Yoko Katsuragi

Mandible reconstruction using the calcium-sulphate three-dimensional model and rubber stick: A new method, ‘mould technique’, for more accurate, efficient and simplified fabrication

BACKGROUND Osteocutaneous flaps are one of the best options for one-stage mandible reconstruction. However, the challenge remains to achieve optimal functional and cosmetic results. A new novel approach involving the preoperative prefabrication of a reconstructive plate through a calcium-sulphate three-dimensional (3D) model facilitates the contouring of vascularised bone grafts. We herein report our preparations and results using this technique. METHODS A total of 17 mandibular defects were reconstructed by this novel approach. A calcium-sulphate 3D model was constructed from computed tomography (CT) data. After the oncologist designed the cut line on the model, the mandibular arc was ground to the neo-mandible shape, which consisted of several linear planes according to the osteotomy of the bone graft. The reconstruction plate was shaped to fit this. After tumour resection, the prefabricated plate was placed to the remaining mandible and revealed the defect to be reconstructed, just as a mould. Rubber sticks were used as a template to shape the bone graft. The preoperative information, and functional and aesthetic results were retrospectively analysed. RESULTS As many as 12 fibular and 5 scapular flaps were applied. Postoperative complications included two salivary fistulae, one abscess and one partial skin loss, all of which were resolved after conservative treatment. Postoperatively, all patients could speak clearly, 12 had a normal diet and 12 had excellent cosmetic results. CONCLUSIONS This is the first report using models made by calcium-sulphate. The largest advantage of this model is that the neo-mandible shape can be demonstrated preoperatively. The refinement of mandible reconstruction after tumour ablative surgery can be achieved with a prefabricated plate through the use of a calcium-sulphate 3D model. It enables more accurate, faster and simplified fabrication of reconstruction plates, thus leading to satisfactory functional and cosmetic results.

The versatile perifascial areolar tissue graft: Adaptability to a variety of defects

Abstract Reconstruction using flaps with good blood circulation is appropriate for covering an intractable ulcer or a fistula in which tendon or bones are exposed. A non-vascularised perifascial areolar tissue (PAT) graft can also survive in such an area. This study reports the versatile application of a PAT graft for use as a non-vascularised graft material. A total of 32 patients were treated between April 2004 and December 2010 (16 men and 16 women). The donor sites were the inguinal region in 20, the thigh in 11, and the subclavian region in one. There were 13 inlay grafts to the dead space after tumour resection, eight closures for cerebrospinal fluid leakage, seven skin ulcers with exposed bones and tendons, three fistulas, and one vascular leak of the common carotid artery. The total survival rate of the grafts was 91%. The complications associated with this procedure included infection in 9% and seroma in the donor site in 19%. However, all cases improved after conservative treatment. The PAT is a pliable loose areolar tissue with a rich vascular plexus, and the harvesting technique is quite simple and minimally invasive. The PAT graft could therefore represent an alternative for flaps that are used as a free graft material for the reconstruction of such defects as intractable skin ulcers, fistulas or dead spaces that usually require reconstruction with vascularised flaps.

A new surgical correction of cryptotia: a new flap design and switched double banner flap.

Cryptotia is a congenital auricular anomaly that frequently occurs in Asians. In cryptotia, the upper third of the auricle is collapsed and buried under the temporal skin. We have treated patients who could not be treated by splinting with bent paper clips, using various surgical methods.1–4 Several problems remain, however, such as conspicuous scars, a shallow auriculotemporal sulcus, and incomplete correction of auricular cartilage. Therefore, we devised a new surgical method using a new skin flap design based on Fukuda’s method2 and a new concept of Tanzer’s double banner flap.5 Using this method, we produced good auricular contour with a deep auriculotemporal sulcus and no conspicuous scars.

How to Reconstruct a Natural and Deep Umbilicus: Three Methods of Umbilicoplasty for Five Types of Umbilical Deformities

BackgroundConventional methods of umbilicoplasty using V-Y advancement flap often result in unnatural wide or shallow umbilical depressions facing upward or downward. Moreover, although the umbilical deformities have many variations, no report has described the selection of an umbilicoplasty method for types of umbilical deformity. To resolve these problems, we devised 3 methods of umbilicoplasty. In this report, we classified all kinds of umbilical deformities into 5 types, and studied the most suitable method for each type of umbilical deformity. MethodThe umbilical deformities are classified into Type 0: the defect of umbilicus; Type I, the low-grade protrusion; Type II, the high-grade protrusion with wide base; Type III, the high-grade protrusion with narrow base; and Type IV, the protrusion in depression. The most suitable method among our 3 methods was adapted to each type. Method 1 with a S-shaped skin incision was adapted to Type 0 and I, Method 2 with fan-style flaps was adapted to Type II, and Method 3 with dividing the umbilical protrusion was adapted to Type III and IV. ResultsSixty-three patients (10 cases of Type 0, 31 cases of Type I, 10 cases of Type II, 5 cases of Type III, and 7 cases of Type IV) underwent umbilicoplasty using the suitable method, and all were well corrected. ConclusionsUsing the best choice among our 3 methods, it is easy to create a natural, vertically long and deep umbilical depression without conspicuous scars in all types of umbilical deformities.

Surgical repair of transverse facial cleft: Oblique vermilion–mucosa incision

Various surgical techniques have been reported for the repair of the transverse facial cleft using a straight-line closure, Z- or W-plasty, local flaps, etc. However, several problems remain such as deviation, distortion and scars in the commissure and cheek. To resolve these problems, we studied the anatomy of the commissure again and devised the most reasonable method for repair of the transverse facial cleft. In our new method, oblique vermilion and mucosa incision lines, 45 degrees to the vermilion-cutaneous junction, were designed. After mucosal closure, the orbicularis muscle was reconstructed by cross-overlap joining the upper muscular bundle over the lower muscular bundle at an angle of 90 degrees. The skin was sutured using horizontal straight-line closure with a small Z-plasty lateral to the nasolabial fold. We performed the new method on seven macrostomias. The patient cohort consisted of four girls and three boys, and their ages ranged from 4 months to 3 years. Symmetrical commissure and natural oral movement was obtained in the past five cases. The scar around the commissure and cheek was inconspicuous in all cases. The new method used the oblique vermilion-mucosa incision and straight-line closure, the cross-overlap joining of the muscular bundles at an angle of 90 degrees , and the horizontal straight-line skin closure with a small Z-plasty lateral to the nasolabial fold. This method, which is anatomically reasonable, can construct a symmetrical and natural commissure without conspicuous scars.

Aesthetic Repair for Syndactyly of the Toes Using a Plantar Rectangular Flap

Background: Use of a dorsal rectangular flap is the most common method of creating a deep interdigital space for syndactyly of the toes. However, the pigmented skin grafts exposed to the dorsal side are conspicuous. To resolve this problem, several methods have been reported. However, the local flap methods could be adapted only in mild syndactylies, and plantar skin flaps exposed to the dorsal side are too whitish. Meanwhile, in the methods using skin grafts from the inframalleolar region, the marginal scars of the skin grafts are still conspicuous on the dorsal side. To resolve these problems, the authors devised a new surgical method using a plantar rectangular flap. Methods: In this method, the authors designed a rectangular flap on the plantar side. Only a small triangular flap and a slight zigzag skin-incision line were designed on the dorsal side. The plantar rectangular flap was put down into the bottom of the interdigital space and was sutured with the dorsal triangular flap. Full-thickness skin was grafted to the raw surface at the sides of the divided toes. Results: The authors performed this method on 18 syndactylies of 12 patients. In all cases, the corrected toes showed a deep and natural interdigital space without exposure of skin grafts or conspicuous scars. Conclusions: The authors devised the plantar rectangular flap to avoid extra skin defects on the dorsal side. Using this method, the authors can create a deep interdigital space without any exposure of skin grafts or whitish plantar skin flaps on the dorsal side. This method is not appropriate for syndactyly of the fingers but is an ideal method for syndactyly of the toes.

Three-step orbitofacial reconstruction after extended total maxillectomy using free RAM flap and expanded cervicofacial flap with cartilage grafts

Facial defect after an extended total maxillectomy is one of the most difficult deformities to reconstruct aesthetically, because the defect is not only large but also three-dimensional. Although free-flap reconstruction is useful, the patchwork-like scar, bad colour match and poor texture match are major problems. The contracture and displacement of the reconstructed eyelids and eye socket are also serious matters. To resolve these problems, we have performed a three-step reconstruction using a free rectus abdominis myocutaneous (RAM) flap and an expanded cervicofacial flap with cartilage grafts. In the first step, a free RAM flap was transplanted to the defect after extended total maxillectomy. In the second step, tissue expanders were placed under the skin of the cheek and neck a year after the RAM flap transplantation. After expansion of the cheek and neck skin, the third step was performed. The inferior part of the external skin island of the RAM flap was raised and sutured to the superior margin of the skin island to create a pouch for the eye socket. Costal cartilage was grafted to reconstruct the orbital floor and malar prominence, and auricular cartilage was grafted to reconstruct the tarsal plates. Finally, the expanded cervicofacial flap was rotated to cover this construct. Two weeks after reconstruction, the neo-eyelids were divided to form the lid fissure. We performed the three-step reconstruction on six cases after extended total maxillectomy. In all cases, a deep and stable eye socket was reconstructed. The reconstructed eyelids and cheek were natural in appearance with good colour and texture match without conspicuous scars. To obtain symmetry and natural appearance in the orbitomaxillary reconstruction, there are five points that should be formed; the eye socket, the groundwork of the eye socket, the orbital floor and malar prominence, the tarsal plates and the surface of the eyelids and cheek. We do not reconstruct the palate to set prosthetic dentures and to clean the surface of the skin island in the nasal cavity. To reconstruct the indispensable five points and achieve satisfying results, we propose this three-step reconstruction.

Breast reconstruction using tissue expander and TRAM flap with vascular enhancement procedures

The transverse rectus abdominis myocutaneous (TRAM) flap can create a good breast shape, however, the patchwork-like scar obviously shows that the breast has been reconstructed. To reconstruct a breast without the patchwork-like appearance, we used a two-stage procedure using a tissue expander before transplanting a de-epithelialised TRAM flap. In addition, to avoid fat necrosis and resorption in a large TRAM flap, we performed two vascular enhancement procedures, surgical delay and supercharging microvascular anastomosis. The surgical delay, which consisted of an extended skin island delay and a vascular delay, was performed when the tissue expander was placed under the breast skin in the first stage. As the extended skin island delay, zones 3 and 4 of the TRAM flap were elevated and silicone sheets were laid under the flaps. As the vascular delay, the deep inferior epigastric vessels (DIEV) on the pedicle side were ligated. In the second stage, the de-epithelialised TRAM flap was transferred into the expanded breast skin pocket. The flap was double pedicled with supercharging microvascular anastomosis between DIEV on the contra-pedicle side of the flap and the thoracodorsal vessels of the recipient site. This surgery was performed on 20 post modified radical mastectomy patients to reconstruct large breasts without patchwork-like scars, and every TRAM flap survived perfectly without fat necrosis or resorption. All patients were satisfied with the reconstructed breasts and the abdominal contour without abdominal wall hernia or any other complications.

Combined sliding flap using a single perforator enables simple closure of the donor site: A case report

We report the case of a 39-year-old man with a dermatofibrosarcoma protuberans (DFSP) on the right shoulder. A wide surgical excision of the tumour was performed, creating a 12-cm-wide defect. An anterolateral thigh flap created from two semicircular skin paddles was harvested and the two skin paddles were slid towards each other to cover the circular defect. The sliding technique is a useful design that preserves the suprafascial plexus and enables a single perforator to supply two split-skin paddles. Using this design, the donor site can be closed primarily without requiring a skin graft. This technique can be applied to other free flaps to reconstruct wide defects after the resection of cancers.

Split-thickness skin flap technique for elevating the radial forearm flap.

The radial forearm flap has been one of the most useful free flaps since Yang et al. first reported it in 1981.1 The advantage of this flap is that it is a thin, soft flap and has long, large vascular pedicles for stable circulation. In contrast, the greatest disadvantage is that the donor site is an exposed region. To resolve this problem, we have devised the split-thickness skin flap method, in which a flap-style split-thickness skin of the forearm flap is grafted back to the donor site. The split-thickness skin flap method allows good color and texture match of the donor site and a scarless radial margin, which is the most conspicuous part of the donor site.