What are the key risk factors of keloid formation after repair of syndactyly of the toe?

PURPOSE: Keloid formation in toes area is rare. However, occurrence of this phenomenon in toes after the surgery of syndactyly repair has been reported. Risk factors of keloid formation in toes after syndactyly reconstructions are currently unknown. This study aimed to investigate the risk factors of keloid formation after the surgery of syndactyly repair of the toes. METHODS: We retrospectively reviewed our case series including patients who were treated surgically at our institution. We hypothesized some key factors of keloid formation and analyzed each of them statistically. RESULTS: A total of 105 patients were treated surgically at our hospital, and 9 patients were involved keloid formations after operations. Among our hypothesized key factors, the results of multivariate logistic regression analysis revealed the number of affected web spaces (OR 0.031; 95%CI 0.001-0.684; p = 0.028) was significantly different. Digital enlargement was not a significant factor (OR 17.731; 95%CI 0.686-458.174; p = 0.091). CONCLUSION: Involving multiple web space was associated with keloid formation after syndactyly release, on the other hand, toe enlargement did not show a significant difference. However, the digital enlargement showed high Odds ratio, we could not deny its high relativity for keloid formation. Further investigations are needed to clarify the key risk factors of keloid formation after the surgery of syndactyly repair of the toes.

Central polydactyly of the foot: An experience of a treatment of 22 patients.

BACKGROUND: The central polydactyly of the foot is a rare congenital disorder, and its characteristics are not well known. This study aims to investigate its disease concept. METHODS: We obtained the medical records of patients who were treated surgically for central polydactyly of the foot at our hospital during a 32-year period from 1990 to 2021 retrospectively. We compared our clinical data with other case series reports to investigate the characteristics of this disorder further. RESULTS: There were 22 patients (13 males and 9 females) included in our case series. Unilateral and bilateral involvements were observed in 19 (right side: 6 patients; left side: 13 patients) and 3 patients, respectively. The second toe is the commonest duplicated toe (observed in 19 toes). 19 patients had distally duplicated toes (with normal metatarsal bone). Proximally duplicated toes were observed in only two patients. CONCLUSIONS: The incidence of central polydactyly of the foot is almost equal among male and female, and bilateral involvements are few. As this abnormality is rarely reported, further investigations are needed to clarify the clinical presentation of central polydactyly of the foot.

Comparison of Vectra three-dimensional stereophotogrammetry measurement and tape measurement in the evaluation of perioperative volume change of the lower abdomen in association with lymphatic microsurgery.

BACKGROUND: Although microsurgical treatment for lower extremity lymphedema (LEL) can improve lower abdominal morphology, methods to evaluate the volume change of the lower abdomen have yet to be established. This study aimed to determine the accuracy and reproducibility of three-dimensional stereophotogrammetry (3DSM) in measuring the volume change in the lower abdomen. METHODS: The perioperative volume changes in the lower abdomen were estimated using tape measurement (TM) and 3DSM in 26 patients with LEL. Thirteen patients with suprapubic lymphedema underwent abdominoplasty simultaneously. Each of them underwent multiple lymphaticovenular anastomoses (LVAs), and five of them underwent vascularized lymph node transfer, simultaneously. Thirteen patients with pelvic lymphatic fluid underwent multiple LVAs. Two patients underwent this surgery twice. When assessed on the Internal Society of Lymphology scale, eight patients were Stage I, 10 patients were Stage II, four patients were late Stage II, and four patients were Stage III. The difference between the two measurement methods and reproducibility of each method were analyzed. RESULTS: During a mean follow-up period of 6 months, all patients had no postoperative complications and their chief complaint improved. The calculated reduction volume between TM and 3DSM showed a high correlation (p < .0001, r = .84). The reduction volume based on TM was significantly larger than 3DSM (991.1 ± 460.3 ml vs. 862.3 ± 333.5 ml, p = .02). The interrater ICC was 0.94 and 0.98 based on TM and 3DSM, respectively. CONCLUSION: 3DSM may be a useful method for assessment of the lower abdominal morphology due to its high accuracy and reproducibility.

Cervical chondrocutaneous branchial remnants: A report of 29 cases and review of the literature.

OBJECTIVE: Cervical chondrocutaneous branchial remnants (CCBRs) are rare masses located in the anterior region of the neck. Though the basic characteristics of these rare masses were first described by Atlan in 1997, a critical amount of information about these masses remains unknown. This study aimed to further clarify the characteristics of these rare masses. METHODS: We retrospectively reviewed the clinical records of patients with CCBRs in our facility during a 32-year period ranging from 1988 to 2019. We then compared our clinical records with other case reports. RESULTS: There were 29 patients with CCBRs in our facility, including 19 males and ten females, Three patients were involved bilaterally (among patients involved unilaterally, the right side included 11 patients, and the left side was 15 patients), eight patients also had associated abnormalities. We submitted CCBRs from 18 patients to pathology, and all of them contained elastic cartilages. Among all the surgical data could be confirmed, cartilages did not reach beyond the musculature of the neck. We could confirm a similar tendency with Atlan regarding sex, the location of CCBRs (involvement side, localization in the neck), and the depth of CCBRs. Among the cases contained in this study, there was a disparity in the rate of associated abnormalities and pathology of contained cartilages. CONCLUSION: Some critical characteristics of CCBRs included, a male predominance, scarcity of bilateral cases and common left side involvement among unilateral involved cases, a common location of CCBRs in the inferior third of the neck and anterior to the sternocleidomastoid muscle, and an involvement of cartilage in CCBRs which has no connections to deep underlying structure of the neck. Further investigations are required to determine the origin of CCBRs and the precise incidence of the associated abnormalities. Systemic examination in patients with CCBRs is recommended because many associated abnormalities have been reported.

Use of the Modified Unilateral Cleft Lip Repair Technique to Establish a Cupid's Bow With a Natural Structure.

INTRODUCTION: There are several surgical techniques for unilateral cleft lip repair. In most of these techniques, the points where the postoperative scars cross the vermilion border are on the peak of the Cupid's bow. These scars make the shape of Cupid's bow indistinct. To maintain the natural shape of the Cupid's bow, we modified the surgical technique. METHODS: We modified the modified Millard's surgical technique (Onizuka's surgical technique). The main point of this modification was as follows: we combined a small triangular flap and a vermilion triangular flap (described by Noordhoff). We maintained the projection point on the lateral side of cleft lip which was coordinated to the peak of the Cupid's bow. RESULTS: We could preserve the shape and symmetry of the peak of the Cupid's bow. CONCLUSION: To keep the projection point on the affected side of cleft lip and the surrounding vermilion border as one curve structure is important in maintaining the natural shape of the Cupid's bow.

Postaxial polydactyly of the hand in Japanese patients: Case series reports.

PURPOSE: The incidence of postaxial polydactyly of the hand is rare in Japan. This study aimed to compare the clinical presentation of postaxial polydactyly between a cohort of patients from Japan and those from other racial and ethnic backgrounds. METHODS: In this retrospective study, we included 30 patients who were treated at our hospital during a 25-year study period (1990-2015). Based on the clinical records of these patients, we characterized the Japanese presentation of the condition. We searched for studies that included other racial and ethnic groups and characterized the clinical presentations. Then, we compared the clinical presentations between Japanese patients and other racial and ethnic groups. RESULTS: A total of 19 male and 11 female patients were treated in our hospital, and bilateral and unilateral involvements (right side: 4 patients; left side: 4 patients) were observed in 22 and 8 patients, respectively. Moreover, 22 postaxial polydactylies were type A and 28 polydactylies were type B, which were classified using the Temtamy-McKusick classification system. In addition, 4 patients had a family history of hand postaxial polydactylies; 18, 6, 4, and 3 patients presented with polydactyly of the foot, syndactyly, systemic abnormalities, and related syndromes, respectively. CONCLUSION: Japanese patients had two distinguishing characteristics: (1) when the condition was unilateral, left side and right side involvement was almost equal with regard to incidence and (2) associated polydactylies of the foot were more common (60%) than those in other cohorts (less than 31%). To better understand postaxial polydactyly of the hand, guidelines to record the clinical presentations in patients with such a condition must be developed.

Intraoperative Detection of Efferent Lymphatic Vessels Emerging from Lymph Node during Lymphatic Microsurgery.

BACKGROUND: Although the usefulness of efferent lymphaticovenular anastomosis (ELVA) in lymphatic microsurgery has been reported, the optimal method to distinguish efferent from afferent lymphatics is not yet established. We propose a novel technique to detect efferent lymphatics appropriate for anastomosis. METHODS: In total, 62 groin lymph nodes (LNs) of 46 limbs were divided into four groups based on the findings of indocyanine green lymphography: n = 15 in normal, 15 in dermal backflow stage 0, 18 in stage I, and 14 in stage II groups. The target LN and afferent lymphatic connecting it were preoperatively detected using ultrasonography. Intraoperatively, 0.05 mL patent blue dye was slowly manually injected from the afferent lymphatic; the lymphatic(s) subsequently stained was diagnosed as the efferent lymphatic(s) emerging from the node. The success rates of efferent lymphatic detection, sizes of LN, and diameter of efferent lymphatics were compared among the groups. RESULTS: Both LN size and diameter of efferent lymphatic were significantly larger in the stage 0 and I groups than the other groups (p < 0.01). Efferent lymphatic could be stained in 13, 13, 18, and 9 LNs in the normal and stage 0, I, and II groups, respectively. A significant difference was observed between the stage I and II groups regarding the success rate of efferent lymphatic detection (p = 0.04). CONCLUSION: Efferent lymphatics could be detected using patent blue dye in 85.5% of the cases. The patients in early-stage lymphostasis might be the most appropriate candidates for ELVA.

Early Detection of Lymphatic Disorder and Treatment for Lymphedema following Breast Cancer.

BACKGROUND: Upper extremity edema following surgical treatment for breast cancer does not always result in chronic breast cancer-related lymphedema. Changes in the findings of indocyanine green lymphography and upper extremity volume following breast cancer surgery were observed prospectively to understand the early changes in lymphatic function and to establish a new strategy for early diagnosis and treatment of breast cancer-related lymphedema. METHODS: Lymphatic function for 196 consecutive breasts was examined using indocyanine green lymphography and bilateral upper extremity volume before surgery and 1, 3, 6, 9, and 12 months after surgery. When a "stardust," "diffuse," or "no flow" pattern was observed, patients were diagnosed with lymphatic disorder and subsequently underwent conservative treatments such as compression sleeve therapy. RESULT: In 35 patients, lymphatic disorder was observed after a mean of 5.2 ± 3.0 months after surgery. In 21 of these patients, no significant limb volume change was observed. In 14 patients, lymphatic disorder and volume change appeared simultaneously. In 11 of 35 patients, lymphatic function improved later, and compression therapy was discontinued. Lymph node dissection, radiation therapy to axillary lymph node, and the use of docetaxel chemotherapy were significant risk factors for lymphatic disorder. No patients experienced cellulitis during the study period. CONCLUSIONS: Lymphatic function disorder could be detected before volume changes. By early intervention with conservative treatments, lymphatic function improved in just under one-third of cases. Indocyanine green lymphography for high-risk patients may be useful for detecting lymphatic disorder early, thereby increasing the chance for disease cure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema.

BACKGROUND: Vascularized lymph node transfer has become a popular surgical option to improve lower extremity lymphedema (LEL), although potential donor sites are limited. The free supraclavicular flap with deep cervical lymph nodes has been recently associated with a minimal risk of secondary lymphedema caused by donor site dissection. However, the effectiveness of this procedure has not yet been evaluated. METHODS: Vascularized supraclavicular lymph node transfer (VSLNT) was performed for patients with International Society of Lymphology late stage II or more severe LEL. The results were compared with lymphaticovenular anastomosis (LVA) performed for patients with the same stages of severity. To evaluate improvement in lymphatic function, indocyanine green lymphography and lymphoscintigraphy were performed. RESULTS: Vascularized supraclavicular lymph node transfer was performed in 13 limbs of 13 patients. The results were compared with 43 limbs of 33 patients who underwent multiple LVA. No severe complications were observed in either group. Improvement in lymphatic function, as measured by the LEL index, was 26.5 ± 4.4 and 21.2 ± 2.0 in the VSLNT and LVA groups, respectively. Lymphatic function was improved in 7 cases in the VSLNT group and 10 cases in the LVA group. CONCLUSIONS: Vascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage LEL. Lymphaticovenular anastomosis is also effective, but to a lesser degree than VSLNT. However, LVA is less invasive and requires a shorter hospital stay.

Suitable therapy options for sub-clinical and early-stage lymphoedema patients.

BACKGROUND: The best therapeutic approach for patients with sub-clinical lymphoedema and symptomatic early-stage lymphoedema has not been determined yet. METHODS: The prognosis of lymphatic function after lymphadenectomy for gynaecological cancer was observed in a cohort study of 192 lower limbs. Lymphatic function was evaluated by indocyanine green lymphography. Splash patterns were examined to determine if patients with this pattern tended to progress to symptomatic lymphoedema, and the efficacy of the compression therapy was also investigated. We also investigated the efficacy of lymphaticovenular anastomosis (LVA) in patients who exhibited a stardust pattern. RESULTS: Patients with splash patterns on lymphography may progress to symptomatic lymphoedema with a significantly higher frequency compared with the others, with a relative ratio of 1.62. Compression therapy did not slow the progression of patients with splash patterns to stardust patterns. LVA for the patients who had recently shown stardust patterns eliminated the need for compression therapy in 44.8% of patients. CONCLUSION: Patients with splash patterns should be followed up carefully for sub-clinical lymphoedema. However, there is no method to completely prevent these patients from developing stardust patterns associated with symptomatic lymphoedema. When patients become symptomatic, their lymphatic function may be improved by LVA. However, the limited effectiveness of this procedure should be clearly explained to patients before surgery.

Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage.

BACKGROUND: Reconstruction of the great toe defect is difficult. The most distal point of the rotation arc of a retrograde-flow medial plantar flap is the plantar side of the proximal phalanx. The purpose of this report was to present a new procedure that extends the rotation arc of this flap. Results of anatomic study and application in two patients were presented. METHODS: An anatomical study was conducted on 10 freshly frozen cadavers to determine the rotation arc of the medial plantar flap based distally on the lateral plantar vessels. To enable anterograde venous drainage, two accompanying veins of the vascular pedicle were separated and anastomosed to each other. This surgical procedure was implemented in two clinical cases with the great toe defect. The maximum size of the elevated flap was 4 × 7 cm. The status of venous congestion of the flap was determined using the blood glucose measurement index. RESULTS: We confirmed that the rotation arc of the medial plantar flap based distally on the lateral plantar vessels could reach the tip of the great toe, preserving all lateral plantar nerves and plantar metatarsal arteries. In the two cases, the congestion of the flap improved with anterograde venous drainage and the flaps survived completely. CONCLUSION: A pedicled medial plantar flap with anterograde venous drainage may be a useful alternative option for the reconstruction of relatively large great toe defects.

External valvuloplasty for subcutaneous small veins to prevent venous reflux in lymphaticovenular anastomosis for lower extremity lymphedema.

BACKGROUND: Subcutaneous ecchymosis caused by venous reflux is a preventable complication following lymphaticovenular anastomosis. The authors developed a series of operative procedures to prevent venous reflux. This is probably the first report on valvuloplasty for small subcutaneous veins (diameter, <1 mm). METHODS: A total of 165 anastomoses in 39 limbs were operated on using this novel procedure (study group). Extended vein dissection was performed to ensure inclusion of some venous valves. Venous regurgitation was assessed using a retrograde milking test. When regurgitation was observed at all peripheral branches, external valvuloplasty was performed at the small subcutaneous vein to prevent backflow. The rate of venous reflux was compared with 151 anastomoses in 34 limbs operated on using conventional procedures (control group). Moreover, the amount of volume reduction was compared between the patients with and without venous reflux. RESULTS: In the study group, the rate of regurgitation was reduced (3.0 percent) by extended vein dissection compared with that in the control group (9.9 percent), whereas the regurgitation ceased completely following external valvuloplasty (0 percent). In addition, postoperative ecchymosis was prevented completely in the study group (8.8 percent in the control group). Perioperative improvement in the lower extremity lymphedema index was significantly different between the patients with and without venous reflux (with venous reflux, 0.0706 ± 0.0742; without venous reflux, 0.0904 ± 0.0614). CONCLUSIONS: The authors' results suggest that these operative procedures could be highly effective in preventing venous reflux. Moreover, venous reflux, if not corrected, leads to worsening of the results. Excellent results were consistently achieved by preventing venous reflux. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Oversight of constipation in inpatients with schizophrenia: a cross-sectional study.

OBJECTIVE: Constipation is often overlooked in patients with schizophrenia. We examined their awareness of constipation and whether they reported it to their psychiatrists. METHOD: Five hundred three inpatients with schizophrenia (International Classification of Diseases, 10th Revision) were interviewed about their recent bowel movements and evaluated for the diagnostic criteria for functional constipation. If constipation was present, patients were asked if they were aware of it and had reported it to their psychiatrists in charge. Additionally, their global psychopathology and functioning were assessed using the Clinical Global Impression-Schizophrenia (CGI-SCH) and the Global Assessment of Functioning (GAF), respectively. RESULTS: The criteria for constipation were met by 184 patients (36.6%); of these patients, only 56.0% (103/184) were aware of it. Moreover, only 34 of the constipated patients (18.5%) reported its presence to their psychiatrists. No significant differences were found in the CGI-SCH overall severity or subscale scores or in the GAF scores between those patients who reported and those who failed to report constipation. CONCLUSIONS: The present study demonstrated that constipation was neither recognized nor reported to psychiatrists by a significant percentage of the patients. These findings underscore the importance of greater vigilance and active evaluation of constipation in patients with schizophrenia for appropriate clinical management.

Three-dimensional invasion of epithelial-mesenchymal transition-positive human peritoneal mesothelial cells into collagen gel is promoted by the concentration gradient of fibronectin.

BACKGROUND: In long-term peritoneal dialysis, myofibroblast-like cells found in the interstitium of the peritoneum are assumed to be a transformed type of mesothelial cell-epithelial-mesenchymal transition-positive [EMT(+)] human peritoneal mesothelial cells (HPMCs)-because they express a mesothelial marker, cytokeratin. However, no direct evidence about how these cells are able to invade from the mesothelium has yet been obtained. AIM: In this study, we aimed to verify whether EMT(+) HPMCs would, in vitro, invade three-dimensionally along certain chemotactic factors. METHODS: We used reverse-transcriptase polymerase chain reaction to measure expression of Snail, E-cadherin, α(5)-integrin, and matrix metalloproteinase 2 (MMP2) messenger RNA (mRNA) in HPMCs exposed to 10 ng/mL transforming growth factor ß1 (TGFß1) and how that expression corresponds to cell motility, as represented by a video movie. We used the Transwell (12 µm pore diameter: Sigma-Aldrich, Tokyo, Japan) to construct a three-dimensional (3D) cell migration chamber. In the lower chamber, a concentration gradient of fibronectin (FN) or albumin(Alb) was formed in 0.1% type I collagen by diffusion (C(0)=22 nmol/L; concentration gradient: C/C(0)=0.7). All cells beneath the membrane were counted 72 hours after 5×10(4) EMT(+) HPMCs (HPMCs after a 48-hour exposure to 10 ng/mL TGFß1) had been spread in the upper chamber. RESULTS: After 72 hours, the increased motility of HPMCs resulting from their exposure to 10 ng/mL TGFß1 had returned to baseline, but they retained an elongated morphology. Expression of Snail and MMP2 mRNA reached maximum at 24 hours. Expression of E-cadherin declined, and expression of α(5)-integrin increased continuously. In the 3D invasion study, significantly enhanced invasion by EMT(+) but not EMT(-) HPMCs was clearly seen in the presence of a FN concentration gradient (p<0.01), although invasion by EMT(+) and EMT(-) HPMCs in the absence of a FN concentration gradient was not statistically significantly different. Compared with the EMT(+) control (no concentration gradient), invasion by EMT(+) HPMCs was 2.1 ± 0.5 times (p<0.05) and 1.4 ± 0.4 times (p=nonsignificant) higher along the FN and Alb concentration gradients respectively. Increased invasion along the FN concentration gradient was significantly inhibited (p<0.05) when the HPMCs were pre-incubated with 5 µg/mL RGDS (a blocker for α(5)-integrin to FN). CONCLUSIONS: We conclude that EMT(+) HPMCs invade collagen gel along the FN concentration gradient because of specific binding to RGDS receptors, which bind integrins such as α(5)-integrin, upregulating invasion-related gene expression associated with synthesis of the cytoskeleton protein α smooth muscle actin.