Yoshiro Abe

The internal pudendal artery perforator flap: free-style pedicle perforator flaps for vulva, vagina, and buttock reconstruction.

Background: Reconstruction of the vulva, vagina, and buttocks following cancer ablation is challenging. Restoring the shape, volume, and function is the key to the best reconstruction for these regions. Perineal reconstruction with a free-style flap based on skin perforators from the internal pudendal artery was evaluated. Methods: The internal pudendal artery perforator flap was designed based on information about the skin perforators. The flap base contained the arterial sounds, which were identified by a handheld Doppler device, on and around the ischiorectal fossa. Types of flaps used included propeller flaps, traditional transposition flaps, and V-Y advancement flaps. Results: Seventy-one flaps were transplanted in 45 cases. The reconstructed regions included vulvar skin in 36 cases, buttock skin in 10 cases, vagina in nine cases, anus in six cases, and pelvic cavity in six cases. The flaps were transplanted in the lithotomy or prone position. Sixty-seven of these flaps survived completely. Four flaps showed partial necrosis, but no total flap failures occurred. Thinning of the fatty tissue of the flap was performed in all cases except pelvic cavity reconstruction. An additional operation to remove bulkiness of the flaps following the initial reconstruction was required in one case. Propeller flaps, transposition flaps, and V-Y flaps were used in 35, three, and seven cases, respectively. Conclusions: This study revealed that the blood circulation of this flap is reliable and that it offers suitable volume not only for vulvar, vaginal, and anal reconstruction, which requires a thin flap, but also for pelvic floor reconstruction, which requires flap volume. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The internal pudendal artery perforator thigh flap: a new freestyle pedicle flap for the ischial region.

Background: Recurrence and complication rates of pressure sores are highest in the ischial region, and other donor sites are needed for recurrent pressure sores. The potential of a new freestyle pedicle flap for ischial lesions, an internal pudendal artery perforator (iPap) thigh flap, was examined through anatomical and theoretical analyses and a case series using computed tomography angiography. Methods: The skin flap was designed in the thigh region based on an iPap. The skin perforators were marked with a Doppler probe. One patient underwent computed tomography angiography with fistulography to identify the damage to or effects on the pedicle vessels of the flap. Debridement of ischial lesions and flap elevation were performed in the jackknife position. Results: The iPap thigh flaps were performed in 5 patients, 4 with ischial pressure sores and 1 with calcinosis cutis of the ischial region. The width and length of the flaps ranged from 5 to 8 cm (mean, 6.6 cm) and 10 to 17 cm (mean, 12.6 cm), respectively. Three patients underwent partial osteotomy of the ischial bone. No complications, including flap necrosis or wound dehiscence of the donor and reconstructed sites, were observed. Conclusions: The perforator vessels of the internal pudendal artery are very close to the ischial tuberosity. Blood flow to the flap is reliable when careful debridement of the pressure sore is performed. The iPap thigh flap is a new option for soft-tissue defects in the ischial region, including ischial pressure sores.

Two-Stage Surgery for Hidradenitis Suppurativa: Staged Artificial Dermis and Skin Grafting

BACKGROUND Hidradenitis suppurativa is a chronic and often refractory skin disease that can require radical excision of the full layer of fatty tissue under the lesion. Closure using a split‐thickness skin graft often results in depression deformity and lack of tissue flexibility. We have developed a two‐stage procedure to preserve fatty tissue during radical excision and apply an artificial dermis graft, and we have performed this procedure in 18 patients (33 lesions). OBJECTIVE To describe our two‐stage procedure and report results of the procedure in our patient series. METHODS In the first step, all diseased skin including the superficial subcutaneous fatty tissue is excised; normal deep subcutaneous fatty tissue is preserved. Artificial dermis is then grafted to the preserved fatty tissue. Two weeks later, split‐thickness skin grafts are applied to the skin defects. We evaluated graft success, any recurrence, and postoperative appearance in our patients, who were followed up for 8 to 36 months. RESULTS All 32 skin grafts were successful. There was only one recurrence, which was treated using reoperation, and postoperative appearances were good. CONCLUSIONS Our new procedure incorporating artificial dermis appears to be a good treatment option for advanced hidradenitis suppurativa.

On-Admission Pressure Ulcer Prediction Using the Nursing Needs Score

Background Pressure ulcers (PUs) are considered a serious problem in nursing care and require preventive measures. Many risk assessment methods are currently being used, but most require the collection of data not available on admission. Although nurses assess the Nursing Needs Score (NNS) on a daily basis in Japanese acute care hospitals, these data are primarily used to standardize the cost of nursing care in the public insurance system for appropriate nurse staffing, and have never been used for PU risk assessment. Objective The objective of this study was to predict the risk of PU development using only data available on admission, including the on-admission NNS score. Methods Logistic regression was used to generate a prediction model for the risk of developing PUs after admission. A random undersampling procedure was used to overcome the problem of imbalanced data. Results A combination of gender, age, surgical duration, and on-admission total NNS score (NNS group B; NNS-B) was the best predictor with an average sensitivity, specificity, and area under receiver operating characteristic curve (AUC) of 69.2% (6920/100), 82.8% (8280/100), and 84.0% (8400/100), respectively. The model with the median AUC achieved 80% (4/5) sensitivity, 81.3% (669/823) specificity, and 84.3% AUC. Conclusions We developed a model for predicting PU development using gender, age, surgical duration, and on-admission total NNS-B score. These results can be used to improve the efficiency of nurses and reduce the number of PU cases by identifying patients who require further examination.

Pencil-core granuloma of the face: Report of two rare cases

48-6815/

Reconstruction of metatarsal bone defects with a free fibular osteomyocutaneous flap incorporating soleus muscle

-seefrontmattera2011Bri i:10.1016/j.bjps.2011.01.017 Lead pencils, whose cores are composed mainly of graphite, clay and various waxes, are still commonly used. Pencil-tip injuries are also common, especially among school-age children. A granulomatous reaction against pencil lead is rare, but nine cases of pencil-core granuloma have been previously reported with only one case occurring on the face. Here we present two cases of pencil-core granuloma which developed on the face.

Usefulness in combined free anterolateral thigh and vastus lateralis muscle flaps

Severe traumatic bone and soft-tissue defects are often treated by lower leg amputation. The amputation level becomes a very important factor with respect to the patients basic daily activities. We report the case of a 51-year-old man who was referred to us with severe traumatic metatarsal bone and dorsum pedis skin and soft-tissue defects. To avoid amputation, a free fibular osteomyocutaneous flap incorporating the soleus muscle was used to reconstruct the second and third metatarsal bones and the soft-tissue defect, respectively. Now, 2 years after the procedure, the patient is able to walk independently. To the best of our knowledge, this is the first report of use of such a composite transfer for a complex midfoot defect.

Extended Hair-bearing Lateral Orbital Flap for Simultaneous Reconstruction of Eyebrow and Eyelid

BackgroundThe anterolateral thigh flap has been a popular flap in reconstructive surgery. However, the details concerning the anterolateral thigh flap combined with the vastus lateralis muscle flap have not been reported. We described the surgical procedures, complication of the donor site, and advantages and disadvantages of this combined flap.MethodsWe analyzed 29 patients who underwent reconstruction with an anterolateral thigh flap–vastus lateralis muscle flap.ResultsThe recipient sites were in the head and neck area (n = 25), extremities (n = 3), and trunk (n = 1). The vastus lateralis was used as a muscle flap in 28 cases. The rectus femoris was harvested in one case because the vastus lateralis could not be harvested with a skin flap. Four cases required two vastus lateralis muscle flaps with a skin flap. Partial ischemia of the muscle flap occurred in one case. Additional donor-site surgery was required in two cases. No donor-site dysfunction was observed in our series.ConclusionThis combined flap is advantageous in that the volume and number of muscle flaps can be adjusted and the skin and muscle flaps can be placed in separate positions. Although harvesting this flap is safe and not difficult, attention should be paid to anatomical variations of the vascular pedicle supplying the skin and muscle flap and to the circulation of the muscle flap.Level of Evidence: level IV, therapeutic study.

Development of Skin Flaps for Reconstructive Surgery: Random Pattern Flap to Perforator Flap

Background: When a tumor in the lateral eyebrow region is resected, reconstruction of the eyebrow and upper eyelid defects is necessary. We perform simultaneous reconstruction of such defects; sideburn hair is included on an extended lateral orbital flap. We describe our method and results of a retrospective evaluation. Methods: We treated 6 patients with partial eyebrow and upper eyelid defects. An extended lateral orbital flap was designed on the lateral region of the lateral canthus including sideburn hair and was elevated with a pedicle of the orbicularis oculi muscle. Flap size, surgical outcomes, and reconstructed eyebrow morphology were evaluated. Results: Mean flap size was 2.7 × 4.1 cm, with a maximum width and length of 3.5 and 5.1 cm, respectively. The mean hair-bearing region was 1.4 × 0.9 cm, with a maximum width and length of 1.8 and 1.3 cm, respectively. Total flap survival and hair growth were confirmed in all patients. The reconstructed eyebrow and eyelid were aesthetically satisfactory. The new eyebrow hair grew long and was directed upward but considered acceptable. No additional surgery was performed for any patient. The donor site scar was acceptable because it followed the wrinkles of the lateral eyelid. No paralysis of the temporal branch of the facial nerve resulted. Conclusions: The procedure for raising an extended hair-bearing lateral orbital flap is relatively easy, although attention must be paid to the temporal facial nerve. This flap is useful for simultaneously reconstructing defects of the upper eyelid and lateral eyebrow.

Effect of Biopsy Technique on the Survival Rate of Malignant Melanoma Patients

Flap transplantation has been an important procedure in plastic and reconstructive surgery to cover and fill various defects. Flap necrosis due to blood circulation failure leads to severe complications, especially in a patient undergoing reconstruction concerning the body cavity after tumor ablation. Surgical procedures for flap transplantation have been further improved and developed. We have reviewed from the random pattern flap to the newest procedure, the perforator flap. Perforator vessels were investigated in the process of development of the fasciocutaneous flap and have become important for blood supply of the skin flap. Blood circulation of the flap has become more stable and reliable than ever with the development and findings of the perforator vessels. Further development of a skin flap will be based on the perforasome concept, which involves the study of the territory and linking of perforator vessels. J. Med. Invest. 63: 159-162, August, 2016.