Lymphedema is a progressive debilitating edematous disease, which significantly worsens the quality of life of cancer survivors. With the advancement of supermicrosurgery that enables secure anastomosis of vessels with a diameter of 0.5 mm or smaller, lymphatic supermicrosurgery has been developed. Lymphaticovenular anastomosis ( LVA ) is one of the lymphovenous shunt operations. It is the most convenient surgery that addresses the pathophysiology of obstructive lymphedema, but has a risk of thrombosis and is likely to be ineffective for progressive lymphedema with severe lymphosclerosis. To minimize the risk of thrombosis at the anastomosis site, lymphaticolymphatic anastomosis ( LLA ) is useful. LLA can be applied when an intact recipient lymphatic vessel is available, such as in cellulitis-induced lymphedema cases. As well as LVA, LLA is hardly effective for progressed lymphedema. For progressed lymphedema, vascularized lymph node transfer ( LNT ) is useful. Most surgeons perform LVA only with vascular anastomosis, but it is desirable to bypass an efferent lymphatic vessel included in a transferred lymph node flap for complete lymphatic bypass because approximately half of lymph fluid drained into a lymph node flows into the efferent lymphatic vessel. Lymphatic supermicrosurgery allows various lymphatic reconstructions in an optimal way.
Reconstruction with like tissue transferred from the feet is a good alternative to restore function and appearance for severe injuries of the hand. The purpose of the current study is to report the clinical results of free tissue transfer from the feet for severe injuries of the proper digits. Eight male patients aged 18 to 58 years ( mean 42 years ) underwent reconstructive surgery. The number of involved fingers was 8, including 4 severe soft-tissue injuries of the digits, three complete amputations, and one ankylosis of the proximal interphalangeal joint after digital amputation. Two fingers were reconstructed with the use of a hemi-pulp flap, two with a medialis-pedis flap, one with a wrap-around flap, one with an osteo-onychocutaneous flap from the big toe, one with second toe transfer, and one with vascularized proximal interphalangeal joint transfer from the second toe. All flaps survived. At the final follow-up, the mean total active motion was 55 % and the mean grip strength was 61 %, compared with those on the contralateral side. A strong relationship between the waiting period from the injury to reconstructive surgery and return to work after the operation was observed ( R = 0.71, p < 0.05 ). The results of free tissue transfer from the feet for severe injuries of the proper digits were satisfactory. Early reconstruction is preferable for an early return to work.
Success in free flap transfer depends on the maintenance of optimal perfusion postoperatively. This need for rapid correction of thrombosis mandates accurate monitoring of tissue perfusion. In this study, we aimed to analyze blood glucose and lactate measurements for flap monitoring that can show the presence of venous thrombus and aid in decision-making, in terms of whether to reoperate or not. We evaluated 6 flaps. Blood flow disorder due to a venous thrombus was found in 1 flap. The mean blood glucose level in the congestive flap was significantly lower and the lactate level was higher than those in the other healthy flaps. This flap was salvaged by reoperation. Accurate monitoring and urgent reexploration are critical for the salvage of compromised flaps.
Twelve patients ( 9 males and 3 females, aged between 37 and 74 years ) underwent osteocutaneous free flap harvesting between April 2008 and December 2013. Reconstruction was performed for bone defects that resulted from tumor resection or osteonecrosis of the mandible. We investigated the functional outcome of the donor site. Scapular body fractures were detected in 4 patients. In these patients, the mean ratio of the length of the harvested bone graft to that of the scapular lateral wedge was 77 %, which was significantly greater than that in the patients without postoperative scapular fracture ( 62 % ). We considered that there would be a risk of postoperative scapular body fracture as a risk in the donor site after harvesting a scapular bone graft, especially when the graft length is over 70 % of the lateral scapular wedge. The shoulder function of the donor site was satisfactory at one year after surgery in all of the patients with or without a scapula fracture.
The purpose of this study was to examine the outcomes of vascularized bone grafts ( VBGs ) from the distal radius with external fixation for the treatment of Preiser’s disease. Two patients with Preiser’s disease who underwent VBG surgery based on the 1, 2 intercompart-mental supraretinacular artery were placed in an external fixator for 10 weeks after grafting. Diagnosis was based on radiographic findings of sclerosis, fragmentation, and scaphoid collapse in the absence of any clear antecedent trauma. Both patients underwent preoperative magnetic resonance imaging ( MRI ) scans that confirmed the diagnosis of avascular necrosis of the scaphoid. Postoperative evaluations included a pain evaluation ( visual analogue scale ), X-ray, MRI, disability of the arm, shoulder, and hand ( DASH ) evaluation, and modified Mayo wrist scoring. A 53-year-old woman was classified as having Herbert stage 3 and Kalainov type 1 disease, and a 67-year-old woman was classified as having Herbert stage 4 and Kalainov type 2 disease. Both patients showed evidence of revascularization, with improvements on T1 and T2 MRI ; however, incomplete revascularization of the entire proximal pole was observed in the 67-year-old patient. In both cases, the clinical results were satisfactory ( modified Mayo wrist scores of 95 and 80 points, respectively ). VBGs are an efficacious treatment for Preiser’s disease and are thus a recommended surgical treatment.
Large defects of the heel and plantar area caused by trauma represents a challeng for reconstructive surgeons. The aim of this report is to review three cases of soft-tissue defect of the heel and plantar area that were reconstructed by free flaps in our institution. The average age of the patients was 52.0 years old, with a mean defect size of 385cm2. Free latissimus dorsi (LD) flap was used in all cases. One case combined medial plantar flap was applied using the chimeric flap technique, and in another case, combined scapular flap was applied using the same pedicle. Sensory nerve coaptation was not performed for any of the flaps. Fasciocutaneous lesion of the flap covered the weight-bearing area and the non-weight-bearing area was covered by a myocutaneous area with split-thickness skin graft. The mean follow-up period was 3.5 years. There was no loss of flaps. The patients regained walking and daily activities without orthosis after multiple secondary operations, mainly debulking operations. Our experience showed that, even using non-sensory tissue, covering a large defect with a free latissimus dorsi flap and covering the weight-bearing area with fasciocutaneous tissue are keys to successful soft-tissue reconstruction.
Medical plantar flap is used for the reconstruction of plantar skin defects in weight-bearing areas. However, this flap is indicated for proximal areas such as the heel. To reconstruct distal areas, the flap should be a reverse-flow flap, as reported for the feeding artery. In this report, we present two cases of medial plantar flaps vascularized by reverse-flow lateral plantar artery. In case 1, a 46-year-old man had squamous cell carcinoma. The tumor was excised. The resultant defect was covered with the flap, which was removed by V-Y plasty. The distally removed distance was about 5 cm. In case 2, a 19-year-old man had a chronic ulcer of the left foot laterally. His past medical history included spina bifida and myelomeningocele. Therefore his foot had mild clubfoot deformity and decreased sensation. The flap was applied and covered the skin defect completely. The edge of the flap reached a distance of 7 cm laterally. However, the flap was congested, so we performed venous anastomosis. The flap is useful for lateral plantar skin defects. Venous anastomosis is required if the flap may be congested.
There are many reconstruction methods for single fingertip injuries; however, for cases of multiple fingertip injuries, there is no established reconstruction method. Therefore, we used the medialis pedis flap for two cases of multiple fingertip injuries, one of which involved the index and middle fingers and the other the index, middle, and ring fingers. All cases became congested at the end of the flap. However, the flaps completely survived and had a protective sensation. The medialis pedis flap has a good color match, texture, and thickness for finger reconstruction. However, there are some problems in cases of multiple fingertip injuries, including flap congestion and flap cutting surgery for finger separation. The addition of cutaneous vein anastomosis will reduce the flap congestion. Moreover, we should wait sufficiently to cut the flap because range of motion exercises can be performed with no flap separation, which results in less contracture of the joints. The medialis pedis flap is a recommended method for the reconstruction of multiple fingertip injuries.
Möbius syndrome, a congenital neurological disorder, is defined as the combination of bilateral facial nerve palsy and abducens nerve palsy that is congenital and nonprogressive. The etiology is unknown and it is thought that disturbances in the 7th and 8th cranial nerves are caused by abnormalities in brainstem genesis, brainstem ischemia in fetal life, or gene depletion. The degree of facial nerve palsy varies from plegia to paresis and the selection of motor source is the most difficult factor in dynamic reconstruction with neurovascular transfer of a myocutaneous free flap. We experienced a case in which we chose the hypoglossal nerve as the motor source in dynamic reconstruction with a myocutaneous free flap for facial nerve palsy due to Möbius syndrome. At 7 years of follow-up, symmetrical appearance of the face at rest with natural smiling was observed.
We report a case of rheumatoid arthritis (RA) with radioulnar impingement that developed with radial head excision after the Sauvé-Kapandji (SK) procedure, and was treated with distal radioulnar joint reconstruction by using a vascularized free bone graft. A 48-year-old woman underwent the SK procedure for RA of the left wrist at another hospital at age 33. Five years later, aggravated arthritis of the ipsilateral elbow was noted, and synovectomy and radial head excision were performed. However, she experienced wrist clicking with pronation and supination of the operated forearm, and prolonged impairment of activities of daily living (ADL). Ulnar head reconstruction with a free vascularized fibular graft and syndesmoplasty of the annular ligament by using the palmaris longus tendon were performed. Bone fusion was achieved three months after the surgery, and the angles of pronation and supination were 55 and 80 degrees, respectively. The wrist clicking with pronation and supination noted before the surgery disappeared, and ADL showed improvement. At present, 18 months after the surgery, no recurrence of the symptoms or progression of degeneration of the reconstructed distal radioulnar joint has been observed on radiography.
Hypoplastic thumb can range from a slight decrease in thumb size to complete absence of the thumb based on the modified Blauth’s classification. Pollicization of the index finger is indicated for cases with Blauth type IIIB or greater. We present a case of bilateral hypoplastic thumbs with syndactyly of the index fingers, both of which could not be identified by Blauth’s classification. We sequentially performed pollicization of the index finger. There were several anomalies in the index finger, which further required modifications in the pollicization procedure. Tip and pulp pinches as well as precision grip were achieved by 11 months after pollicization on the right hand. Meanwhile, functions were more restricted on the left hand, probably due to initial low quality of the left index finger. This type of hypoplastic thumb should be distinguished from the typical hypoplastic thumb classified by Blauth, in terms of embryogenic background and strategy of thumb reconstruction.