First dorsal metacarpal artery perforator-based propeller flap: functional anatomy and clinical application in soft-tissue defects of the dorsal hand and digits.

BACKGROUND: Many approaches have been reported to repair soft-tissue defects of the hand using dorsal metacarpal artery flaps. Use of a perforator-based propeller flap from the first intermetacarpal space to the dorsum of the hand has been described. The aim of this study was to confirm the functional anatomy of a first dorsal metacarpal artery (FDMA) perforator flap. METHODS: Twenty-nine fixed cadaveric hands were dissected to determine the origin, course, and branches of the FDMA. Clinically, five cases of soft tissue defects of the hand underwent reconstructive surgery using an FDMA perforator-based propeller flap. RESULTS: The FDMA was found in 27 specimens (93%). The ulnar branch of the FDMA always supplied the cutaneous perforator (mean ± SD, 4.3 ± 1.6), and the most distal cutaneous perforating branch was found along the metacarpal long axis within 25 mm of the tip of the metacarpal head with high frequency (28/29, 97%). In the two hands that had aplasia of the FDMA, well-developed perforators arose directly from the radial artery and advanced to the metacarpal head. Seven hands (24%) had perforators arising from the palmar arterial system, penetrating through or passing close by the second metacarpal bone. In clinical application, all the flaps survived completely without major complications. CONCLUSIONS: The FDMA perforator-based propeller flap is minimally invasive and technically simple. It is expected to be a new option for hand reconstruction.

Triangular extension of hinge flaps: A novel technique to resolve stomal stenosis and prevent restenosis in staged buccal mucosal urethroplasty.

OBJECTIVES: To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis. METHODS: A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group). RESULTS: In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027). CONCLUSIONS: The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis.

A banner flap with adjacent rotation flap for closure of circular skin defects: a schematic comparison with conventional rotation flap technique.

The local flap method is a minimally invasive, quick, and common technique of closing skin defects. Several methods using multiple local flaps are employed for the purpose of closing relatively large defects, and minimizing the resultant scar and deformity. We present a combined local flap method using a banner flap with an adjacent rotation flap (B-R flap) with the potential for closing circular defects. A retrospective analysis was performed in 15 patients treated with the B-R flap for circular skin defects over a 2-year period. The sizes of the flap and the healthy skin excision area were evaluated using image analysis software, and were compared to a model of a conventional rotation flap that would be necessary to close the same defect. All flaps were successfully engrafted. The B-R flap required a 39.1% smaller rotation flap and an 85.9% smaller area of healthy skin compared to the conventional rotation flap technique. There was one adverse event, partial epidermal necrosis that was conservatively treated and healed. The B-R flap is comparatively less invasive; it allows a smaller area of healthy skin to be excised. It can be a useful option for closing a circular defect.

Severe Functional Loss of the Hand due to Necrotizing Fasciitis with Underlying Vasculitis Neuropathy.

A 72-year-old man presented with an erythematous, painful, swollen, and blistering left hand associated with a systemic fever. The patient was diagnosed with microscopic polyangiitis and was receiving steroid therapy from a year before the incident. Based on a clinical diagnosis of necrotizing fasciitis, emergency surgery was performed within 2 days after the onset. ß-Hemolytic Streptococcus group A was isolated from a culture of the blood and wound. Radical debridement and high-dose penicillin and clindamycin therapy successfully saved the patient's life and affected limb except for the second finger on his left hand, which was completely necrotic. However, the function of the left hand was seriously decreased and did not recover. The important point to note in this case was the preexisting vasculitis neuropathy due to microscopic polyangiitis. The severe postoperative dysfunction of the hand was considered to be due to ischemic neuropathy that was aggravated by compartmental syndrome and microvascular thrombosis. In conclusion, necrotizing fasciitis of an extremity with underlying vasculitis neuropathy can lead to a poor functional prognosis of the limb.

Protective Effect of Extract of Ginkgo biloba 761 against Frostbite Injury in Rats.

BACKGROUND: When frostbite thaws, reperfusion injury has a crucial impact on tissue injury, and production of free radicals induces further tissue damage. This study examined whether extract of Ginkgo biloba 761 could ameliorate frostbite injury as a free radical scavenger. METHODS: Seventy-five Fisher 344 rats were divided into five groups of 15, and frostbite injury was created in each animal by sandwiching the left hind foot between a frozen magnet (-78.5°C) and a room-temperature magnet. Group I received saline; groups II, III, and IV received extract of Ginkgo biloba 761 (200, 100, and 50 mg/kg, respectively); and group V received superoxide dismutase (12 mg/kg). All drugs were injected intraperitoneally three times at 24-hour intervals. The wound surface area was measured throughout the wound healing period. Wounds were also harvested at various times to count cells stained by monoclonal antibodies for 4-hydroxy-2-nonenal and 8-hydroxy-2'-deoxyguanosine. RESULTS: Compared to group I, the wound surface area was significantly smaller in groups II and III on days 1 and 3 after wound creation. Histologic examination revealed significantly more 4-hydroxy-2-nonenal-stained cells and 8-hydroxy-2'-deoxyguanosine-stained cells in group I compared to other groups on day 1. However, there was no difference in the total healing period among the groups. A higher dose test of extract of Ginkgo biloba 761 (300 mg/kg daily) induced animal death, probably because of toxicity. CONCLUSION: Extract of Ginkgo biloba 761 demonstrated a protective effect against frostbite in the present model and probably alleviated reperfusion injury by reducing tissue peroxidation.

Approaches for Excision of Intramasseteric Nodules.

Developmental lesions, including benign or malignant tumors, rarely arise in the masseteric region. This retrospective study was performed to evaluate the adequacy of different surgical approaches in a series of patients with lesions in the masseteric region. The surgical methods, postoperative complications, pathological diagnosis, and aesthetic outcome were compared in 4 patients who underwent excision of intramasseteric mass lesions. A flap was elevated in 3 patients and direct incisional resection was performed in 1 patient. Two patients underwent incisional biopsy to exclude malignancy before the total excision was performed. The final diagnosis was hemangioma in 3 patients and schwannoma in 1 patient. All patients were satisfied with the aesthetic results and there were no major complications. In conclusion, surgery with skin flap elevation was concluded to be the best approach based on overall assessment of technical considerations, complications, and the cosmetic outcome. However, the surgeon should not hesitate to perform direct incisional biopsy when malignancy needs to be excluded.

Polyglycolic Acid Felt for Prevention of Frey Syndrome After Parotidectomy.

BACKGROUND: Frey syndrome is one of the important complications of parotid surgery. Placing a barrier between the parotid gland and the skin flap is considered to be effective for preventing this syndrome by blocking misdirected regeneration of nerve fibers. Neoveil is nonwoven polyglycolic acid (PGA) felt that is used as absorbable reinforcing material. The present study evaluated the effectiveness of this PGA felt as a barrier for preventing Frey syndrome. METHODS: A total of 19 patients who underwent superficial parotidectomy from 2012 to 2017 were retrospectively reviewed. Application of PGA felt (n = 9) or sternocleidomastoid flap (SCMF) transfer (n = 10) was performed to prevent Frey syndrome. The total operating time, intraoperative blood loss, operating time after parotidectomy, and postoperative drainage volume were compared between the 2 groups. RESULTS: The operating time after parotidectomy was significantly shorter in the PGA felt group than in the SCMF group (43.7 ± 10.7 vs 57.8 ± 15.7 minutes). The total operative time was shorter and the drainage volume was smaller in the PGA felt group than those in the SCMF group without statistical significance (210.1 ± 43.4 vs 234.3 ± 52.7 minutes and 80.6 ± 36.8 vs 118.8 ± 83.9 mL). Neither Frey syndrome nor other major complications occurred in either group. CONCLUSIONS: Use of PGA felt successfully prevented Frey syndrome, while being technically simpler and more rapid compared with SCMF transfer.

The vertical orbicularis oculi muscle turn-over procedure for the correction of paralytic ectropion of the lower eyelid.

BACKGROUND: Static reconstruction surgery that tightens the tension of the inferior tarsus, thereby raising the lax lower eyelid, is a common treatment for paralytic ectropion of the lower eyelid. We present one such operative procedure, in which an orbicularis oculi muscle flap was used. METHODS: The surgical technique involves partial resection of the tarsus and the skin, as well as a superior-based orbicularis oculi muscle flap that is sutured to the firm tissue present on the Whitnall tubercle. The muscle flap is approximately 7 mm in width and 15 mm in length, with a superior pedicle that is attached to the tarsus at the medial point of the resected tarsus. The procedure results in contact between the ocular surface and the lower eyelid. RESULTS: The procedure was performed in 11 patients with lower eyelid ectropion due to facial paralysis. Ten cases showed a favorable outcome following surgery, with stable results seen over an average follow-up period of 4.5 years. In one case, recurrence of ectropion was observed 2 months after surgery due to an insufficient correction, and the patient required repeat surgery. CONCLUSIONS: The orbicularis oculi muscle flap was an effective means of suspension and was able to maintain long-term traction tension. This procedure can therefore be considered a favorable treatment option for lower eyelid ectropion due to facial paralysis.

Hinge Flap with Triangular Extension for Reconstruction of Pharyngocutaneous and Laryngocutaneous Fistulas.

Hinge flaps are commonly used for closure of a pharyngocutaneous fistula (PCF) or laryngocutaneous fistula. These flaps are employed to augment the wall of the pharynx or larynx, but the junction between the reconstructed and native lumens can eventually become narrow and irregular after reconstruction with standard hinge flaps. We devised a method of adding a triangular extension to the end of either or both flaps and used it to treat 3 patients. In 1 patient who developed a PCF (4 × 10 cm) after laryngectomy followed by radiotherapy, the fistula was closed with 2 hinge flaps. One flap had a caudal triangular extension. The residual skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap. Another patient who developed a PCF (2.5 × 3 cm) after laryngectomy underwent 2-stage reconstruction using a buccal mucosal graft with a triangular extension, followed by 2 hinge flaps. A patient who developed an laryngocutaneous fistula (1 × 2 cm) after radiotherapy and subsequent partial laryngectomy underwent reconstruction using 2 hinge flaps, each of which had a triangular extension. The skin defect was covered by another flap. Postoperative CT or video fluoroscopic examination of swallowing showed a smooth lumen with no strictures in all 3 patients. The triangular extension of the hinge flap supplements the pharyngeal/laryngeal wall at the junction between the reconstructed and intact regions, thus avoiding postoperative stricture. Especially with PCF reconstruction, restoration of a smooth luminal surface minimizes dysphagia.

Sutureless Microvascular Anastomosis using Intravascular Stenting and Cyanoacrylate Adhesive.

BACKGROUND: Microvascular anastomosis using cyanoacrylate adhesive has a reputation among researchers as an alternative to conventional sutures. However, a degree of ingenuity is required to avoid the collapse of the vascular lumen for the duration of the anastomosis. The aim of this study was to determine the feasibility of intravascular stenting (IVaS) as a temporary stent during sutureless microvascular anastomosis with cyanoacrylate adhesive. METHODS: Sixty male Fisher 344 rats were evenly divided into two groups. The right superficial femoral arteries (RSFAs) were transected in each group. Microvascular anastomoses were then performed with the sutureless (SL) method in one group and conventional sutures (CS) in the other group. The diameter of the RSFA, duration of microvascular anastomosis, and the patency of the RSFA were evaluated immediately after anastomosis and 7 days after the surgery. Tissue samples were obtained for pathological consideration. RESULTS: There was no significant difference in the diameter of the RSFAs between the SL and the CS groups. There was no significant difference in the patency rates of the groups. The anastomosis time of the SL group was significantly shorter than that of the CS group, regardless of the experience of the surgeons. A histological analysis showed a comparable level of foreign body reactions in each group. CONCLUSION: IVaS plays a supportive role in sutureless microvascular anastomosis with cyanoacrylate adhesive. The short-term safety of this technique has now been confirmed at the experimental stage.

Phaeoacremonium Tenosynovitis of the Wrist.

A 79-year-old man presented with a painless, soft, subcutaneous mass lesion of the right volar wrist that had been slowly growing for 3 years. A cloudy, yellow serous effusion was aspirated from the punctured mass, from which Phaeoacremonium spp., an extremely rare cause of tenosynovitis, was isolated in culture. Total synovectomy was performed without the use of antifungal agents. No recurrence or complications occurred as of 6 months after surgery. Fungal infection is rare but should be considered in the differentiation of chronic tenosynovitis.

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.

Large Parosteal Lipoma without Periosteal Changes.

Parosteal lipoma is a rare tumor, accounting for approximately 0.3% of all lipomas. Bony lesions are often found in patients with this tumor (59.2%), making the differential diagnosis of malignant tumors important. Our case was a 64-year-old male patient who complained of a 25 × 15-cm mass on his right thigh that had grown rapidly over a 2-month period. On magnetic resonance imaging, a high-intensity lesion was observed on the surface of the femur beneath the vastus medialis muscle on T1 and T2 images, with low intensity on a T1 fat suppression image. No significant bony changes were detected. During total tumor resection, the tumor was found on the femur with tight continuity, with tiny areas of spiculation palpable on the bone surface. The exact tumor size was 18 × 13 × 6 cm. The pathological diagnosis was lipoma, the same result as in the former open biopsy. This case was the largest parosteal lipoma of the femur reported without periosteal changes. In cases of deep parosteal lipomas, the detection of rapidly progressive and growing pseudotumors with ossification or chondromatous changes implies malignancy. A preoperative biopsy is mandatory and must be followed by careful planning and preparation for handling in malignant cases. Plastic surgeons should therefore keep the diagnosis of parosteal lipoma in mind to provide appropriate (not too much or too little) surgical treatment.

Modification of the Nuss Procedure: The Single-incision Technique.

SUMMARY: The Nuss procedure is a prevalent minimally invasive surgery for pectus excavatum. Although the Nuss procedure has the advantage of leaving less obtrusive scars, the standard technique requires at least 3 skin incisions to insert several instruments. We experienced 7 cases of the modified Nuss procedure using a single incision during a 7-year period. To facilitate passing of the bar, a traction guide was created according to our unique method. There was no need for a bar stabilizer, and no severe intraoperative complications occurred. All patients exhibited satisfactory short-term results; however, 1 patient suffered from bar rotation and required repeat surgery for fixation. Two patients underwent bar removal via the same single incision without any difficulties.

Simultaneous analytical method for the determination of TCH346 and its four metabolites in human plasma by liquid chromatography/tandem mass spectrometry.

TCH346 (dibenzo[b,f]oxepin-10-ylmethyl-prop-2-ynylamine) is a novel propargylamine compound under investigation as a putative agent in the treatment of chronic neurodegenerative illnesses. To support clinical studies an analytical method was developed for TCH346 plus its three amine metabolites and a carboxylic acid metabolite in human plasma. Using a two-step liquid-liquid extraction, one under acidic and one under basic conditions, by pH-switching both the basic and acidic analytes were extracted from 0.5 mL of plasma. All these basic and acidic compounds could be analyzed simultaneously using gradient high-performance liquid chromatographic (HPLC) separation with positive/negative selected reaction monitoring mass spectrometry. As a result of the validation study, the analytical method was shown to be appropriate for the determination of TCH346 and its metabolites CGP70861, GP42120, CGP71090, and GP54840 in plasma for forthcoming clinical studies. The LLOQs were set to 2, 200, 20, 20, and 200 pg/mL for TCH346, CGP70861, GP42120, CGP71090, and GP54840, respectively, and the ULOQ for all analytes was 20 000 pg/mL. All analytes were stable in 50% MeOH at 4 degrees C for at least one year, in human plasma stored below -70 degrees C for at least 7 months, in human plasma below -18 degrees C for at least 6 months, in human plasma at room temperature for at least 1 day, and in the final extract solution at 4 degrees C for at least 3 days.