'Real angiosome' assessment from peripheral tissue perfusion using tissue oxygen saturation foot-mapping in patients with critical limb ischemia.

OBJECTIVES: The "tissue oxygen saturation (StO2) foot-mapping" method was developed using a non-invasive near-infrared tissue oximeter monitor to classify the foot regions as ischemic and non-ischemic areas. The purpose of this study was to evaluate StO2 foot-mapping as a reliable method to detect ischemic areas in the feet of patients with critical limb ischemia (CLI), and to compare the results with assessments from the angiosome model. METHODS: The foot areas of 20 CLI patients and 20 healthy controls were classified into four regions: (1) 0 ≤ StO2 < 30%, (2) 30 ≤ StO2 < 50%, (3) 50 ≤ StO2 < 70%, and (4) 70 ≤ StO2 ≤ 100% to perform StO2 foot-mapping. Each area occupancy rate was compared between the two groups, and the threshold StO2 value for detecting ischemia was set. Next, the locations of ulcers (in 16 patients) were compared to the predicted ischemic regions by the StO2 foot-mapping and by the angiosome model and angiography. RESULTS: In regions (1) and (2) (StO2 < 50%), the area occupancy rate was significantly higher in the CLI group and almost zero in the control group, so that the threshold StO2 value for detecting ischemia was set at 50%. The locations of ulcers were compatible with StO2 foot-mapping in 87.5% of the cases (14/16), while they were compatible with the assessment from the angiosome model in 68.8% of the cases (11/16). CONCLUSIONS: This study suggests that StO2 foot-mapping can successfully and non-invasively detect ischemic areas in the peripheral tissue of the foot, and also more appropriately than the assessment provided by the angiosome model. StO2 foot-mapping can be used to evaluate the real angiosome: the real distribution of the peripheral tissue perfusion in the CLI patient's foot, which is determined by the peripheral microvascular blood flow, rather than the main arterial blood flow.

Extravascular injection of sclerotic agents does not affect vessels in the rat: experimental implications for percutaneous sclerotherapy of arteriovenous malformations.

OBJECTIVES: Sclerotherapy is useful for the treatment of arteriovenous vascular malformations. However, intravascular administration of sclerotic agents into small arteriovenous niduses is often difficult. Extravascular administration of sclerotic agents causes reduction of vascular flow on Doppler echo during clinical sclerotherapy. Therefore, we aimed to investigate whether the extravascular injection of sclerotic agents affects tiny vessels. DESIGN: Animal study. MATERIALS: The effect of extravascular injection of sclerotic agents on vessels was investigated using rat femoral and superficial inferior epigastric vessels. METHODS: After surgical exposure of vessels, absolute ethanol, 5% ethanolamine oleate and 3% polidocanol were injected into perivascular surrounding tissues, and their effect on vessels was evaluated after 14 days using histology and coloured silicone rubber injection. RESULTS: The integrity of the vascular lumen, endothelial cells and vascular patency were not affected by injection of sclerotic agents. CONCLUSIONS: Attenuation of vascular flow of an arteriovenous shunt after extravascular injection of sclerotic agents is transient and/or trivial and does not cause disruption of vessels. Therefore, sclerotic agents should be delivered to obtain sufficient destruction of arteriovenous malformation lesions and blood flow.

Topical negative pressure therapy for para-ileostomal ulceration in a patient with Behçet's disease.

BehCet's disease is a chronic, relapsing, inflammatory disorder. This case report describes how use of an improvised topical negative pressure (TNP) device in a patient with a non-healing para-ileostomal ulcer with Behçet's disease.

Efficacy of a skin-protection powder for use as a dressing for intractable ulcers.

OBJECTIVE: Stomahesive skin-protection powder has been reported to be useful as a skin-care and skin-barrier product for the management of stomas. This study aimed to evaluate its efficacy, in terms of wound healing, moisture retention and pain management, as an alternative to conventional dressing materials. Both clinical and animal studies were undertaken. METHOD: The efficacy of the Stomahesive powder was tested by measuring the thickness of granulation tissue formed in a total skin defect in a db/db mouse model. We then compared the healing process using either the skin-protection powder or a conventional film dressing material. In the clinical study 17 patients with various intractable ulcers were treated with Stomahesive powder, and healing was evaluated. RESULTS: In the mouse model, granulation tissue in the wounds treated with the powder was 2.86 times thicker than that of the wounds treated with the film dressing. In the clinical study, 16 out of 17 wounds healed completely. CONCLUSION: The Stomahesive powder could be an effective treatment modality for contact ulceration, superficial ulcers with complex contours and morphology, and superficial ulcers contaminated by liquid faeces or vaginal discharge that have not responded to conventional dressings. DECLARATION OF INTEREST: None.

Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases.

For this article, 178 consecutive cases of mandibular reconstruction using microvascular free flaps and performed from 1979 to 1997 were studied. The purpose of this report is to compare flap success rates, complications, and aesthetic and functional results. The ages of the 131 men and 47 women ranged from 13 to 85 years, with an average of 55 years. Donor sites included the rib (11 cases), radius (one case), ilium (36 cases), scapula (51 cases), fibula (34 cases), and soft-tissue flaps with implant (45 cases). Complications included total flap necrosis, partial flap necrosis, major fistula formation, and minor fistula formation. The rate of total flap necrosis involving the ilium and fibula was significantly higher than that of all other materials combined (p < 0.05). The overall rate of implant plate removal, which resulted from the exposure or fracture of the plate, was 35.6 percent (16 of 45 cases). Each mandibular defect was classified by the extent of the bony defect and by the extent of the soft-tissue defect. The extent of the mandibular bony defect was classified according to the HCL method of Jewer et al. The extent of the soft-tissue defect was classified into four groups: none, skin, mucosal, and through-and-through. According to these classifications, functional and aesthetic assessments of deglutition and contour were performed on 115 subjects, and speech was evaluated in 110. To evaluate the postoperative results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone-defect groups revealed that there was no significant difference in each category. Regarding deglutition, statistical analysis between pairs of soft-tissue-defect groups revealed there were significant differences (p < 0.05) between the none and the mucosal groups and also between the none and the through-and-through groups. Regarding speech, there was a significant difference (p < 0.05) between the none and the through-and-through groups. Regarding contour, there were significant differences (p < 0.01) between the none and the through-and-through groups and between the mucosal and the through-and-through groups. The points given for each function, depending on the reconstruction material, revealed that there was no significant difference between pairs of material groups. From this prospective study, the authors have developed an algorithm for oromandibular reconstruction. When the bony defect is lateral, the ilium, fibula, or scapula should be chosen as the donor site, depending on the extent of the soft-tissue defect. When the bony defect is anterior, the fibula is always the best choice. When the soft-tissue defect is extensive or through-and-through with an anterior bony defect, the fibula should be used with other soft-tissue flaps.

[Microvascular anastomoses in cervical esophageal reconstruction].

Ischemia or hemostasis in the gastric, jejunal, and colonic pedicle after esophagectomy is believed to contribute significantly to postoperative complications. With the advent of microvascular anastomoses, many surgeons have adopted vascular augmentation (supercharge) as a means of avoiding these difficulties. Microsurgical free tissue transfer represented by the free jejunum and forearm flap also plays an important role in esophageal reconstruction. In this paper, the authors introduce the technical points important for successful revascularization including the choice of recipient vessels, setting up of the reconstructive materials, and postoperative monitoring. In cases of gastric pull-up elevated via posterior mediastinum, the left gastroduodenal vessels are anastomosed to the cervical transverse or superior thyroidal vessels. In cases of duodenal or colonic pull-up elevated via the anterosternal route, the vascular pedicles are anastomosed to the internal mammary vessels which are dissected by resecting the costal cartilage. When the free jejunum flap is used, the cervical transverse or superior thyroidal vessels are most frequently used as recipients. Postoperative monitoring of free flaps is performed using Doppler ultrasound or through a small skin incision made above the transferred tissue. Although gastric or colonic pull-up is difficult to monitor, color Doppler sonography permits quantitative analysis of blood flow and may be a useful option.

Tattoo removal by grafting enzymatically separated epidermis.

A novel method of tattoo removal in which the enzymatically separated epidermis of an excised tattoo was grafted in situ was applied to 3 patients. Unlike the conventional skin-grafting procedure, this method resulted in the complete obliteration of the tattoos without donor site scars. In 1990, Hosokawa and colleagues first reported a technique similar to the one described, but the enzymatic process required surgery to be performed over two consecutive days and, thus, it did not become an established procedure. A modification of Hosokawa's method enabled the authors to reduce the enzymatic processing time to an hour using Dispase. The thinning of the tattooed skin using a Paget's-type dermatome before its exposure to an enzymatic solution facilitated the enzyme's infiltration of the basal layer of the epidermis. Hence, the time taken for the epidermis to separate from the tattooed skin was markedly shortened. Although laser removal continues to be the optimal treatment method, skin grafting or other abrasive procedures, including dermabrasion and cryosurgery, are still necessary for those patients who want complete tattoo obliteration over a shorter time frame and at less expense. In these patients the authors recommend that their procedure be offered as an alternative treatment to laser removal.

Surgical repair for congenital macrostomia: vermilion square flap method.

Congenital macrostomia (transverse facial cleft) is a relatively rare anomaly. Surgical methods used to correct this anomaly include commissuroplasty, muscle-plasty of the orbicularis oris, and closure of the cleft cheek. The authors report a new vermilion square flap surgical technique that combines a lower lip mucocutaneous vermilion border flap with a lazy W-plasty to ensure a natural commissure and cheek skin closure. This technique was used in 8 patients with satisfactory results.

Endoscopic-assisted harvest of the temporoparietal fascial flap.

Elevation of the temporoparietal fascial flap by conventional T or Y incisions in the temporal region frequently leaves conspicuous scarring, hair thinning, or baldness. To avoid such undesirable effects, endoscopic-assisted harvest of the temporoparietal fascial flap was performed in 9 patients with microtia. Through two horizontal incisions in the temporal region, the temporoparietal fascia was dissected, and the flap was harvested using bipolar scissors and coagulating shears. Flaps were dissected and harvested successfully without any complications in 7 patients, although extra incisions were required to facilitate coagulation in 2 patients. The authors introduce this harvesting technique and describe some representative cases. Using endoscopic guidance, this is a versatile, safe procedure with minimal morbidity, and is applicable to other reconstructive procedures that require a temporoparietal fascial flap, including the free flap.

Versatility of the inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation.

We have used the recipient inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation cases with hepatic artery obstruction, enabling us to restore the arterial inflow sufficiently to the transplanted liver. The inferior epigastric artery is easy to access during abdominal surgery. Easy to harvest, it is anatomically constant and has a caliber equivalent to that of the hepatic artery. Donor site morbidity is negligible. There is no risk of rejection because of the autograft. There has been no report on the availability of the inferior epigastric artery for hepatic artery reconstruction. We consider this vessel as a good option for an arterial conduit in case of the inadequacy or thrombosis of the hepatic artery in living-related liver transplantation.

Multi-bracket appliance in management of mandibular reconstruction with vascularized bone graft.

BACKGROUND: The most commonly used tool for maxillo-mandibular fixation to the patient who underwent reconstruction using a vascularized bone graft after mandibular resection is a dental arch-bar. However, the occlusal relationship achieved by this method is not ideal. Different from the dental arch-bar, the multi-bracket appliance which is frequently used in orthodontic treatment can control the position of each individual tooth three dimensionally. Thus, this appliance was applied for maxillo-mandibular fixation to patients who underwent mandibular reconstruction using a vascularized bone graft. METHODS: A multi-bracket appliance was applied to three patients. Prior to the surgery, standard edgewise brackets were bonded to the teeth in the maxilla and in the remaining mandible. After mandibular resection, wires for maxillo-mandibular fixation were applied. The harvested bone was then carefully fixed with miniplates to maintain the occlusion. The multi-bracket appliance was worn for 3 months when the wound contraction became mild. RESULTS: All three cases demonstrated stable and good occlusion. They also demonstrated satisfactory post-surgical facial appearance. CONCLUSIONS: Compared to conventional dental arch-bars, a multi-bracket appliance offers improved management of mandibular reconstruction. Firstly, its properties are helpful in maintaining occlusion of the remaining dentition accurately in bone grafting procedure as well as protecting against postsurgical wound contraction. Secondly, the multi-bracket appliance keeps the oral cavity clean without periodontal injury. As a result, stable occlusion of the residual teeth and good facial appearance were obtained.

Prefabricated free jejunal transfer: a new reconstructive technique for high pharyngeal defects.

A new method that uses a prefabricated free jejunal transfer has been applied to three cancer patients with pharyngoesophageal defects with a high pharyngeal deficit extending up to the nasopharynx. In this method, the jejunum harvested in the usual manner is divided into two segments with a single vascular pedicle. Its distal segment is used to reconstruct the cervical esophagus, and its proximal segment is turned over to create a mucosal patch to cover the high pharyngeal defects. The two segments are then co-apted in a side-by-side anastomosis. The esophagus can be reconstructed in a naturally straight shape without a curved portion or blind loop formation, thus leading to good swallowing function. In our series, all grafts survived well and there was no complication directly related to jejunal transfer. All patients could tolerate a soft diet without difficulty. This method is easy to perform and applicable to any shape or size of very high pharyngeal defects that cannot be reconstructed properly by other methods. Although patients with an advanced hypopharyngeal cancer usually have a poor prognosis, this technique allows a better quality of life for a probable short life span.

Osteogenic potential of cultured periosteal cells in a distracted bone gap in rabbits.

Osteogenesis of cultured periosteal cells was investigated in a bone-defective gap that was created artificially by distraction in the tibia of 12-week-old rabbits. A 10-mm circumferential length of periosteum was stripped from each stump of the osteotomized tibia, and the tibia was distracted rapidly (2 mm/day), resulting in disturbance of callus formation. Periosteal-derived cells, which were isolated from the contralateral tibia, were introduced into cell culture, subcultured twice to a population of 5 x 10(7) cells, and then injected into the defective bone gap when distraction was complete. Following inoculation of the cultured cells, significant new bone formation in the bone gap was observed. The control group which did not undergo cell transplantation showed only slight new callus formation which is supposed to be formed by osteogenic cells from the bone marrow. The bone mineral content of newly formed bone between the distracted tibia was analyzed quantitatively on radiographs. Histologically, the transplanted cells initially formed a mass at the injected site and then gradually differentiated into bone tissue from the peripheral region. Bromodeoxyuridine immunohistochemical stain was utilized to investigate the localization of the transplanted cells. The present study confirms that the orthotopically implanted periosteum-derived cells facilitate osteogenesis in a bone defect created using distraction in rabbits.

Median cleft of the lower lip, mandible and manubrium. A case report.

There is a wide variation in the severity of median clefts of the lower lip and mandible. We report a severe case demonstrating clefts of the lower lip and mandible together with lack of supporting structures in the neck and upper sternum. Since a case with a cleft of the manubrium sterni is very rare, the literature is reviewed and discussed.