Massive soft-tissue defects in extremities greatly increase the risk of infection. Repeated debridement and irrigation at 48-to 72-hour are vitally important for both prevention and treatment of infection. However, the appropriate times of debridement and irrigation before reconstructive surgery to minimize postoperative infection or to control an established infection have not been clarified. We collected and cultured tissue samples at the end of every surgical debridement of massive soft tissue defects with or without fractures in 9 patients. In seven of these 9 cases, the bacteria that were cultured from the wound completely disappeared after repeated debridement and irrigation and they did not show no deep tissue infection was shown, even two years after the wound closure using a free flap. Meanwhile, in two of the 9 cases, bacteria were cultured from the wound despite repeated debridement and irrigation. Unfortunately, these two cases showed deep tissue infection after reconstructive surgery. We demonstrated that repeated debridement and irrigation at 72-hour intervals until bacteria are not detected in a wound might be one of the most important indexes for appropriately deciding on the number of operations before reconstructive surgery to prevent or control infections in the extremities.
Simple methods producing good outcomes in the treatment of lymphedema include manual lymphatic drainage and decongestive lymphatic therapy using a compression bandage (DLT). DLT represents the first treatment for lymphedema regardless of the underlying etiology (primary, secondary or its clinical stage). The International Society of Lymphology has stated that "complex decongestive physiotherapy (CDP) for lymphedema is proved to be effective by the long experience and involves a two-phase treatment program that can be applied to both children and adults." CDP is a program consisting of two phase-dependent treatments and is the international standard therapy for lymphedema. Regarding surgical treatment, no randomized clinical trials or comparative studies of surgical treatment were available, but recently a microsurgical technique including lymphaticovenous anastomosis (LVA) has been reported with good outcomes. We reported several series of upper limb lymphedema cases treated by microsurgical lymphaticovenous implantation (MLVI) combined with compression therapy. We have recently introduced both ultrasonography for mapping the subcutaneous vein and indocyanine green fluorescence lymphography for information on the dermal backflow of lymph fluid. Compression therapy with a bandage was applied 6 months preoperatively and 6 months postoperatively in our series. This combined technique provides increased lymphatic flow through newly created lymphaticovenous bypasses by MLVI surgery, with assistance for pumping function in the lymphatics by compression therapy. In this article, we present how we combined the MLVI and conservative treatment as a simple method for a good outcome.
From an esthetic perspective, we need to choose color-matched and texture-matched flaps for reconstruction of exposed parts. We reviewed flap surgical procedures and evaluated the final appearance in free flap reconstruction of exposed parts over the last decade. Sixty patients with lesions of exposed parts underwent free flap reconstructions between 2002 and 2011. There were 32 males and 28 females. The average age was 40 years. The lesions were located in fifteen head and neck parts, eleven lower thigh parts, and nine foot parts, among others. Thirty patients received free latissimus dorsi flaps, ten free fibula flaps, and nine free anterolateral thigh flaps, among others. Average follow-up period was 50 months. Final appearances were scored out of four in terms of meshed skin graft, unevenness, and color match, and finally classified into four grades: excellent, good, fair, and poor. The survival rate of free flaps was 93.5%. Twenty-four patients required additional surgical procedures, such as defatting and scar revision. Esthetic results were excellent in eight, good in sixteen, fair in twelve, and poor in five. The final appearance was quite good, as the percentage of excellent and good results was approximately 60%. However, we need to continue to improve the esthetic results.