In this paper we analyzed the results of our experiment on a thermal-type blood flow micro-sensor that was designed to detect the flow rate change caused by a thrombus. An animal experiment was performed to evaluate this sensor using a rabbit model. The sensor was inserted into a small vessel directly or through its branches. The temperature inside the vessel rose in 10 seconds when the vessel was clamped and it dropped in 3 seconds when the vessel was opened. The sensor was able to monitor the changes in blood flow immediately. Similar results were observed when the sensor was inserted in a vein. The high sensitivity of the sensor, the flow velocity in the range of 0-1 cm/s, enables the detection of blood flow reduction caused by thrombus formation in a vein. This sensor can be a useful device in clinical settings because it can detect clot formation at the anastomosis.
Perforator-based flap surgery requires precise preoperative detection of suitable vascular pedicles. Indocyanine green fluorography has recently been developed to visualize subcutaneous arteries through the skin surface for this purpose. The examination is performed one or two days before the flap surgery. Patients are injected with indocyanine green intra-arterially or intravenously and fluorescence from subcutaneous arteries is recorded with an infrared video camera system. Practical pictures of a subcutaneous artery can be obtained for preoperative evaluations of the nutrient vessels of a skin flap and the blood flow within a skin flap. Compared with other imaging techniques such as CT angiography and ultrasonic Doppler flowmetry, indocyanine green angiography provides an advantage in identifying precise blood flow of subcutaneous arteries in two-dimensional visualization, which makes it possible to directly apply the information thus obtained to the planning of skin flaps. This method is considered to be a useful preoperative clinical examination that can improve the safety and reliability of flap surgery.
The present training system for microsurgery involves passage from suturing of silastic tubes to practice with experimental living animals or cadavers. However, these methods are neither convenient nor practical for daily exercises. Also there is an issue with animal ethics. I present a unique training exercise course for plastic surgical residents in our institute, from 2007. METHODS: 1) Latex sheet and chicken wing artery were used for microsurgical training. 2) Video-recordings of microvascular anastomoses using these models were presented at our conference. 3) After the conference, instruction under operating microscope was performed for the beginners. RESULTS: Several advantages of this course are noted: 1) the materials are cheap, convenient to manage, and easy to obtain, and neither specific facilities to maintain living animals nor anesthesia is needed. There is also no issue with animal ethics. 2) Video presentation at the conference enables us to evaluate and advise for the basic microsurgical skill of all residents within a limited time. 3) After the conference, instruction under operating microscope was performed for two residences. Significant improvement in their skills was demonstrated after the practice. CONCLUSION: This exercise course was useful especially for young surgeons who wish to learn microsurgical techniques.
In finger tip replantation, venous anastomosis is often a difficult procedure. Instead of venous anastomosis, phlebotomy by fish mouth incision, removal of the nail bed, or delayed venous drainage, is performed. But these treatments are not always effective. We performed palmar plexus salvage procedure for venous drainage reported by Tanabe et al. in 2006 in 3 cases (5 fingers: index 1, middle 2, ring 2) after finger tip replantation with venous congestion. In our cases, 4 fingers were successfully treated and 1 finger failed. This procedure is easy to perform for venous congestion. The complication in our cases included delayed epithelization, delayed sensory recovery, and flexion contracture, especially in elderly patients.
The perforator flap poses a potential number of problems; spasm, kinking, injury of perforators etc., though it is a less invasive method of reconstruction. The muscle-sparing thoracodorsal artery perforator (TDAP) and the lateral thoracic branch-based conjoined flap was harvested. This conjoined flap has two different types of vascular systems; perforators of the descending branch of the thoracodorsal vessels and the direct cutaneous vessels of the lateral thoracic vessels (LTA/V). We can take advantage of these two different vascular systems by vascular augmentation using the LTA/V or conversion into the mosaic type flap with anastomoses between the LTA/V and the serratus branches of the thoracodorsal vessels, in case of vascular compromise. We have successfully managed to salvage a flap with venous congestion without any necrosis using the super-drainage procedure. This “insurance”; the muscle-sparing TDAP and lateral thoracic branch-based conjoined flap can be a great safety net in case of vascular trouble with a small premium of only an additional ten minutes of dissection for the lateral thoracic vessels. This is particularly important when you have to rely on tiny perforators.
Reconstruction of large skeletal defects is a challenging. The purpose of this study was to evaluate the use of a free vascularized fibular graft (FVFG) combined with a locking compression plate in the treatment of large skeletal defects in the upper extremities. Seven patients (age range 5-58 years; mean age, 28 years) with upper extremity skeletal defects were treated with FVFG and a locking compression plate. Of these, 6 patients required reconstruction because of tumor resection and 1 because of traumatic bone defect. The mean follow-up time was 25 months. Grafting union occurred in all patients, except in 1 patient because of death, with a mean healing time of 4.6 months. No additional operation for nonunion and/or delayed union was performed. FVFG combined with a locking compression plate is a useful tool for reconstruction of large skeletal defects in the upper extremities.
Free vascularized osteoperiosteal bone graft harvested from the medial femoral condyle is an effective tool to treat nonunion or necrosis of bone. It can be taken as a thin pliable osteoperiosteal bone or a small corticocancellous strut bone. The former is suitable for being wrapped around the site of nonunion of long bones and the latter can be packed into a small bone defect created after curettage of necrotic bone. We treated seven cases with bone nonunion (ulna, clavicle, scaphoid, talus and intercarpal space after the four corner fusion: each one, radius: 2) and three cases with osteonecrosis (capitulum of the humerus: 1 and talus: 2) using this graft. In all cases, the descending genicular arteries were present. Bone union was achieved in all cases except the patient with nonunion of the ulna. In the patient with systemic lupus erythematosus demonstrating the talus necrosis, the talus was collapsed within two years after surgery although the transplanted bone was confirmed to survive by MRI examination. Numbness appeared in the area innervated by the saphenous nerve of the donor legs in six patients including five patients from whom monitoring skin flaps had been simultaneously harvested.
There are many reported cases of free flap reconstruction for facial deformities however, our thorough search of the literature revealed only 2 such cases arising from lupus erythematosus profundus. In this paper, we report our experience from the reconstruction of a contracted, lupus scar due to long-term internal administration of prednisolone. A free DIEA dermal-fat flap was used with a good outcome to reconstruct an area of pitted atrophy on the left side of the face. A 65-year-old female was diagnosed with systemic lupus erythematosus(SLE)around the year 2000 and began treatment by internal administration of prednisolone ordered by a local dermatologist. Lupus erythematosus profundus developed concurrently in 2005 and led to a severe facial pitting deformity. The illness subsequently remitted, and the patient was referred to our department for reconstruction. A skin flap configuration was devised to minimize the absorption of fat at the atrophic focus, where circulation was regarded as poor, and to prevent hardening of the reconstructed cheek region, and a good outcome was obtained. Currently at 1 year postoperatively, fat volume is adequate on palpation, and flexibility is also reconstituted.
Pasteurized autogenous bone graft combined with a vascularized fibula graft is a good surgical option for the reconstruction of wide bone defects after resection of bone tumors, but their long-term follow-up results are still unclear. We reviewed the long-term follow-up of pasteurized autogenous bone graft combined with a vascularized fibula graft in 4 patients with leg malignant bone tumors. And we assessed the bone union, late postoperative complications and function. The mean duration until bone union of the vascularized fibula graft was 10.8 months, those of the pasteurized autogenous bone graft was 15.2 months and those between the vascularized fibula and the pasteurized autogenous bone graft was 13.0 months. Complete bone union was achieved in all patients. Late postoperative complications included one pseudarthrosis between pasteurized autogenous bone graft and preserved greater trochanter bone, and one fracture. We performed an autogenous cancellous bone graft on the patient with pseudarthrosis. Long term follow-up results revealed a good functional result and no bone resorption. All patients can walk without any kind of external support. Our results showed that pasteurized autogenous bone graft combined with vascularized fibula for reconstruction of wide bone defects after resection of bone tumors, could provide considerably good postoperative function without serious complications in long term follow-up.
Successful replantation is an ideal treatment for fingertip amputation. However, reestablishment of venous outflow is often difficult because the volar vein in the fingertip is very small. Several techniques have been described to obtain satisfactory outflow from replants. However, these techniques are not always applicable. When reestablishment of venous outflow is impossible, we intentionally reduce the pulp volume of the replant, excising pulp tissues to the center of the fingerprint of the distal phalanx and anastomose a digital artery as distally as possible. We applied this technique in eleven cases, and the graft survived in ten of these cases. We performed artery-only replantation with this intentional volume reduction technique, and the success rate was 90%. Fingertip replantation with artery-only anastomosis in Ishikawa's subzone 1 and 2 was reported to show a higher success rate than those in subzones 3 and 4. These observations indicated that a smaller replant volume is associated with a higher rate of successful replantation similar to composit grafts. We hypothesize that a small-volume replant may survive as a composite graft with supercharging artery inflow. This technique may be useful as a last choice for artery-only fingertip replantation when reestablishment of venous drainage is impossible.