Akiyoshi Kajikawa

Blood Gas Analysis of the Jejunum in the Supercharge Technique: To What Degree Does Circulation Improve?

Background: The supercharge technique has become widely prevalent in the field of esophageal reconstruction. Despite the logical advantages with this technique, the actual degree of its effect on the blood circulation is not clear. There may be cases in which the supercharge technique is not necessary for survival of the jejunum. To decide whether or not the supercharge technique is indicated, it is crucial to know how effective it is in improving blood flow to the jejunum. Methods: The effect of the additional vessel anastomosis in the pedicled jejunal transfer was evaluated by blood gas analysis of the venous blood in the mesenteric vein. In 27 patients undergoing pedicled jejunal transfer with additional vessel anastomosis using the internal mammary vessels for reconstruction of the thoracic esophagus, intraoperative blood sampling was performed three times: before anastomosis, after venous anastomosis, and after venous and arterial anastomosis. Results: The venous partial pressure of oxygen showed little increase after the venous anastomosis (mean, 115.7 percent; p = 0.0022). In contrast, venous partial pressure of oxygen increased markedly after the arterial and venous anastomosis in most of the patients (mean, 177.8 percent; p < 0.0001). Similarly, venous partial pressure of carbon dioxide, after both anastomoses, decreased to a lower level than before the additional anastomosis in most patients (mean, 93.1 percent; p = 0.035). Conclusion: The authors conclude that the additional anastomosis of both the artery and the vein is recommended if it is possible.

Bilateral eyebrow reconstruction using a unilateral extended superficial temporal artery flap.

In cases of the bilateral eyebrow reconstruction in men, two superficial temporal artery (STA) flaps are usually designed for both temporal regions according to the flap movable range and the direction of hair growth. Recently, the authors have successfully reconstructed bilateral eyebrows with normal directions of hair growth using a unilateral STA flap, extended by anastomosis of the STA and the occipital artery, with two hair-bearing skin islands. Using this method, the direction of the hair growth can be optimally selected by changing the direction of the skin islands for each eyebrow. The authors were able to reconstruct symmetric eyebrows with the hair growing laterally and a little upward. The invasiveness, bleeding, and operating time required for this method are less than those for the bilateral STA flap method. For cases in which one temporal scalp could not be used, bilateral eyebrow reconstruction remains possible with this method.

A new surgical correction of cryptotia: a new flap design and switched double banner flap.

Cryptotia is a congenital auricular anomaly that frequently occurs in Asians. In cryptotia, the upper third of the auricle is collapsed and buried under the temporal skin. We have treated patients who could not be treated by splinting with bent paper clips, using various surgical methods.1–4 Several problems remain, however, such as conspicuous scars, a shallow auriculotemporal sulcus, and incomplete correction of auricular cartilage. Therefore, we devised a new surgical method using a new skin flap design based on Fukuda’s method2 and a new concept of Tanzer’s double banner flap.5 Using this method, we produced good auricular contour with a deep auriculotemporal sulcus and no conspicuous scars.

Facial reanimation using hypoglossal-facial neurorrhaphy with end-to-side coaptation between the jump interpositional nerve graft and hypoglossal nerve: Outcome and duration of preoperative paralysis.

In this report, we described the use of hypoglossal‐facial neurorrhaphy with end‐to‐side coaptation between the jump interpositional nerve graft and the hypoglossal nerve for facial reanimation and analyzed the relationship between the outcome of surgery and duration of preoperative paralysis.

How to Reconstruct a Natural and Deep Umbilicus: Three Methods of Umbilicoplasty for Five Types of Umbilical Deformities

BackgroundConventional methods of umbilicoplasty using V-Y advancement flap often result in unnatural wide or shallow umbilical depressions facing upward or downward. Moreover, although the umbilical deformities have many variations, no report has described the selection of an umbilicoplasty method for types of umbilical deformity. To resolve these problems, we devised 3 methods of umbilicoplasty. In this report, we classified all kinds of umbilical deformities into 5 types, and studied the most suitable method for each type of umbilical deformity. MethodThe umbilical deformities are classified into Type 0: the defect of umbilicus; Type I, the low-grade protrusion; Type II, the high-grade protrusion with wide base; Type III, the high-grade protrusion with narrow base; and Type IV, the protrusion in depression. The most suitable method among our 3 methods was adapted to each type. Method 1 with a S-shaped skin incision was adapted to Type 0 and I, Method 2 with fan-style flaps was adapted to Type II, and Method 3 with dividing the umbilical protrusion was adapted to Type III and IV. ResultsSixty-three patients (10 cases of Type 0, 31 cases of Type I, 10 cases of Type II, 5 cases of Type III, and 7 cases of Type IV) underwent umbilicoplasty using the suitable method, and all were well corrected. ConclusionsUsing the best choice among our 3 methods, it is easy to create a natural, vertically long and deep umbilical depression without conspicuous scars in all types of umbilical deformities.

Aesthetic Repair for Syndactyly of the Toes Using a Plantar Rectangular Flap

Background: Use of a dorsal rectangular flap is the most common method of creating a deep interdigital space for syndactyly of the toes. However, the pigmented skin grafts exposed to the dorsal side are conspicuous. To resolve this problem, several methods have been reported. However, the local flap methods could be adapted only in mild syndactylies, and plantar skin flaps exposed to the dorsal side are too whitish. Meanwhile, in the methods using skin grafts from the inframalleolar region, the marginal scars of the skin grafts are still conspicuous on the dorsal side. To resolve these problems, the authors devised a new surgical method using a plantar rectangular flap. Methods: In this method, the authors designed a rectangular flap on the plantar side. Only a small triangular flap and a slight zigzag skin-incision line were designed on the dorsal side. The plantar rectangular flap was put down into the bottom of the interdigital space and was sutured with the dorsal triangular flap. Full-thickness skin was grafted to the raw surface at the sides of the divided toes. Results: The authors performed this method on 18 syndactylies of 12 patients. In all cases, the corrected toes showed a deep and natural interdigital space without exposure of skin grafts or conspicuous scars. Conclusions: The authors devised the plantar rectangular flap to avoid extra skin defects on the dorsal side. Using this method, the authors can create a deep interdigital space without any exposure of skin grafts or whitish plantar skin flaps on the dorsal side. This method is not appropriate for syndactyly of the fingers but is an ideal method for syndactyly of the toes.

Breast reconstruction using tissue expander and TRAM flap with vascular enhancement procedures

The transverse rectus abdominis myocutaneous (TRAM) flap can create a good breast shape, however, the patchwork-like scar obviously shows that the breast has been reconstructed. To reconstruct a breast without the patchwork-like appearance, we used a two-stage procedure using a tissue expander before transplanting a de-epithelialised TRAM flap. In addition, to avoid fat necrosis and resorption in a large TRAM flap, we performed two vascular enhancement procedures, surgical delay and supercharging microvascular anastomosis. The surgical delay, which consisted of an extended skin island delay and a vascular delay, was performed when the tissue expander was placed under the breast skin in the first stage. As the extended skin island delay, zones 3 and 4 of the TRAM flap were elevated and silicone sheets were laid under the flaps. As the vascular delay, the deep inferior epigastric vessels (DIEV) on the pedicle side were ligated. In the second stage, the de-epithelialised TRAM flap was transferred into the expanded breast skin pocket. The flap was double pedicled with supercharging microvascular anastomosis between DIEV on the contra-pedicle side of the flap and the thoracodorsal vessels of the recipient site. This surgery was performed on 20 post modified radical mastectomy patients to reconstruct large breasts without patchwork-like scars, and every TRAM flap survived perfectly without fat necrosis or resorption. All patients were satisfied with the reconstructed breasts and the abdominal contour without abdominal wall hernia or any other complications.

Split-thickness skin flap technique for elevating the radial forearm flap.

The radial forearm flap has been one of the most useful free flaps since Yang et al. first reported it in 1981.1 The advantage of this flap is that it is a thin, soft flap and has long, large vascular pedicles for stable circulation. In contrast, the greatest disadvantage is that the donor site is an exposed region. To resolve this problem, we have devised the split-thickness skin flap method, in which a flap-style split-thickness skin of the forearm flap is grafted back to the donor site. The split-thickness skin flap method allows good color and texture match of the donor site and a scarless radial margin, which is the most conspicuous part of the donor site.

Salvage of infected tissue expanders using a new continuous irrigation method with intermittent aspiration

When tissue expander sites are infected, it often results in removal of the expander. To salvage the infected expander and achieve full expansion, we devised a new continuous irrigation method with intermittent aspiration. In this method, the continuous irrigation of the tissue expander pocket was performed without removal of the expander. Saline was continuously infused at 50 ml h(-1) via the IVH catheter and intermittent aspiration was done at 10 cm H(2)O negative pressure via the suction drainage tube for 3 min per hour until the infection was under control. We performed this method on two cases of infection of tissue expander sites and salvaged both expanders. After controlling the infection, reconstructions were successfully performed with enough skin expansion. In this method, the expander left in the pocket acts not only in maintaining the expanded pocket but also helps in irrigating the inner surface of the skin pocket. This method can perform effective irrigation with a relatively small amount of saline (1200 ml per day) and salvage the tissue expander.

End-to-end and end-to-side neurorrhaphy between thick donor nerves and thin recipient nerves: an axon regeneration study in a rat model

During nerve reconstruction, nerves of different thicknesses are often sutured together using end-to-side neurorrhaphy and end-to-end neurorrhaphy techniques. In this study, the effect of the type of neurorrhaphy on the number and diameter of regenerated axon fibers was studied in a rat facial nerve repair model. An inflow-type end-to-side and end-to-end neurorrhaphy model with nerve stumps of different thicknesses (2:1 diameter ratio) was created in the facial nerve of 14 adult male Sprague-Dawley rats. After 6 and 12 weeks, nerve regeneration was evaluated in the rats using the following outcomes: total number of myelinated axons, average minor axis diameter of the myelinated axons in the central and peripheral sections, and axon regeneration rate. End-to-end neurorrhaphy resulted in a significantly greater number of regenerated myelinated axons and rate of regeneration after 6 weeks than end-to-side neurorrhaphy; however, no such differences were observed at 12 weeks. While the regenerated axons were thicker at 12 weeks than at 6 weeks, no significant differences in axon fiber thickness were detected between end-to-end and end-to-side neurorrhaphy. Thus, end-to-end neurorrhaphy resulted in greater numbers of regenerated axons and increased axon regeneration rate during the early postoperative period. As rapid reinnervation is one of the most important factors influencing the restoration of target muscle function, we conclude that end-to-end neurorrhaphy is desirable when suturing thick nerves to thin nerves.