Hideo Iida

Anterolateral thigh flap donor-site complications and morbidity

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.

Anterolateral thigh flap for abdominal wall reconstruction

The free or pedicled anterolateral thigh flap was introduced for the reconstruction of large abdominal wall defects. This flap is superior to the tensor fasciae latae musculocutaneous flap in several respects. These include the wide, reliable skin territory (which can reach the level of the knee) and the long pedicle. Therefore, a pedicled anterolateral thigh flap with reliable blood circulation can easily be positioned above the umbilicus. In addition, the free anterolateral thigh flap has greater freedom of orientation and can be used to repair larger abdominal wall defects than can the tensor fasciae latae flap. Seven patients in whom abdominal wall defects had been reconstructed with pedicled or free anterolateral thigh flaps were reviewed. Their average age was 47.1 years (range, 21 to 74 years), and the average follow-up period was 10.7 months (range, 2 to 21 months). The size of the abdominal wall defects ranged from 12 x 12 cm to 18 x 24 cm, and the size of the transferred flap ranged from 10 x 20 cm to 20 x 20 cm. Three flaps were pedicled and four were free, of which three incorporated the tensor fasciae latae flap. All flaps survived completely, and no postoperative abdominal hernias developed. Despite some variations in vascular anatomy and technical difficulties in elevating the anterolateral thigh flap, the authors conclude that the pedicled or free anterolateral thigh flap is superior to the tensor fasciae latae flap for reconstruction of large abdominal wall defects.

Pelvic ring reconstruction with the double- barreled vascularized fibular free flap

Background: Although hemipelvectomy has been the standard treatment for malignant tumors of the pelvis, limb salvage surgery is now the treatment of choice, even for patients with advanced tumors. For these patients, pelvic reconstruction is needed to maintain the stability of the pelvis and the spinal column and to allow ambulation. In this report, the authors’ experiences with pelvic ring reconstruction are described. Methods: Pelvic ring reconstruction with free double-barreled vascularized fibular grafts was performed after resection of malignant pelvic tumors in five patients. The graft was fixed with a fixation plate and screws in three patients and with the Cotrel-Dubousset rod system in two patients. After surgery, perioperative and postoperative findings were evaluated. Results: In one patient, a pedicled rectus abdominis musculocutaneous flap was transferred to repair defects of the skin and underlying soft tissue. The free fibular graft was transferred successfully in four of five patients; however, the graft was removed in one patient because of infection with methicillin-resistant Staphylococcus aureus. After surgery, three of the four patients with successful grafts could walk with full weight bearing and without a cane; the fourth patient died as a result of multiple metastases to the lung before walking was attempted. Conclusions: The double-barreled fibular graft is well vascularized and can achieve satisfactory bone union. It is a safe and effective method for reconstructing the pelvic ring. Furthermore, the Cotrel-Dubousset rod system can provide rigid fixation soon after surgery and is useful for early rehabilitation of walking.

Preoperative assessment of anterolateral thigh flap cutaneous perforators by colour Doppler flowmetry

An anterolateral thigh flap is very useful in head and neck reconstruction because of its long and large-caliber vascular pedicle, large skin territory and elevation simultaneous with tumour resection. However, the number and locations of cutaneous perforators vary individually, and thus, it is not widely used because flap elevation is often complicated and time-consuming owing to unexpected anatomical variations. To overcome this disadvantage, we assessed the number and locations of cutaneous perforators preoperatively by colour Doppler flowmetry. These data were compared with the intraoperative anatomical findings and their reliability evaluated. A total of 48 cutaneous perforators were found by preoperative colour Doppler flowmetry scanning of 17 anterolateral thigh flaps. All the perforators except two were found intraoperatively. Doppler scanning failed to detect four perforators. Colour Doppler flowmetry assessment therefore has a 92% true-positive rate and a 95.8% positive predictive value. All the flaps except one included multiple perforators, and sufficient blood circulation was observed in all cases. No flaps were unexpectedly changed to anteromedial thigh flaps or contralateral anterolateral thigh flaps because of inappropriate cutaneous perforators or the absence of perforators. Though this investigation is relatively time-consuming (30-40 min) and requires skill, it is very useful for preoperative flap planning and increases the reliability and safety of elevating an anterolateral thigh flap.

Facial dismasking flap for removal of tumors in the craniofacial region.

Objective: This study was aimed at estimating the usefulness of the facial dismasking flap for craniofacial surgery.

INGROWN NAILS : A COMPARISON OF THE NAIL MATRIX PHENOLIZATION METHOD WITH THE ELEVATION OF THE NAIL BED-PERIOSTEAL FLAP PROCEDURE

Seventy‐five procedures were performed on 62 patients with ingrown nails from 1992 to 1996. Those consisted of 51 nail matrix phenolization methods (NMP) and 24 elevation of the nail bed‐periosteal flap procedures (ENF). Ingrown nails were classified into type A (normal nail plate) and type B (incurved nail plate). The duration and intensity of postoperative pain were assessed, and the recurrence rate was monitered.

Epicutaneous Allergic Sensitization by Cooperation between Allergen Protease Activity and Mechanical Skin Barrier Damage in Mice

Allergen sources such as mites, insects, fungi, and pollen contain proteases. Airway exposure to proteases induces allergic airway inflammation and IgE/IgG1 responses via IL-33-dependent mechanisms in mice. We examined the epicutaneous sensitization of mice to a model protease allergen, papain; the effects of tape stripping, which induces epidermal barrier dysfunction; and the atopic march upon a subsequent airway challenge. Papain painting on ear skin and tape stripping cooperatively promoted dermatitis, the skin gene expression of proinflammatory cytokines and growth factors, up-regulation of serum total IgE, and papain-specific IgE/IgG1 induction. Epicutaneous sensitization induced T helper (Th) 2 cells and Th17 differentiation in draining lymph nodes. Ovalbumin and protease inhibitor-treated papain induced no or weak responses, whereas the co-administration of ovalbumin and papain promoted ovalbumin-specific IgE/IgG1 induction. Wild-type and IL-33-deficient mice showed similar responses in the epicutaneous sensitization phase. The subsequent airway papain challenge induced airway eosinophilia and maintained high papain-specific IgE levels in an IL-33-dependent manner. These results suggest that allergen source-derived protease activity and mechanical barrier damage such as that caused by scratching cooperatively promote epicutaneous sensitization and skin inflammation and that IL-33 is dispensable for epicutaneous sensitization but is crucial in the atopic march upon a subsequent airway low-dose encounter with protease allergens.

Keratinocyte Progenitor Cells Reside in Human Subcutaneous Adipose Tissue

The differentiation of adipose-derived stem cells (ASCs) towards epithelial lineages has yet to be demonstrated using a standardized method. This study investigated whether keratinocyte progenitor cells are present in the ASC population. ASCs isolated from subcutaneous adipose tissue were cultured and examined for the expression of the keratinocyte progenitor markers p63 and desmoglein 3 (DSG3) by immunofluorescence microscopy and flow cytometry. In addition, p63 and DSG3 expression levels were assessed before and after differentiation of ASCs into adipocytes by real-time PCR and western blot analysis, as well as in subcutaneous adipose tissue by real-time reverse transcriptase polymerase chain reaction. Both markers were expressed in ASCs, but were downregulated after the differentiation of ASCs into adipocytes; p63-positive cells were also detected in subcutaneous adipose tissue. ASCs co-cultured with human fibroblasts and incubated with all-trans retinoic acid and bone morphologic protein 4 showed an upregulation in DSG3 level, which was also increased in the presence of type IV collagen. They also showed an upregulation in cytokeratin-5 level only in the presence of type IV collagen. These results provide the demonstration that keratinocyte progenitor cells reside in subcutaneous adipose tissue.

Reliability of and indications for pericranial flaps in anterior skull base reconstruction.

Owing to changes in the treatment of skull-base tumors, such as perioperative radiotherapy and advances in approaching the skull base, the use of pericranial flaps should be reconsidered. Therefore, we reviewed the reliability of and indications for pericranial flaps in 26 cases in terms of patient background, the effects of preoperative and postoperative treatment, and the pattern of blood circulation. Flaps were harvested as 25 anteriorly based and 4 laterally based. As a result, postoperative complications were observed in 4 patients. No other risk factors, except for heavy smoking, were observed relative to patient background. Sixteen patients had perioperative radiotherapy, and complication rate was significantly higher in patients with preoperative radiotherapy than patients without preoperative radiotherapy (P = 0.014). However, no complications, such as cerebral spinal fluid leakage and intracranial infection, were observed in patients receiving postoperative radiotherapy. Laterally based pericranial flaps had a high complication rate (25%), but it was not significantly higher than anteriorly based flaps (P = 0.467). Five anteriorly based flaps were harvested with less feeding vessels as usual because of applying dismasking flap approach, but it did not lead to increasing in complication rate. We conclude that a pericranial flap can be used for skull base reconstruction even if postoperative radiotherapy is planned but might be avoided for patients who have received preoperative radiotherapy. In addition, particular care and flap design should be taken to preserve sufficient vascularity when pericranial flaps are raised as laterally based and less feeding vessels as usual.

Usability of the middle temporal vein as a recipient vessel for free tissue transfer in skull-base reconstruction.

In skull-base reconstruction, finding appropriate recipient veins is difficult if the patient has undergone previous craniotomy or requires multiple drainage vessels, because of postoperative scarring and the limited number of veins in the temporal region. Therefore, we have used the middle temporal vein (MTV) to overcome these problems. We examined the presence and caliber of the MTV in 12 patients undergoing skull-base reconstruction. The MTV was identified in all cases and used for reconstruction, alone or with the superficial temporal vein (STV), in 8 patients without postoperative flap loss and was only measured in 4 patients. The caliber of the MTV was significantly greater than that of the STV, and there was no significant difference between the usage of the MTV and STV in the length of reconstruction time. Therefore, the MTV is of an appropriate caliber, and its use does not require complicated procedures as alternative recipient vessels.