The concept of "whole perforator system" in the lateral thoracic region for latissimus dorsi muscle-preserving large flaps: An anatomical study and case series.

BACKGROUND: Previous studies have reported on the abundant cutaneous perforating blood vessels around the latissimus dorsi (LD) lateral border, such as a thoracodorsal artery perforator (TDAP) of septocutaneous type (TDAP-sc) and muscle-perforating type (TDAP-mp), or the lateral thoracic artery perforator (LTAP). These perforators have been clinically utilized for flap elevation; however, there have been few studies that accurately examined all the cutaneous perforators (TDAP-sc, TDAP-mp, LTAP) around the LD lateral border. Here, we propose a new "whole perforator system" (WPS) concept in the lateral thoracic region and a methodology that enables elevating large flaps with reliable perfusion in a muscle-preserving manner. METHODS: We first performed an anatomical study that verified the number and perforating points of all perforators around the LD lateral border using the results of dynamic contrast-enhanced magnetic resonance imaging of patients with breast cancer. Following the anatomical evaluation, we performed large muscle-preserving flap transfer that contained all of the perforators around the LD lateral border in an actual clinical setting. RESULTS: A total of 175 latissimus dorsi from 98 patients were included. The mean number of perforators (TDAP-sc + TDAP-mp + LTAP) per side was 4.51±1.44 (2-9); TDAP-sc was present in 57.1% (100/175) of cases, and TDAP-mp in 76.6% (134/175); the TDAP total prevalence rate (TDAP-sc + TDAP-mp) was 96.0% (168/175). The LTAP existence rate was 94.3% (165/175). Distance from the axillary artery to the TDAP-sc was 148.7±56.3 mm, which was significantly proximal to the TDAP-mp (183.8±54.2 mm) and LTAP (172.2±81.3 mm). CONCLUSION: The lateral thoracic region has an abundant cutaneous perforator system derived from the descending branch of the thoracodorsal and lateral thoracic arteries. Clinical application of the lateral thoracic WPS flap is promising, with a large survival area even with muscle-preserving procedures and requiring a relatively simple procedure.

Chronological flap volume and distribution changes after reconstruction of total maxillectomy defect using a rectus abdominis myocutaneous flap.

BACKGROUND/PURPOSE: After total or subtotal maxillectomy, reconstruction using a free rectus abdominis myocutaneous (RAMC) flap is a fundamental and useful option. The purpose of the present study was to clarify the degree of flap volume change and volume distribution change with time after total or subtotal maxillectomy and free RAMC flap reconstruction and to examine the factors affecting the results. METHODS: A total of 20 patients who underwent total or subtotal maxillectomy with free RAMC flap reconstruction were examined, and the flap volume change rate (volume at final evaluation [POD 181-360] / volume at initial evaluation [POD 5-30]) was investigated using the results of imaging tests. Moreover, the flap was divided into four blocks (A-D) in the cranio-caudal direction, and the volume change of each block was individually analyzed. RESULTS: The overall volume change rate of fat/muscle/total was 0.84 ± 0.21/0.36 ± 0.08/0.67 ± 0.15, at the mean follow-up period of 309±35 days after the operation. The multiple regression analysis revealed that weight loss (for fat), postoperative RT (for fat and muscle), and young age (for muscle) were independently associated with flap volume loss. The results also indicated that the fat volume was stable, whereas the muscle volume decreased to <40% over time, assuming there were no influencing factors. Regarding flap volume distribution change, the fat volume tended to gather toward the central-cranial direction, while the muscle volume gathered toward the cranial direction, and total flap volume gathered toward the central direction.

Boomerang-shaped Lateral-to-back Flap Utilizing Multiple Thoracodorsal Artery Perforators around the Lateral Border of Latissimus Dorsi Muscle for Reconstruction of Large Circular Defect.

We herein report the successful reconstruction of an extensive circular skin defect of the elbow region using a boomerang-shaped lateral-to-back muscle-sparing latissimus dorsi myocutanous flap utilizing multiple thoracodorsal artery perforators around the lateral border of the latissimus dorsi. The patient was a 74-year-old woman who presented with pleomorphic sarcoma in the left elbow region. The tumor was extensively resected and the skin defect was 13.5 × 12 cm. The boomerang-shaped lateral-to-back muscle-sparing-latissimus dorsi myocutanous flap was transferred as a free flap with the pedicle vessels anastomosed to the brachial artery and vein. The 2 wings of the boomerang were bent in a U shape to completely cover the skin defect. The donor site was closed primarily. This flap can be a versatile option for reconstructing extensive skin defects in various areas with little donor-site morbidity.

Sequential Scalp Assessment in Hair Regeneration Therapy Using an Adipose-Derived Stem Cell-Conditioned Medium.

BACKGROUND: An adipose-derived stem cell-conditioned medium (ADSC-CM) reportedly exerts skin-rejuvenating and hair growth-promoting effects. In the therapeutic application of ADSC-CM for alopecia, changes to the interfollicular scalp remain unclear although some evidence has indicated hair growth-promoting effects. OBJECTIVE: To evaluate the effects of ADSC-CM not only on hair follicles, but also on the interfollicular scalp. METHODS: Forty patients (21 men, 19 women; age range, 23-74 years) with alopecia were treated by intradermal injection of ADSC-CM every month for 6 months. Eighty fixed sites on patients were investigated by trichograms, physiological examinations, and ultrasonographic examinations at 4 time points (before treatment and 2, 4, and 6 months after the initial treatment). RESULTS: Hair density and anagen hair rate increased significantly. As physiological parameters, transepidermal water loss value gradually increased, with significant differences at 4 and 6 months after the initial treatment, but hydration state of the stratum corneum and skin surface lipid level showed no obvious changes. As ultrasonographic parameters, dermal thickness and dermal echogenicity were increased significantly. CONCLUSION: Intradermal administration of ADSC-CM on the scalp has strong potential to provide regenerative effects for hair follicles and the interfollicular scalp. An adipose-derived stem cell-conditioned medium offers a promising prospect as an alternative treatment for alopecia.

Simple-safe-sure Fluid Drainage Just above Breast Tissue Expander using 18-Gauge Blunt Cannula.

The presence of seroma after breast tissue expander (TE) insertion for a long duration can cause infection and purulency; thus, obvious fluid collection around TEs should be drained as early as possible. However, due to the risk of puncture, it may not be possible to completely drain the fluid if it is located above the TE. To manage such cases, we used an 18-gauge blunt cannula and achieved good results. Among 98 cases in which breast reconstruction was performed with a TE, 5 patients had symptoms of infection with fluid collection just above the TE. In all 5 cases, resolution of the infection was observed in an outpatient setting without the removal or puncture of the inserted TE, by performing a drainage technique using an 18-gauge blunt cannula. An 18-gauge blunt cannula minimized the risk of expander rupture during drainage and enabled the complete aspiration of fluid, even when it was located just above the TE; thus, the resolution of infection with the preservation of the expander was possible in cases that would otherwise have been impossible to treat without the removal of the TE. This drainage procedure using an 18-gauge blunt cannula is considered to be simple, safe, and sure, with benefits that exceed the risk; thus, there should be no reason to hesitate in performing this drainage procedure, even in cases involving slight fluid collection around the TE.

Soft silicone foam dressing is more effective than polyurethane film dressing for preventing intraoperatively acquired pressure ulcers in spinal surgery patients: the Border Operating room Spinal Surgery (BOSS) trial in Japan.

Preventing intraoperatively acquired pressure ulcers (IAPUs) in patients undergoing spinal surgery in the prone position using a Relton-Hall frame is challenging. We investigated the efficacy of soft silicone foam dressings in preventing IAPUs. A prospective dual-center sham study was conducted among patients undergoing elective spinal surgery in a general hospital and a university hospital in Japan. The incidence of IAPUs that developed when soft silicone foam dressings and polyurethane film dressings were used was compared on two sides in the same patient. IAPUs developed on the chest in 11 of 100 patients (11%). Polyurethane film dressings were associated with a significantly higher rate of IAPUs than soft silicone foam dressings (11 versus 3, P = 0·027). A multivariate logistic regression analysis revealed that a diastolic blood pressure of <50 mmHg (P = 0·025, OR 3·74, 95% confidence interval [CI] 1·18-13·08) and the length of surgery (by 1 hour: P = 0·038, OR 1·61, 95% CI 1·03-2·64) were independently associated with the development of IAPUs. The use of soft silicone foam dressings reduced the risk of IAPUs (P = 0·019, OR 0·23, 95% CI 0·05-0·79) and was more effective than film dressings for preventing IAPUs in spinal surgery patients.