Hiroyuki Ohjimi

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.

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

&NA; 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.

Emergence of vancomycin resistance during therapy against methicillin-resistant Staphylococcus aureus in a burn patient—importance of low-level resistance to vancomycin

OBJECTIVES Staphylococcus aureus with low-level resistance to vancomycin (VLSA) which could develop into vancomycin-resistant S. aureus (VRSA) is most important. However, VLSA is difficult to detect by standard laboratory methods. We describe here improved methods to detect VLSA. METHODS Three methicillin-resistant S. aureus (MRSA) strains, designated Fu6, Fu10, and Fu18, were sequentially isolated from the burn wound site of a patient, during vancomycin therapy. The properties of these strains were compared with those of reference strains Mu3 and Mu50 (previous resistant isolates from other patients). RESULTS The isolated strains, Fu10 and Fu18, had identical phenotypes and genotypes. The vancomycin resistance of Fu10 was equivalent to that of strain Mu3, whereas Fu18 had much higher vancomycin resistance than Fu10 and Mu3, although reaching the level of Mu50. Fu18 showed similar growth to Mu50 on gradient gels and on Mu3 medium. CONCLUSIONS Our data indicate that the VLSA developed vancomycin resistance during exposure to vancomycin in vivo. The population analysis of tested VLSA and vancomycin intermediately resistant S. aureus (VISA) indicates that a penem at relatively low concentrations induced a significant increase in the number of vancomycin-resistant subpopulations. Furthermore, we confirmed that gradient gel analysis and Mu3 medium are simple and useful methods for the detection of VLSA judged as VSSA by its conventional MIC alone.

A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum

IntroductionAlthough the Nuss procedure for pectus excavatum is widely employed, a variety of complications have been reported with relatively high frequency; those that involve cardiac and pericardial injuries can be life threatening. To reduce such dangers, we present here a newly developed sternal elevator.Materials and methodsThe elevator is horseshoe shaped. Its elevator side has the same curvature as a Nuss introducer, so that interference between devices is minimal and no extra skin incision is needed for the elevator insertion. The elevator holds the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer.ResultsThe authors have used the elevator for 61 pectus excavatum cases between March 2004 and December 2009 without any major complications. The entire process of substernal tunneling was endoscopically observed, which eliminated any blunt and blind dissection, even in a significantly depressed funnel chest case. With the device, the sternum was effectively elevated again for the placement of the second plate in 30 cases.ConclusionOur newly developed sternum elevator makes the Nuss procedure safer and more affordable without introducing any extra scarring.

Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps.

&NA; In this study, the vascular architecture of rectus abdominis free flaps nourished by deep inferior epigastric vessels was investigated using an ex vivo intraoperative angiogram. Oblique rectus abdominis free flaps were elevated and isolated from the donor site. In 11 patients, the vascular architecture of these flaps was analyzed before the flap was thinned. Radiographic study identified an average of 2.1 large deep inferior epigastric arterial perforators in each flap. In nine of the 11 flaps, the axial artery was visible. In four flaps, the axial artery originated from the perforator of the lateral branch of the deep inferior epigastric artery; in five others, it originated from the medial branch. In each flap, the angle of the axial perforator from its anterior rectus sheath in the vertical plane was measured; its mean was 50.6 degrees. All flaps survived, although three showed partial necrosis in the distal portions. In two of these three flaps, the axial artery was not visible in the angiograms, and the third revealed a one‐sided distribution of axial flap arteries. Using ex vivo intraoperative angiography, the architecture of the individual flap, its axial perforator, and its connecting axial flap vessel could be investigated. This information can help the surgeon safely thin and separate the flap. (Plast. Reconstr. Surg. 109: 2247, 2002.)

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.

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.

A new digital image analysis system for measuring blepharoptosis patients' upper eyelid and eyebrow positions.

PurposeTo accurately assess eyelid and eyebrow position, we have developed a new measurement method using a digital image analysis system. Materials and Methods(1) Plotting the corneal limbus by transferring to the software digital images of the patient’s eyes in the primary gaze position; (2) determining the corneal ring, center, and longitudinal diameter; and (3) measuring the upper eyelid and eyebrow position. The method was tested on 24 patients with senile blepharoptosis and 45 young healthy eyelids without ptosis. ResultsThe upper eyelid position of patients with blepharoptosis was significantly lower, and their eyebrow position is significantly higher than those of healthy subjects. The upper eyelid and eyebrow position of the patients with blepharoptosis corelated, but no correlation was observed in the healthy subjects. ConclusionOur measuring system is a simpler, easier, and more accurate way of measuring both upper eyelid and eyebrow position than are currently used techniques.

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.

Vascular augmentation of an extended latissimus dorsi myocutaneous flap through an intercostal vessel: A preliminary report

Abstract The extended latissimus dorsi (LD) flap, which includes adipofascial tissue around the posterior iliac crest, is a good option to reconstruct a large breast. However, poor vascularity in the extended part may cause partial fat necrosis. To minimise this problem, vascular augmentation of the extended adipofascial part was performed. When dissecting under the LD muscle, a single perforator from the 11th intercostal vessels was secured and traced upwards along the rib. After the flap was transferred to the chest, the intercostal vessels were anastomosed to the serratus branches of thoracodorsal vessels. This vascular supercharged extended LD flap technique was applied for selected patients. Intraoperative angiography showed that the contrast medium injected into the intercostal artery spread across the lumbar adipofascial part of the flap. This implies that vascular supercharge through the 11th intercostal vessel promotes the vascularity of the extended LD flap and may help to reduce the flap complication rate.