Clinical Application of the Internal Mammary Artery Perforator Adipofascial Flap.

BACKGROUND: Skin ulcers on the anterior chest wall are caused mainly by radiation therapy for breast cancer and anterior mediastinitis after thoracotomy, and they are often refractory. Some muscle flaps are commonly used for anterior chest wall reconstruction, but muscle flaps accompany high invasion. We used the internal mammary artery perforator (IMAP) adipofascial flap and IMAP skin flap for the anterior chest wall reconstruction. METHODS: We examined the IMAPs using a handheld Doppler device and contrast-enhanced computerized tomography preoperatively. Each flap was designed based on the location of the IMAP and the size of the flap was dependent on the coverage required by the size and location of the skin ulcer. The location of the IMAPs functioned as the pivot point of the flap and the flap was flipped or swung on the defect. RESULTS: We used IMAP adipofascial flap for 2 cases and IMAP skin flap for 1 case. In those 3 cases, we could elevate the flap with no complications even after the internal mammary artery had been harvested. There was no recurrence of the skin ulcer or wound infection after the operation. CONCLUSIONS: In this study, we reported 3 cases of skin ulcer on the anterior chest wall reconstructed with the IMAP adipofascial and skin flap. To our knowledge, this is the first report of the use of the IMAP flap as an adipofascial flap. The IMAP adipofascial flap accompanies less invasion than muscle flaps and the surgical procedure is relatively easy. The IMAP adopofascial flap is considered as one of the effective means for anterior chest wall reconstruction.

Changes in the activities of daily living (ADL) in relation to the level of amputation of patients undergoing lower extremity amputation for arteriosclerosis obliterans (ASO).

BACKGROUND: The relationship between the level of amputation and the activities of daily living (ADL) in Japanese patients with arteriosclerosis obliterans (ASO) is unclear. METHODS AND RESULTS: In the present study 81 patients with ASO who underwent lower extremity amputation and were discharged from hospital after rehabilitation we evaluated. The patients were classified into 4 groups: toe amputation group (Toe), heel-preserving amputation group (Heel), below-knee amputation group (BK), and above-knee amputation group (AK). ADL at discharge and factors affecting the length of hospitalization were determined. Patients were walking at discharge in 94.5%, 94.0%, 59.0%, and 0.0% of the Toe, the Heel, BK, and AK group, respectively. However, the ratio of patients able to walk independently was 68% in the Toe group and 19% in the Heel group. In addition, the length of hospital stay was significant shorter in the Toe group than in the other groups. Factors affecting the length of hospital stay were the amputation level, cerebrovascular disease, reoperation, and diabetes. CONCLUSIONS: ADL are less affected and the length of hospital stay is shorter for patients undergoing toe amputation than other levels of lower extremity amputation. However, heel-preserving amputation maintains a comparable level of ADL in terms of ambulatory discharge.

Quality of life improvement and long-term effects of peripheral blood mononuclear cell transplantation for severe arteriosclerosis obliterans in diabetic patients on dialysis.

BACKGROUND: Severe arteriosclerosis obliterans (ASO) can be intractable, especially in diabetic patients on hemodialysis (HD). Recently, the transplantation of autologous peripheral blood mononuclear cells (PBMNCs) has been reported to have beneficial effects, but the long-term effects and impact on quality of life (QOL) have not been studied. METHODS AND RESULTS: Autologous PBMNCs were transplanted into 7 diabetic patients on HD who had severe ASO (5 cases with Fontaine IV and 2 with Fontaine III) after administration of 5 microg/kg granulocyte colony stimulating factor; QOL and degree of ischemia was assessed by measuring skin temperature, skin perfusion pressure (SPP), ankle-brachial index (ABI), and ulcer size, and from angiographic findings. At 4 weeks after the procedure, skin temperature was significantly improved, and SPP and ABI also were increased. These beneficial effects persisted for up to 24 weeks. Angiographic findings and ulcer size improved in 3 of 7 and 3 of 4 patients, respectively. SF-36v2 analysis revealed significant improvements in pain scores. No serious complications were detected. CONCLUSION: Transplantation of PBMNCs resulted in improvement in pain and leg ischemia for over 6 months without serious complications. This therapy is safe and effective for severe ASO in diabetic patients on HD.