Flap Monitoring Using Interstitial Fluid Glucose Measurements.

Background: Various flap monitoring techniques have been used in the early detection of anastomotic thrombus; however, the use of automatic and continuous monitoring methods is presently uncommon. The purpose of this study was to investigate trends in interstitial fluid glucose concentration (IFG) in flap monitoring by measuring IFG automatically and continuously. Methods: Nine patients underwent unilateral breast reconstruction using a transverse rectus abdominis myocutaneous flap with vascular anastomosis. Two IFG measuring devices were attached to each patient. One device was attached to the flap (flap IFG) and the other to the healthy breast (control IFG). In each case, flap IFG, control IFG, and IFG ratio (flap IFG/control IFG) were recorded in the initial 72 h post-surgery (first half) and also in the subsequent 72 h (second half). In all of the cases, the mean values recorded in the first half and those in the second half were compared. Results: All flaps survived. The flap IFG didn't fall below 40 mg/dL in the first half. The minimum flap IFG and IFG ratio were 42 mg/dL and 0.55 in the first half. The flap IFG was significantly higher in the first half than in the second half in all cases, and the IFG ratio was similar in 8 cases. Furthermore, mean flap IFG and mean IFG ratio in all cases in the first half were significantly higher than in the second half. Conclusions: IFG measurements may complement conventional flap monitoring, particularly in the early postoperative period.

Historique: Diverses techniques de surveillance du lambeau sont utilisées pour favoriser le dépistage précoce du thrombus anastomotique, mais peu de méthodes de surveillance automatique et continue sont utilisées en ce moment. La présente étude visait à examiner les tendances du glucose interstitiel (GI) lors de la surveillance du lambeau par une mesure automatique et continue. Méthodologie: Neuf patientes ont subi une reconstruction mammaire unilatérale au moyen d'un lambeau myocutané du grand droit transverse avec anastomose vasculaire. Chaque patiente était dotée de deux dispositifs de mesure du GI. L'un d'eux était fixé au lambeau (GI du lambeau) et l'autre au sein en bonne santé (GI témoin). Dans chaque cas, les chercheurs ont enregistré le GI du lambeau, le GI témoin et le ratio du GI (GI du lambeau/GI témoin) pendant les 72 premières heures suivant l'opération (première moitié), puis pendant les 72 heures suivantes (deuxième moitié). Dans tous les cas, les chercheurs ont comparé les valeurs moyennes enregistrées pendant la première moitié à celles enregistrées pendant la deuxième moitié. Résultats: Tous les lambeaux ont survécu. Le GI du lambeau n'a pas chuté sous 40 mg/dl pendant la première moitié. Le ratio minimal du GI était de 42 mg/dl et 0,55 pendant la première moitié. Dans tous les cas, le GI du lambeau était beaucoup plus élevé pendant la première moitié que pendant la deuxième moitié, et le ratio du GI était semblable dans huit cas. De plus, dans tous les cas, le GI moyen du lambeau et le ratio moyen du GI était beaucoup plus élevé pendant la première moitié que la deuxième. Conclusions: Les mesures de GI peuvent compléter la surveillance habituelle du lambeau, notamment au début de la période postopératoire.

Pediatric-acquired Idiopathic Blepharoptosis with the Eyelids Being Habitually Opened Using the Frontalis Muscle.

Pediatric-acquired idiopathic blepharoptosis is rare, and no studies on surgery for the disease have been reported. We present a case of the disease with an atypical postoperative course. The patient initially underwent levator aponeurosis advancement. However, she cannot sufficiently open the affected eyelid without conscious effort and has developed a habit of opening the eyelids using the frontalis muscle. She underwent secondary frontalis suspension with the fascia latae, and then she was able to open her eyelids well all the time. When the disease duration in pediatric-acquired blepharoptosis is long, the habit of opening the eyelids using the frontalis muscle may be difficult to break. In such cases, we believe that frontalis suspension is the best operation.

A Novel Dissection Method of the Internal Mammary (Thoracic) Artery: Anastomotic Vessel of the DIEP Flap.

Deep inferior epigastric perforator flaps are commonly used for breast reconstruction using autologous tissue. For such free flaps, the internal mammary artery provides stable blood flow as the recipient for anastomosis. We report a novel dissection method of the internal mammary artery. First, the perichondrium and costal cartilage of the sternocostal joint are dissected with electrocautery. Then, the incision on the perichondrium is extended along the cephalic and caudal ends. Next, this C-shaped superficial layer of perichondrium is elevated from the cartilage. The cartilage is incompletely fractured with electrocautery, with the deep layer of perichondrium intact. Then, the cartilage is completely fractured by leverage and removed. The remaining deep layer of perichondrium is incised at the costochondral junction and shifted aside, revealing the internal mammary artery. The preserved perichondrium creates a rabbet joint to protect the anastomosed artery. This method not only enables a more reliable, safer dissection of the internal mammary artery, but also allows reusage of the perichondrium as underlayment in the setting of anastomosis, and coverage for the incised rib edge, protecting the anastomosed vessels.

Comparison of Two Types of Tapes for Taping After Breast Reconstruction Using Silicone Materials.

BACKGROUND: Several kinds of tapes are used for postoperative wounds, which occasionally cause contact dermatitis and result in noticeable pigmentation. A comparison of the postoperative course between different tapes has not been reported. This study aimed at investigating the differences between two postoperative tapes used after breast reconstruction with silicone materials for simple mastectomy. MATERIALS AND METHODS: Eighty-eight nonconsecutive patients undergoing tissue expander operation and 75 nonconsecutive patients undergoing tissue expander and silicone breast implant operations were included in this prospective study. Two postoperative tapes were used: a nonwoven surgical tape (Yu-ki ban®) or a hypoallergenic polyester-woven fabric tape (Atofine TM), which have different base materials, a removed keratinocyte area, and moisture permeability. We determined the differences in the incidence of skin complications, scar width, and aesthetic results with respect to scarring between the patients using Yu-ki ban and those using Atofine. RESULTS: Statistically similar results were achieved for the patients who underwent reconstruction using either the tissue expander or silicone breast implant. Scar width was similar between the groups; however, the incidence of skin complications was significantly lower in patients using Atofine than in those using Yu-ki ban. Aesthetic results with respect to scarring were better in patients using Atofine than in those using Yu-ki ban, with a significant difference in the incidence of pigmentation between the groups. CONCLUSION: The tape with higher moisture permeability and a lower removed keratinocyte area should be used to reduce the incidence of contact dermatitis and achieve better aesthetic results with respect to scarring.

Making the upper edge of a silicone breast implant invisible by fat onlay-grafting harvested from the affected inframammary fold.

BACKGROUND: In silicone breast implant (SBI)-based breast reconstructions, aesthetic outcomes are often low due to the visible upper edge of the SBI. To ameliorate this, grafting fat harvested from the SBI operative field has not been reported to date. Therefore, we aimed to develop a novel technique for fat onlay-grafting, harvested from the inframammary fold (IMF) of the reconstructed breast, and investigate its usefulness. METHODS: A total of 90 patients who underwent SBI-based breast reconstruction after a simple mastectomy were included in this study. The harvested fat was recorded by weight and grafted evenly to the medial and median upper edge of the SBI on the pectoralis major muscle. We applied this technique to 30 patients (fat onlay-grafting group) and compared them with the 60 patients (no-grafting group) who did not undergo our technique using the postoperative 1-year aesthetic outcome scores of the medial and median upper edge of the SBI. Furthermore, we investigated the correlation between the weight of harvested fat and body mass index. RESULTS: No postoperative wound complications occurred, and infection, hardened fat, and fat lysis were not found in the fat onlay-grafting group. The medial and total aesthetic outcome scores in the fat onlay-grafting group were significantly higher than those in the no-grafting group (P<0.05). The average weight of harvested fat was 11.9 [5-32] g. The correlation between the weight of the harvested fat and body mass index was significantly positive (R2=0.7119, P<0.05). CONCLUSIONS: Our technique made the upper edge of the SBI invisible. Further, it was simple and less invasive with safe augmentation. Therefore, we believe that this technique can contribute to better aesthetic outcomes in SBI-based breast reconstruction.

Breast reconstruction using delayed pedicled transverse rectus abdominis muscle flap with supercharging: reports of three cases.

Breast reconstruction using a pedicled transverse rectus abdominis muscle (TRAM) flap is a well-established surgical procedure. Although studies suggest that transplanting this flap using a delayed method reduces the risk of partial flap necrosis, challenges persist. Hence, we present three cases of breast reconstruction using a pedicled TRAM flap with both delaying and supercharging. Patient age, excised tissue volume for mastectomy, and follow-up period were as follows: Case 1, 58 years, 429 cm3, 5 months; Case 2, 35 years, 910 cm3, 6 months; and Case 3, 56 years, 489 cm3, 4 months. One patient (Case 2) required a large flap tissue volume to achieve breast symmetry, whereas the other two (Cases 1 and 3) had long, longitudinal scars from previous cesareans sections. In a delayed surgery, the flap was partially elevated with partial dissection and no ligation of the deep inferior epigastric artery and vein (DIEAV). An artificial dermis with a silicone membrane (Teldermis®) was used to prevent adhesion of the rectus abdominal muscles and DIEAV to the surrounding tissue. Supercharging was performed by anastomosis between the ipsilateral DIEAV and internal thoracic AV. Flaps in zones I-III and in half of zone IV for Case 2, and zones I-III for Cases 1 and 3, were transferred; all survived without infection. This method allowed the transferring of a larger tissue volume compared with the conventional pedicled TRAM flap-transfer method. Thus, it may be useful for patients who require larger tissue volume or high-risk patients.

Use of an Orbital Septum Flap for Correcting Severe Blepharoptosis.

BACKGROUND: Several surgical procedures are available for the treatment of severe blepharoptosis with poor levator function. However, the procedures have advantages and disadvantages. Particularly, complications such as lagophthalmos and lid lag are commonly observed after conventional interventions. Thus, the present study aimed to introduce a surgical technique that uses an orbital septum flap without the orbital oculi muscle for the correction of severe blepharoptosis. METHODS: The technique utilizes the orbital septum flap, which is connected with the frontalis muscle via the galea aponeurosis and frontal periosteum, to suspend the tarsal plate. In this case series, the technique was used for the correction of blepharoptosis in 16 eyes from 12 patients. RESULTS: The margin reflex distance in all patients improved at 6 months after surgery. Two patients presented with lagophthalmos and three with mild recurrence. However, revision surgery was not required, and none of patients presented with lid lag. CONCLUSIONS: For the correction of blepharoptosis, the use of the orbital septum flap without the orbital oculi muscle can be easily selected compared with other conventional methods that are more likely to cause overcorrection and closure disorders. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Thorax anthropometric position index: a simple evaluation of the inframammary fold position in the thorax.

Appropriate positioning of the inframammary fold (IMF) is essential for breast reconstruction. The purpose of this study was to quantitatively measure and evaluate the anthropometric position of the IMF in the thorax. A total of 145 Japanese women with unilateral breast cancer were analyzed. To indicate the superior-inferior position of the IMF on the non-diseased side, the distances from the sternal notch (SN) to the IMF along the midline (SN-IMFM) and from the SN to the umbilicus (UB) (SN-UB) were measured. A new index, the thorax anthropometric position (TAP) index for the IMF, was then defined as the ratio of SN-IMFM to SN-UB. The TAP index was calculated for each patient, and its correlations with demographic parameters, including age, body height, and body mass index, were statistically assessed. The TAP index was normally distributed and ranged from 0.500 to 0.704, with a mean of 0.590. Multivariate analysis revealed that age was an independent factor associated with a higher TAP index (p < .01). In addition, the paired t-test showed that the TAP index was significantly greater in the standing position than in the supine position (p < .001). The position of the IMF in the thorax could be objectively described by the TAP index, and it was suggested to become inferior with age and the standing position. The index, along with these findings, will provide useful information for the evaluation of the breast contour in an objective and simple manner.

A Novel Technique to Achieve Rapid Wound Healing of Donor Site Wounds in Split-Thickness Skin Grafts of a Patient Undergoing Anticoagulation Therapy.

Split-thickness skin grafts constitute an established and widely used procedure for treating skin ulcers. However, in patients on anticoagulation therapy, wound healing abnormalities can prevent smooth epithelialization of their donor site. We aimed to investigate the usefulness of a technique to facilitate smooth wound healing through partial dimension reduction, and spared skin grafts back of donor sites with split-thickness skin grafts for patients undergoing anticoagulation therapy and investigate its usefulness. Partial dimension reduction and spared skin grafting back was performed on the donor site in 4 cases (group A), and the conventional method (moist dressing) was performed in 3 cases (group B). We compared the time to achieve complete epithelialization, the degree of pain, the frequency of dressing changes during the perioperative period, and the cosmetic results 6 months after surgery in both groups. The spared skin graft achieved good circulation. The time to achieve complete epithelialization was 3.1 weeks (2.5-4 weeks) in group A and 5.7 weeks (3-8 weeks) in group B; group A tended to experience less pain and fewer dressing changes during the perioperative period than group B. In addition, group A yielded superior cosmetic results to group B. Our technique can contribute to increasing the defense against physical stimulation in the donor site. Therefore, rapid wound healing and easy wound management can be achieved. We believe that it may be useful in split-thickness skin grafts for patients undergoing anticoagulation therapy.

Modification of the position of the angulus oris with a rotation flap and a YV flap in lip reconstruction.

Functionally, the lip serves to prevent food and drink from spilling out of the beginning of the gastrointestinal tract, and it is also used for vocalization. In addition, the lip has cosmetic importance as part of the face involved in making expressions, and in many cultures, it is considered to be sexually appealing. The results of lip reconstruction procedures must therefore be both functionally and cosmetically satisfactory. When the orbicularis oris muscle and oral mucosa are excised, functional reconstruction is prioritized. In contrast, if there are no functional problems, cosmetic reconstruction is the main focus. This case involved the reconstruction of a right upper lip defect caused by a dog bite. When the skin defect was covered with a local flap, the right angulus oris shifted medially, so we incorporated a YV flap at the right angulus oris to modify its position and allow for a cosmetically satisfactory result. We believe that this method can be used not only for cases in which asymmetry of the angulus oris is expected to occur at the time of lip reconstruction, but also for cases in which it has already occurred in the initial operation.

Effective Salvage Surgery of a Severely Congested Propeller Perforator Flap Using a Postoperative Delay Technique and Negative-Pressure Wound Therapy.

Wound edge-based propeller perforator flaps have often been applied to soft tissue reconstruction of sacral pressure sores. Although this flap often causes necrosis due to overtension and twisting of the perforators, salvage surgery using a postoperative delay technique has not been reported thus far. In this article, we present a case in which we successfully reconstructed a sacral pressure sore using a wound edge-based propeller perforator flap. The flap caused severe congestion, which had a concern due to the potential wide-ranging flap loss; it was subsequently salvaged by an emergent delay procedure and negative-pressure wound therapy on day 2 postoperatively.

Optimal intraoperative selection of the projection of silicone breast implant using simplified cotton sizers.

BACKGROUND: It is occasionally difficult to accurately measure the projection of the unaffected breast in unilateral breast reconstruction and decide the optimal projection of a silicone breast implant (SBI). SBI ready-made sizers are useful for selecting the optimal SBI; however, the cost of procuring multiple types of this ready-made sizers is high. Therefore, we aimed to develop a novel technique for selecting SBIs using simplified cotton sizers, intraoperatively. METHODS: We applied the novel technique on 15 patients who underwent SBI-based breast reconstruction after simple mastectomy, among whom two or three SBI candidates had similar height and width but different projection. The breast reconstructed using a cotton SBI sizer was compared with the unaffected breast in the sitting position. We then selected the optimal SBI with a little higher projection than that of the unaffected breast. At the postoperative 1 year, we confirmed whether we could select better SBI among the prepared SBIs. RESULTS: Creating and applying the cotton SBI sizer required approximately 10 min in all cases. Optimal SBI selection among the prepared SBIs was seen in 14 cases; capsule contracture occurred in 1 case. CONCLUSIONS: A simplified cotton SBI sizer is recommended because it is easy and inexpensive to develop and provides reliable assistance in identifying the optimal SBI projection.

Exposed Artificial Plate Covered With Perifascial Areolar Tissue as a Nonvascularized Graft.

Perifascial areolar tissue (PAT) is a loose connective tissue on deep fascia, such as on the groin, thigh, or temporal region, which has abundant vascular plexus and mesenchymal stem cells. Nonvascularized PAT grafts can survive even on hypovascular wound beds. Therefore, PAT grafting is a possible alternative to conventional flap surgery to cover exposed bone or artifacts. In this article, we describe 2 cases of PAT grafting for the treatment of skin ulcers with exposed bone and artificial plate after mandible reconstruction. After negative-pressure wound therapy, PAT was used to covering exposed artificial plate for both cases, and a skin graft onto the PAT graft was performed in 1 case. The ulcers improved in both cases without recurrence. The gold-standard treatment of intractable ulcers and fistulas with an exposed tendon, bone, or artifact is coverage by a well-vascularized skin flap. However, PAT grafting has advantages in similar situations, occasionally together with skin grafting and/or negative-pressure wound therapy, because it is technically simple and less invasive.

Microsurgical Training using Reusable Human Vessels from Discarded Tissues in Lymph Node Dissection.

The use of human vessels at the beginning of microsurgery training is highly recommended. But vessels with the appropriate length for training are not often obtained. Whether these vessels may be reused for training has not been reported. Accordingly, we harvested vessels from discarded tissues in lymph node dissection and demonstrated that vascular anastomosis training using the same human vessels several times is possible by placing the vessels in a freezer and defrosting them with hot water. Vascular walls can be stored for microsurgical training until about 4 years after harvest, as shown in the gross appearance and histologic findings of our preserved vessels. We recommend the technique presented here for the longterm reuse of human vessels for microsurgery training that closely resembles real procedures.