Classification of recipient veins in microsurgical flap reconstructions of the lower extremities.

It is difficult to cure severe open fractures of the lower extremities due to the frequent occurrence of severe damage to soft tissues or blood vessels, as well as bone defects, and concomitant infection, such as osteomyelitis. If appropriate treatment is not performed, long-term complications, such as nonunion of the bone, intractable ulcers, or other disorders, may arise. Between 1993 and 2010, we reviewed the records of 27 patients, and 28 limbs were treated. A total of 31 free-tissue transfers were performed on these 28 limbs. In this study, we classified the degree of damage based on the operative appearance of the condition of the recipient vein. A state that was normal or near-normal was described as type I-normal. A vein that was buried under a scar, but was comparatively easy to detach and retained a moderate adventitia was classified as type II-moderate. A vein with close adhesion between the wall and the scar that was not easy to detach was described as type III-severe. We also examined the relationships between recipient vein type and each of the following: (1) concomitant injury, (2) bone reconstruction, (3) preoperative infection, (4) length of time from injury to reconstruction, (5) eventual reoperation, and (6) flap necrosis. The results showed that there was a statistically significant relationship between recipient vein type and each of the following: bone reconstruction, preoperative infection, eventual reoperation, and flap necrosis. The selection of recipient vein is a factor that greatly affects the outcome of reconstruction of open fractures of the lower extremities. It is important to preoperatively estimate the condition of recipient vein even though it is difficult to preoperatively assess the condition. In some cases, only recipient veins in poor condition can be found intraoperatively on the affected leg. Under such circumstances, a cross-leg flap or a vein graft should be performed without hesitation to use recipient veins in a better condition.

Changes in the blood flow and prevention of vasospasm of the femoral artery by topical application of lidocaine in rats.

Free-tissue transfer with anastomosis has become an important microsurgical technique. Sometimes vasospasm occurs after anastomosis. We examined the changes in blood flow and the effect on the treatment of vasospasm of the femoral artery of rats. The rat models of vasospasm were generated by topical application of epinephrine. We topically applied 2% lidocaine as a single dose (0.2 mL) and a continuous infusion (1.0 mL/h). Our results suggest that although the effect lasts for a short period, a single application of 2% lidocaine has a rapid effect and is effective for treating a sudden manifestation of vasospasm. In contrast, continuous topical application may be more effective for maintaining the blood flow and preventing vasospasm. Therefore we believe that persistent vasospasm should first be treated with several topical applications of lidocaine; if this helps improve the condition, continuous topical application can be subsequently used as a preventive measure.

Medial plantar venous flap technique for volar oblique amputation with no defects in the nail matrix and nail bed.

BACKGROUND: Skin grafting is a simple technique used during volar oblique amputation; however, it is not appropriate to use this technique if the bone or tendon is exposed. Moreover, in volar oblique amputation, if the severed section is large and elongated, skin grafting makes the lack of volume conspicuous, and reconstruction with a V-Y advancement flap occasionally results in a nail deformity that resembles a parrot's beak. We used a medial plantar venous flap for the correction of large volar oblique amputation. METHODS: Reconstructive surgery was performed on patients with volar oblique amputation in whom the proximal severed volar regions extended from the nail matrix to the distal interphalangeal (DIP) joint. The medial plantar venous flap was harvested, the distal subcutaneous vein or communicating vein of the medial plantar area was anastomosed to the proper digital artery, and the proximal vein of the flap was anastomosed to the dorsal subcutaneous vein of the stump of the digit. RESULTS: The flaps survived in all the patients. At 12 months after the surgery, all the treated fingers had attained a good shape. Patients who underwent reconstruction with medial plantar venous flaps attained good sensory restoration. CONCLUSION: In volar oblique amputation, if the remaining nail matrix and nail bed are uninjured, then patients can expect the restoration of shape, function and sensory input after surgery. In this study, we used the medial plantar venous flap for large volar oblique amputation cases and obtained good results.

A novel approach for preventing the development of persistent vasospasms after microsurgery for the extremities: intermittent topical lidocaine application.

Vasospasm is often encountered after harvesting the recipient artery in tissue transfer surgery, particularly in the extremities. Further, after anastomosis, thrombosis is a major complication arising due to vasoconstriction. Therefore, we decided to apply lidocaine topically on the recipient artery to prevent postoperative vasospasm. We had applied lidocaine topically on the recipient artery in seven patients with persistent vasospasm before the completion of the surgery. After surgery, 0.2 mL lidocaine (4%) was directly applied on the vascularized region every 15 minutes for the first 3 hours, every 30 minutes for the next 3 hours, and every 1 hour for the next 18 hours. Although four patients experienced a disturbance in the blood flow immediately after the surgery, they showed improvements after lidocaine application. In three of these four patients, vasospasm was also suspected to occur at 15 minutes after the surgery; however, topical application of lidocaine was found to be effective in these patients. Thrombosis was not observed in any case. We believe that if the site of lidocaine application is appropriate, even a small dose of low-concentration lidocaine (4%) can produce an adequate effect. Moreover, the intervals between lidocaine applications should be carefully considered.

Construction of synthetic dermis and skin based on a self-assembled peptide hydrogel scaffold.

Using biocompatible peptide hydrogel as a scaffold, we prepared three-dimensional synthetic skin that does not contain animal-derived materials or pathogens. The present study investigated preparation methods, proliferation, and functional expression of fibroblasts in the synthetic dermis and differentiation of keratinocytes in the epidermis. Synthetic dermis was prepared by mixing fibroblasts with peptide hydrogel, and synthetic skin was prepared by forming an epidermal layer using keratinocytes on the synthetic dermis. A fibroblast-rich foamy layer consisting of homogeneous peptide hydrogel subsequently formed in the synthetic dermis, with fibroblasts aggregating in clusters within the septum. The epidermis consisted of three to five keratinocyte layers. Immunohistochemical staining showed human type I collagen, indicating functional expression around fibroblasts in the synthetic dermis, keratinocyte differentiation in the epidermis, and expression of basement membrane proteins. The number of fibroblasts tended to increase until the second week and was maintained until the fourth week, but rapidly decreased in the fifth week. In the synthetic dermis medium, the human type I collagen concentration increased after the second week to the fifth week. These findings suggest that peptide hydrogel acts as a synthetic skin scaffold that offers a platform for the proliferation and functional expression of fibroblasts and keratinocytes.

Atypical Apert syndrome: sequential and segmental distraction osteogenesis of the skull, midface, and mandible.

We describe a boy with Apert syndrome, including cranial deformities and syndactyly (acrocephalosyndactyly), though intracranial hypertension, exophthalmos, and midfacial hypoplasia were mild. We treated him by mandibular distraction, in addition to fronto-orbital distraction, and Le Fort III midfacial distraction, with good results.

Early surgical intervention for Japanese children with infantile hemangioma of the craniofacial region.

Although the indications for surgical intervention in patients with infantile hemangioma during the proliferation and early involution are controversial, it is considered in certain cases. Thirty-two Japanese patients (3 boys and 29 girls) were surgically treated at 24 months or earlier to resolve complications (obstruction of the visual axis, ulceration and bleeding, and deviation of the nasal septal cartilage) or to achieve esthetic improvement. Results were evaluated by 3 indicators: outcome, scarring, and resolution of the functional problem. Excellent or good surgical results were obtained in 81.2% of all patients and in 95% of patients in nonorbital areas. Earlier surgical intervention can be an option for treating infantile hemangioma in the craniofacial region.

Secondary correction of deformities of the vermilion with exposed oral mucosa after cleft lip repair.

There is much discussion on the deformities of the vermilion after cleft lip repair such as a notch and uneven thickness of the vermilion because of insufficient union of the orbicularis oris muscle, vertical scar contracture of the vermilion, and suture sufficiency. However, it is relatively rare for a corrective method of the coloration and texture of the vermilion to become an issue. Prominent deformities can remain because of the exposed oral mucosa in the vermilion region. This exposure is due to the difference in the widths of the dry lip and wet lip. Furthermore, because wet lip is placed in a dry environment, there are a number of complaints such as constant scab formation. For such postoperative deformities of the vermilion, conventional secondary corrections have been performed such as Z-plasty and V-Y plasty. In our study, we used the scar of the vermilion as a pedicle flap and obtained relatively good results. The advantages of this method include not wasting tissue, relatively easy correction of coloration and texture of the vermilion, and formation of the labial tubercle. This method is thought to be a useful technique for vermilion deformities after cleft lip repair with exposed oral mucosa.

Location of communicating veins for medial plantar venous flap.

BACKGROUND: The medial plantar venous flap is suitable for reconstruction of the palmar surface of the finger. However, it is sometimes difficult to detect and harvest the distal subcutaneous vein of the flap. In such a situation, the communicating vein can be used as a distal vein for the flap. However, the location of these veins is not obvious. METHODS: By using 20 feet from 10 cadavers and ultrasound imaging for 40 feet from 20 healthy individuals, we investigated the location of communicating veins. RESULTS: In cadavers, 11 communicating veins (45.8%, n = 24) were located in the area above the abductor hallucis muscle and 12 veins (50%) in the area below it. Ultrasound imaging revealed 15 bifurcations of the communicating veins (31.3%, n = 48) in the upper area and 27 bifurcations in the lower area of the medial plantar region (56.3%). CONCLUSION: It was observed that the communicating veins were concentrated in the areas above and below the abductor hallucis muscle.

A simplification for harvesting medial plantar venous flap with communicating veins: usefulness of preoperative ultrasound imaging.

BACKGROUND: The medial plantar venous flap is ideally suited for reconstruction of injuries to the palmar surface of the finger. However, when the distal veins of such flaps are narrow, harvesting is no longer simple and anastomosis to the digital artery presents a challenge. METHODS: Using ultrasound imaging, we investigated the presence or absence of communicating veins in the medial plantar region in 40 feet of 20 healthy individuals. In addition, we performed preoperative ultrasound imaging in 8 patients. RESULTS: The investigation in healthy individuals revealed a mean number of 1.2 communicating veins in the medial plantar region. Communicating veins were confirmed preoperatively in 6 of our 8 patients. CONCLUSION: Preoperative ultrasound imaging to investigate the course and diameter of subcutaneous veins and communicating veins in the medial plantar region allows the flap design to be determined appropriately and for the surgery to proceed more simply.

Clinical success of mandibular distraction for obstructive sleep apnea resulting from micrognathia in 10 consecutive Japanese young children.

In recent years, obstructive sleep apnea has gained attention as one of the causes of sudden death in young children. There have been some reports, mainly from the United States and Europe, that mandibular distraction osteogenesis is effective as a treatment for obstructive sleep apnea syndrome caused by micrognathia in young children. However, there has not been any report yet in Japan. In this study, we performed mandibular distraction osteogenesis using internal devices in 10 young children with obstructive sleep apnea. To enable distraction to be performed smoothly without any difficulties, we modified a surgical procedure by adding an osteotomy of the coronoid process to a vertical ramus osteotomy. Postoperative evaluations using cephalograms and polysomnography were performed, and great improvements were observed. As a result, all patients either avoided or were weaned from tracheostomy, and very good results were obtained similar to those in reports from the United States and Europe. We report our experience in Japan.

The place of chemical leeching with heparin in digital replantation: subcutaneous calcium heparin for patients not treatable with systemic heparin.

BACKGROUND: In patients with replanted digits, systemic heparinization or other techniques may be used for prevention of thrombosis of the vascular anastomoses or to prevent coagulation at the drainage site (e.g., a fish-mouth incision or partially removed nail). However, systemic heparin may be contraindicated or require cautious administration in certain patients. The authors injected calcium heparin subcutaneously into the congested replanted digits of seven patients with a history of or undergoing treatment for hemorrhoids or gastric ulcer and drained the congestion by means of a fish-mouth incision. METHODS: With this method, 0.8 ml (20,000 U) of calcium heparin for subcutaneous injection was diluted with 1.2 ml of saline to prepare a solution containing 1000 U in 0.1 ml; this calcium heparin solution (1000 U) was initially injected into the tip of the congested digit. If required, additional doses of 500 U each were administered every 24 hours until the congestion improved. RESULTS: No worsening of bleeding from hemorrhoids or gastric ulcer was seen after the administration of calcium heparin in these patients. Regarding duration of action, continuous bleeding for approximately 6 hours was obtained after subcutaneous injection of 1000 U, and thereafter, adequate drainage was achieved for approximately 24 hours by stimulating the drainage site. CONCLUSIONS: Among patients in whom systemic heparin is contraindicated or who require cautious administration, this is a very effective technique in those in whom congestion fails to improve despite thrombectomy, patients in whom thrombectomy or vascular reanastomosis is not possible, and patients with congestion caused by narrow anastomosed veins.

Sinus pericranii associated with craniosynostosis.

Sinus pericranii is a vascular tumor of the head having communication with the dural venous system. The tumor enlarges with increased intracranial pressure when the patient is in the lateral recumbent position. Since Stromeyer used the term "sinus pericranii" in his report in 1850, approximately 170 cases have been reported. However, relatively few cases of sinus pericranii have been reported in association with craniosynostosis or by plastic surgeons. In this study, we report seven cases of sinus pericranii associated with craniosynostosis. There were two patients with Apert syndrome, two with Crouzon syndrome, two with oxycephaly, and one with trigonocephaly. The sites of occurrence were the parietal region in six patients and the frontal region in one patient. In either type of case, the tumor was clinically a soft subcutaneous mass of the head. The clinical characteristics of the tumor were its disappearance when the patient was in a sitting position and its appearance when the patient was in a recumbent position or crying. The patients were preoperatively diagnosed with sinus pericranii from imaging test findings, such as from magnetic resonance imaging and aforementioned clinical findings. In all cases, treatment for sinus pericranii was performed during the surgery for craniosynostosis. For patients with lesions in either site, we did not perform craniotomy, and we used a minimally invasive method of tumor excision and resection of the sites of communication using electrocoagulation. Perioperatively, heavy hemorrhage was not observed, and, postoperatively, no recurrence has been observed in any patient. In this study, we examine the etiology, diagnosis, and treatment of sinus pericranii, in particular for patients with craniosynostosis.

Finger palmar surface reconstruction using medial plantar venous flap: possibility of sensory restoration without neurorrhaphy.

BACKGROUND: Because plantar anatomic features are similar to those of the palmar surface of the finger, palmar surface finger reconstruction using a medial plantar venous flap enables grasping without slippage, results in strength that can withstand friction, and provides a cushioning effect. Furthermore, sensory restoration is thought to be excellent due to the similarity of the tissues. METHODS: We performed finger palmar surface reconstruction in 6 patients using venous flap without harvesting the medial plantar subcutaneous nerve branch and assessed the sensory restoration using a static 2-point discrimination test (s-2PD), moving 2-point discrimination test (m-2PD), and Semmes-Weinstein test (S-W test). RESULTS: The mean s-2PD at 12 months after surgery was 8.6 mm, the mean m-2PD was 6.00 mm, and the S-W test score was 3.84-3.22 CONCLUSION: These findings indicate that sensory improvement can be obtained by finger palmar surface reconstruction without grafting of the medial plantar subcutaneous nerve branch to the digital nerve.

Simultaneous hybrid of maxillary Le Fort I halo distraction and mandibular set-back for patients with severe cleft jaw deformity.

One of the surgical tactics and retrospective chart review of clinical cases are described for severe maxillo-mandibular discrepancy. The recently developed Le Fort I Halo distraction combined with mandibular sagittal splitting osteotomy is initially carried out simultaneously. Materials include six adult patients revealing severe jaw deformity with mandibular prognathism somehow ranging from 17-19 years of age. The required adjustment of the maxillo-mandibular discrepancy ranged from 14-23 mm to obtain the preferred occlusion. The simultaneous combination of over 10-mm maxillary Le Fort I Halo distraction with mandibular set-back secured rigidly by sagittal splitting was accomplished. The amount of mandibular set-back ranged from 4-6 mm. The amount of maxillary Le Fort I halo distraction ranged from 10-17 mm (Table I). The retention period of the halo brace was 21-22 days. In addition, the Delair type of face mask was used for 3-4 months as a night splint for consolidation after removal of the halo brace. Satisfactory maxillary distraction and mandibular set-back as planned preoperatively was obtained in all six cases. No particular postoperative complications were noticed. Compared with standard Le Fort I advancement for cleft patients, more advancement can be obtained easily with halo distration, particularly in cases where a large amount of advancement > 10 mm is required. This combination is worthwhile for a severe cleft jaw deformity, and is an alternative for standard double jaw osteotomy.

Hemostasis by means of a cautery knife equipped with an air spray for burns over a large area.

In operations in which debridement is performed over a large area (e.g., surgery for whole-body burns), it is necessary to keep the length of the operation short and the amount of blood loss as small as possible to minimize stress to the patient's body. In this study, we developed a cautery knife to which an air spray is attached for surgical procedures in which debridement is performed as treatment for burns over a large area. We have demonstrated herein that this device is very effective for reducing both blood loss and the duration of surgery as well as for simplifying the achievement of hemostasis.

Clinical application of distraction osteogenesis for traumatic maxillofacial deformities.

Treatment including occlusal function is important for maxillofacial fractures. Because distraction osteogenesis is now used frequently for the treatment of various types of congenital maxillary hypoplasia, the authors applied this technique to six cases of traumatic maxillofacial deformity caused by old maxillofacial fractures. Several kinds of devices were used for the various deformities associated with severe malocclusion, resulting in extension of both bone and soft tissues. In each case, favorable facial aesthetics and occlusion were achieved. Distraction osteogenesis also appears to be an extremely effective method for repair of traumatic maxillofacial deformities.

Temporoparietal fascia plication in rhytidectomy.

BACKGROUND: The temporal region has a complex subcutaneous fascial structure known as the temporoparietal fascia, which is part of the subcutaneous musculoaponeurotic system. The temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) of the face in the inferior border, the frontalis muscle, and the orbicularis oculi muscle in the anterior border. Therefore, a properly planned temporoparietal fascia plication can increase the tightness of the SMAS. In addition, plication of the temporoparietal fascia can provide lifting to decrease lateral canthal wrinkles with elevation of the lateral brows in rhytidectomy. Furthermore, plication of the temporoparietal fascia can yield deep tissue support, which prevents alopecia and visible scar formation in the temporal region by decreasing the tension along the skin incision. METHODS: Plication of the temporoparietal fascia was performed for 16 patients who had undergone face-lifts over the previous 10 years. Careful subcutaneous dissection, performed immediately under the hair follicles to avoid frontal nerve injury, provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy and protects the auriculotemporal nerve and the superficial temporal vessels. RESULTS: There were no complications such as hematoma, facial nerve injury, alopecia, or visible scar formation attributable to the temporoparietal fascia plication. CONCLUSION: Temporoparietal fascia plication can be performed simply during rhytidectomy as an additional procedure. It not only augments the effects of the rhytidectomy, especially in the lateral brows, the lateral canthal, and the temporal regions, but also decreases the risk of possible complications.