A comparison of thinning and conventional free-flap transfers to the lower extremity.

This study compares the application of conventional free flaps and thinning flaps to the lower extremities. Thirty patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a conventional flap group, reconstructed using conventional free flaps (15 cases), and a thinning flap group, reconstructed using thinning flaps (15 cases). Postoperative complications, long-term results, and revisional surgery were studied in the two groups. Although survival after surgery was the same in both, in the conventional flap group, 11 patients required secondary revisional surgery, the excessive bulk of the flap resulting in poor aesthetics and difficulty in wearing shoes. The conventional flap group also required longer treatment. In the thinning flap group, only 5 of 15 patients received secondary revisional surgery. As a reconstruction material for the lower extremities, thinning flaps are both aesthetically and functionally superior to conventional bulky flaps.

Accessing the Orbital Roof via an Eyelid Incision: The Transpalpebral Approach.

THIS ARTICLE OUTLINES A NEW SURGICAL TECHNIQUE FOR ACCESSING THE ORBITAL ROOF: the transpalpebral approach. It involves making an incision on the double fold of the upper eyelid, then dissecting the orbital septum and the orbicular muscle of the eye. This exposes the orbital roof and enables the surgeon to approach without a coronal incision of the scalp; the direct eyelid incision provides adequate workspace. We use this approach in three orbital roof fractures and one orbital hemangioma. This orbital approach offers a simpler surgical technique, a less invasive one, and still provides excellent exposure of the superior orbital cavity.

A case report of caudal regression syndrome associated with an intraspinal arachnoid cyst.

We report here a rare case of caudal regression syndrome associated with an intraspinal arachnoid cyst. The patient was a 6-month-old baby girl with multicomplex congenital abnormalities: sacrococcygeal dysgenesis and ventral curvature, large terminal cyst (myelocystocele), spinal arachnoid cyst, cerebellar hypertrophy (suspected), high imperforate anus, partial dysgenesis of the large intestine, omphalocele, atresia of the vagina, bilateral incomplete ureter duplication, incomplete pseudoduplicated bladder and bilateral talipes equinovarus. We performed plastic repair of the myelocystocele and perineal lesion for caudal regression syndrome and partial removal of the cyst wall for the intraspinal arachnoid cyst. She has been well for 3 years postoperatively, and her mental development is normal.

Drill-hole guide for internal fixation of fractures of the mandibular condyle.

We have developed a drill-hole guide valuable in accurately positioning the fracture of the mandibular ramus. It operates by introducing a Kirschner wire through the fracture stump from the mandibular angle to the condyle. A 2.0- to 2.4-mm-diameter Kirschner wire is drilled into the ramus from below and proceeds up to the condylar fragment through the stump of the fracture. With this guide, 15 patients with 23 subcondylar fractures underwent open reduction with Kirschner wire fixation. In each case, wire, by means of a pinning technique, was inserted accurately from the mandibular angle to the repositioned condyle.

Modification of the gluteus maximus V-Y advancement flap for sacral ulcers: the gluteal fasciocutaneous flap method.

We designed a modified gluteus maximus V-Y advancement flap method for closing a sacral ulcer. The purposes of our method were to simplify the surgical procedure and to avoid a functional deficit of the gluteus maximus muscle that was sacrificed by the conventional method. After excising the sacral ulcer, the V-Y advancement flap is marked on the bilateral buttock. Fascial incision of the gluteus maximus is made at the same incision in the skin. One-third of each medial flap is elevated as a fasciocutaneous flap by dissecting the layer between the fascia and the muscle at the parasacral region. The flaps are then moved medially and sutured. We operated on 24 patients with sacral ulcers using this technique. The patients included 19 with a sacral pressure sore and 5 with a radiation ulcer on the sacrum. Eighteen ambulatory patients also were included in this group. The results showed no flap necrosis in any patient. No functional deficit of the gluteus maximus muscle was observed postoperatively in the ambulatory patients. Average blood loss was 250 ml during the procedure. We conclude that the gluteus V-Y advancement flap as a fasciocutaneous flap is superior to the conventional musculocutaneous flap method.

An elastic plastic splint to compress the ear after reconstruction using a temporoparietal fascial flap.

We designed a new splint that is used to compress the ear after reconstruction using the temporoparietal fascial flap method to reduce postoperative swelling rapidly. The splint, which is made of an elastic plastic material, was applied to 3 patients with an acquired ear defect. The application period using this splint was from 10 days after surgery up to 3 to 6 months. Swelling of the reconstructed ear subsided rapidly after application of the splint. The contour was then enhanced in all patients. We were able to apply compression to the region as required, using a sponge attached to the splint. The splint is soft enough to remain in place, even if the patient continues regular activities. We conclude that the elastic plastic splint is useful to compress the ear after reconstruction using the temporoparietal fascial flap method.

Treatment of scalp arteriovenous malformation.

We report seven patients with scalp arteriovenous malformations, including two patients with lesions > 10 cm in diameter, who were successfully treated. The principal complaint of each patient was a deforming mass. Each of four patients had a history of blunt traumatic injury. The lesions, each consisting of the nidus, feeders, and draining veins, evolved in all patients. The nidus consisted of fistulae, which exhibited various angioarchitectures as revealed by angiography. A hemangiomatous component was histologically recognized in one patient. In five patients, in whom the lesions were relatively small and whose nidi included only large fistulae, the malformations were remedied by surgical intervention alone or were cured with embolization alone using liquid adhesives. In the two patients with lesions > 10 cm, the nidi consisted of numerous large fistulae and plexiform fistulae in one patient and plexiform fistulae and a hemangiomatous component in the other patient. These patients were treated with a combination of transarterial embolization and surgical intervention. Preoperative embolization greatly reduced blood loss during resection. Total excision and scalp reconstruction using a soft tissue expander were performed in both patients. The cosmetic results were excellent in all of the patients, and no recurrence has been recognized during the follow-up period, which ranges from 31 to 99 months. The treatment of scalp arteriovenous malformations should strive to improve deforming features and to attain a permanent cure. Because each nidus includes a variety of anomalous angioarchitectural features, there should be different means and a combination of treatments for each patient. Embolization alone could be adequate treatment in relatively small lesions, the nidi of which consist only of several large fistulae. For malformations with more extensive, large fistulae or with anomalous components other than large fistulae, a combined endovascular and surgical approach and scalp reconstruction seems to be the best treatment.

A new method for the relief of adult phimosis.

Infantile circumcision is not ordinarily performed in Japan. Adult circumcision causes esthetic problems with scarring and color change, especially in Asian patients. We report our experience with 10 adults who underwent a new method of surgery for correction of phimosis via a longitudinal incision of the prepuce along the constricted area ventrally to release constriction, followed by transverse closure of the wound; removal of excess skin by pinching at the dorsal root of the penis, incising circumferentially except for 2 cm. of ventral skin, and closing the dorsal wound. Functional results in all cases were satisfactory and preputial constriction was fully relieved. Cosmetic results were superior to those of conventional circumcision and dorsal slit methods of adult circumcision because contrasting coloration was obscured behind pubic hair and scarring was coincidental with or beneath the pubic hairline.

Activation of endogenous thromboxane A2 biosynthesis mediates presynaptic inhibition by endothelin-3 of dog stellate ganglionic transmission.

Effects of endothelin-3 on ganglionic transmission were investigated in dog cardiac sympathetic ganglia. Positive chronotropic responses to preganglionic stellate stimulation were inhibited by endothelin-3 (0.5-2 micrograms) given directly to the ganglia through the artery. To find possible inhibitory effects of the peptide at presynaptic sites, acetylcholine released from the isolated stellate ganglia was determined. The amount of acetylcholine released during preganglionic stimulation was reduced by exposure to endothelin-3 (10(-9) to 10(-6) M). A similar reduction of acetylcholine release was observed after application of a stable thromboxane A2, a thromboxane A2/prostaglandin H2 receptor agonist, U-46619, and prostaglandin E2 at concentrations from 10(-8) to 10(-4) M, but not by the same concentrations of prostaglandins F2 alpha and I2. The reduction elicited by endothelin-3 was unaffected by a phospholipase C inhibitor, neomycin, or a protein kinase C inhibitor, H-7, but was antagonized by pretreatment with phospholipase A2 inhibitors, dexamethasone or methylprednisolone, and by cyclooxygenase inhibitors, aspirin and indomethacin. In addition, the reduction also was antagonized by pretreatment with a thromboxane A2 synthetase inhibitor, OKY-046, and a specific thromboxane A2 receptor antagonist, S-145, but not by a specific prostaglandin E2 receptor antagonist, SC-19220. Furthermore, endothelin-3 (10(-7) M) stimulated the OKY-046- and indomethacin-sensitive formation of thromboxane A2 in the ganglia. These results indicate that endothelin-3 inhibits the sympathetic ganglionic transmission by reducing acetylcholine release at preganglionic terminals and that this inhibition seems to involve activation of endogenous thromboxane A2 production.

Increase of acetylcholine release by nebracetam in dog cardiac sympathetic ganglion.

The effects of nebracetam (4-aminomethyl-1-benzylpyrrolidine-2-one hemifumarate, WEB 1881FU), a potential cognitive enhancer, on acetylcholine release from the preganglionic nerve terminals were investigated in the isolated dog stellate ganglia. Acetylcholine release from the isolated ganglia by preganglionic stimulation (5 Hz) was enhanced in the presence of nebracetam, 10(-7) to 10(-5) M. The release was decreased to a certain extent by bethanechol, 10(-5) M, and this decrease was completely antagonized by AFDX-116 (10(-5) M), a selective M2 muscarinic antagonist, but was unaffected by nebracetam (10(-6) M). Under the depleted condition of acetylcholine induced by pretreatment with hemicholinium-3 (10(-5) M) in combination with prolonged preganglionic stimulation, the release was increased to a degree by nebracetam or choline alone and was markedly increased in the presence of both nebracetam and choline. Nebracetam did not directly act on choline acetyltransferase activity, but acetylcholine formation was stimulated in the isolated ganglion incubated with the agent at 10(-6) M and in the ganglion isolated from the dog to which nebracetam, 5 mg/kg, was previously administered i.v. Uptake of choline in the isolated ganglia was not altered by nebracetam (10(-6) M) but was enhanced under the depleted conditions. These findings suggest that nebracetam enhances acetylcholine release from presynaptic sites of dog stellate ganglia not by blocking presynaptic M2 muscarinic autoreceptors but by accelerating acetylcholine formation, and by increasing choline uptake when acetylcholine is depleted.

Presynaptic facilitation by the new nootropic drug nebracetam, of ganglionic muscarinic transmission in the dog cardiac sympathetic ganglion.

Effects of nebracetam (4-aminomethyl-1-benzylpyrrolidine-2-one hemifumarate, WEB 1881 FU, CAS 118607-07-1), a new nootropic drug, on impulse transmission in the cardiac sympathetic ganglia were studied in spinal dogs by monitoring heart rate as an indicator of the ganglionic function. The ganglionic stimulants were given directly into the cardiac sympathetic ganglia through the right subclavian artery (i.a.). Nebracetam, 5 mg/kg, i.v. caused a slight and temporal increase in heart rate. After nebracetam, the frequency-response curves of heart rate for preganglionic stellate stimulation (0.25-4 Hz) were not altered in the untreated and atropine-pretreated animals, but the curves (2.5-40 Hz) were shifted to the left in the hexamethonium-pretreated animals. The enhancement of ganglionic muscarinic transmission was dose-dependent on nebracetam i.v. at doses ranging from 0.5 to 15 mg/kg, with a maximal effect at 5 mg/kg. This enhanced muscarinic transmission by nebracetam was almost abolished after subsequent administration of pirenzepine 0.5 mg/kg i.v. The enhancement in the muscarinic transmission by nebracetam was also eliminated after depletion of acetylcholine at preganglionic sites caused by treatment with hemicholinium-3 in combination with preganglionic stimulation. Furthermore, nebracetam failed to affect dose-dependent post-ganglionic stimulation by McN-A-343 (1-32 micrograms), 1,1-dimethyl-4-phenylpiperazinium (1-32 micrograms) and angiotensin II (0.1 and 0.2 micrograms) administered i.a. directly to the ganglia. These results suggest that nebracetam facilitates the ganglionic muscarinic transmission through acting on presynaptic sites.

Endothelin-3 inhibits ganglionic transmission at preganglionic sites through activation of endogenous thromboxane A2 production in dog cardiac sympathetic ganglia.

The effects of endothelin-3 (ET-3) on ganglionic transmission of dog cardiac sympathetic ganglia and possible mechanisms involved were investigated in vivo and in vitro. Positive chronotropic responses to preganglionic stellate stimulation and those to dimethylphenylpiperazinium as well as McN-A-343 administered to the ganglia were inhibited by ET-3. The amount of acetylcholine released by preganglionic stimulation was reduced dose dependently after exposure to ET-3. The reduction elicited by ET-3 was antagonized by pretreatment with phospholipase A2 inhibitors (dexamethasone and methylprednisolone) and cyclooxygenase inhibitors (aspirin and indomethacin). In addition, the reduction of acetylcholine release was similarly induced by exposure to exogenously applied STA2, a stable thromboxane A2 analogue; U-46619, a TXA2/PGH2 receptor agonist; and prostaglandin E2. Furthermore, the reduction produced by ET-3 was antagonized by pretreatment with a thromboxane A2 synthetase inhibitor (OKY-046) and a specific thromboxane A2 receptor antagonist (S-145), but not by a specific prostaglandin E2 receptor antagonist (SC-19220). These results indicate that ET-3 inhibits the sympathetic ganglionic transmission via reducing acetylcholine release from the presynaptic nerve terminals of ganglia and that this inhibition involves the activation of endogenous thromboxane A2 production.

[Antihypertensive effect of naftopidil (KT-611), a novel alpha 1-adrenoceptor antagonist, in freely moving experimental hypertensive rats and dogs].

The antihypertensive effect of naftopidil (KT-611) following single oral administration was investigated in normotensive Wistar Kyoto rats (WKY), spontaneously hypertensive rats (SHR), DOCA-Salt hypertensive rats (DHR), 2-kidney 1-clip renal hypertensive rats (RHR) and Grollman type renal hypertensive dogs with 1-kidney (RHD); and it was compared with that of the selective alpha 1-adrenoceptor antagonist prazosin. The blood pressure and heart rate were measured under the unanesthetized, unrestrained state through an arterial catheter that was chronically implanted into the abdominal aorta. In SHR and WKY, both KT-611 (10 and 30 mg/kg, p.o.) and prazosin (1 and 3 mg/kg, p.o.) markedly inhibited the pressor response to the alpha 1-adrenoceptor agonist phenylephrine (3 micrograms/kg, i.v.). KT-611 (10 to 100 mg/kg, p.o.) showed a dose-dependent hypotensive effect in SHR, DHR and RHR but not in WKY. The hypotensive effect of KT-611 reached maximum at 0.5-1 hr, lasted for 4-6 hr and was more potent in DHR and RHR than in SHR. The potency of KT-611 was 1/10-1/30 weaker than that of prazosin. In RHD, single oral administration of KT-611 (1 to 10 mg/kg) caused a dose-dependent and long-lasting hypotensive effect. These results suggest that KT-611 has a long-lasting hypotensive effect in experimental hypertensive animal models.

Correction of a chest wall deformity utilizing latissimus dorsi with a turnover procedure.

Infraclavicular hollowing and the abnormal anterior axillary fold are often seen in patients with Poland's syndrome and related conditions. The operative procedure described in this article corrects these deformities. The procedure uses the latissimus dorsi island flap. The inserted muscle is moved anteriorly and sutured between the deltoid and the biceps. Then the muscle flap is twisted between its origin and where it is inserted. The muscle fibers act like a pivot and the thickness of the flap is increased, which enables us to achieve a round anterior axillary fold. The muscle flap fills the infraclavicular region and softens the deep hollow area.

The role of psychiatry in aesthetic surgery.

Twenty-five patients seeking aesthetic surgery were investigated and treated with the cooperation of the plastic surgeon and a psychiatrist. Three-fourths of the patients revealed psychiatric problems in their backgrounds. On the recommendation of the psychiatrist, eight cases underwent operations, in spite of psychiatric problems, and were satisfied with the treatment. Patients not operated on had been persuaded to abandon their operation after psychiatric therapy. In conclusion, the cooperation of the psychiatrist was found to be very effective in the treatment of those seeking aesthetic surgery.

Special surgical techniques for relief of phimosis.

Almost one-half of the population of adolescent and adult Japanese males suffers from some degree of phimosis, i.e., the condition in which the prepuce is too long or too tightly covers the glans penis and causes complications. This condition makes local hygiene difficult, promotes secondary infection and purulence, retards maturation of the penis, and leads to sexual dysfunction that is psychologically and maritally distressing. Circumcision shortly after birth is not ordinarily praticed in Japan, and when relief of phimosis and its complications is attempted later in life by the conventional technique of circumcision or by limited operations like dorsal slit of the prepuce or incision of the frenulum of the prepuce, the condition and its related problems are not readily or always satisfactorily corrected. Consequently, new surgical techniques have been devised and are practiced at the Ohjimi Clinic for the relief of phimosis, especially for the sexual dysfunction that results from it.