Hiroaki Nakazawa

Sinking skin flap syndrome: A case of improved cerebral blood flow after cranioplasty

Sinking skin flap syndrome is defined as a series of neurologic symptoms with the skin depression at the site of cranial defect, which develop several weeks to months after large external cerebral decompression. The case of a 28-year-old female with the sinking skin flap syndrome is reported together with the evaluation of cerebral blood flow using xenon computed tomography (CT). Although her general condition stabilized within 7 months after the injury, the skin of the bilateral temporal regions was markedly depressed due to large bone defects. She was confined to bed and showed reduced levels of consciousness. We decided to treat this case by performing cranioplasty with a hydroxyapatite ceramic implant. Not only were good cranial contour reconstructed after cranioplasty, but neurologic conditions were also improved after cranioplasty. Regarding the change in cerebral blood flow in the present case, as measured with xenon CT, the cerebral blood flow 3 days after the injury was 18.7 ± 12.3 mL/100 mL/min and 26.5 ± 11.6 mL/100 mL/min in the left and right hemispheres, respectively. After the bilateral cranioplasty, it had increased by approximately 2-fold to 36.4 ± 23.2 mL/100 mL/min in the left hemisphere and approximately 1.5-fold to 43.8 ± 23.3 mL/100 mL/min in the right hemisphere as compared with the levels obtained 3 days after the injury. Therefore, xenon CT appears to be useful in the monitoring of regional cerebral blood flow in patients with cranial bone defects that are directly affected by atmospheric pressure and in predicting functional prognosis. For the sinking skin flap syndrome cases, cranioplasty is not only useful for cerebral protection and improvement of appearance, but cranioplasty is also useful for improving neurologic symptoms.

Reconstruction of a large abdominal wall defect using combined free tensor fasciae latae musculocutaneous flap and anterolateral thigh flap.

A large abdominal wall defect was reconstructed with the use of a flap combining the tensor fasciae latae musculocutaneous flap and the anterolateral thigh flap in four individuals who had undergone extensive abdominal wall resection because of cancer. The flap was harvested as a single combined composite flap and was transferred to the recipient site by means of microvascular surgery. Morbidity was minimal and the outcome was satisfactory in all instances.

Effects of Different Negative Pressures on Reduction of Wounds in Negative Pressure Dressings

Negative pressure dressings stimulate the healing of tissue‐deficient wounds by applying continuous or intermittent negative pressure. This study was designed to determine the most effective negative pressure level for the reduction of the wound by using negative pressure dressings in animal studies. Fifty male Wister rats weighting 200–250 grams were used throughout the study. The animals were divided into five groups of ten animals each as follows: group 1: No negative pressure and a closed dressing method using a polyurethane foam and an adhesive drape. Group 2–5: 25, 50, 75 and 125 mmHg negative pressure and a closed dressing method using a polyurethane foam and an adhesive drape. The wounds were measured along the vertical and horizontal lengths of the body axis and the wound area was calculated. The reduction of the wound area was weaker in the group with a negative pressure of 25 mmHg, and similarly higher among the groups with negative pressures of 50, 75, or 125 mmHg. There were no significant differences in the reduction of the wound area among the latter three groups.

The flashlamp-pumped pulsed dye laser (585 nm) treatment of hypertrophic scars in Asians.

Hypertrophic scars are common and cause functional and psychologic morbidity. Various treatment modalities have been advocated in the past, but the flashlamp-pumped pulsed-dye laser-585 nm (PDL) has been shown to be effective in the treatment of a variety of traumatic and surgical scars. This study was performed to determine the effectiveness of the PDL treatment of hypertrophic scars in Asians and to elucidate possible side effects and complications. Thirteen Asian patients with 19 hypertrophic scars that had no response to conservative therapies, such as pressure therapy, intralesional corticosteroid injection, or silastic gel sheeting for more than 6 months, were treated with the PDL. Three months after the last laser treatment, improvement in the appearance, reduction in scar height, and erythema as a result of the PDL treatment were evaluated and compared with baseline values. Compared with the baseline appearance, hypertrophic scars treated with the PDL showed a satisfactory clinical improvement of 84% (16 of 19), a significant percentage of scar flattening of 58.9 ± 22.1%, and of erythema elimination of 75.7 ± 19.9% at month 3 after the last laser treatment. The PDL treatment of hypertrophic scars can effectively improve scar pliability and texture and decrease erythema and associated symptoms. In addition, multiple treatment sessions are suggested for achieving greater response, but lower fluences are recommended for prevention of side effects in Asians with a higher melanin content of the skin.

Treatment of hypertrophic scars using a long-pulsed dye laser with cryogen-spray cooling.

Hypertrophic scars are common and cause functional and psychologic morbidity. The conventional pulsed dye laser (585 nm) has been shown previously to be effective in the treatment of a variety of traumatic and surgical scars, with improvement in scar texture, color, and pliability, with minimal side effects. This prospective study was performed to determine the effectiveness of the long-pulsed dye laser (595 nm) with cryogen-spray cooling device in the treatment of hypertrophic scars. Fifteen Asian patients with 22 hypertrophic scars were treated by the long-pulsed dye laser (595 nm) with cryogen-spray cooling device. In 5 patients, the scar area was divided into halves, one half of which was treated with the laser, whereas the other half was not treated and was used as a negative control. All patients received 2 treatments at 4-week intervals, and evaluations were done by photographic and clinical assessment and histologic evaluation before the treatment and 1 month after the last laser treatment. Treatment outcome was graded by a blind observer using the Vancouver General Hospital (VGH) Burn Scar Assessment Scale. Symptoms such as pain, pruritus, and burning of the scar improved significantly. VGH scores improved in all treated sites, and there was a significant difference between the baseline and posttreatment scores, corresponding to an improvement of 51.4 ± 14.7% (P < 0.01). Compared with the baseline, the mean percentage of scar flattening and erythema elimination was 40.7 ± 20.7 and 65.3 ± 25.5%, respectively (P < 0.01). The long-pulsed dye laser (595-nm) equipped with cryogen spray cooling device is an effective treatment of hypertrophic scars and can improve scar pliability and texture and decrease scar erythema and associated symptoms.

Skin Graft Fixation with Negative-Pressure Dressings

The tie‐over bolster dressing is the most commonly used method for securing skin grafts. However, it requires surgical skill and experience to make a skin graft adhere closely to a grafting site when the site has a complicatedly curved surface. The lack of appropriate tension and pressure on the skin graft may produce hematoma, dislocation, or wrinkles in the graft. The grafting site for the dorsum of a hand is particularly complicated and irregular and requires delicate changes in pressure when the tie‐over bolster dressing is used for sites supported and not supported by bones. We have obtained a high survival rate at such difficult sites by managing skin grafts with negative‐pressure dressings. This paper describes the details of the technique with case reports. We have used this technique for skin graft fixation in 10 patients and confirmed its high utility as evidenced by a survival rate of 95% or higher of the grafted areas. Unlike existing techniques that apply pressure on skin grafts, this technique applies a negative pressure to the space between the skin graft and the grafting site to remove hematomas and pull the whole skin graft onto the grafting site with uniform force for adhesion.

Negative-pressure dressings in the treatment of pressure ulcers.

Applying negative pressure to wounds may speed the formation of granulation tissue, decrease the amount of localized edema, increase blood flow, and accelerate healing. In the present study, we treated ten patients with stage IV chronic pressure ulcers using this negative pressure dressing technique. The long (A) and short (B) diameters of each ulcer were measured to determine size, and the vertical distance from the skin to the deepest point of the ulcer was measured to determine depth. Lesions were measured initially and at weekly intervals. The area of each lesion was taken to be 3.14 x A/2 x B/2 (cm2). When we compared the area of ulcer before and after the treatment, the area had been reduced in all cases, and the average reduction was 55.1%. The depth of ulcer also decreased in all cases, and the average reduction was 61.2%. Over the period of evaluation, the method was considered markedly effective in reducing the size and depth of ulcers.

Successful treatment of a case of electrical burn with visceral injury and full-thickness loss of the abdominal wall

A 13-year-old male received high-voltage electrical burns with a resultant large direct wound on the upper abdomen involving the full-thickness of the abdominal wall, including the peritoneum. Early debridement, exploratory laparotomy and temporary restoration of the excised abdominal wall with a fascial prosthesis were carried out at 6 h post-burn. The bilateral upper and right lower limbs were amputated on the 10th post-burn day. The patient developed a 4x4 cm duodenocutaneous fistula on the 28th post-burn day, but was free of peritonitis. After 5 months of the conservative treatment, the fistula closed, and the abdominal wall defect was reconstructed with a free latissimus dorsi musculocutaneous flap. One month later, the patient was discharged following an uneventful recovery.

The use of temporary diverting colostomy to manage elderly individuals with extensive perineal burns

The regimen of burn treatment for five elderly individuals who had sustained burns that had involved the perineum included formation of colostomy to divert fecal passage. The inclusion of diverting colostomy in this group of patients had made the management of burn wound that had included eventual skin grafting technically easy. A total of 168 patients were admitted to the Burn Unit at the Kagoshima City Hospital between 1997 and 2000. There were 36 patients who had perineal involvement. Of these, there were five elderly patients aged 60 years or older. There were two men and three women who were between 60 and 81 years of age. The mean age was 72 years. The total body surface involvement varied between 7 and 55% with an average body surface involvement of 30%. The sigmoid colon was as the colostomy site. Although, two patients died of injury, the morbidities associated with colostomy procedure were nil.

The estimation of tissue loss during tangential hydrosurgical debridement.

Abstract The preservation of healthy tissue during surgical debridement is desirable as this may improve clinical outcomes. This study has estimated for the first time the amount of tissue lost during debridement using the VERSAJET system of tangential hydrosurgery. A multicenter, prospective case series was carried out on 47 patients with mixed wound types: 21 (45%) burns, 13 (28%) chronic wounds, and 13 (28%) acute wounds. Overall, 44 (94%) of 47 patients achieved appropriate debridement after a single debridement procedure as verified by an independent photographic assessment. The percentage of necrotic tissue reduced from a median of 50% to 0% (P < 0.001). Median wound area and depth increased by only 0.3 cm2 (6.8%) and 0.5 mm (25%), respectively. Notably, 43 (91%) of 47 wounds did not progress into a deeper compartment, indicating a high degree of tissue preservation.