Shinya Tahara

Do multiple venous anastomoses reduce risk of thrombosis in free-flap transfer? Efficacy of dual anastomoses of separate venous systems.

Whether or not multiple venous anastomoses reduce the risk of free-flap failure is a subject of controversy. We report here, for the first time, on the importance of selecting 2 separate venous systems of the flap for dual anastomoses. The efficacy of multiple anastomoses was verified through a retrospective review of 310 cases of the free radial forearm flap transfer. Dual anastomoses of separate venous systems (the superficial and the deep) showed a lower incidence of venous insufficiency than single anastomosis did (0.7% versus 7.5%; P < 0.05). On the other hand, dual anastomoses of a sole venous system showed no significant difference in the incidence of venous insufficiency compared with single anastomosis (11.5% versus 7.5%; P = 0.48). Our results suggest that dual venous anastomoses of separate venous systems is conducive to reduced risk of flap failure and affords protection against venous catastrophe through a self-compensating mechanism that obviates thrombosis of either anastomosis.

Eye socket reconstruction with free radial forearm flap.

Deformity of the orbital region and contraction of the eye socket were encountered in 3 patients who in their infancy underwent exenteration of the orbit and postoperative irradiation for the treatment of retinoblastoma. These major problems were attributed to the less-vascularized cicatricial conjunctiva left in place. To solve these disadvantages, a microvascular technique using a free radial forearm flap was adopted. A large permanent eye socket was achieved and depression deformity of the orbital region was corrected in a one-stage operation. This is, to our knowledge, the first report on the use of a free vascularized skin flap for “malignant contracture” of an anophthalmic eye socket. The excellent cosmetic results of this method are demonstrated.

Endoscopic endonasal reduction for blowout fracture of the medial orbital wall.

Endoscopic endonasal reductions have been addressed in 63 patients with blowout fracture of the medial orbital wall since 1992. The operations were carried out under general anesthesia with a magnified operative space projected on a television monitor by a charge coupled device video camera attached to the endoscope. The middle nasal turbinate was fractured toward the nasal septum, the uncinate process was cut off, and the bulla was opened. The ethmoidal bony partition and the mucous membrane were removed; however, the fractured bone chips of the medial orbital wall were preserved. The herniated orbital contents were pressed back into the orbital cavity, and the medial wall was set with 2-mm-thick bent silicone plates placed in the ethmoidal sinus. The plates were removed in the outpatient clinic 2 months after the operation. The surgical results of 21 patients treated with endoscopic reduction were compared with those of four patients treated with transfacial reduction with an iliac bone graft. All of the patients had isolated medial wall fracture and became aware of diplopia within 15 degrees in any direction from the primary position (straight gaze) before the operation; the follow-up period covered 6 months. The patients were classified into two categories according to postoperative double vision: “good,” indicating no double vision or diplopia of more than 45 degrees, and “poor,” diplopia of less than 45 degrees. Improvement of diplopia was observed in all patients without any complication. Of the 21 patients who underwent endoscopic reductions, 17 were classified as “good” and four as “poor.” On the other hand, of the four patients who underwent transfacial reductions, three were classified as “good” and one as “poor.” Significant differences were not observed between the surgical results of our two methods. Endoscopic endonasal reduction showed greater aesthetic advantages and, moreover, required no grafting. This technique is suggested as one of the most reasonable treatments of medial orbital wall fractures.

Primary Tracheojejunal Shunt Operation for Voice Restoration following Pharyngolaryngoesophagectomy

A primary tracheojejunal shunt operation was performed for voice restoration following pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. A fistula was created between the membranous part of the trachea and the lower part of the transplanted jejunum. The membranous part of the trachea was tubed to construct the tracheojejunal shunt. All three patients who had the tracheojejunal shunt operation retained phonatory function. Pitch formation was seen in the voice waveform with use of the tracheojejunal shunt. No leakage was seen at all during deglutition and a swallowing function was obtained in all patients who had the tracheojejunal shunt.

Simple reconstruction with titanium mesh and radial forearm flap after globe-sparing total maxillectomy: a 5-year follow-up study.

Background: Reconstruction of eye globe–sparing total maxillectomy defects is one of the major challenges to reconstructive surgeons. In 1994, the authors developed an uncomplicated and easy reconstructive method, where a titanium mesh is applied for the support of orbital contents, a radial forearm free flap for covering the mesh and the cheek lining, and an obturator prosthesis for palatal and dental rehabilitation. Methods: Five patients who underwent primary reconstruction with the authors’ method after globe-sparing maxillectomy with loss of the orbital floor from 1994 to 1999 and who were followed up for more than 5 years were retrospectively reviewed for (1) the presence of diplopia, (2) the shape of the reconstructed orbital floor assessed by coronal section magnetic resonance imaging, and (3) the presence of infection/exposure of the titanium mesh. Results: Only one of the five patients developed slight diplopia. Coronal magnetic resonance imaging showed that the orbital floor restored with titanium mesh had in all cases maintained a proper shape and position for more than 5 years. No infection or exposure of the titanium mesh had developed in any of the cases, despite exposure to irradiation of not less than 30 Gy. All the patients had well-retentive obturator prostheses. Conclusion: This long-term follow-up study demonstrated that the authors’ method attained a long-lasting successful outcome functionally and is the method of choice for reconstruction after globe-sparing total maxillectomy.

Extended preseptal fat resection in Asian blepharoplasty.

The thickness of the upper eyelid is a bothersome condition that can be alleviated by blepharoplasty in Asians. Preseptal fat lies widely deep to the orbicularis oculi in the lower part of the upper eyelid, and the retro-orbicularis oculus fat (ROOF) pad lies in the lateral supraorbital area. We demonstrate the effectiveness of preseptal fat resection (PSFR) extended with ROOF resection in Asian patients. Three levels of PSFR were carried out in 258 eyelids of 129 Asian patients in conjunction with bilateral blepharoplasty: partial PSFR in 84 eyelids, total PSFR in 86, and extended PSFR that included ROOF resection in 68. The series revealed that PSFR was effective in reducing the thickness and heaviness of the eyelid, without major complications. PSFR including ROOF resection is an optional adjunct for Asian patients undergoing blepharoplasty. Nonetheless, the function of the grinding structures in the upper eyelid should be appropriately preserved.

Short-term postoperative flow changes after free radial forearm flap transfer: Possible cause of vascular occlusion

The risk for free flap thrombosis is greatly influenced by blood flow. Postoperative hemodynamic changes in vascular pedicles of the microvascular skin flap have not been reported, however. This study focuses on the intraoperative and postoperative changes in the flow volume in the vascular pedicles of the free forearm flap examined by color Doppler ultrasonography. The arterial flow volume increased continuously until day 7, compared with which, the volume after flap elevation was 36%. On day 1, it reached only 52%. In the venous pedicle, the flow volume through the cutaneous vein was only 37% compared with that through the radial vena comitans after flap elevation, whereas the volume through both veins was equal on day 7. Drastic changes in the flow explain the possible vascular occlusion during the early postoperative period in the free forearm flap transfer.

IMPORTANCE OF THE DEEP VEIN IN THE DRAINAGE OF A RADIAL FOREARM FLAP: A HAEMODYNAMIC STUDY

The free radial forearm flap has two drainage veins, the cutaneous and the deep, but no established consensus has been reached on the selection of the drainage pedicle. In our study, the flow volumes of the veins were examined by colour Doppler ultrasonography after 20 forearm flaps had been raised. The volume through the deep vein was significantly higher than that through the cutaneous vein (p < 0.01). In comparing the total flow (both veins open), the flow rate through the deep vein alone (cutaneous vein occluded) was over 80% in 13 cases, 60%̵1;80% in seven, and under 60% in none; that through the cutaneous vein alone (deep vein occluded) was 60%̵1;80% in eight, 40%̵1;60% in eight, under 40% in four, and over 80% in none. Our results show the importance of the deep vein, as indicated by its high drainage capacity from the early stages of flap transfer.

Therapeutic strategy for the triad of acquired anophthalmic orbit.

Background: In treating patients with anophthalmic orbits, it is essential to achieve a long-lasting natural appearance and comfortable retention of eye prostheses. In 1992, the authors developed a therapeutic strategy based on a simple algorithm for treating the three common symptoms of acquired anophthalmic orbit: severe eye socket contracture is surgically treated with a radial forearm free flap transfer, upper lid depression is treated with lipoinjection, and lower lid retraction is treated with an auricular cartilage graft. Methods: From 1992 to 2004, 18 acquired anophthalmic orbits (11 enucleated and seven exenterated) were treated at Kobe University Hospital based on the authors’ therapeutic strategy. Aesthetic outcomes were evaluated according to patient and surgeon satisfaction. Results: Sixteen patients underwent auricular cartilage grafts, eight received radial forearm free flap transfers, and seven were treated with lipoinjection. Optional revisional surgery was carried out in four cases. The aesthetic outcome was assessed as good in six patients, moderate in eight patients, and poor in four patients; the last four had undergone total maxillectomy with orbital exenteration or had eyelid defects because of previous cancer surgery. Conclusions: The authors’ therapeutic strategy for acquired anophthalmic orbit is simple and, with slight modification, fitting for most cases, although it necessitates innovative surgery in cases with orbital rim and/or eyelid defects.

Transconjunctival Levator Aponeurotic Repair Without Resection of Müller’s Muscle

The number of patients with acquired ptosis is on the rise, and correction of blepharoptosis without any postsurgical scars on the eyelid is desired by most. Despite the advantages of the transconjunctival approach for blepharoptosis surgery, its use has been diminishing. The authors performed transconjunctival levator aponeurotic surgery without resecting Müller’s muscle for 21 eyelids in 14 patients with blepharoptosis. In 13 of these patients, 20 eyelids were successfully corrected. No major complications such as entropion, eyelid lag, or persistent irritation of the eye were observed. One eyelid with severe blepharoptosis showed an undercorrection of 1.5 mm. Aesthetic “double eyelid” with symmetric folds was achieved for all but one patient. The advantage is that without a skin incision, the reported method requires less downtime, leaves no conspicuous scar on the eyelid, and meets with marked satisfaction by most patients. It is beneficial for candidates who desire no skin incision but have indications for levator aponeurotic surgery and do not present with excessive upper eyelid laxity. This approach presents some challenges, however. One of these involves determining the degree of aponeurosis advancement according to the degree of the open eye during surgery and creating the desired “double-eyelid” shape and size, especially in Asians. Also, the surgeon needs to gain familiarity with the surgical anatomy of the everted eyelid. This method could, with refinements, become the procedure of choice for the correction of blepharoptosis in selected patients.