Postoperative thrombosis represents a potentially devastating complication of microvascular free-tissue transfer and is the most common cause of flap failure. We performed a retrospective review of 267 free flap transfers that were performed our institution from 2000 to 2014. During the study period, pedicle thrombosis was detected in 19 of the 22 free flaps that were re-explored emergently. The majority of re-exploration procedures were carried out within the first 48 hours, except in one case. Of these 19 flaps, 10 flaps were salvaged completely, and partial and total flap loss was seen in 5 and 4 flaps, respectively ( flap survival rate, 78.9 % ). In all 4 of the cases in which total flap loss occurred, the flaps were used to reconstruct head and neck lesions. Careful monitoring and urgent re-exploration are critical for salvaging compromised flaps. We demonstrate a technique in which small side holes are made in the vascular pedicle and the target thrombus is removed with dilator forceps. We consider that this technique is useful for achieving complete mechanical thrombus removal.
During nerve reconstruction, nerves of different thicknesses are often sutured together. When we suture thick nerves to thin nerves, differences in the number of contacting axon fibers are sometimes seen between end-to-side neurorrhaphy and end-to-end neurorrhaphy. We examined whether the type of neurorrhaphy affects the number or thickness of regenerated axon fibers. End-to-end neurorrhaphy resulted in a significantly greater number of regenerated axonal fibers after 6 weeks than end-to-side neurorrhaphy ; however, no such differences were seen at 12 postoperative weeks. While the regenerated axonal fibers were thicker at 6 weeks than at 12 weeks, no significant differences in axon fiber thickness were detected between end-to-end and end-to-side neurorrhaphy. We suggest that end-to-end neurorrhaphy results in greater numbers of regenerated axons and increased axon thickness during the early postoperative period. As rapid reinnervation is one of the most important factors influencing the restoration of target muscle function, we consider that end-to-end neurorrhaphy is desirable when suturing thick nerves to thin nerves.
We report two rare cases of median nerve fibrolipomatous hamartoma ( FLH ) . The first case involved a 31-year-old male who presented with numbness of the right fingers, palm swelling, and impaired thumb opposition. Carpal tunnel release and biopsy were performed because schwannoma was suspected based on the patient's magnetic resonance imaging ( MRI ) findings. However, the pathological diagnosis was FLH. Since intense numbness persisted for one month after the procedure, we resected an 18-cm section of the median nerve including the tumor and carried out nerve reconstruction with a bilateral sural nerve graft. In addition, we transferred the flexor digitorum superficialis of the ring finger to enable thumb opposition. In the thirteen years since the surgery, the patient has almost completely regained the sensation in the median nerve area and is able to perform thumb opposition. The second case involved a 20-year-old male, who presented with numbness of the right palm. FLH was diagnosed based on the patient's MRI findings, and carpal tunnel release was performed. Although the tumor has not grown since, the numbness of the palm persists.
A 33-year-old male suffered a severe Gustilo-type IIIB open fracture of the lower right leg after being run over by a car. As extensive soft-tissue loss was observed over a wide and complex area, reconstructive surgery was performed using latissimus dorsi musculocutaneous and serratus anterior flaps approximately two weeks after the incident. While the posterior tibial arteries and veins were selected as recipient vessels, revascularization could not be achieved, which resulted in avascular necrosis of the flaps. Thus, salvage surgery involving free flap reconstruction was conducted using the femoral arteries and veins as recipient vessels. This time, the procedure was successful. Tibial union was achieved within one year of the surgery, and the patient recovered to a point where he could engage in weight-bearing walking outdoors. Free omental flaps are an effective option for the reconstruction of injured extremities, where extensive soft-tissue loss is observed over a wide and complex area, no appropriate local recipient vessels are available, and there is an urgent risk of deep infection.
Achilles tendon defects associated with infection and skin defects are not uncommon. The three main problems that have to be addressed when treating such defects include the control of local infections, the provision of soft tissue coverage, and the restoration of ankle plantar flexion. The reconstruction of such wounds using conventional methods usually involves multiple procedures, and the functional results are not always satisfactory. We present a case involving segmental loss of the Achilles tendon associated with infection and the loss of skin and the surrounding soft tissue. The patient was successfully managed using a composite anterolateral thigh flap and vascularized fascia lata tissue. He was able to walk without any support at 16 postoperative weeks. At the latest follow-up ( at 2 postoperative years ), he exhibited a normal gait and was able to walk without pain and fatigue. He was also able to stand on his tiptoes and displayed normal plantar flexion strength. The combined use of an anterolateral thigh flap along with vascularized fascia lata tissue represents a useful option for the reconstruction of complex Achilles tendon defects.
The hand is easily damaged, and impact injuries often affect bones and joints in addition to skin and soft tissue. Thus, choosing an appropriate therapeutic strategy for such injuries is often challenging. Here, we describe a case in which a hand injury resulted in skin and osteochondral defects, which were reconstructed using a free flap and an osteochondral graft from the same upper extremity. A 23-year-old male crushed both upper extremities in a serious traffic accident. His right upper limb was minced from the shoulder to hand, and his left hand had a partial skin defect on the ulnar side and an osteochondral defect affecting half of the 5th metacarpal bone head. The right upper limb was too severely damaged to allow it to be salvaged so it was amputated from the shoulder. We therefore focused on saving the left hand. We initially planned to use a pedicle flap from the forearm to repair the skin defect, but the patient did not consent to this strategy. Therefore, we selected a lateral upper arm free flap. The osteochondral defect was reconstructed via capitate osteochondral grafting. The skin flap and osteochondral reconstruction procedures were both successful, and the patient was satisfied with the outcomes.
The use of a free jejunal transfer to reconstruct the defects produced during the resection of the pharynx, larynx, or cervical esophagus is becoming a standard approach. Jejunal flap necrosis due to inadequate blood circulation is a serious postoperative complication of jejunal transplantation. However, the methods used to evaluate implant blood flow in such cases vary among institutions. From January 2013 to January 2015, we monitored the blood flow through the mesentery using a pencil Doppler probe in eight patients. The monitoring was ceased after the viability of the jejunal flap had been directly confirmed using an endoscope. No abnormalities were detected during the Doppler scans, and no postoperative complications occurred in these patients. The setting up of the monitoring equipment was easy, and we were able to evaluate the blood flow of the implants directly and indirectly. Thus, the monitoring of mesenteric flaps using a pencil Doppler probe is useful for evaluating postoperative blood flow in transplanted intestines.
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