The purpose of this article is to the present the surgical technique of “network-like reconstruction” based on the neural signal augmentation / neural supercharge concept for the treatment of reversible facial palsy patients. With construction of the facial-hypoglossal network system using the end-to-side neurorrhaphy technique, both facial and hypoglossal motor signals are provided to the compromised facial mimetic muscles. The remaining potential of incompletely or completely paralysed muscles without atrophy is activated by a neural ‘supercharge’ effect. This reconstructive concept offers a significant advantage for the treatment of facial palsy patients with persistent incomplete type and reversible complete type without distinct mimetic muscle atrophy. In this article, the procedure of network-like reconstruction is shown by the presentation of a movie file.
The development of microvascular surgery has been contributed the patients' quality of life after the expanded resection of malignant tumor or large tissue defect caused by trauma. On the other hand, vascular complication, such as thrombosis, relates to the flap necrosis and strict monitoring of flap condition is necessitated. We basically monitor the flap every 4 hours for 5 days by inspection or palpation. In addition, we have been introduced blood glucose measurement, regional oxygen saturation index ( rSO2 ), pulse oximeter ( SpO2 ) and indocyanine green fluorescent ( ICG ) imaging for flap auxiliary monitoring. Because each of those methods has advantage and disadvantage, understanding of characteristics of each methods may helps us the earlier detection of vascular trouble, which directly relate to the flap salvage rate.
The goal for foot reconstruction is to restore the structure and walking function. To achieve this goal, it is important to assess precisely the defects in anatomical structure, residual function, reconstructive procedure, and postoperative therapy, including rehabilitation and fitting of braces or footwear. We experienced twelve free tissue transfers and thirteen pedicle skin flaps for foot reconstruction in our hospital or branch hospitals. In all cases, tailored braces or footwear were used postoperatively under advice from a prosthetist. The free flaps we selected were: one rectus abdominis musculo-cutaneous flap, six latissimus dorsi musculo-cutaneous flaps, three groin flaps, a free scalp flap, and a scapular flap. Two of the patients who underwent free latissimus dorsi musculo-cutaneous transfer had a failed procedure due to vascular thrombus. The pedicled flaps we used were: six distally based sural flaps, five medial plantar flaps, and two lateral calcaneal flaps. Partial flap necrosis was encountered in two of six distally based sural flaps. Ulceration developed in one flap due to bulkiness. As restoring foot contour is ideal for foot reconstruction, we conclude that using thin flaps or thinning of flaps avoids bulkiness. Subsequent footwear fitting is also very important.
Between January 2001 and July 2011, we treated 11 severely injured extremities from 11 patients ( mean age, 58 years; range, 16 to 92 years; 8 men ) with bone and soft tissue reconstruction using vascularized tissue transfers. There were five traffic accidents, four work-related injuries, one farm injury, and one sports injury and two closed and nine open fractures ( 2 IIIA and 7 IIIB ). Reconstruction procedures were latissimus dorsi flap for the forearm in one, radial forearm flap for the foot in one, latissimus dorsi flap and vascularized fibula for the thigh in three, vascularized fibula for the lower leg in five, and vascularized ilium for the lower leg in one. All flaps survived, and bone union was achieved in all patients. All three patients with reconstructed thighs could walk without support. One fistula around a grafted fibula was treated with negative pressure wound therapy. Of six patients with reconstructed lower legs, four could walk without support, but 2 died from unrelated causes. One patient with a reconstructed forearm had moderate range of motion but returned to farming. Vascularized tissue transfers that enable simultaneous reconstruction of composite tissue defects require long operative times and are highly individualized to each patient. Therefore, careful preoperative planning is essential for selecting donor and recipient vessels and for reducing the risk of tissue transfer to obtain maximum functional results.
In skin flap transplantation, the lymph vessels are not usually anastomosed but remain severed. Although studies have shown spontaneous regeneration of lymphatic channels from flap to regional lymph nodes via lymphoscintigraphy, the lymphatic drainage pathway changes that occur after flap transfer are unclear. Here, we observed lymphatic flow around flaps using indocyanine green ( ICG ) fluorescence lymphangiography in 12 patients. In all cases, the flaps were transplanted after resection of malignant tumors in the extremities. We injected ICG into the normal skin distal to the flap and then observed the lymphatic flow through the flaps. Normal lymphatic flow ( linear pattern ) in the flap was not observed; rather, in most cases, diffused dye patterns ( stardust or diffuse ) arising from extravascular fluorescence were observed. This finding indicates that an anatomically functional normal channel in the flap was not regenerated in these cases. We presume that flap layout, flap size, postoperative duration, radiation therapy, and scarring around the flap affect lymphangiogenesis through the flap. Since ICG fluorescence lymphangiography is limited, especially for visualizing the deep lymphatics, its combination use with other methods is needed to clarify the three-dimensional lymphatic pathways around the flap.
For patients with an unresectable tumor or a huge tumor on the body surface with metastasis, palliative surgery can be performed to address issues of odor, bleeding, pain, or infection associated with tumor involvement to improve quality of life ( QOL ). We report herein a rare case of a 38-year-old woman who presented with a large soft-tissue tumor in the left thigh measuring 22 × 20 × 15 cm. Tumor growth had first been noticed 6 years earlier, with a progressive increase in size. Histopathological examination showed myxoid / round cell liposarcoma. Palliative free flap transfer was selected due to the possibility of tumor disintegration and massive bleeding, although disease stage had already progressed. We removed the sarcoma with inadequately wide margins, and performed reconstruction with a free latissimus dorsi musculocutaneous flap. The patient died on postoperative day 102, but massive bleeding from the sarcoma and dyspnea from rapid growth of pulmonary metastasis could be prevented. We believe that palliative free flap transfer in this patient improved QOL and quality of death.