Background: Pressure ulcers remain a challenge for plastic surgeons to effectively manage because of the patient's underlying physical condition, weakness, risk factors associated with the diagnosis, and resultant insufficient wound healing that results in incomplete treatment or recurrence after surgery. This review describes and analyzes the current literature regarding the management of pressure ulcers.
Methods: Risk factors primarily associated with wound dehiscence and recurrence were identified via a PubMed literature search using “ischial pressure ulcers, sacral pressure ulcers, and surgical coverage” as keywords. We analyzed and compared them to data from the Committee of the Japanese Society of Pressure Ulcers in 2016 and our facility.
Results: Many published reports contain pedagogical comments on the successful management of pressure ulcers that remain significant. Some reported risk factors associated with flap dehiscence and ulcer recurrence are age, low serum albumin levels, previous operative failures at the same site, and ischial ulcers. The prevalence of deep pressure ulcers at the sacrum was more than three times higher than that at any other site. At our facility, the most frequently performed surgeries were for ischial ulcers, and 86% of pressure ulcers healed after surgery.
Conclusions: Surgical site infection and surgical time were independent risk factors associated with wound dehiscence in the early phase after reconstruction. The effectiveness of closed wound management with negative-pressure wound therapy has been reported to be satisfactory for reconstructive surgeries with flaps for refractory pressure ulcers.

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Background: Aortic graft infection (AGI) is an intractable complication of prosthetic graft replacement surgery. The selection of a reconstruction method is controversial, especially in cases where omental flaps are not available.
Methods: A retrospective survey was conducted based on the medical records of patients who underwent prosthetic graft replacement with an anterolateral partial sternotomy (ALPS) approach and mediastinal reconstruction with transthoracic latissimus dorsi (LD) flap at Kobe University Hospital between July 2019 and May 2021. In the ALPS approach, the left third intercostal space was incised in addition to the conventional median sternotomy. The left fifth rib was partially excised to create a passage between the lateral thoracic area and thoracic cavity (transthoracic route). After the graft replacement surgery, the left LD flap was passed through the transthoracic route to fill the dead space around the graft.
Results: Our study included five patients (four males; mean age, 74.0 years). Three and two patients experienced AGI recurrence and infectious aortic aneurysms. In all cases, the omental flap was unavailable for mediastinal reconstruction owing to a history of laparotomy. One patient with an infectious aortic aneurysm died of heart failure on postoperative day 24. The mean hospital stay for the four survivors was 67.3 days. The mean postoperative follow-up was 513.3 days with no recurrence of infection.
Discussion: Compared to the extra-thoracic route, the transthoracic route shortens the distance from the base of the LD flap to the aortic graft, allowing more muscle tissue to be filled into the dead space (between the pectoralis major and thoracic wall). Trans-thoracic LD flap transfer using the ALPS approach is a versatile reconstruction method for treating AGI when the omental flap is unavailable, especially for recurrent graft infections.

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Background: Dexmedetomidine has been indicated for sedation during non-intubation surgery and procedures performed under local anesthesia in Japan since 2013. We reviewed 10 patients who received dexmedetomidine during local anesthesia surgery at our hospital.
Methods: Dexmedetomidine was administered to patients scheduled for surgery under local anesthesia, who requested sedation, or were expected to undergo surgery for more than 1 h. The initial loading dose was 6 μg/kg/h, administered intravenously for 10 min, followed by maintenance dosing at 0.1–0.4 μg/kg/h. Vital signs and sedation levels were monitored during the surgery. Dexmedetomidine administration was terminated 15–30 minutes before the expected end of surgery. The sedation levels and side effects in each case were reviewed.
Results: Between 2018 and 2020, 10 patients underwent surgery in our hospital under local anesthesia and sedation with dexmedetomidine for diseases including abscesses, artificial infections, and benign and malignant tumors. Appropriate sedation levels were achieved in all cases. Adverse effects included respiratory depression and hypotension in two cases each. However, these were easily resolved by slowing down or stopping the drug administration or applying stimulation. No other adverse events were observed.
Conclusions: Dexmedetomidine is suitable for plastic surgery because patients can be easily awakened and can communicate even when appropriately sedated. Further, it causes lesser respiratory depression than other sedatives. In our case, respiratory depression and hypotension were observed; however, the patient recovered quickly, and the surgery could be performed relatively safely.

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Background: It is well known that the possibility of abuse must be considered when examining pediatric burns; however, in reality, many of these are accidental injuries. Some burns are due to lack of supervision or childcare, which should be considered negligence.
Methods: We reviewed the age, department at first consultation, and social worker intervention from the medical records of 189 burn patients aged < 12 years between January 2016 and January 2019.
Results: Twenty-seven percent (50 children) of the patients were aged 12–23 months. The most common first consultation department was plastic surgery, followed by after-hours surgery and emergency surgery. In total, 5.8% (11 children) of the cases were reported to the child protection center for parenting-related interventions.
Conclusion: Pediatric burns due to negligence are often caused by dangerous home environments. Suitable interventions and support can prevent their recurrence. Cooperation with physicians, social workers, and nurses and continuous childcare support, even after discharge, are also important.

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Background: In cases of infectious thoracic aortic aneurysm (TAA), in which the omentum is unavailable, the aortic graft can be wrapped in a latissimus dorsi (LD) flap. However, it remains unclear which intrathoracic approach is best for LD flap application. We measured the intrathoracic approach in cadavers and assessed its outcomes in clinical cases.
Methods: In 20 cadavers, the distances between the origin of the left subclavian artery and the intersections of the second, third, and fourth intercostal spaces (ICSs) with the posterior axillary line were measured. Adequate approaches were used in five patients with infectious TAA who were followed up for 4–57 months.
Results: In cadavers, passing the LD flap through the second ICS dorsally enabled adequate wrapping of the total descending aorta. Passing the LD flap through the fifth to seventh ICSs enabled thorough wrapping of the distal descending aorta. The distance between the origin of the left subclavian artery and the intersection of the second ICS and posterior axillary line was shorter than that between the origin and intersections of the third or fourth ICSs and the line. Clinically, these approaches achieve a full-circumference wrapping closure. The infection was well-controlled, with no anastomotic failures.
Conclusions: The graft can be circumferentially wrapped when the LD flap is passed through the second ICS for the total descending aorta and through the fifth to seventh ICSs for the distal descending aorta. LD flaps may be a good alternative when the omentum is not available.

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Introduction: Debridement is critical for promoting healing of chronic wounds. Although the effectiveness of ultrasound debridement in wounds with biofilms is known, its clinical indications and limitations remain unclear. We report the results, indications, and limitations of the use of a new ultrasound debridement device for treating chronic wounds.
Materials and methods: The study included five patients with wounds (a total of seven wounds) covered by biofilms that were treated with ultrasound debridement from April to July 2021. To evaluate the efficacy of debridement, pre- and post-debridement photographs were compared and evaluated by three surgeons. The panel was ranked according to two criteria based on unhealthy granulation, necrotic tissue, and gel-like substance/film using a 5-point scoring system, with a maximum score of 10. A score of > 7 after debridement was considered successful debridement. The numeric and faces pain rating scales were used to evaluate pain.
Results: Four of the seven wounds were judged to have been successfully debrided. In wounds with a high percentage of hard necrotic tissues, debridement tended to be ineffective. The average debridement score was 5.7 for all patients and 9.2 for those without hard necrotic tissues. The gel-like substance was completely removed in all cases. Pain was mild, ranging from 1 to 3 on the numerical rating scale and from 1 to 2 on the faces pain rating scale. The bleeding amount was lesser with ultrasound debridement than with debridement using a sharp curette.
Conclusions: Ultrasound debridement is effective in reducing pain and removing biofilms with minimal bleeding. Its main applications include the removal of morbid granulation and soft necrotic tissues and gel-like substances. Ultrasound debridement is a good indication for use in conjunction with surgical or hydraulic debridement to facilitate the removal of hard necrotic tissues.

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Resurfacing the sole, especially the load part, is demanding, and the gold standard for reconstruction of this part has not been set at present. In this study, we successfully reconstructed a plantar forefoot with repeated calluses and ulcerations after trauma reconstruction, with a horny and strong split-thickness skin graft taken from the sole, using a combination of artificial dermis and negative pressure wound therapy. There was no recurrence two years after the surgery.

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We report an unusual case of a patient receiving prolonged steroid therapy, who underwent a tongue reconstruction surgery. The patient was diagnosed with tongue cancer (T3N0M0, stage III), who required right hemiglossectomy, right supra-omohyoid neck dissection, tracheostomy and reconstruction with a free radial forearm flap. The operation was completed without complications. Postoperatively, we suspected venous congestion, but recognized fresh bleeding from the flap paddle using pin-prick tests and good pulsatility of the anastomosed vessels. The flap color recovered within days and flap was tacked. Flap skin in patients receiving prolonged steroid therapy is fragile and easily develops purpura in the early postoperative phase. Traumatic maneuvers like frequent pin-prick testing are therefore inadvisable.

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Chopart amputation has many advantages over below-the-knee amputation because the lower limb length is preserved. Problems such as postoperative equinovarus deformities and ulcerations may be prevented using various methods. We performed Chopart amputation in two patients and instructed both to wear ankle-foot orthoses. As a result, the patients were able to walk with only mild postoperative difficulties. Subsequently, one patient suffered from contralateral foot gangrene and had a below-the-knee amputation. However, because of the remaining heel on the side of the Chopart amputation, he was able to use a wheelchair independently.
Chopart amputation is often avoided due to the aforementioned complications; hence, more proximal amputations, such as below-the-knee amputations, are usually performed. However, our results suggest that using an ankle-foot orthosis can reduce postoperative complications and that choosing Chopart amputation over below-the-knee amputation can improve patients' quality of life.

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