, full thickness axillary defects remained. We performed reconstruction with a pedicled latissimus dorsi flap on day 78. This case highlights some of the important surgical considerations in the management of axillary NF.

Prevention points for plate exposure in the mandibular reconstruction.

INTRODUCTION: The rate of complications for mandibular reconstruction after segmental mandibulectomy is higher with reconstruction plates than with vascularised bone grafts. We have experience of over 100 patients using reconstructive plates for reconstruction immediately after segmental mandibulectomy and have considered factors contributing to plate exposure. PATIENTS AND METHODS: Seventeen cases utilised our prevention methods in which reconstructive plates were used for mandibular reconstruction were reviewed. The flaps used with reconstruction plates were rectus abdominis myocutanenous flaps in 10 cases, anterolateral thigh flaps combined vastus lateralis muscle in four cases, and the omentum in one case; no flap was transferred in two cases. RESULTS: In only one of 17 cases was a plate exposed at 3 months postoperatively. No plate exposure occurred during the follow-up period in the other 16 cases. Because no flap had been transferred in the patient with plate exposure, a possible contributing factor was the persistence of dead space beneath the plate. CONCLUSION: This series suggests that factors other than flap selection contribute to the exposure of reconstructive plates. Use of a reconstruction plate is a useful reconstructive method, especially for patients who cannot tolerate transfer of a vascularised bone graft.

The best salvage operation method after total necrosis of a free jejunal graft? Transfer of a second free jejunal graft.

AIM: Transfer of a free jejunal graft is the first choice for reconstruction after total laryngopharyngo-oesophagectomy (TPLE). After total necrosis of a jejunal graft, possible salvage procedures include temporary external fistula formation and transfer of a second free jejunal graft. The present study determines the most appropriate salvage method. PATIENTS AND METHODS: We have transferred over 600 vascularised free jejunal grafts during the past 22 years for reconstruction, immediately after TPLE, either at the National Cancer Center Hospital or at Okayama University Hospital. A second free jejunal graft was transferred to treat the first vascularised free jejunal graft that had undergone total necrosis in five of these patients. We reviewed the total number of operations, the interval between the operation and the start of oral feeding, the outcomes and the follow-up periods of the five patients. RESULTS: Each of the second free jejunal grafts was positioned without complications. All patients resumed postoperative oral food intake after a mean interval of 20.4 days. Four of the five patients remain free of tumour recurrence and in good health. CONCLUSION: Our results suggest that the best salvage method after total necrosis of an initial free jejunal graft is to transfer a second jejunal graft. Therefore, the severity of contamination of the neck due to jejunal graft necrosis must be minimised at re-operation to transfer a second free jejunal graft using microvascular anastomosis.

A novel model for supermicrosurgery training: the superficial inferior epigastric artery flap in rats.

The purpose of this study was to determine the usefulness of a new flap model, the superficial inferior epigastric artery (SIEA) flap for supermicrosurgical training. Experimental groups were randomly divided into three groups of 10 rats each. In each group SIEA flaps were elevated and then returned to their original locations with or without vascular anastomosis of the superficial inferior epigastric vessels. Group 1: free SIEA flap, group 2: free SIEA flap with 1 hour ischemia time, group 3: free SIEA flap with 4 hours ischemia time, group 4: SIEA flap without vascular anastomosis. The viability rate was 80% with group 1, 50% with group 2, and 40% with group 3. All nonvascularized flaps (group 4) underwent complete necrosis. These findings suggest that preservation of blood flow in a flap has a beneficial effect on the prevention of microthrombosis in the subcutaneous capillary network of the skin and increases the flap survival rate. The SIEA flap with preserved circulation is an ideal model for developing supermicrosurgical skills.

Successful delayed venous drainage in 16 consecutive distal phalangeal replantations.

The authors describe, in the first report of this type of replantation surgery, a high success rate using delayed venous anastomosis in 16 consecutive distal phalangeal replantations under digital block. Among these replantations, seven fingers (43.8 percent) showed postoperative venous congestion and five fingers were reoperated on with delayed venous drainage under digital block. All the reoperated fingers were successfully drained by additional single or double venous drainage with a vein graft. As a result, 13 fingers survived (81.3 percent success rate). All operations were performed under a digital block.

Flow-through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects.

New flow-through perforator flaps with a large, short vascular pedicle are proposed because of their clinical significance and a high success rate for reconstruction of the lower legs. Of 13 consecutive cases, the authors describe two cases of successful transfer of a new short-pedicle anterolateral or anteromedial thigh flow-through flap for coverage of soft-tissue defects in the legs. This new flap has a thin fatty layer and a small fascial component, and is vascularized with a perforator originating from a short segment of the descending branch of the lateral circumflex femoral system. The advantages of this flap are as follows: flow-through anastomosis ensures a high success rate for free flaps and preserves the recipient arterial flow; there is no need for dissecting throughout the lateral circumflex femoral system as the pedicle vessel; minimal time is required for flap elevation; there is minimal donor-site morbidity; and the flap is obtained from a thin portion of the thigh. Even in obese patients, thinning of the flap with primary defatting is possible, and the donor scar is concealed. This flap is suitable for coverage of defects in legs where a single arterial flow remains. It is also suitable for chronic lower leg ulcers, osteomyelitis, and plantar coverage.