Cheiloplasty for False Median Cleft Lip Associated With Holoprosencephaly: The Use of Skin Graft for Philtrum Reconstruction, the Risk of Simultaneous Columella Reconstruction.

A false median cleft lip is a congenital malformation associated with holoprosencephaly. Cheiloplasty is an effective treatment for false median cleft lip. In the past, holoprosencephaly had a poor prognosis with extremely low survival rates; consequently, cheiloplasty was rarely performed. However, with the recent improvement in survival and prognosis with advances in medical care, patients survive and can now undergo cheiloplasty. We report a case of cheiloplasty performed using a skin graft for philtrum reconstruction. The lip contour was satisfactory because the insufficient tissue was resolved by filling the skin graft, which could not be resolved by midline suture closure. We did not perform columella reconstruction considering the safety; however, oxygenation temporarily destabilized owing to postoperative airway stenosis. Careful postoperative management is necessary even if the columella is not reconstructed.

Intra-soft tissue and intramedullary antibiotic perfusion in combination with negative pressure wound therapy.

OBJECTIVE: Intra-soft tissue and intramedullary antibiotic perfusion (iSAP and iMAP), which combine continuous administration of antibiotic solution to the wound and negative pressure wound therapy (NPWT), have been reported to be a useful management approach for hard-to-heal ulcers in the field of orthopaedic surgery. We report the efficacy of this treatment and discuss the key points. METHOD: The recipients of this treatment had contaminated fresh severe trauma with a high risk of infection, or hard-to-heal ulcers which were expected to be difficult to manage with conventional NPWT alone. Continuous administration of 1200µg/ml of gentamicin (GM) solution to the wound was performed along with NPWT. The GM solution was administered subcutaneously using a small catheter for iSAP, while intramedullary administration used a bone marrow needle for iMAP. RESULTS: iSAP was employed in all 10 patients who took part, and iMAP in three of these patients. The average treatment time was 13.6 days with iSAP and 9.3 days with iMAP. The mean serum GM level during the therapy was 1.02µg/ml. Moderate GM-induced acute kidney injury was suspected in one case, but resolved spontaneously after GM administration was stopped. Favourable wound bed preparation was achieved in all cases without recurrence of infection. CONCLUSION: Combination with continuous suction by NPWT is able to keep the local concentration of antibiotic above the minimum inhibitory concentration of biofilm-coated bacteria within the wound. We have referred to this treatment as continuous local antibiotic perfusion. Further investigation of local pharmacodynamics in the wound and side-effects of this treatment are warranted.

The superficial branch of the radial nerve and sensory disturbance in the radial forearm flap donor-site.

Introduction: Sensory disturbance due to injury of the superficial branch of the radial nerve (SBRN) is a donor-site morbidity of the radial forearm (RF) flap. The relationship between the SBRN preservation method and the post-operative sensation at the flap donor-site was retrospectively investigated. Methods: We included 39 patients who underwent head and neck reconstruction with a free RF flap at Hyogo Cancer Center between April 2014 and March 2018. The patients were classified into the following three groups according to the SBRN preservation method: group 1, zero preservation, excision of the entire SBRN; group 2, main trunk preservation, excision of all branches except the main trunk of the SBRN; and group 3, complete preservation, preservation of the entire SBRN. Objective sensations and subjective symptoms at the flap donor-site were analyzed. Results: The mean objective sensory scores were 3.18, 2.97, and 1.78 in groups 1, 2, and 3, respectively. Differences between groups 1 and 3 and between groups 2 and 3 were significant (p = 0.0035 and p = 0.037, respectively). The mean subjective symptom scores were 2.40, 1.33, and 1.40 in groups 1, 2, and 3, respectively. Differences between groups 1 and 2, and between groups 1 and 3 were significant (p = 0.032 and p = 0.019, respectively). Conclusions: Zero preservation method had a higher risk of subjective symptoms and objective hypoesthesia development at the flap donor-site than the complete preservation method. Despite inevitable objective hypoesthesia, the main trunk preservation prevented the development of subjective symptoms. Complete preservation is optimal for RF flap harvest; however, in case of perforator crossing, main trunk preservation is another option.

Absorbable Barbed Continuous versus Nonabsorbable Nonbarbed Interrupted Suturing Methods for Donor-site Closure of the Rectus Abdominis Myocutaneous Flap.

Abdominal incisional hernia is a complication of the rectus abdominis myocutaneous (RAMC) flap harvest. This study aimed to compare the incidence of abdominal incisional hernia and donor-site closure time between absorbable barbed continuous (ABC) and non-absorbable non-barbed interrupted (nAnBI) methods. Methods: This study included 145 patients who underwent free RAMC flap reconstruction after head and neck cancer surgery at Kobe University Hospital between January 2012 and March 2020. The nAnBI method was selected between January 2012 and August 2016, and the ABC method was selected between September 2016 and March 2020. The incidence of abdominal incisional hernia and the average time required for donor-site closure were compared between the two groups. Results: Of the 145 patients surveyed, 116 (57 and 59 in the nAnBI and ABC groups, respectively) were followed-up for at least 90 days after the surgery. The incidence rates of abdominal incisional hernia were 0% and 5.1% (n = 3) in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.244). The average donor-site closure times were 127.6 and 111.3 minutes in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.122). Conclusions: No significant differences in the incidence of abdominal incisional hernia and donor-site closure time were observed between the nAnBI and ABC groups. However, there was a tendency for increased hernia occurrence and shorter wound closure time in the ABC group. A randomized prospective multicenter study is warranted to validate our findings of the ABC method.

Salvage surgery for mesenteric lymph node metastasis by resection of the first jejunal flap and reconstruction with the second jejunal flap.

We report a case of a second free jejunal transfer to treat metastasis in the mesenteric lymph node of the first jejunal flap. A 73-year-old man underwent total pharyngolaryngectomy, bilateral neck dissection, and free jejunal transfer for recurrent hypopharyngeal cancer [left pyriform sinus, pT2N0, moderately differentiated squamous cell carcinoma (SCC)] after radiotherapy. Seven years post-surgery, he underwent transoral videolaryngoscopic surgery for oropharyngeal cancer (soft palate, pT1N0, well-differentiated SCC). Ten years after the first jejunal transfer, metastasis was found in the mesenteric lymph node surrounding the jejunal flap's vascular pedicle. Under general anesthesia, resection of the first jejunum including the affected lymph node, and second jejunal transfer were performed. Lymph node pathological examination revealed poorly differentiated SCC, compatible with pharyngeal cancer metastasis. After neck dissection and jejunal flap transfer, lymphatic collateral pathways toward the flap's mesenteric lymph node might form. Possibly, hypopharyngeal or oropharyngeal cancer metastasized via this pathway.

A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection.

Introduction: Post-sternotomy surgical site infection (SSI) is a serious complication of cardiovascular surgery. Here, we proposed a new clinical classification and reconstructive strategy for this condition. Methods: A retrospective study based on medical records was performed on 100 consecutive cases requiring wound management by plastic surgeons for post-sternotomy SSI at Kobe University Hospital between January 2009 and December 2021. We classified 100 cases into four categories according to the anatomical invasiveness of the infection (type 1, superficial SSI; type 2, sternal osteomyelitis; type 3, mediastinitis; and type 4, aortic graft infection). The standard treatment plan comprised initial debridement, negative pressure wound therapy with continuous irrigation, and reconstructive surgery. Reconstructive methods and their outcomes (in-hospital mortality rate, follow-up period, and infection recurrence rate) were investigated for each SSI category. Results: There were nine SSI cases in type 1, 28 in type 2, 25 in type 3, and 38 in type 4. The pectoralis major (PM) muscle advancement flap was mainly selected in types 1 and 2 (100 and 70.4%, respectively), while the omental flap or latissimus dorsi (LD) myocutaneous flaps were mainly selected in types 3 and 4 (77.3 and 81.8%, respectively) for reconstructive surgery. The in-hospital mortality rates for types 1, 2, 3, 4 were 44.4, 3.6, 12.0, and 15.8%, respectively. The mean follow-up periods for types 1, 2, 3, 4 were 542.8, 1514.5, 1154.5, and 831.1 days, respectively. Infection recurrence rates for types 1, 2, 3, 4 were 0, 11.5, 13.3, and 19.2%, respectively. All of these recurrent cases, except for 4 cases of type 4 that required surgical intervention, were treated with conservative wound management. Conclusion: A volume-rich flap (omental or LD flap) was required to fill the dead space after debridement in mediastinitis (type 3) or aortic graft infection (type 4), whereas superficial SSI (type 1) or sternal osteomyelitis (type 2) received a less-invasive flap (PM muscle advancement flap). Our new classification method was based on the anatomical invasiveness of the infection, providing both a simple and easy diagnosis and definitive treatment strategy.

Extra-Anatomical Bypass Grafting and Latissimus Dorsi Myocutaneous Flap Reconstruction for Post-sternotomy Mediastinitis With Prosthetic Aortic Graft Infection.

Extra-anatomical bypass grafting is a surgical method used to remove an infected aortic graft and promote revascularization with a new graft in the non-infected area. Here, we report a case of intractable post-sternotomy mediastinitis (PSM) with aortic graft infection which was treated with extra-anatomical bypass grafting. A 56-year-old woman with a history of multiple aortic dissection and prosthetic graft replacement in the thoracoabdominal area developed PSM with aortic arch graft infection. Bacterial culture of the exposed prosthetic graft tissue yielded multidrug-resistant Pseudomonas aeruginosa. Meticulous debridement of the wound and management by negative pressure wound therapy with continuous irrigation was performed. However, the infection of the prosthetic graft could not be controlled. Extra-anatomical bypass was performed between the left common carotid artery and right subclavian artery via the right common carotid artery. Then, the infected graft was removed. After the resolution of infection, the mediastinal wound was reconstructed with a pedicled latissimus dorsi myocutaneous flap, which was harvested from the right dorsum. No recurrence of infection occurred in the nine-month follow-up period. Debridement and removal of exposed artificial graft are considered the gold standard for treating wound infection. In situ replacement of infected aortic grafts carries a risk of re-infection due to residual bacterial contamination of the periprosthetic tissue. Extra-anatomical bypass would be a useful option for reducing the risk of re-infection in patients with intractable PSM and prosthetic aortic graft infection. Further studies are warranted to evaluate the risks and benefits of this operative method.

Congenital Cheek Fistula: A Rare Case of Developmental Abnormality in the Buccal Area.

A congenital cheek fistula is a rare malformation in the buccal area. Here, we report the case of a congenital cheek fistula in a 50-year-old woman who visited our clinic with complaints of swelling and pain in her left cheek. Physical examination revealed a small hole in the left corner of the mouth present since birth. She had no other congenital malformations in the maxillofacial region such as an accessory ear and cleft lip. Manual compression of the cheek mass induced serous discharge from the hole. Magnetic resonance imaging (MRI) showed a cystic lesion in the left cheek and a fistula within the orbicularis oris muscle that opened into the small hole. After immediate incision and drainage of the cyst, both the cyst and fistula were surgically resected. The cystic lesion was completely delineated from the boundary of the parotid gland. The orbicularis oris muscle was partially incised to remove the fistula and the surrounding scar tissue. Histopathological examination of the resected specimen revealed a cavity consisting of epithelium inside the fistula. The postoperative course was insignificant. No recurrence of the cyst was observed six months postoperatively. The operative and pathological findings demonstrated that the ectoderm-derived epithelial tissue was enclosed by the mesoderm-derived muscle tissue. The mixture of different germ layer-derived tissues suggested that the fistula was a type of congenital transverse facial cleft induced by malfusion of the mandibular and maxillary prominences during embryonic development. The differential diagnoses of the congenital cheek fistula included orocutaneous fistulas and salivary fistulas. MRI was useful in delineating the border between the lesion and the surrounding tissue.

Experimental study on the efficacy of a hybrid artificial nerve: The hot dog method.

INTRODUCTION: We hypothesized that hybrid artificial nerves might overcome the limitations of a nerve conduit by isolating nerve fascicles from autologous nerves. Nerve sacrifice during harvest, a drawback of conventional autologous nerve transplantation, may be reduced by the hot dog method. The hot dog method (based on the morphology of hybrid artificial nerves) adds nerve conduits to autologous nerve fascicles. METHODS: Forty-eight rats with a 10-mm sciatic nerve defect were divided into six groups (n = 8 per group) according to the neural reconstruction method: autologous nerve transplantation, the hot dog method, nerve conduit, nerve fascicle transplantation, sham control, and nerve fascicle isolation were classified as Groups I, II, III, IV, V, and VI, respectively. The sciatic nerve function was assessed in these groups, a histological evaluation was performed, and statistical analyses were conducted based on these data. RESULTS: Group III (nerve conduit) and Group IV (nerve fascicle transplantation) showed the lowest functional and axonal regenerative effects, followed by Group II (hot dog method) and Group I (autologous nerve transplantation). Group VI (nerve fascicle isolation) tended to achieve better recovery in motor function and axonal regeneration than Group I (autologous nerve transplantation). CONCLUSIONS: The hot dog method is simple, safe, and easy to execute. This method can serve as a new neural reconstruction method that uses artificial nerves.

Perineal reconstruction with pedicled rectus abdominis myocutaneous flap after posterior pelvic exenteration -A 3D model study.

INTRODUCTION: Limited literature exists regarding the positional relationship between the pedicled-rectus abdominis myocutaneous (p-RAMC) flap and residual pelvic organs post posterior pelvic exenteration (PPE). PRESENTATION OF CASE: Four patients underwent PPE and reconstruction with a p-RAMC flap. After harvesting the p-RAMC flap with the deep inferior epigastric artery and veins as the vascular pedicle, the intra-pelvic shortest pathway of the flap was created. We dissected the subcutaneous tissues of the flap donor site toward the perineal defect along the inner wall of the pelvis. The pubic origin of the rectus abdominis muscle was preserved. A three-dimensional model was constructed using an image processing software. The vascular pedicle ran almost linearly along the inner wall of the pelvis. The muscle belly was placed on the pelvic floor through the posterior wall of the urinary bladder which filled the dead space of the resected area. All flaps survived without significant complications. DISCUSSION: Assigning the cranial side of the flap to the perineum and caudal side to the pelvic floor could reduce postoperative intrapelvic complications. By preserving the pubic origin of the rectus abdominis muscle, a shock absorber of the pedicle of the flap was created, preventing over-traction of the flap while passing through the intrapelvic pathway. CONCLUSION: A p-RAMC flap via intra-pelvic shortest pathway is an ideal reconstructive method for large skin defect in perineal area after PPE.

Two cases of debulking surgery for lower limb diffuse plexiform neurofibroma with transcatheter arterial embolisation.

INTRODUCTION: Diffuse plexiform neurofibroma (DPN) in patients with neurofibromatosis type 1 (NF1) causes motility dysfunction in severe cases. Transcatheter arterial embolisation (TAE) is an effective haemorrhage control method in vascular tumour surgery. PRESENTATION OF CASE: We performed debulking surgery for DPN in the buttock and posterior thigh of two NF1 patients. Preoperative TAE with gelatine particles to tumour feeder vessels was conducted in both cases. Operative bleeding volumes were 500 and 4970 mL, respectively. In the latter case, the resection area extended to the upper poles of the buttocks, and the tumour invaded deeply into the surrounding tissues. Massive haemorrhage occurred, and internal iliac arterial balloon was inflated temporarily to further suppress the bleeding. Delayed wound healing due to TAE occurred; debridement and wound closure were required. Motor function improvement was confirmed in both patients. DISCUSSION: Bleeding volumes varied because of highly developed collateral pathways and tumour invasiveness. As the upper pole of the buttock was perfused by the superior gluteal artery and its numerous collateral vessels, complete haemostasis was difficult despite adequate TAE. Because delineating the tumour border from the normal tissue was impossible due to the high tumour invasiveness, cutting into the hypervascular tumour was inevitable. As gelatine particles were absorbed but remained within the vessels, prolonged wound ischaemia and delayed healing occurred. CONCLUSION: Although TAE with gelatine particles and balloon occlusion were reliable haemorrhage control methods in debulking surgery for lower limb DPN, optimal haemorrhage control technique, compatible with haemostasis and wound healing, was desired.