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Summary:. Midfacial reconstruction for extensive defects of the hard nasal structures and bilateral maxillae is challenging. Postoperative radiotherapy causes skin contracture, making secondary reconstruction extremely difficult. A 57-year-old man underwent resection of the nasal bone, nasal cartilage, and hard palate for cancer of the nasal cavity. Postoperative radiotherapy (70 Gy) resulted in bilateral osteoradionecrosis. Severe depression deformity of the midface causes a disorder in closing the mouth, resulting in difficulty in conversation and oral intake. We performed simultaneous reconstruction of the bilateral maxillary and nasal hard structures using double free flaps (fibular osteocutaneous and anterolateral thigh flaps). A 16-cm right fibular osteocutaneous flap was elevated, and an 8-cm proximal bone was resected to obtain the length of the peroneal vessels. The distal 8 cm was cut into three pieces while maintaining the blood flow. The removed nonvascularized fibula was processed into two pieces of cortex: nasal bridge and columella. All areas of the skin island were de-epithelialized to bilaterally fill the maxillary sinuses. Next, the ipsilateral anterolateral thigh flap was elevated with the central 6-cm part for closure of the palate and the proximal area to fill the nasal cavity. The distal area consisted of a fascial flap to cover the reconstructed nasal structure. The chimeric double flap allowed for oral intake, conversation, and nasomaxillary prominence. Computed tomography performed 8 months postoperatively showed maintained bony structures. We used the extra fibula as a nonvascularized cortex piece to prevent infection and exposure, which enabled simultaneous reconstruction of the bilateral maxillae and hard nasal structure.

Summary:. Reconstruction of extended total maxillectomy is challenging. This study aimed to isolate the skull base from the nasal cavity to avoid intracranial infection, cerebrospinal fluid fistula, and palate closure to maintain feeding and conversation. However, facial appearance and symmetry are important for quality of life. We report primary multiple buttress reconstruction using a removed nonvascularized fibula that reduced the risk of infection and exposure. A 74-year-old woman experienced a local recurrence of right maxillary sinus cancer after subtotal maxillectomy and postoperative radiotherapy (60 Gy). We performed extended total maxillectomy, including the right eyeball, orbit, temporal bone, palate, and zygomatic arch. Primary reconstruction was performed using fibular and anterolateral thigh free flaps. The proximal fibula bone was resected to obtain the length of the peroneal vessels, and the distal 9 cm of the fibula was made into two pieces while keeping the peroneal vessels attached. The nonvascularized 5-cm fibula was split sagittally with an L-shaped section to maintain the strength of the fragments. An anterolateral thigh flap was elevated from the ipsilateral thigh attached to the partial vastus lateralis muscle, which was divided into proximal (to the cheek skin and prosthetic eye bed) and distal (to the nasal cavity and palate) skin islands. Two nonvascularized bone fragments were fixed at the lateral and infraorbital rims. The dead space around the built-up pillar made of transferred bone was filled with vastus lateralis muscle to prevent infection and depression. This approach allowed for one-stage multiple buttress reconstruction for extended total maxillectomy.

Summary:. We must take special care when treating postoperative fluid accumulation around breast implants (BIs) to exclude any serious complications, including BI-associated anaplastic large cell lymphoma. However, most late-onset fluid accumulation is caused by other conditions, such as traumatic hematoma and residual postoperative seroma. Surgeons must choose whether to conservatively observe or remove such BIs, while also determining whether to perform partial capsulectomy or total capsulectomy to solve the problem of fluid accumulation. We treated a 72-year-old woman who noticed swelling in her right breast 4 years after undergoing bilateral BI reconstruction. Before she was referred to our hospital, the fluid had been drained by needle aspiration five times, but the swelling returned to a similar size within a month. No malignant findings were observed by needle-aspirated cytology or flow cytometry. The patient requested the simultaneous removal of the left BI. Therefore, we performed both BI removal with total capsulectomy on the right side and partial capsulectomy of the superficial layer on the left side. A pathological examination of the capsule on the right side indicated a chronic expanding hematoma and synovial metaplasia characterized by papillary projections rich in CD68-positive cells, thus indicating reactive synovial cells. In contrast, the left superficial capsule was much thinner and showed less synovial metaplasia. Our findings indicate the advantages of total capsulectomy to solve the problem of repeated serous fluid accumulation around BIs, according to histological changes in the capsule.

Summary:. Indocyanine green (ICG) fluorescence imaging is useful for assessing flap viability; however, it is associated with a risk of anaphylactic shock, even in patients with no history of drug allergies. SnapshotNIR is a noncontact, camera-type handheld tissue oximeter that can measure the tissue oxygen saturation of the body surface. The device emits red and near infrared light wavelengths and then optimizes the measurement of the differential reflectance from oxygenated and deoxygenated hemoglobin, and StO2 is calculated. A 20 × 15 cm surgical field can be evaluated in less than 3 seconds by holding the camera at a distance of 30 cm. We applied this device at zone II in a deep inferior epigastric perforator (DIEP) flap, and compared the findings with the border of flap perfusion detected by ICG imaging. Left breast reconstruction using a free DIEP flap was performed for a 60-year-old woman. The DIEP flap was vascularized by a perforator vessel coursing to the right abdominis muscle. First, Diagnogreen (5 mg; Daiichi Sankyo Co., Tokyo, Japan) was intravenously injected, and the ICG fluorescence perfusion border detected by PDE-neo (Hamamatsu Photonics, Hamamatsu City, Shizuoka, Japan) was determined. The ICG border was defined by two reconstructive surgeons after fluorescence had spread out for 2 minutes. Next, zones Ⅱ and Ⅳ of the DIEP flap, contralateral to the perforator, were evaluated using photographs obtained by SnapshotNIR. There were significant StO2 value differences between the ICG-negative area and ICG-positive area. This device can be widely applied in the noninvasive evaluation of flap viability.

Summary:. Infantile hemangioma (IH) is a common pediatric vascular tumor and is easily diagnosed in most cases based on the clinical course and appearance, but deep IHs are difficult to diagnose based on external appearance alone. Clinical and imaging findings are therefore important clues to the diagnosis of soft tissue tumors; however, a definitive diagnosis is decided based on the pathological examination of biopsy or resection specimens. A 1-year-old girl with a subcutaneous mass on her glabella was referred to our hospital. At 3 months of age, her mother noticed a tumor that swelled when she cried. It gradually enlarged, and ultrasonography and magnetic resonance imaging were performed at 12 months of age. Doppler ultrasonography showed a hypo-vascular mass. Magnetic resonance imaging revealed a subcutaneous mass with low-intensity on T1-weighted image and slightly high-intensity on T2-weighted image, with tiny flow voids. Computed tomography showed no frontal bone defect. The soft tissue tumor could not be diagnosed based on these imaging findings; thus, we decided to perform total resection under general anesthesia. A histopathological examination showed a highly cellular tumor with capillaries with opened small vascular channels and glucose transporter 1 positivity. Thus, it was diagnosed as deep IH transitioning from the proliferative phase to the involuting phase. Deep IHs are difficult to diagnose because characteristic imaging findings disappear during the involuting phase. We emphasize the importance of performing Doppler ultrasonography in the early phase (eg, at 6 months of age) for soft tissue tumors of infancy.

Summary:. Local flaps from the upper lip and cheeks have been the first choice for two-thirds to total resection of the lower lip. However, these local flap techniques involve many clinical problems, including small a mouth, drooling, scarring, and hypesthesia. The improvement of free anterolateral thigh (ALT) flap transfer can solve these problems with expansion of the application of free flaps for lower lip reconstruction. The patient in this case was a 56-year-old man with squamous cell carcinoma of the lower lip (cT3N1M0). Subtotal lower lip resection preserving both corners of the mouth with bilateral neck dissection was performed. Simultaneously, a sensory ALT flap was elevated with an 8 × 6 cm skin island and a lateral femoral cutaneous nerve. The lateral and medial sides of the fascia lata were processed into 1-cm-wide strings, which were tunneled through the orbicularis oris muscle of the upper lip and sutured to the orbicularis oris muscle at the mucosal side of the philtrum. The lateral femoral cutaneous nerve and right mental nerve were sutured. At 3 months, a second surgery was performed to replace the ALT flap on the white labial side with a clavicle full-thickness skin graft. This surgery achieved four important factors: opening and closing of the mouth, sensory function of the lower lip, cosmetic appearance, and minimization of donor-site damage. We believe the worldwide improvement of microsurgery techniques enables lower lip reconstruction using the sensory ALT flap to be selected as the first choice for two-thirds to total lower lip defects.

Summary:. The medical imaging projection system (MIPS) is a real-time surgical navigation device using indocyanine green (ICG) emission signals and active projection mapping. The difference between the object and the projected image is within 1 mm, and the time lag is within 0.1 seconds. We herein report the application of the MIPS to vascularized lymph-node transplantation (VLNT) surgery for lower extremity lymphedema to detect inguinal lymph nodes and perform color-coded navigation surgery for lymph-node resection. A left superficial inguinal lymph node was planned to be used as a donor for VLNT to the right lower leg in a 73-year-old woman with lower extremity lymphedema. Under general anesthesia, multiple intradermal injections of 0.1 ml of ICG were administered around the left inguinal donor site. The MIPS showed a clear linear projection image from a lateral injected point connecting to a lateral superficial inguinal lymph node. The left superficial circumflex iliac artery and vein were dissected for vascularized VLNT. Intraoperative real-time MIPS navigation continuously guided the transection plane colored by ICG fluorescence signals without shifting the visual focus from the surgical field. This is the first report of the intraoperative use of ICG projection mapping for VLNT donor-site surgery. The MIPS was able to visualize functional lymph nodes to facilitate minimally invasive donor-site surgery.

Mandibular reconstruction involving the central segment after malignant tumor resection requires the achievement of both functional and aesthetic quality. Three-dimensional reproduction based on the concept of a double arc composed of a marginal arc and an occlusal arc is important. Most reports of fibula flaps applied three-segmented closed wedge fibula osteotomy (bilateral and central segments); however, the aesthetic outcome sometimes became too stout for female patients because of the large central segment. We performed four-segmented fibula osteotomy for a 78-year-old woman using a semiopen wedge technique characterized by a half-open wedge and half-closed wedge. This procedure obtained a slim mandibular contour and made double-barrel reconstruction easier to apply. We used titanium plates that were prebent according to the shape of a three-dimensional model constructed from CT data. Small bone cortex fragments made from a surplus fibula segment were inserted in a half-opened area. The build-up preparation for central mandibular reconstruction was all performed at the lower leg area before cutting the peroneal pedicle. This prefabricated double-barrel fibula free flap was transferred to the mandibular defect with arterial and venous anastomosis to the right superior thyroid artery, right external jugular vein, and right common facial vein. Although the patient was nearly 80 years of age, the bone segments, including free cortex tips, were fused with smooth remodeling. Semiopen wedge osteotomy can be a key to reproducing an aesthetically slim feminine chin with a functional height of mandibular bone maintained for stability of the dental prosthesis.

Summary:. We applied double-flap reconstruction with a vascularized fibula osteo flap and a Y-shaped anterolateral thigh (ALT) flap, which was separated into a fascial flap and a de-epithelialized fat flap to replace the temporomandibular joint capsule and temporal soft tissue volume, respectively. This technique achieved excellent functional and cosmetic results with acceptable operation time and donor site scarring. A 16-year-old girl had a rapidly growing mandibular osteosarcoma. Right mandibulectomy from the right first premolar tooth to right condylar head (including temporalis muscle, masseter muscle, buccal mucosa, and part of the right maxilla) was performed. A left fibula osteo flap and left ALT flap were prepared in a prefabricated manner using a three-dimensional model and a prebent titanium plate. The area of the ALT flap was 23 × 6 cm. A proximal 8 × 4 cm skin flap was positioned to replace the left cheek mucosa, and the distal part was divided into two layers: a de-epithelialized fat flap and a fascial flap. The de-epithelialized fat flap was used to prevent the depression deformation at the temporal area, and the fascial flap was used to cover around the alternate condylar head made by the fibula instead of the resected temporomandibular joint capsule. The peroneal artery and veins were microscopically anastomosed to the distal end of the artery and veins of the descending branch of the ALT flap in a flow-through manner. At 12 months after surgery, the occlusal function and aesthetic balance were excellent.

Summary:. Surgical invasion is a risk factor of pyoderma gangrenosum (PG). A total of 25% of postoperative PG cases were reported to occur after breast surgeries, including bilateral breast reduction and breast reconstruction following cancer resection. Immunosuppressive therapy and less-invasive wound therapy are necessary; however, the complete healing of ulcers takes 5.1 months on average. We herein report a case of skin grafting under a surgical concept of less-invasive and short-term treatment. An 82-year-old woman complained of a high fever and severe pain at her breast wounds after bilateral breast cancer resection. Although we performed emergency debridement surgery to remove the necrotic tissue, suspecting surgical site infection and inflammation, her high fever persisted. She was diagnosed with PG because of the physical findings of characteristic painful, sterile ulcerations, bullae and pustules, and the pathological abundance of neutrophils in the absence of infection and vasculitis. Oral administration of prednisolone 30 mg/day improved the symptoms, and we applied negative-pressure wound therapy (NPWT) from day 16 following debridement surgery. After the gradual reduction of oral steroid intake to 12.5 mg/day, we performed skin grafting surgery. To limit the surgical invasion, we used the surplus skin around the ulcers. Split-thickness mesh skin grafts were fixed by NPWT to avoid the use of tie-over sutures. We achieved short-term treatment of PG with a less-invasive surgical strategy using skin around the ulcers and NPWT.

Background:. Postoperative free flap monitoring is essential for immediately detecting obstruction of anastomosed vessels with successive recovery surgery for salvaging flaps. We performed postoperative nursing monitoring using handheld Doppler sonography, but nurses reported feeling anxious with this approach and demanded a clear-cut evaluation method. Therefore, we implemented monitoring with the fingerstall-type tissue oximeter Toccare, a noninvasive device that enables easy flap checking by simply touching the flap with a probe. Method:. Handheld Doppler was used for nursing monitoring from April to October 2020, with anxiety associated with its use reported. We collected information via an anonymous questionnaire to determine the reason for the anxiety. Toccare was subsequently applied for postoperative free flap monitoring by nurses. The protocol involved measuring tissue oxygen saturation by touching the flap with a Toccare probe every 4 hours from 24 to 100 hours postoperatively. Seven months later, a second anonymous questionnaire was conducted, and results were compared. Result:. Free deep inferior epigastric artery perforator flaps and anterolateral thigh flaps (n = 5 each) were included. The average tissue oxygen saturation values in the deep inferior epigastric artery perforator and anterolateral thigh flaps were 52.0% and 52.4%, respectively. According to the second questionnaire about Toccare, 7% felt anxious, 62% felt slightly anxious, and 31% did not feel anxious. Toccare was preferred by 89% of nurses who had used both methods. Conclusions:. Flap monitoring using Toccare reduced nurses’ anxiety. A numerical evaluation method with easy handling and clear doctor call criteria is essential for low-anxiety nursing monitoring.

Summary:. Patients with severe group A Streptococcus (GAS) induced necrotizing soft tissue infection sometimes develop Streptococcal toxic shock syndrome, which is a life-threatening condition with an extremely high fatality rate. Obtaining survival is the most important goal; however, an early diagnosis for debridement surgery and quick granulation formation for skin grafting surgery can better preserve the extremity functions. The patient was a 47-year-old man with a history of atopic dermatitis who presented with GAS-induced necrotizing soft tissue infection in his left lower extremity. His vital signs indicated shock, and he was diagnosed with streptococcal toxic shock syndrome. Emergency surgery was performed with his body pressure maintained with noradrenaline. Intraoperatively, rapid antigen detection tests (RADTs) were negative in the medial thigh and positive in the lower leg, which helped in decision-making regarding the area of aggressive debridement surgery. The wound culture results matched the intraoperative rapid antigen detection test results. A collagen/gelatin sponge with the sustained release of basic fibroblast growth factor was used as an artificial dermis before skin grafting. Excellent granulation was obtained, and skin grafting surgery was performed on the 11th day after collagen/gelatin sponge placement. He was discharged home on the 42nd day with normal lower extremity functions. First, an intraoperative diagnosis using GAS-rapid antigen detection tests with an appropriate sampling method from small incisions avoided excessive surgical debridement. Second, collagen/gelatin sponge with the sustained release of basic fibroblast growth factor promoted quick granulation tissue formation for wound bed preparation. These efforts resulted in the successful less-invasive treatment of a patient with streptococcal toxic shock syndrome caused by GAS-induced necrotizing soft tissue infection.

Summary:. Edwardsiella tarda is an anaerobe associated with freshwater and marine life. Necrotizing soft tissue infection caused by E. tarda is rare, but its mortality rate is extremely high (61.1%). We experienced a survival case of Fournier’s gangrene with E. tarda. A key clinical feature for the diagnosis was gas production; however, there have been no previous reports of such a phenomenon in relation to E. tarda. A 64-year-old man was admitted with a 3-day history of a high fever. His medical history, which included paraplegia from the Th6 level down, made the focus of inflammation at the perineum difficult to notice. Whole-body CT revealed subcutaneous gas from the posterior scrotum around the entire circumference of the anus. During emergency surgery, an incision at the posterior scrotum revealed extensive fascia necrosis, and E. tarda and Streptococcus anginosus were identified. We speculated the gas production in this case to be the product of a mixed infection of aerobes and anaerobes, which acted synergistically to induce bacterial growth. Timely surgical debridement and antibiotic therapy led to the patient’s survival.

Summary:. Replacing an infected prosthetic thoracic aorta graft carries a high re-infection risk. We previously reported two clinical cases successfully treated with a new muscular wrapping technique: latissimus dorsi (LD) muscle flap with a distally based serratus anterior (SA) extension; however, a cadaveric study to prove the regular existence of the distal attachment area was lacking. We tried to establish an appropriate way of elevating the combined muscle flap safely. All of the cadavers were preserved using the Thiel embalming technique to retain flexibility. We checked for the existence of the distal attachment area between the LD and SA. Combined muscle flaps were elevated proximally while identifying the thoracodorsal artery, including the LD and SA branches. After the SA branch was ligated and cut, the SA muscle was manually peeled from the LD muscle with only the distal tight attachment area remaining. Contrast-enhanced computed tomography was performed using a multislice computed tomography system. Six human cadavers (three men, three women: 91 years old, on average) were examined. All six LD and SA combined muscle flaps showed a distal tight attachment area at the level from the seventh rib to the ninth rib. The tip of the SA muscle easily reached the sternum. Contrast-enhanced computed tomography failed to reconfirm the distal vascular flow from the LD to the reverse SA muscle, which we had visualized in a clinical case. We demonstrated the anatomical reliability of the new Y-shaped muscular flaps, which are suitable for preventing re-infection of aortic graft replacement.

Summary:. Surgical excision of a giant congenital melanocytic nevus (GCMN) results in a full-thickness skin defect that is usually difficult to reconstruct even with tissue expansion or skin grafting. Here, we report the first case of GCMN treated with a combination of cultured epithelial autografts (CEAs) and mesh-skin grafts to reconstruct a large skin defect after surgical excision. A 14-month-old girl had a GCMN occupying 20% of the total body surface area of her neck and back. A 5-stage, full-thickness excision was performed between the age of 14 and 25 months. In each intervention, the wound after excision was covered with 1:6 mesh-skin grafts and CEAs, except for the neck, where patch skin grafts and CEAs were used. The skin grafts and CEAs were engrafted without shedding and epithelialization was completed within 3-4 weeks. Eighteen months after the last surgery, a mesh-like scar remained, with no recurrence or severe contracture observed. The cosmetic appearances of the donor sites (the scalp and lower abdomen) were acceptable. The application of CEAs with mesh-skin grafts has been established for the treatment of severe burns. This combined method also provides a possible option for the treatment of GCMNs.

Summary. Curettage is common in the treatment of a giant congenital melanocytic nevus (GCMN) in infants and should generally be performed before 6 months of age. Post-curettage retarded epithelialization often interferes with the ability to perform multiple operations within a short interval, and thus, it is difficult to treat large lesions in the neonatal period. We herein report a case of a GCMN comprising 20% of the total body surface area, which required multi-stage curettage, in which a cultured epithelial autograft was used to promote epithelialization of the post-curettage wound. The patient was a 1-month-old boy with a GCMN in his head, neck, chest, back, buttock, left upper arm, and a few satellite lesions. A four-stage operation was performed between 3 and 6 months of age; the cultured epithelial autograft took well after each operation, and complete epithelialization was observed at postoperative days 20, 23, 27, and 12, respectively. Seven months after the last surgery, hypertrophic scar formation was only observed in a small area of the left upper arm without axillary contracture. The color of the treated area improved, except for slight partial re-pigmentation. A skin biopsy was obtained from the re-pigmented area. The results demonstrated that nevus cells remained in the basal layer of the epidermis, hair follicles, and deep layer of the remaining dermis, suggesting that the recurrent nevus cells in the regenerated epidermis migrated from hair follicles. We conclude that the combination of curettage and the application of a cultured epithelial autograft is a promising option for GCMN treatment.

Summary:. A 48-year-old man with a protruding tumor on the parietal region had undergone treatment of alopecia using artificial synthetic fibers 2 or 3 times a year for 10 years from 30 to 39 years old. Three months before the first consultation at our hospital, he noticed a small tumor that had gradually shown bleeding and discharge, with expansion of the affected area. A diagnosis of squamous cell carcinoma (SCC) was made based on a biopsy, and we resected the tumor with a 1-cm surgical margin from the reddened area around the protruding tumor (14 × 11 cm), including the periosteum membrane. No tight adhesion was found between the periosteum and skull, so we excised the outer table of the skull of the central part (diameter: 8 cm) for a pathological analysis. A pathological study showed moderately differentiated SCC with a negative surgical margin. The whole tumor was surrounded by scar tissue with buried artificial hair implants. The second surgery was performed on the 15th postoperative day. An anterolateral thigh flap was divided into 2 flaps to fit the circle-shaped wound. This is the second report of SCC developing after artificial hair implantation in the frontal-parietal scalp. The whole protruding tumor was surrounded by scar tissue with buried artificial hair implants. Proving the direct causal relationship between inflammation of scar tissue and SCC generation is difficult; however, our pathological findings support the possibility of the harmful effects of artificial hair implants.