International microsurgery simulation society (IMSS) consensus statement on the minimum standards for a basic microsurgery course, requirements for a microsurgical anastomosis global rating scale and minimum thresholds for training.

INTRODUCTION: Microsurgery is a surgical technique that uses optical magnification as well as specific instruments to address necessary reconstructive procedures in different medical specialties. The apprenticeship of this technique requires overcoming a steep learning curve. There is a need for standardization of the training criteria in microsurgery. The International Microsurgery Simulation Society (IMSS) was born in 2011, since then its main objective has been to connect the main international specialists and educators of this sub-specialty to share and discuss the ethical and scientific basis of preclinical microsurgery teaching. METHODS: In order to achieve a consensus on the minimum standards for the organization of basic microsurgery training courses, the requirements for a microsurgical anastomosis global rating scale and minimum thresholds for training, a total of nineteen independent global experts participated in a formal consultative consensus development program. The agreement criteria for each statement was established when consensus of 65-100% was reached. RESULTS: There have been established six recommendations concerning minimum standards for a basic microsurgery course, one recommendation in relation to minimum thresholds for training and four recommendations regarding the global rating scale as gold standard for a microsurgical anastomosis assessment. The eleven defined recommendations reached the agreement threshold of 65-100%. CONCLUSIONS: The development of this consensus sets the minimum recommended requirements for conducting basic microsurgery training courses, as well as suggestions for objective assessment of the learning curve and skills of trainees.

Negative pressure wound therapy with instillation without open-window thoracostomy for empyema.

Treatment of empyema is very challenging. The use of negative pressure wound therapy (NPWT), and NPWT with instillation and dwell time (NPWTi-d) for wound closure have attracted attention. However, they are both limited to use after open-window thoracostomy (OWT) performed to control infection. In some patients with poor general conditions, who cannot undergo surgery, no treatment for empyema is available. Therefore, we devised a new treatment for such patients with NPWTi-d without OWT (non-OWT NPWTi-d). Here we present the cases of two patients with refractory empyema after intrathoracic irrigation and drainage, who underwent non-OWT NPWTi-d using the fistula of the thoracic drain. Both the patients recovered. The first patient was treated for 31 days. As the empyema persisted, he underwent a repeat intrathoracic drainage after which the wound healed. The second patient was treated for 20 days. Non-OWT NPWTi-d may be a new option to treat empyema.

Modified Posterolateral Approach for Pterygium Colli.

Pterygium colli is a congenital deformity associated with malformation syndromes. Various surgical procedures have been reported, but these procedures have advantages and disadvantages. The modified posterolateral approach has been reported as a new surgical procedure for pterygium colli. However, there has been no confirmatory report. In this study, a case of pterygium colli that was treated with the modified posterolateral approach was reported.An 11-year-old girl with Turner syndrome was referred with chief complaints of web neck deformity and an abnormal hairline. The modified posterolateral approach was selected. Hairy excessive skin was excised at the posterolateral and posterior neck. An inferior skin incision was made parallel to the hairline, and a superior skin incision was made along the desired hairline. Hairless excessive skin was excised along the posterior midline of the neck. Undermining was extended over the sternocleidomastoid muscle, and flaps were rotated upward and inward. Z-plasty was performed at the posterior midline of the neck to prevent hypertrophic scar formation. The web neck deformity disappeared, but the patient expressed concern for excessive skin at the posterior midline. Thus, secondary surgery was performed 12 months later. The operative scar was opened 2 months after secondary surgery owing to suture abscess, and the wound was closed directly. The web neck deformity had not recurred, and the natural hairline was maintained at 65 months after the primary surgery.The modified posterolateral approach is beneficial for pterygium colli, because it allows the correction of the web neck deformity and abnormal hairline without a noticeable scar.

Pedicled Flaps Versus Free Flaps for Back Reconstruction.

BACKGROUND: Back reconstructions using a flap are relatively rare, and clinical reports on such reconstructions are few. We analyzed whether a pedicled flap or free flap was best for treating back defects and established a simplified algorithm for flap selection. METHODS: We retrospectively analyzed the cases of 22 patients who underwent flap reconstructions for the back between July 2000 and August 2016. We extracted data on the operative time, defect size, patients' height and body weight, and reoperation, and each defect size was calculated as a percentage in relation to the body surface area (BSA). We compared these values between both flap types using univariate analysis. In addition, reconstructions using pedicled flaps were classified as single pedicled flap and combination pedicled flap reconstructions. The reasons for reoperation were also reviewed. RESULT: Seventeen patients underwent reconstructions using pedicled flaps, and 5 patients underwent reconstructions using free flaps. The operative time and the percentage of defect size in relation to the BSA were significantly lower when using pedicled flaps than when using free flaps (P = 0.002, P = 0.046, respectively). There was no significant difference in terms of the rate of reoperation (P = 0.16) between the 2 types of reconstructions. The operative time was also significantly shorter when using combination pedicled flaps than when using free flaps. However, there was no significant difference in terms of the percentage of defect size in relation to the BSA between combination pedicled flaps and free flaps. Reoperation was necessary because of flap necrosis in pedicled flaps and skin graft necrosis in free flaps. CONCLUSIONS: Our results demonstrated that pedicled flaps should be the first choice for back reconstruction, independent of the defect size, reoperation rate, and reason for reoperation. This is because the operation time required is significantly lower, which benefits patients and surgeons. Free flaps can be used when pedicled flaps cannot be used efficiently.

Pedicled buccal fat pad for the augmentation of facial depression deformity: A case report.

RATIONALE: Tissue augmentation of facial depression deformities can be achieved by volume replacement with autologous fat injection, dermal filler injection, etc. Here, we report a case of tissue augmentation of a facial depression deformity using a pedicled buccal fat pad (BFP). PATIENT CONCERNS: A 64-year-old woman was referred with a chief complaint of facial depression deformity. DIAGNOSES: Her molars had been removed at another hospital 12 years prior to this referral, and the patient suffered from a left cheek depression deformity as a sequela of a postextraction infection. INTERVENTIONS: An incision was made in the left gingivobuccal sulcus under local anesthesia, and BFP was carefully excised from its normal location. The subcutaneous scar tissue was dissected, and a pocket was created via the same mucosal incision. BFP was then pushed into the pocket. OUTCOMES: The depression deformity immediately disappeared postoperatively. The transplanted BFP remained unabsorbed and soft 43 months postoperatively. The patient did not have any complications. LESSONS: This novel procedure has 2 advantages. First, the pedicled BFP is a vascularized tissue and is not absorbed postoperatively; control of contour is easy, and only 1 treatment session is required. Complications associated with fat necrosis can be avoided. Second, only a single intraoral incision is required; the risk of donor-site morbidity is very low, and scar formation does not occur on exposed skin. Third, this procedure can be performed without special instruments and equipment. The main disadvantages are limited rotation arc and volume of pedicled BFP. Despite its limited application, this procedure is simple and useful, with low invasiveness.

S-shaped Wound Closure Technique for Dumbbell-shaped Keloids.

Dog-ear collection, Z-plasty, and W-plasty are often performed for excision of dumbbell-shaped keloids; however, these procedures require additional incisions or excision of normal skin. Thus, an S-shaped wound closure technique was performed. The keloid lesions were extralesionally excised above the deep fascia, and the wound edges were shifted in opposite directions along the major axis to form an S-shape. The incision was closed by applying deep fascial sutures, subcutaneous sutures, and superficial sutures. Postoperative external beam radiation therapy was started within 6 hours after surgery at a dose of 20 Gy applied in 4 fractions. All wounds were covered with silicone-gel sheeting and fixed with tape after suture removal. No intralesional corticosteroid injection or oral tranilast was administered. Corticosteroid tape was applied in cases with suspected postoperative recurrence. Scoring was performed using the Manchester Scar Scale. A total of 8 lesions were treated. Temporary erythema and scar elevation were observed in 2 chest lesions; however, both were flattened and turned white using corticosteroid tape. Other than these 2 lesions, there was no recurrence or complication. The mean score improved from 15.8 to 7.2. The S-shaped wound closure technique has 3 advantages. First, no additional incision or excision is required, and additional scarring and keloid recurrence can be avoided. Second, aesthetic results are good, and noticeably long and zigzag-shaped scars can be avoided. Third, dispersion of tension on the scar can be expected. Although the S-shaped wound closure technique has limited application, it is a useful option for keloid treatment.

Processing insect abundance: trading and fishing of zazamushi in Central Japan (Nagano Prefecture, Honshu Island).

BACKGROUND: This article presents the links between technique, commerce and consumption in fishing for zazamushi, a mixture of aquatic insect larvae sold as food souvenirs in Japan. Since zazamushi are mainly collected for economic reasons, we suggest that demand for them has incited technical development among collectors in order to fish more insects. METHODS: Several fishermen and traders were interviewed in semi-directed interviews about their practices and knowledge. To understand the passage from a faunal composition to a commercial composition, our research follows a fishing session closely, as well as the selection of insects that follows it. The insects collected were separated from inanimate matter, then identified, counted and weighed at each stage of the process. RESULTS: Our results suggest that the current technique corresponds to an evolution in subsistence and recreational collecting towards a more systematic fishing of the insects, the aim of which is commercial. In their response to trade issues, the collectors have moved away from the banks to fish the insects in the river current, thus increasing the amount of one species captured compared to another. Although the technique is efficient (and similar to other harvesting techniques), it requires the thorough sorting of organic debris and insects (in our example, the catch contains approximately 78 % of inanimate matter and 22 % of insects, of which 3.29 % are retained for consumption, i.e., less than 2 out of 100 insects). The selection of insects to be consumed takes place mainly during cleaning. This stage depends on traders and reflects the different compositions sold as souvenirs. CONCLUSIONS: Our research shows that the consumption of insects is not explained just by ecological factors that are favourable or unfavourable, but also by technological and economic factors related to their commerce. It suggests that the traders have gradually established the insects that are currently sold as zazamushi and that this commercial development may have had an influence on the preference for insects consumed. It also shows that the cleaning of the insects constitutes an important stage prior to their consumption, one that should not be underestimated.

The neutral self-assembling peptide hydrogel SPG-178 as a topical hemostatic agent.

Conventional self-assembling peptide hydrogels are effective as topical hemostatic agents. However, there is a possibility to harm living tissues due to their low pH. The aim of the present study was to demonstrate the efficacy of SPG-178, a neutral self-assembling peptide hydrogel, as a topical hemostatic agent. First, we measured the bleeding duration of incisions made on rat livers after application of SPG-178 (1.0% w/v), SPG-178 (1.5% w/v), RADA16 (1.0% w/v), and saline (n = 12/group). Second, we observed the bleeding surfaces by transmission electron microscopy immediately after hemostasis. Third, we measured the elastic and viscous responses (G' and G″, respectively) of the hydrogels using a rheometer. Our results showed that bleeding duration was significantly shorter in the SPG-178 group than in the RADA16 group and that there were no significant differences in transmission electron microscopy findings between the groups. The greater the G' value of a hydrogel, the shorter was the bleeding duration. We concluded that SPG-178 is more effective and has several advantages: it is non-biological, transparent, nonadherent, and neutral and can be sterilized by autoclaving.

Evaluation of the microvascular research center training program for assessing microsurgical skills in trainee surgeons.

BACKGROUND: We established the Microvascular Research Center Training Program (MRCP) to help trainee surgeons acquire and develop microsurgical skills. Medical students were recruited to undergo the MRCP to assess the effectiveness of the MRCP for trainee surgeons. METHODS: Twenty-two medical students with no prior microsurgical experience, who completed the course from 2005 to 2012, were included. The MRCP comprises 5 stages of training, each with specific passing requirements. Stages 1 and 2 involve anastomosing silicone tubes and blood vessels of chicken carcasses, respectively, within 20 minutes. Stage 3 involves anastomosing the femoral artery and vein of live rats with a 1-day patency rate of >80%. Stage 4 requires replantation of free superficial inferior epigastric artery flaps in rats with a 7-day success rate of >80%. Stage 5 involves successful completion of one case of rat replantation/transplantation. We calculated the passing rate for each stage and recorded the number of anastomoses required to pass stages 3 and 4. RESULTS: The passing rates were 100% (22/22) for stages 1 and 2, 86.4% (19/22) for stage 3, 59.1% (13/22) for stage 4, and 55.0% (11/20) for stage 5. The number of anastomoses performed was 17.2±12.2 in stage 3 and 11.3±8.1 in stage 4. CONCLUSIONS: Majority of the medical students who undertook the MRCP acquired basic microsurgical skills. Thus, we conclude that the MRCP is an effective microsurgery training program for trainee surgeons.

Vascularized peripheral nerve grafting promotes myelination of regrowing optic nerve.

We investigated whether the use of vascularized peripheral nerve grafts on the optic nerve stump enhances axonal regeneration of retinal ganglion cells compared with isolated nonvascularized grafts. The rat median nerve was microsurgically sutured with its supplying artery and vein to the optic nerve stump. The number of retinal ganglion cells with regenerating axons was evaluated by retrograde labeling into the grafted peripheral nerve, and the myelination of the regenerating axon fibers was examined by electron microscopy. The number of retinal ganglion cells with regenerating axons was significantly higher in the vascularized graft than in the nonvascularized graft. The ratio of myelinated axon fibers was also increased in vascularized grafts. Thus, grafting with their supplying arteries and veins to an injured nerve stump represents a promising strategy to accelerate axonal regeneration from neurons of the central nervous system.