An anatomic study of nipple position and areola size in Asian men.

BACKGROUND: In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men. OBJECTIVES: The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men. METHODS: Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI. RESULTS: Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI. CONCLUSIONS: Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.

A phase III, multicenter, single-arm study to assess the utility of indocyanine green fluorescent lymphography in the treatment of secondary lymphedema.

OBJECTIVE: Indocyanine green (ICG) fluorescent lymphography might be useful for assessing patients undergoing lymphatic surgery for secondary lymphedema. The present clinical trial aimed to confirm whether ICG fluorescent lymphography would be useful in evaluating lymphedema, identifying lymphatic vessels suitable for anastomosis, and confirming patency of lymphaticovenular anastomosis in patients with secondary lymphedema. METHODS: The present phase III, multicenter, single-arm, open-label, clinical trial (HAMAMATSU-ICG study) investigated the accuracy of lymphedema diagnosis via ICG fluorescent lymphography compared with lymphoscintigraphy, rate of identification of lymphatic vessels at the incision site, and efficacy for confirming patency of lymphaticovenular anastomosis. The external diameter of the identified lymphatic vessels and the distance from the skin surface to the lymphatic vessels using preoperative ICG fluorescent lymphography were measured intraoperatively under surgical microscopy. RESULTS: When the clinical decision for surgery at each research site was made, the standard diagnosis of lymphedema was considered correct. For the 26 upper extremities, a central judgment committee who was unaware of the clinical presentation confirmed the imaging diagnosis was accurate for 100.0% of cases, whether the assessments had been performed via lymphoscintigraphy or ICG lymphography. In contrast, for the 88 lower extremities, the accuracy of the diagnosis compared with the diagnosis by the central judgment committee was 70.5% and 88.2% for lymphoscintigraphy and ICG lymphography, respectively. The external diameter of the identified lymphatic vessels was significantly greater in the lower extremities than in the upper extremities (0.54 ± 0.21 mm vs 0.42 ± 0.14 mm; P < .0001). Also, the distance from the skin surface to the lymphatic vessels was significantly longer in the lower extremities than in the upper extremities (5.8 ± 3.5 mm vs 4.4 ± 2.6 mm; P = .01). For 263 skin incisions, with the site placement determined using ICG fluorescent lymphography, the rate of identification of lymphatics vessels suitable for anastomosis was 97.7% (95% confidence interval, 95.1%-99.2%). A total of 267 lymphaticovenular anastomoses were performed. ICG fluorescent lymphography was judged as "useful" for confirming patency after the anastomosis in 95.1% of the cases. CONCLUSIONS: ICG fluorescent lymphography could be useful for improving the treatment of patients with secondary lymphedema from the outpatient setting to surgery.

Restoration of Bilateral Cranial Defects by Hybridization of Microvascular Free Flaps and Artificial Bones.

Although treatment methods for cranial reconstruction have significantly improved over the past decades, patients having potentially negative influences, such as a history of infection, epidural dead space, or inadequate scalp, remain at high risk of postoperative failure from implant infection and exposure necessitating removal. A 41-year-old male patient sustained severe craniofacial injuries in a traffic accident. Cranioplasty with titanium mesh implants failed due to implant infection, leading to implant removal and debridement. Following repeated local infections and a craniectomy, the patient developed large bilateral complex cranial defects. We then performed a multistage operation, consisting of vascularized free-flap transfers to cover the intracranial dead spaces, and bony reconstruction using hydroxyapatite implants, which achieved full restoration of the defects. We believe that this is the better operative plan for treatment of cranial defects in patients with high-risk factors.

Composite grafting for distal digital amputation with respect to injury type and amputation level.

PURPOSE: This study evaluated the composite graft survival rate in distal digital amputations with respect to injury type and amputation level. METHODS: Twenty-seven patients with complete fingertip amputations (32 digits) distal to the distal interphalangeal joint who were treated by composite grafting from January 2010 to February 2012 were enrolled. Injury type was classified as clean-cut, blunt-cut, or crush-avulsion. Amputation level was classified according to Ishikawa's classification: subzones I-IV. Graft survival was categorised as complete, partial, or no survival. RESULTS: The graft was more likely to exhibit complete survival in clean-cut injuries (50%) than in blunt-cut (10%) or crush-avulsion injuries (12.5%). However, when complete and partial survival were combined, there was no significant difference among injury types (clean-cut = 83.3%, blunt-cut = 70.0%; crush-avulsion = 68.8%). Composite grafting in sub-zone I provided good results (complete survival = 50%; partial survival = 50.0%; no survival = 0%). When complete and partial survival were combined, there was no significant difference with respect to amputation level except sub-zone I (II = 70.6%; III = 66.7%; IV = 60%). In sub-zone II, clean-cut injuries exhibited better graft survival than blunt-cut or crush-avulsion injuries. In sub-zones III and IV, no complete graft survival was observed. CONCLUSION: In conclusion, all types of injuries in sub-zone I and clean-cut injuries in sub-zone II are candidates for composite grafting. Blunt-cut and crush-avulsion injuries in sub-zone II are marginal candidates for composite grafting. Any type of injury in sub-zone III or IV is contraindicated for composite grafting and should be treated by microanastomosis.

Concentration of Rat Bone Marrow Nucleated Cells Using Hypo-osmotic Hemolysis in Distilled Water.

BACKGROUND: Bone marrow aspirates contain primarily red blood cells. To achieve efficient cell transplantation for regeneration, the red blood cells need to be removed from the aspirates. Cell isolation is typically performed using density gradient centrifugation. However, this method entails issues of clinical safety and convenience. This study describes an efficient method to concentrate bone marrow nucleated cells by hypo-osmotic hemolysis. METHODS: The optimal hemolysis conditions were determined by diluting the bone marrow suspensions with distilled water in various dilution ratios. Then, the resulting cell fractions were transplanted in a rat cranial defect model to evaluate their effects on bone formation and their angiogenic effects. RESULTS: The optimal hemolysis conditions were a 3.3-fold dilution in distilled water and a hypo-osmotic exposure time of 45 seconds. Nucleated cells obtained using this method included granulocytes and mononuclear cells. These cells contain cytoplasmic angiogenic factors, including vascular endothelial growth factor, basic fibroblast growth factor, and hepatocyte growth factor. In a rat cranial defect model, callus formation and angiogenesis were significantly increased following transplantation of concentrated marrow nucleated cells in this manner. CONCLUSIONS: These results suggest angiogenic and osteogenetic effects of transplanting marrow nucleated cells using this hypo-osmotic method.

A case of microstomia subsequent to toxic epidermal necrolysis surgically treated by simple technique.

SUMMARY: Toxic epidermal necrolysis (TEN) is a rare but severe adverse dermatitis that is an autoimmune reaction to drugs such as nonsteroidal anti-inflammatory drugs. TEN most severely affects the mucous membranes including the mouth and could develop into microstomia; however, microstomia in relation to TEN has rarely been reported in the literature. We describe an adult female patient who developed microstomia due to scar contracture of the bilateral oral commissures subsequent to TEN and was successfully treated by a simple surgical technique consisting solely of transverse incision of the commissure and longitudinal closure.