Purpose: To demonstrate the usefulness of color Doppler ultrasound (CDU) in identifying perforators, the survival rate of flaps with perforators that were solely inspected by CDU was studied while evaluating data obtained by CDU. Methods: Twenty one patients scheduled for perforator flap surgery from 2004 to 2012 were examined preoperatively by the author solely by CDU to detect perforators. From the penetrating point to the skin end, the entire length was included in the design. Studying the survival rate of the flaps, data including peak systolic velocity (PSV), resistance index (RI), acceleration time (AT), and diameter of perforators were evaluated. Horizontal length of the perforator was calculated by dividing the depth by the tangent of angle at which the perforator intersected with the horizontal plane. Result: All of the flaps survived completely. The perforators detected by CDU coincided with the actual perforators. The lowest PSV was 7.2cm/sec and all the results of AT were normal. The values of RI were more than 0.7 in 13/16 cases, which indicates that modification of normal values is needed. The longest horizontal length was 5.7cm leaving a possibility of false positive by Doppler flowmetry in detecting the penetrating point of the deep fascia. Conclusions: Color Doppler ultrasound is very useful in designing perforator flaps and provides an opportunity to rate the perforators. It might be safe to choose a perforator with a PSV is more than 8cm/sec and AT less than 0.1s. The normal value of RI needs to be modified.
The submental flap is a minimally invasive option in head and neck reconstruction, because elevation of the flap is simple and accompanied by low donor site morbidity. In this study, we utilized the submental flap after ablative surgery of head and neck cancer for 6 patients. There were no complications except one partial flap loss. The reason for partial flap loss was the deficiency of skin perforator from the submental artery around the lateral border of the anterior belly of the digastric muscle. As a recent cadaveric study demonstrated that skin perforators were mostly located around the medial border, rather than the lateral border of the anterior belly of the digastric muscle, it might be desirable to center the skin island of the flap around the medial border. The submental vessels are located in the submandibular region, which is the frequent site of nodal metastases from head and neck cancer. When using the submental flap for head and neck cancer patients, preoperative evaluation of negative nodal metastases in the submandibular region (level I) is essential. In addition, preparation of countermeasures in case of encountering possible nodal metastases during flap elevation would be desirable. With sufficient knowledge of the anatomy of the submental artery and its skin perforator, the submental flap can be used safely for head and neck cancer patients.
A successful facial nerve reconstruction provides not only powerful facial movement but also a natural looking smile. However, one unfavorable result of reanimation is mass movement. To prevent this, we use cross face nerve grafting (CFNG) to reconstruct the orbicularis oculi muscle, and hypoglossal- facial anastomosis (HFA) to reconstruct the zygomatic major muscle. We performed 16 HFAs. All patients had presented unilateral complete facial paralysis. The result of facial nerve function was assessed by the modified House-Brackmann grading scale 12 months after operation. Our results were: excellent (2), good (7), fair (2) and poor (5). Especially with the successful cases, the period of paralysis before surgery was within 6 months. To get successful result, the length of duration between the onset of facial nerve palsy and operation should not exceed 6 months.
In this study, we aimed to analyze the utility of free flaps or pedicle flaps for the treatment of soft tissue defects in patient with Gustilo type III B and III C open fracture of the lower limb and the associated outcomes. We retrospectively evaluated 7 patients. The mean follow-up period was 17 months (range: 12-23 months), and the mean patient age was 48 years (range: 23-65 years). Radical debridement and temporal external fixation or pinning were performed on the day of injury, and soft tissue reconstruction was performed from 2-28 days after injury. Flaps survived in 5 patients. Negative pressure wound therapy (NPWT) was initiated for 2 patients, during the interval between initial debridement and definitive soft tissue coverage with the flaps. Flap failure caused by arterial thrombosis and infection was noted in 2 patients. Six patients achieved bone union and were able to perform full-weight bearing exercises. One patient underwent amputation of the limb below the knee. These results suggest that adequate debridement and short-term NPWT may improve clinical outcomes in patients with Gustilo type III B open fracture of the lower limb.
Instead of achieving good sensory recovery, the range of movement of replanted fingers in Tamai Zone IV may not always be satisfactory because of joint stiffness or extensor tendon adhesion around the replantation site. We discuss herein the efficacy of treatment of lacerated lateral bands on range of motion in eight patients (11 digits) who underwent digital amputation in Zone IV. All digits underwent both flexor digitorum profundus and central slip repair. No digits underwent flexor digitorum superficialis repair or primary arthrodesis of the PIP and DIP joints. Both lateral bands were repaired in five digits; in the remaining six digits, both lateral bands remained ruptured. Overall, the total range of active motion (TAM) averaged 77.4° (range, 40°-133°). The average TAM was 84.6° (range, 45°-133°) in the digits that underwent lateral band repair compared with 71.3° (range, 40°-123°) in the unrepaired digits. There was no difference in TAM or DIP joint motion, regardless of whether the lateral bands were repaired. Our findings suggest that repair of lacerated lateral bands is not beneficial for recovery of TMA in replanted digital units.
In general, woman with greater BMI tend to have larger breast. Obesity is one risk factor in breast reconstruction, as it can lead to difficulty in breast reconstruction. However, reports on breast reconstruction in obese patients are limited in Japan, because Japanese woman are thinner than Western woman. We performed large-breast reconstruction using free deep inferior epigastric perforator (DIEP) flap following mastectomy in an obese patient with BMI of 35 and E-cup. Postoperatively, this patient developed some minor complications, which were atelectasis, wound infection and seroma. However, these complications were managed non-operatively and flap survived completely. In breast reconstruction in obese patient, care must be taken during the procedure and post-surgical complication may be more common than in ordinary patients. We were able to safely and successfully reconstruct this patient’s breast using a free DIEP flap.
Two cases of severely injured ankle joints were successfully treated with vascularized iliac bone grafting and Ilizarov external fixator. The first case was due to persistent ankle tuberculosis. The second case was caused by collapse of the talus after total ankle arthroplasty. In both cases, there were serious bone defects after debridement of a large amount of diseased tissue surrounding the ankle joint. For delivery of antibacterial drugs through healthy vascularized bone in the first patient, and for augmentation of healthy bone stock to the collapsed talus in the second patient, a vascularized iliac bone transfer was performed. Ilizarov fixator was used for postoperative immobilization and early weight bearing without negative influence to the grafted bone. As a result, the grafted bones successfully survived and bone unions were achieved in both patients. Since vascularized iliac bone graft has a rectangular shape and rich cancellous bone, it is a very good candidate for use in devastating bone defects of the ankle joint. Further, combination with Ilizarov fixator enables the patient to bear weight in the early postoperative phase.
We present a case of tardy nerve palsy resulting from carbon ion radiotherapy (CIR) that was treated by neurolysis and wrapping technique with an adipofascial flap. A 51-year-old woman, who had undergone CIR for treatment of epithelioid hemangioendothelioma in the right forearm, suffered from median and radial nerve palsy after a two year period. The patient had severe neuropathic pain in the forearm and progressive radial and ulnar nerve palsy. External neurolysis of the involved nerves was performed, and the lesions were enveloped with a radial forearm perforator adipofascial flap for the median nerve, and a lateral upper arm adipofascial flap for the radial nerve. After the operation, recovery of the motor palsy was limited, though the neuropathic pain was eliminated. CIR for lesions, including the main nerve trunk, should be carefully considered because of the difficulty of surgical treatment for tardy nerve palsy due to carbon ion radiotherapy.