Toshihiko Yamauchi

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.

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.

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.

Refinements in the elevation of reconstructed auricles in microtia.

Background: In the treatment of microtia, the search has been for surgical techniques that prevent postoperative complications and realize sufficient and stable projection of the constructed ear. Methods: Cartilage was fixed with absorbable synthetic thread instead of wire because wire has a high risk of exposure. A subcutaneous pedicle was added to the concha to prevent skin necrosis. Dead space and hematoma creation were prevented with vacuum aspiration, bolster fixation, and microdrainage with small tubes. A triangular skin flap connecting to the ear lobe was used to prevent shrinkage on the posteroinferior portion of the concha. Projection of the inferior portion of the auricle was supported with a hydroxyapatite-tricalcium phosphate ceramic. Results: Our technique was applied to 42 patients, and none of them experienced slip of the fixed cartilage, auricular deformation, skin necrosis, or infections. Shrinkage of the inferior portion of the auricle was minimal, and good projection was obtained. Conclusions: The authors’ technique prevents complications and realizes good shape and projection of the auricle in total reconstruction of the auricle. Hydroxyapatite-tricalcium phosphate ceramic is a useful material that complements the cartilage shortage.

A surgical treatment of severe late posttraumatic enophthalmos using sliced costal cartilage chip grafts.

The efficacy of sliced costal cartilage chip grafts for the treatment of late posttraumatic enophthalmos was investigated. Surgery was conducted based on the method reported by Matsuo et al. in 1989. After making an incision in the lower eyelid, dissecting the subperiosteum of the medial orbital wall, orbital floor and lateral orbital wall was performed to the posterior of the orbit, and then costal cartilage chips were gradually grafted in a step-like configuration to the subperiosteum from a location posterior to the equatorial plane of the eyeball. At this time, as well as to the area of concave depression in the orbital bone caused by the fracture, grafts were made to the subperiosteum of the non-deformed medial and lateral orbital wall, to move all of the orbital tissue, including the eyeball, forward. This was performed for five cases of severe late posttraumatic enophthalmos. Among the five cases, there were four cases of severe orbital fracture and one case for which malignant orbital tumor extirpation and radiation therapy had been performed. Following surgery, although mild enophthalmos remained in three of the five cases, esthetically satisfactory results were obtained for all cases. Costal cartilage chip grafts were shown to be an effective method for the treatment of late posttraumatic enophthalmos.

Minimally invasive functional reconstruction after extended oropharyngeal resection including soft palate and base of tongue using a pectoralis major myocutaneous flap.

Excision of large oropharyngeal carcinomas that affect the base of the tongue and the soft palate severely impairs swallowing and articulation. In the present study we describe a minimally invasive technique that effectively restores swallowing and articulation by the insertion of a pectoralis major myocutaneous flap with a bilobular skin island. One lobe of the skin island is used to reconstruct the base of the tongue and the other to reconstruct the oropharynx. The soft palate is reconstructed by folding the tip of the lobe that is used to reconstruct the oropharynx in half along the long axis to fill the rhinopharynx. We have done this procedure for 13 patients with oropharyngeal carcinoma. Six months postoperatively all 13 were able to swallow without aspiration. Nine of the 13 patients were able to hold a normal conversation, but the remaining four had severe rhinolalia aperta. However, this condition was easily corrected by secondary reconstruction using a pharyngeal flap and a palatal mucoperiosteal flap ( n = 3) or by the use of a small speech aid ( n = 1).

Take percentage and conditions of cultured epithelium were improved when basement membrane of the graft was maintained and anchoring mesh was added.

To achieve a higher take rate for epithelial grafts, this study investigated grafting techniques. Seventy-seven nude mice received flap grafting in which cultured human epithelium was grafted inside the flap, and 55 nude rats received transplantation of epithelium to a full-thickness skin defect. In each group, four models were studied, including model 1, in which epithelium was cultured with the conventional method; model 2, in which epithelium was cultured with fibrin gel to avoid sheet damage, then absorptive mesh was incorporated into the epithelium for anchoring to the graft bed; model 3, in which epithelium was cultured with fibrin gel and combined with absorptive mesh and artificial dermis containing fibroblasts; and model 4, in which the model 2 epithelium was grafted after artificial dermis was transplanted. The take for these models was evaluated grossly and histologically. The results show that the take percentage of models 2 and 3 was significantly higher than that of model 1 (conventional epithelium) and that there was no significant difference between model 3 (simultaneous grafting) and model 4 (two-step grafting). The difference in the take percentages of the grafts to the flap and to the full-thickness skin defect was also insignificant. In immunohistochemistry, human keratin appeared in all epidermis layers and diversification of the layer was observed in models 2, 3, and 4. In these three models, type IV collagen appeared in the basal layer and the formation of basal membrane was confirmed. These findings suggest that epithelia cultured on fibrin gel and combined with absorptive mesh could be used in a new technique for better, more stable take.

V-Y fasciocutaneous flap of the medial thigh including the long saphenous vein for reconstruction of intrapelvic dead space

Some patients develop an intrapelvic infection and fistula caused by the presence of intrapelvic dead space after the resection of rectal cancer, and the treatment is sometimes quite difficult. We have developed a new surgical technique for the treatment and prevention of such fistulas that uses a fasciocutaneous flap from the medial thigh. A V-shaped fasciocutaneous flap with a pedicle on the anterior side of the thigh is designed on the medial thigh and gluteal region. After raising the fasciocutaneous flap that contains the long saphenous vein, the gluteal section including a thick layer of fatty tissue is de-epithelialised, and the flap is rotated and advanced towards the dead space to fill it. Four patients were operated on using our technique. One was a secondary reconstruction: the patient had developed a small fistula after reconstructive surgery, but it healed with conservative treatment. As a result, all four patients achieved satisfactory outcomes. The advantages of our technique include: no change in the position of the body is required for reconstruction; operations are simple; sufficient volume of tissue is obtained from the thick fatty tissues of the gluteal region; and the fasciocutaneous flap contains the long saphenous vein and has good venous circulation. We consider this technique useful for the reconstruction of intrapelvic dead space.

New umbilicoplasty procedure for postoperative umbilical defect using a rabbit head-shaped scar flap with bilateral subcutaneous pedicles.

Postoperative umbilical defect is a clinical condition that mainly occurs following abdominal wall plasty to correct an omphalocele or gastroschisis. Unlike umbilical protrusions and umbilical hernias, however, postoperative defects in the umbilical region are associated with a postoperative scar. Another problem is that, because many of the cases are in infants, there is very little skin and subcutaneous fat to use in reconstruction. Consequently, reconstructing a naturallooking umbilicus of sufficient depth has been difficult using conventional methods.1–8 We have solved this problem with the development of a new procedure that allows reconstruction of a naturallooking umbilicus of sufficient depth.