Kensuke Kiyokawa

Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage

In reconstruction of the nipple-aerola complex, it is important to maintain nipple projection. The conventional methods of reconstructing the nipple using local skin flaps maintain the feature for a certain period postoperatively, but the height of the nipple eventually flattens as the scars soften over time. Considering that sustaining the feature of the nipple is most important for achieving and maintaining nipple projection, we have therefore devised a new operative technique. Rolled auricular cartilage is placed in the center of the bridge of the dermal base and is wrapped with bilobed dermal-fat flaps. This technique has the following advantages: The cartilage produces and sustains a good form of the feature without subcutaneous depression because the cartilage is supported by the bridge of the dermal base. Since the dermal base forms a bridge, the method is safe, maintains good circulation, and does not lead to any necrosis in the flap. This method also was compared with a method in which the rolled auricular cartilage is wrapped with a trilobed dermal fat flap.

Posterior Glottis Morphological Study in Excised Human Larynges

Two sets of investigations were conducted with excised human larynges. 1) The glottis was closely observed and photographed from above and below in three conditions: neutral, adduction, and abduction. 2) The structure surrounding the posterior glottis was histologically investigated in the same three conditions. The results are as follows. 1) The structure surrounding the posterior glottis consists of three portions: the posterior wall of the glottis, the lateral wall of the posterior glottis, and the cartilaginous portion of the vocal fold. 2) During vocal fold adduction, the posterior part of the larynx closes completely not at the glottis but at the supraglottis, resulting in formation of a conic space in the posterior glottis that can be viewed only from below. 3) The posterior glottis accounts for approximately 35% to 45% of the entire glottic length and 50% to 65% of the entire glottic area. 4) The mucosa of the posterior glottis has ciliated epithelium. The lamina propria consists of two layers. 5) The posterior glottis can be regarded as a respiratory glottis.

A retrospective study of 66 esophageal reconstructions using microvascular anastomoses: problems and our methods for atypical cases.

We have studied 66 patients who underwent esophageal reconstruction using microvascular anastomoses. This series comprises 28 patients with reconstruction using a free jejunal interposition between the pharynx and the cervical esophagus following pharyngolaryngoesophagectomy for hypopharyngeal carcinoma and 38 atypical patients in whom other methods of reconstruction were used. Successful transfer was achieved in 98.5 percent (65 of 66). Issues concerning atypical reconstruction and our procedures in these cases are discussed. In order to obtain adequate tension in the jejunum on the anal side, in particular, since the anastomosis is located in a deep or narrow space, autosuture instruments were used. The anastomotic leakage rate was 2.8 percent (1 of 36); the stenosis rate was 2.8 percent (1 of 36). To prevent necrosis in the trachea, a greater omentum flap was used in three patients, a mesenterium flap in two, and a pectoralis major musculocutaneous flap in one. There were no significant complications. In patients with a short gastric pedicle or in those in whom a double cancer occurred in the hypopharynx and thoracic esophagus, a gastric pedicle and a free jejunum flap were used together. As a result of this method, the incidence of any reflux of digestive juice was reduced to 0 percent (0 of 6). To reduce the possibility of an ischemic complication at the oral end of the colonic pedicle, we added a microvascular anastomosis of the colonic pedicle, thereby reducing both leakage [0 percent (0 of 9)] and necrosis [0 percent (0 of 9)]. These procedures involving microvascular anastomoses have reduced the incidence of complications in esophageal reconstructions.

Cryopreserved cultured epidermal allografts achieved early closure of wounds and reduced scar formation in deep partial-thickness burn wounds (DDB) and split-thickness skin donor sites of pediatric patients

Burn treatment in children is associated with several difficulties, e.g. available skin replacement is small, donor area could expand, and subsequent hypertrophic scar and contracture could become larger along with their physical growth. In order to have better clinical results, the authors prepared cryopreserved cultured epidermal allografts from excess epidermal cells of other patients, and applied the epidermal allografts to 55 children, i.e. 43 cases of deep partial-thickness burn wounds (DDB) due to scald burn and 12 cases with split-thickness skin donor sites. In the 43 DDB patients, epithelialization was confirmed 9.1+/-3.6 days (mean+/-S.D.) after treatment. In 10 of the 43 patients, epithelialization was comparable between the area which received the epidermal allografts (grafted area) and the area which did not receive the epidermal allografts but was covered with usual wound dressing (non-grafted area). As a result, epithelialization day was 7.9+/-1.7 in grafted areas and 20.5+/-2.3 in non-grafted areas. In the 12 patients with split-thickness skin donor sites, epithelialization was confirmed 6.3+/-0.9 days after treatment. Epithelialization of the grafted and non-grafted areas was comparable in 8 of the 12 patients, and it was 6.5+/-1.1 days and 14.1+/-1.6 days, respectively. In these 10 DDB patients and 8 split-thickness skin donor site patients, redness and scar formation were also milder in the grafted area. The 55 patients have been followed up for 1-8 years (mean, 4.75 years), and scar formation was suppressed in both DDB and split-thickness skin donor sites. These findings showed that cryopreserved cultured epidermal allografts achieve early closure of the wounds and good functional outcomes.

Impact on Outcome of Additional Microvascular Anastomosis—Supercharge—on Colon Interposition for Esophageal Replacement: Comparative and Multivariate Analysis

Abstract. The impact on the outcome of an additional microvascular anastomosis—supercharge—on colon interposition for esophageal replacement was retrospectively evaluated by comparing it with colon interposition without supercharge. A series of 53 patients had undergone colon interposition for esophageal replacement at Kurume University Hospital from 1981 to 1996. The postoperative courses and the morbidity and mortality rates were compared between the 24 patients who underwent colon interposition without supercharge from 1981 to 1988 and the other 29 patients who underwent colon interposition with supercharge from 1989 to 1996. Risk factors for leakage of the esophagocolostomy and for hospital mortality after colon interposition were evaluated by multivariate analysis. Colon interposition with supercharge required a longer operation time but resulted in a lower incidence of necrosis in the colon graft and leakage in the esophagocolostomy (Odds ratio = 34), a shorter duration until peroral intake, and a shorter hospital stay compared to colonic interposition without supercharge. The addition of supercharge to colon interposition for esophageal replacement has been an effective option that has prevented serious complications caused by graft ischemia.

A method that preserves circulation during preparation of the pectoralis major myocutaneous flap in head and neck reconstruction

&NA; The present article describes a method that preserves circulation during” the preparation of the pectoralis major myocutaneous flap used in head and neck reconstruction. The major disadvantage of this flap is its poor circulation and consequent partial necrosis. To solve this problem, we analyzed the circulation and hemodynamics of the pectoralis major myocutaneous flap (the perforator of the anterior intercostal branch located about 1 to 2 cm medial to the areola in the fourth intercostal space is important), evaluated the safe donor sites in the chest wall for a skin island (the perforator is included on the skin islands central axis), improved the surgical procedure for elevating flaps (for preventing perforator injuries), and devised a means to transfer flaps, thereby increasing the range of the flaps (the transfer route is under the clavicle). Using this technique, head and neck reconstruction was performed on 62 patients. The diagnosis included oral cancer (21), oropharyngeal carcinoma (10), parotid carcinoma (10), hypopharyngeal carcinoma (9), and other head and neck malignant tumors (12). Of these, partial or marginal necrosis of the flap caused by circulatory problems was detected in three patients (5 percent). Using our method, the problems associated with inadequate circulation in the pectoralis major myocutaneous flap were greatly alleviated, thus reconfirming the usefulness of this flap in head and neck reconstruction. (Plast. Reconstr. Surg. 102: 2336, 1998.)

New continuous negative-pressure and irrigation treatment for infected wounds and intractable ulcers.

Background: Continuous irrigation and the vacuum-assisted closure system are effective methods for the treatment of infected wounds and intractable ulcers. The objective of this study was to simultaneously use both of the above methods as a new approach for obtaining more satisfactory, accelerated wound healing. Methods: After debridement of the wound, indwelling irrigation and aspiration tubes are placed in the wounds that have been sutured closed. With open wounds, a sponge with the same shape as the wound is placed directly onto the wound surface, and after the two tubes are inserted in the sponge, the wound is covered with film dressing to make the wound completely airtight. A bottle of physiologic saline solution is then attached to the irrigation tube, and a continuous aspirator (Mera Sacume) is attached to the aspiration tube. The bottle of physiologic saline solution is placed at the same height as the wound, and with a pressure gradient between the two of 0, continuous aspiration is applied. Results: All nine cases treated as closed air cavity wounds with this method healed after 2 to 3 weeks. In eight cases of open wound, recurrence of infection was observed in only one case. Conclusions: The two treatments of continuous irrigation and negative pressure were observed to have an additive and synergistic effect for earlier wound healing. Furthermore, the present method can dramatically reduce the number of dressing changes required, patient pain, psychological stress, and treatment cost.

Functional reconstruction of swallowing and articulation after total glossectomy without laryngectomy : Money pouch-like reconstruction method using rectus abdominis myocutaneous flap

When a total glossectomy is performed without a laryngectomy, the functional recovery of swallowing and articulation is extremely important in maintaining the patients quality of life. The authors established a money pouch-like reconstruction method in which a round and raised tongue is rebuilt using a rectus abdominis myocutaneous flap. In this method, the skin island of the rectus abdominis myocutaneous flap is created about 20 percent larger than the defect in both width and length. The skin island is sutured to the defect such that the excess skin folds into the shape of a money pouch. This allows the tongue to be reconstructed with its tip and dorsum touching the hard palate and its base bulging in the dorsal and posterior directions. Misswallowing was not detected in the three patients who had this surgery, and each of them had improved articulation sufficient to carry out daily conversations.

Reconstruction for palmar skin defects of the digits and hand using plantar dermal grafting.

&NA; The plantar skin is considered suitable for skin grafting onto the volar aspect of the digits and hand. However, this method is not widely used because it is associated with problems at the donor site. To solve these problems, a new method was developed in which two different layers of the plantar skin are harvested from the same site. In this method, a split‐thickness skin graft of the upper layer including the corneal layer of epidermis and a dermal graft of the lower layer are harvested from the same plantar skin. The split‐thickness skin graft is returned to the original donor site, whereas the dermal graft is used for the palmar skin defects on the digits and hand. To prevent drying, the dermal graft was covered with a wound‐covering material to achieve good graft takes. Reconstruction was performed for 17 patients using this method, involving digit‐only reconstruction in 8 patients, and wider reconstruction in the other 9. Excellent color and texture match of the graft and donor sites were obtained with no noticeable marginal scarring, and the durability of the skin was satisfactory. This method was useful for skin grafting to the digits and palms with minimal sacrifice to the donor site.

Cranioplasty with split lateral skull plate segments for reconstruction of skull defects.

This paper reports the use of cranioplasty using segments of split lateral skull plate to correct large skull defects (larger than 8 x 8 cm). The subjects consisted of 10 patients with head trauma who had undergone decompression surgery, and two patients who had undergone tumour resection. Bone grafts were obtained by cutting approximately 2 cm wide strips from the lateral skull plate using a bone saw that was inserted from a free margin of the bone defects. By cutting strips laterally from the bone defect, the necessary amount of split lateral skull plate can be obtained without performing craniotomy. The pieces of split lateral skull plate are then fixed to the defect using wire or titanium mini-plates. At this point, the selection of bone grafts that match the curvature of the dura mater is important, so that no dead spaces are created between the dura mater and the bone grafts. Infection was not detected in any of the 12 patients, and all bone grafts took completely. One of the 12 patients suffered from a pathological fracture and bone resorption 6 months after surgery. The fracture occurred because the use of basket-shaped reconstruction plates resulted in large spaces between the plate segments, and in addition the intracranial pressure was kept low by a V-P shunt, thus rendering the patient more vulnerable to atmospheric pressure.