Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries.

BACKGROUND: Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes. METHODS: Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up. RESULTS: Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis. CONCLUSION: APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

Animation Deformity: Evaluating the Role of Morphotopologic Features in Suggesting Preventive Surgical Procedures.

BACKGROUND: Animation deformity is an undesirable complication after subpectoral implant reconstruction and is defined as skin distortion during activation of the pectoralis major muscle. However, detailed anatomical features of deformities have yet to be clarified. This study aimed to elucidate how (morphology) and where (topology) animation deformity occurs in reconstructed breasts, and to assess causes and prevention of animation deformity. METHODS: This study included 100 consecutive patients with breast cancer, who underwent unilateral subpectoral implant reconstruction. Animation deformity was evaluated, and the patients were grouped according to both morphologic and topologic features. Univariate and multivariate analyses were performed to identify independent factors associated with deformities. RESULTS: The patients were divided into three groups based on skin distortions with or without implant movement: group I, 60 patients with upper-medial dimpling; group II, 41 patients with upper-lateral folding; and group III, 52 patients with mid-lower lines. Overall, 86 patients (86 percent) showed one or more types of deformity. Among the patients with animation deformity, 24 (28 percent) had implant movement. The authors' study identified axillary dissection as an independent factor for the upper-lateral folding group (OR, 0.30), implant volume for the mid-lower lines group (OR, 1.01), and age for implant movement (OR, 1.06). CONCLUSIONS: Animation deformity was commonly observed in the cohort of patients who underwent subpectoral implant reconstruction and exhibited three morphotopologic patterns of deformity. The current study demonstrated that the morphotopologic grouping of animation deformity may assist in suggesting possible causes and preventive surgical procedures for these deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Growth Factors of Subcutaneous Benign Lipoma: Consideration from Anatomical Position of Occurrence.

Subcutaneous lipomas are the most common benign soft-tissue tumors. Theoretically, adipocyte sites could be the primary foci; however, lipomas are likely located in the occipital, neck, shoulder, torso, and thigh areas. To date, no study has reported the anatomical relationship between these subcutaneous structures and lipomas. Therefore, we aimed to investigate the anatomical locations of lipomas and considered their growth factors. In addition, we discussed the mechanism of fat amplification to improve the success of fat grafting. Methods: In the present study, lipomas measuring more than 5 cm in diameter from patients hospitalized between 2017 and 2021 were retrospectively examined using preoperative computed tomography and magnetic resonance imaging as well as clinical records with intraoperative pictures. Results: In total, 22 lipomas of 22 patients were examined. All lesions (100%) were accompanied by neurovascular perforators. Nineteen lesions (86%) were located deep in the superficial fascia, where it was clearly defined. Moreover, all lesions were located at the mobile adipofascial layer adjacent to an anchored fixed or less mobile structure. Conclusions: Lipoma growth might require neurovascular perforators that supply both blood flow and continuous stretching stimuli. The mobile adipofascial layer with bones adjacent to a fixed or less mobile area might also be necessary to grow lipomas. If these findings can be used as clues to elucidate the mechanism of fat amplification in the future, it may lead to an improvement in the survival rate of fat grafts.

Lower limb lymphedema staging based on magnetic resonance lymphangiography.

OBJECTIVE: Dermal backflow (DBF) and reduced lymphatic visualization are common findings of lymphedema on various imaging modalities. However, there is a lack of knowledge about how these findings vary with the anatomic location and severity of lymphedema, and previous reports using indocyanine green lymphography or lymphoscintigraphy show variable results. Magnetic resonance lymphangiography (MRL) is expected to clarify this clinical question due to its superior ability for lymphatic visualization. This retrospective study aimed to investigate the following: (1) Are there any characteristic patterns for DBF and lymphatics' visualization, depending on the anatomic location within lower limbs and severity of lymphedema? (2) Is it possible to classify the severity of lymphedema based on MRL findings? METHODS: Two radiologists performed consensus readings of MRL of 56 patients (112 limbs) with lower-limb lymphedema. The frequency of visualized DBF and lymphatics was analyzed in six regions in each lower limb. The results were compared with the International Society of Lymphology clinical stages and etiology of lymphedema. Characteristic findings were categorized and compared with the clinical stage and duration of lymphedema. RESULTS: DBF and lymphatics were observed more frequently in the distal regions than the proximal regions of lower limbs. DBF appeared more frequently as the clinical stage increased, reaching statistical significance (P < 10-3) between stages 0 or I and II. DBF above the knee joint was rarely observed (0.48%) in early stages (0 and I) but appeared more frequently (13.5%, P < 10-5) in stage II. Lymphatics appeared less frequently as the stage progressed, with significant differences (P < .05) between stages I and II and between II and III. The frequency of lymphatics above the knee joint decreased significantly (P < .05) between stages I and II and between II and III as the stage progressed, reaching 0% in stage III. An MRL staging was proposed and showed significant positive correlations with the clinical stage (r = 0.79, P < .01) and the duration of lymphedema (r = 0.57, P < .01). CONCLUSIONS: MRL-specific patterns of DBF and lymphatics that depended on the site within the lower limb and clinical stage were shown. The DBF pattern differed from those observed in previous studies with other imaging techniques. The proposed MRL staging based on these characteristic findings allows new stratification of patients with lymphedema. Combined with its excellent ability to visualize lymphatic anatomy, MRL could enable a more detailed understanding of individual patient's pathology, useful for determining the most appropriate treatment.

Analysis of collateral lymphatic circulation in patients with lower limb lymphedema using magnetic resonance lymphangiography.

OBJECTIVE: Although the development of lymphatic collaterals is expected following lymphedema, little is known about the anatomic details of such compensatory pathways or their association with symptoms. Magnetic resonance lymphangiography (MRL) has been shown to be superior to lymphoscintigraphy and indocyanine green lymphography in visualizing lymphatics. This study aimed to analyze MRL images of lower limbs to elucidate the patterns of lymphatic collateral formation and their association with the clinical stages of lymphedema. METHODS: We enrolled 56 consecutive patients (112 lower limbs) with lymphedema who underwent MRL. Two radiologists performed a consensus reading of MRL images for the presence or absence of collateral lymphatic pathways, and the results were compared with the clinical stages. Furthermore, the frequency of abnormal MRL findings in 43 asymptomatic lower limbs of patients with unilateral lymphedema was analyzed and compared with that in the 69 symptomatic lower limbs of the patients. The imaging findings were also compared with the cause of lymphedema. RESULTS: All three collateral pathways (anterolateral, deep, and posteromedial lymphatics) were visualized at a higher (P < .05) frequency in stage II than in stage 0 lower limbs. The frequency of visualization of the three collaterals was significantly higher in symptomatic (stages I-III) lower limbs than in asymptomatic (stage 0) lower limbs. Most (76.8%) of the symptomatic limbs exhibited at least one of these collaterals, and the frequency was significantly higher than in the asymptomatic limbs (P < .001). Most (81.4%) of the asymptomatic (stage 0) lower limbs had at least one abnormal finding in terms of lymphatic circulation, although this proportion was significantly lower compared with the symptomatic limbs (98.6%). The collaterals tended to appear less frequently in primary lymphedema than in secondary lymphedema, reaching statistical significance in the posteromedial lymphatics. CONCLUSIONS: These results suggested that the two superficial lymphatic groups and the deep lymphatic system act as major collaterals of the lower limbs in patients with lymphedema. Furthermore, MRL of most patients with unilateral lymphedema demonstrated abnormal findings, including collateral formation, not only in the affected lower limb but also in the asymptomatic lower limb. In primary lymphedema, the collaterals may appear less frequently than in secondary lymphedema. Collaterals should be taken into consideration in planning the site of lymphaticovenous anastomosis and assessing disease progression. MRL can visualize preclinical alterations in lymphatic flow and compensatory pathways; therefore, we expect that it will be useful for the early diagnosis of lymphedema.

Pediatric-Specific Midfacial Fracture Patterns and Management: Pediatric Versus Adult Patients.

PURPOSE: The purpose of this study was to compare the midfacial fracture patterns and management approaches between pediatric and adult patients. METHODS: We retrospectively analyzed 164 pediatric patients (<16 years old) and 564 nongeriatric adult patients (16 to 65 years old) with midfacial fractures at a single institution between 2011 and 2016. The location of the fractures, along with the etiology and management of the midfacial fractures, were compared. RESULTS: Significantly greater proportions of pediatric versus adult patients had sports-related injuries (P < 0.001) and sustained nasal fractures (P < 0.001). On the other hand, significantly greater proportions of adult versus pediatric patients were injured in falls, traffic accidents, or assaults (P = 0.004, P < 0.001, and P = 0.002) and sustained maxillary or zygomatic fractures (P = 0.039 and P < 0.001). Bivariate logistic regression analyses revealed that the risks of nasal, maxillary, and zygomatic fractures were significantly related to age status after adjusting for etiology (P < 0.001, P = 0.045, and P < 0.001). In contrast, the risks of hospitalization and surgical treatment were significantly associated with etiology, but not with age status (P = 0.290 and P = 0.847). CONCLUSION: These data suggest that the age-related structure and composition of the facial skeleton affect the pediatric-specific fracture patterns independent of the etiology. The comparisons in this study may serve as a guide for the management of pediatric midfacial fractures.

Advantages of open treatment for syndactyly of the foot: defining its indications.

For the repair of syndactyly of the foot, skin grafting is often used to close the skin defect, but open treatment is not common. However, with grafting, an additional scar at the donor site and patchwork-like scar at the recipient site are inevitable. Our aim was to describe the process of epithelialisation and define the indications for open treatment of syndactyly of the foot. The open treatment was used on 16 webs. The texture of epithelialised surface resembled volar skin; the visible scar was mainly at the dorsal edge; and web creep occurred predominantly on the volar side and resembled the natural slope of the commissure. Open treatment is better than skin grafting because of better match of texture without a patchwork-like scar, and it is indicated in cases of simple incomplete syndactyly of the foot that extends proximal to the distal interphalangeal joint.

Cleft palate repair using a marginal musculo-mucosal flap.

OBJECTIVE: To describe a modified procedure consisting of a mucoso-periosteal flap palatoplasty with a marginal musculo-mucosal flap (3M flap). This is also the first report of a primary repair for complete cleft palate using the 3M flap. We describe the lengthening effect of the nasal mucous layer of the soft palate and evaluate the fistula formation rate associated with this method. METHODS: This procedure has been performed on 21 patients with unilateral complete clefts and on 27 patients with incomplete clefts. A mucoso-periosteal flap raised from the hard palate was used mainly for closure of the cleft and not for the push-back. The 3M flap repaired the deficit of the nasal mucosa, making sure that the soft palate was lengthened. Intravelar veloplasty was performed also. RESULTS: The dimension of the nasal mucosal defect that can be filled with the 3M flap is 10 to 12 mm in length, oriented anterior-posterior, and 15 to 20 mm wide. Oronasal fistula formation was recognized in only 3 of 48 cases (2 of 21 complete clefts, 1 of 27 incomplete clefts) and were located at the hard-soft palate junction at the anterior portion of the 3M flap. CONCLUSIONS: This method has the theoretical advantages of (1) preventing fistula formation by filling the tissue deficiency with the 3M flap; (2) achieving better velopharyngeal function due to elongation of the soft palate and retropulsion of the muscular bundle, utilizing the 3M flap; and (3) minimizing maxillary growth retardation by adopting a non-push-back method of hard palate repair.

Secondary repair of cleft lip nose deformity using subcutaneous pedicle flaps from the unaffected side.

We used three types of subcutaneous pedicle flaps harvested from the unaffected side of the nostril to repair postoperative nose deformity caused by primary cleft lip surgery. By moving the subcutaneous pedicle flap from a nearby tissue-rich area, it was possible to achieve a favourable symmetrical nasal contour for the narrowing of the nostril cavity, depression of the nostril floor and the columella deviation of the affected side. The method, we used here is technically simple. We believe this procedure is a method of choice for repairing small deformities of the nose occurring after primary or secondary cleft lip surgery.