Narushi Sugiyama

Flow-through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects

New flow-through perforator flaps with a large, short vascular pedicle are proposed because of their clinical significance and a high success rate for reconstruction of the lower legs. Of 13 consecutive cases, the authors describe two cases of successful transfer of a new short-pedicle anterolateral or anteromedial thigh flow-through flap for coverage of soft-tissue defects in the legs. This new flap has a thin fatty layer and a small fascial component, and is vascularized with a perforator originating from a short segment of the descending branch of the lateral circumflex femoral system. The advantages of this flap are as follows: flow-through anastomosis ensures a high success rate for free flaps and preserves the recipient arterial flow; there is no need for dissecting throughout the lateral circumflex femoral system as the pedicle vessel; minimal time is required for flap elevation; there is minimal donor-site morbidity; and the flap is obtained from a thin portion of the thigh. Even in obese patients, thinning of the flap with primary defatting is possible, and the donor scar is concealed. This flap is suitable for coverage of defects in legs where a single arterial flow remains. It is also suitable for chronic lower leg ulcers, osteomyelitis, and plantar coverage.

Successful delayed venous drainage in 16 consecutive distal phalangeal replantations

The authors describe, in the first report of this type of replantation surgery, a high success rate using delayed venous anastomosis in 16 consecutive distal phalangeal replantations under digital block. Among these replantations, seven fingers (43.8 percent) showed postoperative venous congestion and five fingers were reoperated on with delayed venous drainage under digital block. All the reoperated fingers were successfully drained by additional single or double venous drainage with a vein graft. As a result, 13 fingers survived (81.3 percent success rate). All operations were performed under a digital block.

A Novel Model for Supermicrosurgery Training : The Superficial Inferior Epigastric Artery Flap in Rats

The purpose of this study was to determine the usefulness of a new flap model, the superficial inferior epigastric artery (SIEA) flap for supermicrosurgical training. Experimental groups were randomly divided into three groups of 10 rats each. In each group SIEA flaps were elevated and then returned to their original locations with or without vascular anastomosis of the superficial inferior epigastric vessels. Group 1: free SIEA flap, group 2: free SIEA flap with 1 hour ischemia time, group 3: free SIEA flap with 4 hours ischemia time, group 4: SIEA flap without vascular anastomosis. The viability rate was 80% with group 1, 50% with group 2, and 40% with group 3. All nonvascularized flaps (group 4) underwent complete necrosis. These findings suggest that preservation of blood flow in a flap has a beneficial effect on the prevention of microthrombosis in the subcutaneous capillary network of the skin and increases the flap survival rate. The SIEA flap with preserved circulation is an ideal model for developing supermicrosurgical skills.

Prevention points for plate exposure in the mandibular reconstruction.

INTRODUCTION The rate of complications for mandibular reconstruction after segmental mandibulectomy is higher with reconstruction plates than with vascularised bone grafts. We have experience of over 100 patients using reconstructive plates for reconstruction immediately after segmental mandibulectomy and have considered factors contributing to plate exposure. PATIENTS AND METHODS Seventeen cases utilised our prevention methods in which reconstructive plates were used for mandibular reconstruction were reviewed. The flaps used with reconstruction plates were rectus abdominis myocutanenous flaps in 10 cases, anterolateral thigh flaps combined vastus lateralis muscle in four cases, and the omentum in one case; no flap was transferred in two cases. RESULTS In only one of 17 cases was a plate exposed at 3 months postoperatively. No plate exposure occurred during the follow-up period in the other 16 cases. Because no flap had been transferred in the patient with plate exposure, a possible contributing factor was the persistence of dead space beneath the plate. CONCLUSION This series suggests that factors other than flap selection contribute to the exposure of reconstructive plates. Use of a reconstruction plate is a useful reconstructive method, especially for patients who cannot tolerate transfer of a vascularised bone graft.

Histologic Evaluation of Lymphaticovenular Anastomosis Outcomes in the Rat Experimental Model: Comparison of Cases with Patency and Obstruction.

Background: Lymphaticovenular anastomosis plays an important role in the surgical treatment of lymphedema. The outcomes of lymphaticovenular anastomosis are evaluated based on changes in edema; however, isolated assessment of the anastomosis itself is difficult. The authors used an animal experimental model to conduct a detailed examination of histologic changes associated with lymphaticovenular anastomosis and determined the factors important for success. Methods: The experimental lymphaticovenular anastomosis model was created using lumbar lymph ducts and iliolumbar veins of Wistar rats. The authors performed anastomosis under a microscope and reviewed postoperative histologic changes using optical and electron microscopy. In addition, electron microscopy and histology were used for detailed examination of the area in the vicinity of the anastomotic region in cases with patency and obstruction. Results: The patency rates immediately after, 1 week after, and 1 month after lymphaticovenular anastomosis were 100 percent (20 of 20), 70 percent (14 of 20), and 65 percent, respectively. A detailed examination of the anastomotic region with electron microscopy revealed that, in cases with patency, there was no notable transformation of the endothelial cells, which formed a smooth layer. In contrast, in obstruction cases, the corresponding region of the endothelium was irregular in structure. Conclusions: Vessel obstruction after lymphaticovenular anastomosis may be associated with irregular arrangement of the endothelial layer, leading to exposure of subendothelial tissues and platelet formation. One part of the postoperative changes after anastomosis and a cause of obstruction were elucidated in this study. The authors’ results may enable improvements in lymphaticovenular anastomosis by translating back to real clinical operations.

Unilateral lower limb lymphedema resulting from a heart surgery performed 50 years prior

Highlights • To our knowledge, there have been no reports of lymphedema resulting from heart surgery.• Here we experienced a very rare case of lymphatic edema resulting from cardiac surgery that the patient underwent 50 years previously.• In this report, we report the patient’s therapeutic course and attempted to determine the cause of the lymphatic edema outbreak.• Knowing the outbreak mechanism of lymphatic edema would definitely ease the investigation of an unconventional case like this one.