An approach to achieve tension-free closure and mitigate recurrence in the management of recurrent cervical keloids.

Keloid is a burdensome condition that negatively affects patient's quality of life. It is influenced by a spectrum of risk factors, including tension. We propose an approach to address the tension-free closure and optimize surgical outcomes in neck keloid. A retrospective review of neck keloid patients who underwent surgical treatment between 2014 and 2022 was performed. Five patients underwent surgical interventions. Two patients had sufficient and three had insufficient tissue redundancy. The former underwent keloid excision with tension-free closure. The latter underwent keloid excision with full thickness skin graft for tension-free closure. One patient required re-excision with free flap coverage. All patients received postoperative low dose radiation. All patients were satisfied with the results and there were no signs of keloid recurrence during the follow-up period. Tension during closure following keloid excision is a modifiable risk factor. An appropriate algorithm providing tension-free closure can minimize the recurrence.

Comparative analysis of RADAR vs. conventional techniques for AVF maturation in patients with blood viscosity and vessel elasticity-related diseases through fluid-structure interaction modeling: Anemia, hypertension, and diabetes.

PURPOSE: This study aims to compare two surgical techniques, the standard Vein-to-Artery and the newer Artery-to-Vein (Radial Artery Deviation And Reimplantation; RADAR), for enhancing the success of Arterio-Venous Fistula maturation in end-stage renal disease patients. The impact of diseases like anemia, diabetes, hypertension, and chronic kidney disease were considered. The goals are to advance Arterio-Venous Fistula (AVF) surgery, improve patient outcomes, and contribute to evidence-based surgical guidelines. METHODS: Fluid-structure interaction modeling was employed to investigate how hemodynamic and mechanical stresses impact arteriovenous fistula maturation, with a particular focus on the role of wall shear stress in determining maturation outcomes. The critical threshold for vessel injury was identified as wall shear stress values exceeding 35 N/m2, while stenosis formation was projected to occur at levels below 1 N/m2. This work introduced a novel approach by considering disease-related factors, including blood viscosity (anemia), and vessel elasticity (diabetes, hypertension, and chronic kidney diseases), which directly influence hemodynamics and the generation of wall shear stress. Furthermore, the model was designed to incorporate varying thicknesses and elasticities for both the vein and artery, accurately representing authentic vascular anatomy. RESULTS: The RADAR technique has demonstrated superior performance compared to the standard technique by providing appropriate wall shear stress in critical regions and minimizing the risk of wall damage. Its use of a thicker vessel also reduces the risk of vessel injury, making it particularly effective for patients with Chronic Kidney Disease (CKD), hypertension, anemia, and diabetes, ensuring optimal blood flow and fewer complications. However, there are minor concerns about stenosis formation in hypertension and anemia cases, which could be mitigated by adjusting the anastomosis angle to be lower than 30°. CONCLUSION: Diabetes and hypertension have significant physiological effects that increase the risks associated with arteriovenous fistula maturation. The anemic condition resulting from CKD may help reduce vessel injury but raises concerns about potential stenosis formation. Despite these co-morbidities, the RADAR technique has demonstrated its ability to induce more favorable hemodynamic changes, promoting arteriovenous fistula maturation.

Superficial Inferior Epigastric Artery Flap: Vascular Pattern and Territory Across the Midline.

BACKGROUND: Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline. METHODS: Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory. RESULTS: Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area. CONCLUSIONS: Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation.

The advanced concepts for septal l-strut re-designing in septorhinoplasty for better strength and stability by considering of center of gravity.

PURPOSE: This study contributes to the multidisciplinary understanding of septal L-strut reshaping and introduces innovative surgical design concepts based on engineering principles of static equilibrium. The objective is to enhance structural strength and stability, ultimately leading to improved surgical outcomes. METHOD: Finite element analysis is employed to model the three-dimensional septal cartilage in septoplasty. A significant contribution of this work is the introduction of an innovative redesigns for the septal L-strut structure. These redesigns represent the first-ever attempt to incorporate the center of gravity theory into the modeling of the septal L-strut. RESULTS: Our findings emphasize the significance of attaining a lower center of gravity in the design of the septal L-strut, as it contributes to optimal core strength and stability. To achieve this, we recommend widening the caudal septum and shaping the interior fillet corner to its maximum size, taking into account its specific shape. Notably, the utilization of a standard 20x20 mm septal L-strut, the C-shaped technique, and the septal support graft technique provide superior strength due to enhanced basement support. CONCLUSION: To enhance surgical outcomes in septal L-strut procedures, design modifications are proposed to improve strength and stability, resulting in optimized performance. Recommendations include widening the caudal septum and incorporating fillet shapes in the geometry to lower the center of gravity.

The ultrasound-guided proximal intercostal block: anatomical study and clinical correlation to analgesia for breast surgery.

BACKGROUND: The ultrasound-guided proximal intercostal block (PICB) is performed at the proximal intercostal space (ICS) between the internal intercostal membrane (IIM) and the endothoracic fascia/parietal pleura (EFPP) complex. Injectate spread may follow several routes and allow for multilevel trunk analgesia. The goal of this study was to examine the anatomical spread of large-volume PICB injections and its relevance to breast surgery analgesia. METHODS: Fifteen two-level PICBs were performed in ten soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the 2nd(15 ml) and 4th(25 ml) ICS, respectively. Fluoroscopy and dissection were performed to examine the injectate spread. Additionally, the medical records of 12 patients who had PICB for breast surgery were reviewed for documented dermatomal levels of clinical hypoesthesia. The records of twelve matched patients who had the same operations without PICB were reviewed to compare analgesia and opioid consumption. RESULTS: Median contrast/dye spread was 4 (2-8) and 3 (2-5) vertebral segments by fluoroscopy and dissection respectively. Dissection revealed injectate spread to the adjacent paravertebral space, T3 (60%) and T5 (27%), and cranio-caudal spread along the endothoracic fascia (80%). Clinically, the median documented area of hypoesthesia was 5 (4-7) dermatomes with 100 and 92% of the injections covering adjacent T3 and T5 dermatomes, respectively. The patients with PICB had significantly lower perioperative opioid consumption and trend towards lower pain scores. CONCLUSIONS: In this anatomical study, PICB at the 2nd and 4th ICS produced lateral spread along the corresponding intercostal space, medial spread to the adjacent paravertebral/epidural space and cranio-caudal spread along the endothoracic fascial plane. Clinically, combined PICBs at the same levels resulted in consistent segmental chest wall analgesia and reduction in perioperative opioid consumption after breast surgery. The incomplete overlap between paravertebral spread in the anatomical study and area of hypoesthesia in our clinical findings, suggests that additional non-paravertebral routes of injectate distribution, such as the endothoracic fascial plane, may play important clinical role in the multi-level coverage provided by this block technique.

Comparison of impact of target delineation of computed tomography- and magnetic resonance imaging-guided brachytherapy on dose distribution in cervical cancer.

PURPOSE: The dose distributions obtained from three imaging approaches for target delineation in cervical cancer using high-dose-rate (HDR) brachytherapy were investigated. MATERIAL AND METHODS: Ten cervical cancer patients receiving four fractions of HDR brachytherapy were enrolled. Based on different imaging approaches, three brachytherapy plans were developed for each patient: with the high-risk clinical target volume (HRCTV) delineated on magnetic resonance (MRI) images for every fraction (approach A; MRI-only); on MRI for the first fraction and computed tomography (CT) images for the subsequent fractions (approach B; MRI1st/CT); and on CT images for all fractions (approach C; CT-only). The volume, height, width at point A, width at maximum level, and dosimetric parameters (D100, D98, D95, and D90 of the HRCTV; and D0.1cc, D1cc, and D2cc of all organs at risk, or organ at risk - OAR: bladder, rectum, sigmoid colon, and bowel) provided by each approach were compared. RESULTS: The mean HRCTV volume, width, and height obtained from approach C (CT-only) were overestimated compared to those from approaches A (MRI-only) and B (MRI1st/CT). The doses to the HRCTV for approaches A and B were similar. However, the HRCTV doses for approach C were significantly lower than those for approaches A and B for all parameters (D95-D100). As to the OAR, the three approaches showed no differences. CONCLUSIONS: A combination of MRI and CT is a safe alternative approach for cervical cancer HDR brachytherapy. The technique provides comparable dosimetric outcomes to MRI-based planning, while being more cost-effective.

Inferior External Pudendal Artery Anastomosis: Additional Approach to Prevent Skin Necrosis in Replanted Penis.

BACKGROUND: Microsurgical anastomosis of the dorsal artery of the penis either with or without anastomosis of the cavernosal artery is the preferred technique for penile replantation. However, postoperative penile skin necrosis is commonly reported with this technique. This study aimed to characterize the anatomy of the vascular supply of the penis pertinent to penile replantation surgery and to report a successful case of penile replantation without postoperative necrosis using anastomosis of the inferior external pudendal artery. METHODS: The authors dissected 15 penises of fresh cadavers under acrylic dye injection by means of the inferior external pudendal and dorsal arteries of the penis to identify vascular anastomoses between arteries supplying the penis and to measure other parameters of the arteries. RESULTS: Mean diameters at the base of the penis of the inferior external pudendal, dorsal, and cavernosal arteries were 0.94, 1.43, and 0.80 mm, respectively. Penile skin is mainly supplied by the inferior external pudendal artery under three patterns with anastomoses across the midline. Preputial skin receives additional blood supply from perforators of the dorsal artery without visible anastomosis between the perforators and the inferior external pudendal artery. Deep structures receive blood supply from the dorsal, cavernosal, and urethral arteries, with visible anastomoses between the arteries. In a patient with amputated penis, the inferior external pudendal artery diameter was 0.7 mm, which was sufficient for microsurgical anastomosis. No postoperative necrosis developed, and patency of the inferior external pudendal artery was confirmed with duplex ultrasound. CONCLUSION: The diameter of the inferior external pudendal artery at the base and midshaft of the penis is sufficiently large for microsurgical anastomosis, and additional vascular anastomosis of at least one inferior external pudendal artery may help to prevent postoperative penile skin necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Anatomy of medial plantar superficial branch artery perforators: Facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction.

BACKGROUND: Medial plantar artery perforator (MPAP) flap was proposed as proper option for finger pulp reconstruction. To provide the previously unavailable vessel information required for this small flap design, this study aimed to gather all necessary anatomy of MPA, MPAP, and their territories of blood supply to apply in clinical MPAP flap reconstruction minimizing perforator injury. METHODS: Dissection of 30 Thai cadaveric feet for visualizing superficial branch of MPA and its perforators (MPAP) using acrylic dye cannulation were performed. Diameter, length, number of branches, course, distributing areas of these vessels, and also their areas of blood supply were recorded in relation to specified landmarks, eg, C-MTH line; medial calcaneal tuberosity to plantar side of the first metatarsal head and S point; emerging point of superficial branch of MPA from deep fasciae into subcutaneous layer. RESULTS: Average diameter of MPA at its origin and total length are 1.63 ± 0.3 and 52.8 ± 16.1 mm, respectively. It provides 1-3 perforators, with an average size and length of 0.36 ± 0.11 and 23.2 ± 5.47 mm, respectively. Its distribution is mostly in the posteromedial quadrant within 50 and 30 mm from the midpoint of C-MTH line and the S point, respectively. The estimated perforator flap area is 2.5 cm × 1.5 cm and 4.5 cm × 2.5 cm for single and double perforators, respectively. CONCLUSIONS: MPAP flap was proved as another ideal option for finger pulp reconstruction. Its limitation is small size of perforators but this can be overcome by using MPA for microsurgical anastomosis instead.

Dosimetric analysis and preliminary clinical result of image-guided brachytherapy with or without hybrid technique for cervical cancer using VariSource titanium ring applicator with "Siriraj Ring Cap".

PURPOSE: Titanium ring cap applicator (VariSource) was applied in treating cervical cancer patients by using image-guided brachytherapy (IGBT). However, its sizes appeared to be relatively large for most of our patients. Thus, we have developed a specific applicator "Siriraj Ring Cap," which is slightly smaller and more suitable for our patients. This study was to evaluate effectiveness of this equipment. METHODS AND MATERIALS: Locally advanced cervical cancer patients were treated with external beam radiation therapy with or without concomitant chemotherapy. Siriraj Ring Cap was applied in all of the patients for at least one fraction. Dosimetric analysis was performed in each fraction of IGBT. Clinical outcomes of these patients were evaluated. RESULTS: Twenty-nine patients with 117 dosimetric planning were evaluated between January and December of 2014. Siriraj Ring Cap was fit to all patients in this study. By using this applicator, radiation doses to the targets (D90 high-risk clinical target volume and D90 intermediate-risk clinical target volume) were higher in each fraction. There were no statistically differences of radiation doses to the bladder, rectum, sigmoid colon, and small bowel. Within 2-year followup, 3 patients (10.3%) developed locoregional recurrence. Two-year disease-free survival and overall survival were 75.9% and 89.7%, respectively. According to RTOG/EORTC complication criteria, Grade 1, 2, and 3 gastrointestinal complications were developed in 2 (6.9%), 4 (13.8%), and 1 (3.4%) patients, respectively. For genitourinary complications, 3 patients (10.3%) and 1 patient (3.4%) had Grades 1 and 2, respectively. CONCLUSIONS: Siriraj Ring Cap is feasible for IGBT in cervical cancer patients with narrow vagina. Dosimetry and clinical outcomes were satisfactory by using our specific applicator.

Vascular Nature and Existence of Anastomoses of Extrinsic Postauricular Fascia: Application for Staged Auricular Reconstruction.

A staged auricular reconstruction in microtia patients was developed by using superficial mastoid fascia (as part of extrinsic postauricular fascia) to cover the cartilagenous framework due to its highly vascularized nature. Three branches of external carotid artery (superficial temporal artery, posterior auricular artery and occipital artery) were found to supply this fascia, this study was therefore aimed to investigate the dimension of blood supply from each vessel and also to demonstrate the existence of anastomoses among these arteries. Thirty-eight pinnas and postauricular fascias from Thai fresh adult cadavers were included to document the anastomoses by showing both perfused dye connection (10 dissections) and visible anastomotic branches (8 dissections) among them. Distribution of each vessel trunk and its branches were demonstrated using superimposed illustration in the other 20 dissections with dye injection into each artery to designate 3 zones of anastomotic area between each arterial pair. Maximal size of viable postauricular fascial flap for staged reconstruction according to this vascular study was thus estimated to be at least 5 cm above and 3 cm below the Frankfurt horizontal plane and about 6 cm posterior to external acoustic meatus owing to the course of posterior auricular artery and its anastomoses. In addition, greater size of flap with dual blood supply from both superficial temporal and posterior auricular arteries can be raised by harvesting beyond 5 cm above external acoustic meatus.