Separation of the seventh costal-sternal junction-A new technique to improve outcomes for the Nuss procedure for pectus excavatum.

BACKGROUND: In the standard Nuss procedure for pectus excavatum, the costal arch is often elevated together with the sternum, resulting in unevenness of the lower part of the thorax. This complication is commonly called rib flaring. This paper presents a technique to avoid rib flaring and evaluates its effectiveness. MATERIALS AND METHODS: In our technique, a part of the seventh costal cartilage is removed, disconnecting the costal arch from the sternum. The effectiveness of this technique was evaluated in a retrospective clinical study of 63 pectus excavatum patients who were randomly collected and were divided into two groups. One group-defined as the Standard Group-includes 27 patients (29.8 ± 6.5SD y/o) on whom standard Nuss procedure was conducted; the other group-defined as the Separation Group-includes 36 patients (31.8 ± 6.1SD y/o) on whom the cartilage removal was conducted in addition to the standard Nuss procedure. The degree of postoperative costal-arch elevation was defined as ECA (Elevation of Costal Arch) and was compared between the two groups. RESULTS: ECA was significantly greater for the Standard Group (10.2 ± 3.3SD mm) than for the Separation Group (-1.1 ± 3.42SDmm). CONCLUSION: Postoperative protrusion of the costal arch is prevented by the separation of the seventh costal cartilage from the sternum. Our original technique is a useful option for the treatment of pectus excavatum.

Bone-cartilage proportion in deformed ribs of male pectus excavatum patients.

This study verifies the hypothesis that bone/cartilage proportion in deformed ribs of male pectus excavatum patients varies according to their ages. Anatomical evaluation of the thoraces was performed for 79 male pectus excavatum patients, referring to their three-dimensional computer-tomographic images. The patients were divided into Child Group (5-9 years old: n = 35); Adolescent Group (12-15 years old: n = 15) and Adult Group (18+ years old: n = 29). For each patient, the most concave point of the sternum was identified and the pair of ribs closest to the point were defined as Key Ribs. On each Key Rib, the most ventral point was defined as Prominent Point (PP); the junction between the bone and cartilage was defined as Costo-Chondral Junction (CCJ). The distances of these points from the spine were defined as Distance of Prominent Point (DPP) and Distance of Costo-Chondral Junction (DCCJ), respectively. The horizontal length of the Key Rib was defined as Rib Length (RL). Inter- and intra-group comparisons were performed for DPP/RL and DCCJ/RL. Inter-Group Comparison: DCCJ/RL is significantly smaller and DPP/RL is significantly greater in Adult Group than in Child Group, meaning CCJs shift medially and PPs shift laterally as patients get older. Intra-Group Comparison: In Child Group, DCCJ/RL is significantly greater than DPP/RL, meaning CCJs exist lateral to PPs. Contrarily, in Adult Group, DCCJ/RL is significantly smaller than DPP/RL, meaning CCJs exists medial to PPs. Bone/cartilage proportion in the concave part of the chest shifts according to patients' ages. To perform the Nuss procedure effectively, this age-related anatomical change must be taken into consideration.

Normobaric oxygen therapy increases cartilage survival ratio in auricular composite grafting in rat models.

PURPOSE: This study aims to clarify whether normobaric oxygen therapy improves the survival of auricular composite grafts in rats. METHODS: For 10 male SD rats, 1.5 cm2 composite grafts were harvested from bilateral ear regions including whole auricles. The harvested grafts were transferred caudally and sutured there. The 10 rats were randomly divided into two groups and kept for 21 days in two different circumstances. The first group (Control group: five rats carrying 10 grafts) was kept in room air (20% oxygen) throughout the 21 days, and the second group-named NBO (normobaric oxygen) group (five rats carrying 10 grafts)-was kept in normobaric 60% oxygen for 3 days and then in room air for 18 days. All the 10 rats were sacrificed on the 21st day. Surviving areas of the grafts and the height of the surviving auricular cartilage were examined for statistical comparison of the two groups. Furthermore, the conditions of chondrogenesis occurring around the perichondrium were compared between the two groups. RESULTS: Surviving areas did not present statistically significant differences between the two groups. The height of surviving cartilage was significantly greater for the NBO group (2610 ± 170 SD µm) than that for the Control group (1720 ± 190 SD µm). Chondrogenesis occurred at positions more distant from the recipient bed in the NBO group than that in the Control group. CONCLUSION: Normobaric oxygen therapy increases the thickness of surviving cartilage in auricular composite grafting in rats, thus suggesting that NBO therapy may also be effective in composite grafting for humans.

Thoracic outlet syndrome after the Nuss procedure for pectus excavatum: Is it a rare complication?

OBJECTIVE: The present study aims to elucidate the frequency of thoracic outlet syndrome after the Nuss procedure for pectus excavatum and the conditions in which thoracic outlet syndrome is likely to develop. METHODS: A retrospective study including 85 pectus excavatum patients (58 males and 27 females) was conducted. Thoracic outlet syndrome was defined as a condition in which the patient has numbness, lassitude, or pain of the upper limbs at rest or during motion of the upper limbs. The frequency of the thus-defined thoracic outlet syndrome was evaluated in 85 patients. Age, sex, Haller indices, and the positions of the correction bars were compared between the patients who developed thoracic outlet syndrome and those who did not. RESULTS: Preadolescent patients (18 out of 85) did not develop postoperative thoracic outlet syndrome. In total, 15.2% of adult male patients (7 out of 46) and 33% of adult female patients (7 out of 21) developed postoperative thoracic outlet syndrome. For both male and female groups, Haller indices were significantly greater for patients who had postoperative thoracic outlet syndrome than for those who did not. Correction bars were generally placed at higher intercostal spaces in patients who developed postoperative thoracic outlet syndrome than in those who did not. CONCLUSION: A considerable percentage of adult patients develop thoracic outlet syndrome after the Nuss procedure for pectus excavatum. Maturity of the thoracic wall, femininity, severity of the deformity (represented by greater Haller indices), and placement of correction bars at superior intercostal spaces are risk factors for postoperative thoracic outlet syndrome.

Preservation of deep-layer fat of lateral zones prevents postoperative seroma after TRAM-flap harvesting for breast reconstruction: a retrospective study.

OBJECTIVE: The present study elucidates whether or not preserving fat tissues deeper than the Scarpa's fascia in zone 3 and zone 4 reduces postoperative fluid collection after harvesting the transverse rectus-abdominis muscle (TRAM) flap. METHODS: Thirty-one patients for whom breast reconstruction with free TRAM flaps had been performed were included in the study. Fat tissues deeper than the Scarpa's fascia in zone 3 and zone 4 were addressed in two ways. With 17 patients, these tissues were preserved on the abdominal wall; with 14 patients, these fat tissues were harvested as part of the TRAM flap. The former and latter groups were named the Preservation Group and Non-Preservation Group, respectively. Drainage tubes were placed at the donor site until daily drainage became less than 20 ml, at which time the tubes were removed. The total amount of postoperative fluid drained from the donor site and the days required before tube removal were compared between the two groups. RESULTS: The total volume of drained fluid was significantly greater for the Non-Preservation Group (444 ± 48.2 ml) than for the Preservation Group (230 ± 21.9 ml); the period before removal of drainage tubes was significantly longer for the Non-Preservation Group (12.4 ± 0.84 days) than for the Preservation Group (7.6 ± 0.55 days). CONCLUSION: Preservation of deep-fat tissues in zone 3 and zone 4 reduces postoperative fluid exuded from the donor site, and enables earlier removal of drainage tubes. For cases where optimal breast shape can be achieved without these fat tissues, the fat tissues should be preserved.

Scoring of Deformed Costal Cartilages Reduces Postoperative Pain after Nuss Procedure for Pectus Excavatum.

OBJECTIVE: The present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients. METHODS: A total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (n = 24); those who received no such scoring were categorized as the Non-Scoring Group (n = 22). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups. RESULTS: The maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days). CONCLUSION: High stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced.

Correction of secondary deformity after Nuss procedure for pectus excavatum by means of cultured autologous cartilage cell injection.

INTRODUCTION: For some cases of pectus excavatum, ideal chest shape cannot be achieved solely by performing the Nuss procedure. This manuscript presents a case where the residual deformity following Nuss was corrected using injection-transplantation of cultured autologous chondrocytes. PRESENTATION OF CASE: The treatment was performed for an 18-year-old male, who sought improvement of his chest shape after previously undergoing the Nuss procedure. A 1cm(2) auricular cartilage piece was harvested from his ear. Chondrocytes were isolated from the cartilage piece and were cultured. The cultured chondrocytes were processed into gel form and were injection-transplanted to the deformed region of the patient's chest. The grafted chondrocytes consolidated in one month, presenting elasticity equivalent to ordinary costal cartilage. The patient's chest remains in an optimal shape after a one-year postoperative follow up. DISCUSSION: Secondary correction of the chest deformity after previous operation for pectus excavatum is often tricky, because of the possible adhesion of the lungs or pericardium with the thoracic wall. Transplantation of cultured autologous chondrocytes does not require intra-thoracic maneuvers, and so is less invasive than other surgical interventions. Hence, priority can be placed, in some cases, on the chondrocyte transplantation rather than the re-correction of the thorax with the Nuss procedure or Ravitch procedure. CONCLUSION: Transplantation of cultured autologous chondrocytes is recommended as a useful option for secondary correction of chest deformity after the Nuss procedure.

The "Sea" should not be operated on in scar revision for "Island-Like" scars.

Scars developing on body surfaces not only restrict body movement, but are also problematic from a cosmetic standpoint. Hence, revision is conducted by removing the scar and re-suturing the resultant defects. In performing scar revision, care should be taken to prevent the re-sutured wounds from developing hypertrophy again. Scars often present a pattern where hard, red parts are separated by soft parts in between. As the hard and soft parts may be analogized as islands and seas respectively, we call this the "Island-Like" scar. Two strategies can be taken to treat scars of this type. The first is to remove the entire scar-including both hard and soft parts; the second is to remove only the hard parts and leave the soft parts untouched. The authors conducted a biomechanical study using finite element analyses and found that as a body moves, greater stresses occur in the peri-wound regions with the first strategy than with the second strategy. A wound's likelihood to develop hypertrophy increases as the stresses working on it increase. Hence, it is hypothesized that the second strategy carries less risk of the operated wounds developing re-hypertrophy than the first strategy. Based on this logic, in performing scar revision for scars consisting of hard and soft parts, it is recommended only to remove only hard parts and not to operate on soft parts in between.

Ischaemic complications 20 years after harvesting of a radial forearm flap in a patient with scleroderma.

We present the case of a 67-year-old woman with scleroderma who had progressive necrosis of the finger together with severe pain 20 years after harvesting of a radial forearm flap. After reconstruction of the radial artery the ulceration of her right middle finger healed spontaneously within a month, and the pain disappeared.

Rubinstein-Taybi syndrome (RTS) with postaxial polydactyly of the foot: 4-year follow-up until improvement of dysbasia.

Rubinstein-Taybi syndrome (RTS), also known as 'broad thumbs syndrome' or 'broad thumb-hallux syndrome', is a malformation syndrome characterized by the triad of broad thumbs or first toes, a peculiar facial expression called 'comical face' and mental retardation. Although various malformations are combined with the triad, polydactyly is rare. We treated a male patient with RTS complicated by postaxial polydactyly of the foot. His clinical course was different from typical patients with polydactyly, especially in the aspect of walking development. Osteoplasty-combined surgery, which was ideal for anatomical reconstruction, was performed on the patient at 2 years and 11 months of age. A 4-year follow-up period was required until there was an improvement of dysbasia.

Rhomboid perforator flap for a large skin defect due to lumbosacral meningocele: a simple and reliable modification.

To date, very few studies have reported the use of perforator flaps in newborn infants with an immature vascular system. Therefore, it is not clear whether perforator flaps can be used in newborns, as in adults. In this study, we applied the perforator flap procedure to a newborn infant, who had a large skin defect due to lumbosacral meningocele. We used the rhomboid perforator flap, which was a combination of using a rhomboid flap reported by Ohtsuka et al and preserving paraspinal perforator vessels according to Thomas. Although perforator vessels were so thin as to necessitate careful dissection and flap design, a good result was obtained by this procedure. We consider that the rhomboid perforator flap is a simple and reliable procedure for the treatment of lumbosacral meningocele.