Akihiko Takushima

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

&NA; 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. (Plast. Reconstr. Surg. 108: 1555, 2001.)

Choice of osseous and osteocutaneous flaps for mandibular reconstruction.

Microvascular free flap transfer currently represents one of the most popular methods for mandibularreconstruction. With the various free flap options nowavailable, there is a general consensus that no single kindof osseous or osteocutaneous flap can resolve the entire spectrum of mandibular defects. A suitable flap, therefore, should be selected according to the specific type of bone and soft tissue defect. We have developed an algorithm for mandibular reconstruction, in which the bony defect is termed as either “lateral” or “anterior” and the soft-tissue defect is classified as “none,” “skin or mucosal,” or “through-and-through.” For proper flap selection, the bony defect condition should be considered first, followed by the soft-tissue defect condition. When the bony defect is “lateral” and the soft tissue is not defective, the ilium is the best choice. When the bony defect is “lateral” and a small “skin or mucosal” soft-tissue defect is present, the fibula represents the optimal choice. When the bony defect is “lateral” and an extensive “skin or mucosal” or “through-and-through” soft-tissue defect exists, the scapula should be selected. When the bony defect is “anterior,” the fibula should always be selected. However, when an “anterior” bone defect also displays an “extensive” or “through-and-through” soft-tissue defect, the fibula should be usedwith other soft-tissue flaps. Flaps such as a forearm flap, anterior thigh flap, or rectus abdominis musculocutaneous flap are suitable, depending on the size of the soft-tissue defect.

Hepatic Artery Reconstruction with Double- Needle Microsuture in Living-Donor Liver Transplantation

In living‐donor liver transplantation (LDLT), reconstruction of the hepatic artery is challenging because the recipient artery is located deep in the abdominal cavity and the operating field is limited. Also, the hepatic artery of the graft is short and the recipient artery is occasionally damaged. To overcome these difficulties, we developed a double‐needle microsuture technique for artery reconstruction. A total of 161 adult patients received 163 LDLTs using this new technique. The first suture was placed at the most difficult point in the artery to be visualized through the microscope. Each stitch was placed from the inner side of the arterial wall to the outer side. The posterior stitch was tied pulling toward the back. The subsequent sutures were advanced anteriorly on either side adjacent to the previous suture. Hepatic artery thrombosis occurred in 4 patients (2.5%), only 2 (1.2%) of which were associated with arterial reconstruction. Intimal dissection developed in the recipient artery in 2 patients (1.2%). Three (50%) of these 6 complications occurred more than 10 days after LDLT. In conclusion, this suturing technique allows for safe intimal adaptation even when the arterial tunica intima is separated from the tunica media, because all stitches are carried from inside of the vessel to the outside, contributing to more satisfactory results. Liver Transpl 12:46–50, 2006.

Experience of sclerotherapy and embolosclerotherapy using ethanolamine oleate for vascular malformations of the head and neck

Sclerotherapy is effective in the treatment of vascular malformations. However, in lesions with relatively high blood flow, its effect is not always adequate. We therefore developed a three-grade classification of vascular malformations to facilitate the selection of treatments according to vascular flow. We also developed the technique of embolosclerotherapy, in which transarterial embolisation is done before sclerotherapy to control blood flow in the lesion during sclerotherapy. We now have 14 years’ experience with 112 cases of vascular malformations of the head and neck treated with sclerotherapy. Results were evaluated with pretreatment and post-treatment photographs, and reduction of volume was calculated on findings from magnetic resonance imaging. Clinical improvement in 110 cases was graded as excellent in 32 (29%), good in 48 (43%), fair in 19 (17%), and poor in 11 (10%). In 84 cases, mean rate of reduction of volume was 35%. The most common complication was haemolytic haemoglobinuria (n=37, 33%). Our results suggest that this three-grade classification is useful to judge resistance to sclerotherapy and decide on treatment. Our experience indicates that ethanolamine oleate (EO), with or without arterial embolisation, was effective using our classification of vascular dynamics. We consider EO to be equivalent or superior to other sclerosants such as ethanol.

Comparative study of different combinations of microvascular anastomoses in a rat model: end-to-end, end-to-side, and flow-through anastomosis.

Background: This study aimed to compare several microvascular anastomotic techniques by patency rate using a free flap model in rats. Methods: A microsurgical transfer model of a pectoral skin flap to the cervical region was used. In experiment 1, 120 rats were divided into four groups (n = 30 in each group) depending on the type of microvascular anastomotic technique. For group 1, end-to-end anastomoses were performed for arteries and veins. For group 2, end-to-side anastomoses were performed for arteries and end-to-end anastomoses were performed for veins. For group 3, flow-through anastomoses were performed for arteries and end-to-end anastomoses were performed for veins. For group 4, end-to-end anastomoses were performed for arteries and end-to-side anastomoses were performed for veins. Flap survival was assessed on day 3 and the success rates of the four groups compared. In experiment 2 (n = 10), postoperative blood flows of end-to-end and flow-through arterial anastomoses were measured. Results: In experiment 1, the success rates in groups 1, 2, 3, and 4 were 76.7, 83.3, 100, and 83.3 percent, respectively. Differences between group 3 and the other groups were statistically significant. In experiment 2, the blood flow of flow-through arterial anastomosis (1.8 ml/minute) was much higher than that of end-to-end anastomosis (0.18 ml/minute). Conclusions: Flow-through arterial anastomosis presented a higher blood flow through the anastomotic site, resulting in a higher success rate than conventional anastomoses. In veins, end-to-side anastomosis was equivalent to end-to-end anastomosis even though the diameter of the donor vein was larger than the recipient vein.

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.

Secondary reconstruction of failed esophageal reconstruction

Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.

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.

Comparative study of different combinations of microvascular anastomosis types in a rat vasospasm model: versatility of end-to-side venous anastomosis in free tissue transfer for extremity reconstruction.

BACKGROUND There have been many studies comparing the patency rates of end-to-end and end-to-side microvascular anastomoses in both arteries and veins. Most of them failed to demonstrate a significant difference. The purpose of this study was to compare three different combinations of microvascular anastomoses in a rat vasospasm model, and determine which type of anastomosis is the most tolerant to vasospasm. METHODS Ninety Wistar rats were divided into three groups (n = 30 for each). In each group, a free pectoral skin flap was elevated and microsurgically transferred to the anterior cervical region. In group 1, end-to-end anastomoses were performed on both arteries and veins, in group 2 end-to-side anastomoses were performed on arteries and end-to-end anastomoses were performed on veins, and in group 3 end-to-end anastomoses were performed on arteries and end-to-side anastomoses were performed on veins. After revascularization, vasospasm was induced with topical epinephrine. Flap survival was assessed on day 3, and the success rates of the three groups were compared. RESULTS The flap success rate was 73.3% (22 of 30) in group 1, 66.7% (20 of 30) in group 2, and 96.7% (29 of 30) in group 3. The differences between groups 1 and 3 and between groups 2 and 3 were statistically significant. Overall, venous thrombosis was much more frequent than arterial thrombosis. CONCLUSIONS In a rat epinephrine-induced vasospasm model, venous thrombosis was much more frequent than arterial thrombosis. The type of arterial anastomosis did not affect the success rate, but end-to-side venous anastomosis had a higher success rate than end-to-end venous anastomosis.

Availability of end-to-side arterial anastomosis to the external carotid artery using short-thread double-needle microsuture in free-flap transfer for head and neck reconstruction.

We seldom have difficulties in the selection of appropriate recipient arteries for microvascular free flap transfer in the head and neck region because many sizable branches (branch artery) of the external carotid artery (ECA) or subclavian artery are available. However, we occasionally encountered the lack of an appropriate recipient artery, especially in secondary reconstruction or reconstruction following the extensive ablation of recurrent cancer. For these challenging cases, we have used end-to-side arterial anastomosis directly to the ECA. Between July 1997 and December 2004, end-to-side anastomosis of the flap artery to the ECA was employed in 16 cases. The reason for its use included the marked size discrepancy between the jejunal artery and branch artery in 4 jejunal transfer cases, the lack of 2 appropriate recipient arteries for double free flap transfers in 1 case, and the lack of an available branch artery as a recipient due to poor regional conditions in 11 cases. Fifteen of 16 flaps underwent an uneventful postoperative course, except 1 whose flap artery was pressed by the submandibular gland and sustained thrombosis 3 days postoperatively. In this case, however, the flap survived perfectly after prompt thrombectomy and reanastomosis. Eventually, all 16 flaps survived completely. We reconfirmed the availability of end-to-side anastomosis to the ECA when a suitable branch artery is not available. Although end-to-side anastomosis to the ECA is laborious compared with end-to-end anastomosis, our newly developed short-thread double-needle microsuture combined with the back-wall-first technique helps to ensure easier anastomosis. Using this device, because all stitches are carried from inside the vessel to outside, the surgeon can place the first stitch at any point on the posterior wall and advance the next suture to the preferred site of the previous suture, and suturing can be performed more safely even in cases where the tunica intima is separated from the tunica media due to arteriosclerosis, previous irradiation, or surgery.