A very rare case of breast cancer in a female-to-male transsexual.

The incidence of breast cancer in female-to-male (FTM) transsexuals who received mastectomy and sex reassignment surgery is very rare. In fact, there is only one previous medical report of such a case. We experienced a case of an FTM transsexual who developed breast cancer 12 years after mastectomy and hysterectomy with bilateral salpingo-oophorectomy. Because he had been continuously receiving testosterone during the last 15 years and because histopathological examination revealed positive estrogen receptor and androgen receptor expression, we suggest that exogenous testosterone may have initiated the development of breast cancer via two distinct pathways. We describe the clinical course and condition of the patient and recommend that medical personnel consider the possibility of hormone-related cancer in FTM transsexuals receiving cross-sex hormones.

Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps.

The free radial forearm flap is a very common material for penile reconstruction. Its major problems are donor-site morbidity with large depressive scar after skin grafting, urethral fistula due to insufficiency of suture line for the urethra, and need for microvascular anastomosis. A new method using combined bilateral island SCIP flaps for the urethra and penis is developed for gender identity disorder (GID) patients. The advantages of this method are minimal donor-site morbidity with a concealed donor scar, and possible one-stage reconstruction for a longer urethra of 22 cm in length without insufficiency, even for GID female-to-male patients. A disadvantage is poor sensory recovery.

Sex reassignment surgery for male to female transsexuals: initial experience in Okayama university hospital.

The first case of sex reassignment surgery (SRS) in our hospital was performed in January 2001; as of February, 2005, 4 cases of MTF-SRS had been performed. In the 2 most recent cases, we used penile and scrotal skin flaps to avoid complications. The depth and width of the new vagina was made to be adequate for sexual intercourse. Future attention should be focused on devising a surgical technique that will help prevent the complications of partial necrosis of the epidermal skin and wound dehiscence. Although ours is only an initial experience, we describe our surgical technique herein.

Successful delayed venous drainage in 16 consecutive distal phalangeal replantations.

The authors describe, in the first report of this type of replantation surgery, a high success rate using delayed venous anastomosis in 16 consecutive distal phalangeal replantations under digital block. Among these replantations, seven fingers (43.8 percent) showed postoperative venous congestion and five fingers were reoperated on with delayed venous drainage under digital block. All the reoperated fingers were successfully drained by additional single or double venous drainage with a vein graft. As a result, 13 fingers survived (81.3 percent success rate). All operations were performed under a digital block.

Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?

This is the first report on the effectiveness of minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema. Fifty-two patients (age: 15 to 78 years old; 8 males, 44 females) were treated with lymphaticovenular anastomoses under local anesthesia and by postoperative compression using elastic stockings. The average duration of edema of these patients before treatment was 5.3 +/- 5.0 years. The average number of anastomosis in each patient was 2.1 +/- 1.2 (1-5). The patients were followed for an average of 14.5 +/- 10.2 months, and the result were considered effective (82.5%) even for the patients with stage III (progressive edema with acute lymphangitis) and IV (fibrolymphedema), but others showed no improvement. Among these cases, 17 patients showed reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference excluding edema in bilateral legs was 41.8 +/- 31.2% of the preoperative excess length. These results indicate that minimal invasive lymphaticovenular anastomosis under a local anesthesia is valuable instead of general anesthesia.

Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects.

The major problems in dealing with established mandibular loss are severe soft-tissue contracture and a limited number of recipient vessels. The skin portion of the iliac osteocutaneous flap often necrotizes in cases without perforators of the deep circumflex iliac vessel. To overcome these problems, eight patients with established mandibular loss and no skin perforators of the deep circumflex iliac vessel were treated with a sequential vascularized iliac bone graft and a superficial circumflex iliac perforator flap with a single recipient vessel. Regarding the recipient vessels, the ipsilateral cervical vessels were used for four patients, and the contralateral facial and ipsilateral superficial temporal vessels were used for two cases each. The superficial circumflex iliac perforator flaps were 7 to 28 cm in length and 3 to 15 cm in width. The iliac bone grafts ranged from 7 to 13 cm in length, and three cases were repaired with the inner cortex of the iliac bone. There were no serious complications, such as flap necrosis or bone infection and resulting absorption. The advantages of this method are that both pedicles are very close to each other and of suitable diameter for anastomosis. Simultaneous flap elevation and preparation for the recipient site is possible. The skin flap and vascularized bone graft can be obtained from the same donor site. A single source vessel can nourish both the large skin area and bone sequentially. Longer dissection of the superficial circumflex iliac system to the proximal femoral division is unnecessary. A large flap can survive with a short segment of the superficial circumflex iliac system. Only the vascularized inner cortex of the iliac bone needs to be used, and the outer iliac cortex can be preserved, which results in less morbidity at the donor site.

Superficial circumflex iliac artery perforator flap for reconstruction of limb defects.

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.

Medial and lateral malleolar perforator flaps for repair of defects around the ankle.

Reconstruction for defects around the ankle continues to be challenging. Repairs have been effected with the dorsalis pedis flap, the medial plantar flap, and with reverse-flow island flaps using the anterior and posterior tibial systems and the peroneal system. However, sacrifice of the major vessels of the lower leg and wide and long scars at the donor site are disadvantages of these flaps. To overcome these disadvantages, the authors developed island lateral and medial malleolar flaps with the perforators located close to the ankle. These flaps are easy to elevate, involve a short operating time, require no sacrifice of major vessels or muscles of the lower legs, and the use of these adipofascial flaps makes donor scars more acceptable. Malleolar perforator flaps are suitable for the repair of small ankle defects.

Deep peroneal nerve transfer for established plantar sensory loss.

Patients with established or irreversible plantar sensory loss often have normal sensation on the dorsal aspect of the foot, due to an intact deep peroneal nerve. A new method of deep peroneal nerve transfer is proposed for repair of plantar sensory loss caused by extensive nerve gaps or high-level lesions of the posterior tibial nerve. Two cases in which this technique was used are described. The surgical technique is relatively easy, with a short operating time, rapid nerve regeneration after surgery, accurate sensory recovery, and minimal donor-site morbidity with sensory loss only on the first web space of the foot.

Medial plantar perforator flaps with supermicrosurgery.

Since the 1980s, the concept of the perforator flap has been modified to include new perforator flaps. A medial plantar perforator flap, which has no fascial component and is nourished only with perforators of the medial plantar vessel and a cutaneous vein, or with a small segment of the medial plantar vessel, was developed. A free medial plantar perforator flap was successfully transferred for coverage of a soft-tissue defect in the finger. The advantages of this flap are minimum donor site morbidity, minimum damage to the posterior tibial and medial plantar systems, no need for deep dissection, possible thinning of the flap with primary defatting, a short time for flap elevation, use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, a concealed donor scar, and possible application as a flow-through flap as a free flap and an island perforator flap for plantar weight-bearing defects.

Free perforator flap for the treatment of defects after resection of huge arteriovenous malformations in the head and neck regions.

The authors report two cases of huge arteriovenous malformations in the head and neck regions treated successfully with preoperative superselective transarterial embolization and resection followed by a free perforator flap transfer. Based on the authors' previous cases, en block mass resection of the malformation was possible with bleeding of less than 150 ml. The massive defects could be repaired with free perforator flaps using an anterolateral thigh flap and a deep inferior epigastric artery perforator flap. One patient who lost facial muscle underwent reconstruction by simultaneous muscle transfer, and both patients regained acceptable cosmetic appearance and dynamic facial function. Now, more than 4 to 7 years after surgery, the patients have shown no reexpansion of the malformation. The important points of this treatment are complete embolization to accomplish total resection with minimal bleeding, free flap transfer to prevent postoperative reexpansion or recurrence of arteriovenous malformations, and the selection of recipient vessels because of arterial embolization in part of the lesion.

Free gluteal artery perforator flap with a short, small perforator.

The introduction of supermicrosurgery has led to the development of a new gluteal perforator flap nourished only by a musculocutaneous perforator of the superficial gluteal artery system. This flap has a perforator that is short (3-4 cm in length) and small (less than 1 mm). The successful transference of a free gluteal perforator flap for the coverage of soft-tissue defects in the foot and face in two patients is described in this article. With this flap, deeper and longer dissection for a pedicle vessel is unnecessary, flap elevation time is shorter, thinning of the flap with primary defatting and creation of an adiposal flap with customized thickness for tissue augmentation are possible, the donor site is in a concealed area with minimal donor site morbidity, and application of the flap as a scarred flap for previous operations in the gluteal region is possible. The disadvantages of this flap are necessity of dissection for a smaller perforator and of anastomosis of small-caliber vessels of less than 1.0 mm.

New anterolateral thigh perforator flap with a short pedicle for reconstruction of defects in the upper extremities.

Three cases of successful transfer of a new free anterolateral thigh (ALT) perforator flap for coverage of soft-tissue defects in the hand and upper arm are described. This new flap has a thin superficial fatty layer, no fascial component, and is vascularized with a perforator of the descending branch of the lateral circumflex femoral system. The free flap is nourished by anastomosing of the perforator or the proximal small segment of the descending branch. The advantages of this flap are no need for deep dissection, minimal time for flap elevation, minimal donor site morbidity, preservation of the main trunk of the lateral circumflex femoral system, possible thinning of the flap with primary defatting, possible application as a flow-through flap, and a concealed donor scar. This flap is suitable for coverage of defects in the fingers, hands, and arms.

Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg.

Over the last 9 years, the authors analyzed lymphedema of the lower extremity in a total of 25 patients, comparing the use of supermicrosurgical lymphaticovenular anastomosis and/or conservative treatment. The most common cause of edema was hysterectomy, with or without subsequent radiation therapy for uterine cancer. Among 12 cases that underwent only conservative treatment, only one case showed a decrease of over 4 cm in the circumference of the lower leg. The average period for conservative treatment was 1.5 years, and the average decreased circumference was 0.6 cm (8 percent of the preoperative excess). Thirteen patients were followed after lymphaticovenular anastomoses, as well as pre- and postoperative conservative treatment. The average follow-up after surgery was 3.3 years, and eight patients showed a reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference, excluding edema in the bilateral leg, was 4.7 cm (55.6 percent of the preoperative excess). These results indicate that supermicrosurgical lymphaticovenular anastomosis has a valuable place in the treatment of lymphedema.

Dynamic reconstruction of large abdominal defects using a free rectus femoris musculocutaneous flap with normal motor function.

Reconstruction of large abdominal wall defects with conventional reconstruction including the component separation technique is difficult because of strong transverse tension and loss or weakness of the rectus abdominis muscle. To overcome this problem, dynamic reconstruction of the abdominal wall using a free innervated rectus femoris musculocutaneous flap was performed for large defects with separation of the bilateral rectus abdominis muscles. The intact motor nerve of the rectus femoris muscle was transferred without transection, and only the pedicle vessels were anastomosed to the omental vessels. Four and one-half years after surgery, the rectus femoris muscle had voluntary strong muscle contraction and there was no abdominal protrusion, herniation, or donor morbidity. This new method with dynamic function can replace conventional techniques for large abdominal defects without rectus muscle function.

Free radial forearm osteocutaneous perforator flap for reconstruction of total nasal defects.

A case in which a radial forearm osteocutaneous perforator flap was successfully transferred for one-stage reconstruction of total nasal loss is described. This thin flap consists of vascularized radial bone, superficial adiposal tissue, and no deep fascia. It is nourished by a single perforator of the radial artery and a cutaneous vein. The advantages of this flap are minimal donor-site morbidity, easy reconstruction for preservation of the radial arterial system, and no need for longer dissection through the radial artery. The donor defect can be repaired with a flow-through flap, such as an anterolateral thigh flap or a latissimus dorsi perforator flap.