Shimpei Miyamoto

Combined use of free jejunum and pectoralis major muscle flap with skin graft for reconstruction after salvage total pharyngolaryngectomy.

Salvage total pharyngolaryngectomy after failed organ‐preserving therapy often results in composite defects involving the alimentary tract, trachea, and neck skin. This retrospective study examined combined use of the free jejunum flap and the pectoralis major muscle flap with skin graft for such a complex reconstruction. We reviewed 11 patients who underwent free jejunum transfer for alimentary reconstruction and pedicled pectoralis major muscle flap transfer with a skin graft on the muscle for simultaneous neck skin resurfacing after salvage total pharyngolaryngectomy from 2005 through 2010. The operative morbidity rate was 27.3%. No pharyngocutaneous fistula developed in this series. Oral intake could be resumed within 3 weeks after surgery in all patients. Seven of 11 patients had a functional tracheostoma with adequate stomal patency. Combined use of free jejunum and pectoralis major muscle flap with skin graft provided secure wound closure even for complicated cases.

Comparison of reconstruction plate and double flap for reconstruction of an extensive mandibular defect

Functional reconstruction of the anterior mandibular defect in combination with a significant glossectomy is a challenging problem for reconstructive micro‐surgeons. In this retrospective study, clinical results were compared between mandibular reconstruction plate (MRP) procedures and double flap transfers. The subjects were 23 patients who underwent immediate reconstruction, after an anterior segmental mandibulectomy in combination with a significant glossectomy, from 1993 to 2009. The patients were divided into two groups based on the reconstructive methods used: MRP and soft tissue free flap transfer (MRP group: 12 patients) or double free flap transfer (double flap group: 11 patients). Operative stress, postoperative complications and oral intake ability were compared between the groups. The rate of recipient‐site complication in the double flap group tended to be lower than that in the MRP group. The most frequent complications in the MRP group included infection and orocutaneous fistula. Operative stresses (operation time and blood loss) were significantly less in the MRP group than in the double flap group. Overall, 19 patients (82.6%) were able to tolerate an oral diet without the need for tube feeding. This study demonstrates that laryngeal preservation is possible in more than 80% of patients even after such an extensive ablation. Double flap transfer provides a more stable wound closure than MRP and should be the preferred reconstructive procedure if the patients can tolerate the associated operative stresses.

Current role of the iliac crest flap in mandibular reconstruction

The purpose of this study was to examine the current role of the iliac crest osteocutaneous flap in mandibular reconstruction, with a focus on the reliability of its skin island. We reviewed outcomes in 18 cases of immediate mandibular reconstruction with the iliac crest flap. Intraoral mucosal defects were closed with the skin island of the iliac crest flap in 13 patients (iliac crest flap group) and were closed with another free flap, because of poor circulation of the iliac crest skin island, in five patients (double‐flap group). Postoperative results were poor in the iliac crest flap group. The rate of partial or total loss of the skin island was 46.2% in the iliac crest flap group and 20.0% in the double‐flap group. The presence of a dominant perforator did not reduce the overall rate of recipient‐site complications or reoperation. Combined use of another skin flap for intraoral lining provided better results. These results suggest that the skin island of the iliac crest flap should not be used for intraoral lining, unless adequate circulation of the skin island can be confirmed. If the circulation is questionable, combined use of another skin flap is strongly recommended.

Flow-through fibula flap using soleus branch as distal runoff: a case report.

The flow‐through fibula flap utilizing the soleus branch as a distal runoff has not yet been reported. We herein present a patient with left tibial adamantimoma in whom wide resection of the tumor resulted in a segmental tibial defect 22 cm in length. The defect was successfully reconstructed with a flow‐through free fibula osteocutaneous flap using the soleus branch of the peroneal artery as a distal runoff. The short T‐segment of the peroneal artery was interposed to the transected posterior tibial artery. The soleus branch has a constant anatomy and a larger diameter than the distal stump of the peroneal artery. Short interposed flow‐through anastomosis to the major vessels is much easier and more reliable than the conventional methods. We believe that our method represents a versatile option for vascularized fibula bone grafting for extremity reconstruction.

Pedicled superficial femoral artery perforator flaps for reconstruction of large groin defects

Soft‐tissue defects after wide resection of groin sarcomas have been reconstructed with well‐characterized flaps, such as rectus abdominis, gracilis, and anterolateral thigh flaps. To our knowledge, the use of superficial femoral artery perforator (S‐FAP) flaps for this purpose has not been reported. We report on three female patients in whom groin defects after sarcoma resection were reconstructed with pedicled S‐FAP flaps. The dimensions of the skin defects ranged from 13.5 × 11 to 16 × 14.5 cm. Sizable perforators from the superficial femoral arteries were identified preoperatively around the apex of the femoral triangle with computed tomographic angiography or color Doppler ultrasonography. The lengths of the flaps ranged from 17 to 19 cm. The main perforator penetrated the sartorius muscle in two patients and emerged between the sartorius and the adductor longus muscles in the other patient. The postoperative course was uneventful, and results were satisfactory in all patients. The main advantages of the S‐FAP flap over more commonly used flaps are that it is easier to harvest and is associated with less donor‐site morbidity. We believe that the S‐FAP flap may be a versatile option for the coverage of groin defects.

Combined use of the cephalic vein and pectoralis major muscle flap for secondary esophageal reconstruction

Secondary reconstruction of thoracic esophageal defects is a challenging problem for microsurgeons. Because of previous surgeries and coexisting disease, gastric pull‐up, and creation of a pedicled colon conduit are often impossible. Transfer of a supercharged pedicled jejunum flap or free jejunal interposition is usually the last resort; however, identifying appropriate recipient vessels and adequately covering the reconstructive conduit are often difficult. We performed secondary thoracic esophageal reconstruction with combined use of the cephalic vein as a recipient vein and the pectoralis major muscle flap for coverage in three patients. Two patients underwent transfer of a supercharged pedicled jejunum flap, and the other patient underwent free jejunal interposition. No wound complications occurred, and all patients could resume oral intake. The cephalic vein is a more reliable recipient vein than is the internal mammary vein. The skin graft‐covered pectoralis major muscle flap provides secure external coverage to prevent anastomotic leakage even in complicated cases. Combined use of the cephalic vein and the skin graft‐covered pectoralis major muscle flap is a versatile option for secondary thoracic esophageal reconstruction.

Efficient design of a latissimus dorsi musculocutaneous flap to repair large skin defects of the upper back

Closing large skin defects of the upper back is a challenging problem. We have developed an efficient design for a latissimus dorsi musculocutaneous flap for reconstruction in this region. The longitudinal axis of the skin island was designed to be perpendicular to the line of least skin tension at the recipient site so that primary closure of the flap donor site changed the shape of the recipient site to one that was easier to close. We used this method for four patients with skin cancers or soft‐tissue sarcomas of the upper back in 2011 and 2012. The size of skin defects after wide excision ranged from 11 × 10 to 25 × 20 cm2, and all skin defects could be covered by the flaps and all wounds of donor site could be closed without skin grafts. No wound complications occurred in any patient. Functional and aesthetic outcomes were satisfactory in all patients. This flap design is effective for reconstructing large skin defects of the upper back.

Combined use of anterolateral thigh flap and pharyngeal flap for reconstruction of extensive soft-palate defects

Functional reconstruction of extensive soft‐palate defects is challenging for microsurgeons. The versatility of the combination of a free anterolateral thigh flap and a superiorly based pharyngeal flap for oncologic soft‐palate reconstruction was investigated.

Flow‐through anastomosis for both the artery and vein in leg free flap transfer

Free flap transfer is an essential part of limb‐sparing surgery for leg sarcoma; however, this procedure is associated with a high failure rate. The aim of this study was to identify factors that contribute to microvascular compromise and flap failure for leg free flap transfer, while focusing on anastomotic techniques (end‐to‐end, end‐to‐side, and flow‐through anastomoses).

Large‐to‐small end‐to‐side anastomosis to the internal mammary vein: A solution to vessel size discrepancy

The internal mammary vein is commonly used as a recipient vein in microvascular esophageal reconstruction and autologous breast reconstruction. Size discrepancy frequently becomes a problem because the internal mammary vein is usually narrower than flap veins. Although most surgeons prefer to perform end-to-end anastomosis with a venous coupler, we believe conversion to endto-side anastomosis to the internal mammary vein is a possible solution for vessel size discrepancy. We report on a 65-year-old man with esophageal cancer who underwent subtotal esophagectomy and immediate reconstruction with a supercharged jejunal pull-up because of a history of gastrectomy. The jejunum was subcutaneously pulled up to the cervical region on the basis of the fourth jejunal vessels, and the second jejunal vessels were used for supercharging. As recipient vessels, the right internal mammary vessels were dissected by removing the second costal cartilage; however, the right internal mammary vein was much smaller than the second jejunal vein (approximately 1.2 mm versus 4.0 mm in external diameter). We, therefore, performed end-to-side anastomosis between the second jejunal vein and the internal mammary vein (Fig. 1). The esophagojejunal anastomosis was performed in an end-to-end fashion. The postoperative course was uneventful, and the monitoring segment of the jejunal flap remained pink throughout. To the best of our knowledge, no article described end-to-side anastomosis to the internal mammary vein, perhaps out of concern that a smaller recipient vein cannot accept the flow from a larger vessel. We believe that this concern is misplaced because our previous studies in a rat free-flap model have demonstrated the feasibility of large-to-small end-to-side venous anastomosis. End-toend anastomosis has a high risk of failure when a significant size discrepancy is present; in such cases, the advantages of end-to-side anastomosis become clear. When the internal mammary vein is found during preparation to be extremely small, we recommend not dividing the vein before flap harvest and leaving end-to-side anastomosis as an option.