In reconstructive surgery, a high-quality flap must be planned based on the condition of the skin defects. One type of high-quality flaps is a thin flap, which has superficial fat lobules just under the dermis. A super thin flap is a flap in which most of the superficial fat lobules have been removed. If the fat lobules are reduced preserving the polygonal venous network just under or in the dermis, blood circulation within the super thin flap is guaranteed. The drainage vein following the polygonal venous network becomes a concomitant vein along the nutrient artery of the flap or a large cutaneous vein, which is independent of the nutrient artery. How the drainage vein is treated is important for flap survival. In some cases, a large cutaneous vein is needed to anastomose with a vein at the recipient site.
Anteromedial thigh flaps are rarely used because they have several source vessels and the perforator may not exist. We preoperatively found the perforator of the branch of the rectus femoris muscle using color Doppler ultrasonography, and harvested the anteromedial thigh flap based on its perforator in 3 cases. The skin defects were located on the dorsal side of the great toe after toe transfer in 2 cases, and on the dorsal side of the thumb and ring finger after trauma in 1 case. The flaps used were a one-staged thinning flap in 1 case, a sensory flap in 1 case, and chimeric flaps, including an anteromedial thigh flap and a tensor fascia lata perforator flap, in 1 case. The perforator was observed on the midpoint of the thigh using color Doppler ultrasonography and intraoperative findings in all cases. All flaps survived, but sensory recovery was poor with the sensory flap.
We evaluated the blood flow in anastomosed vessels by ultrasound imaging (Venue 40®) after free flap transplantation. We examined 20 head and neck reconstructions. There were 8 rectus abdominis musculocutaneous flaps, 5 antero-lateral thigh flaps, and 7 forearm flaps. In all cases, the blood flow in the anastomosed vessels and the flap penetrating branch was confirmed using Venue 40®, and the position was marked on the skin. On bed-side observation of the flaps after surgery, blood flow was evaluated using conventional methods (flap color tone, pin prick test, etc.) and Venue 40®. No abnormality was observed in 14 cases. As abnormality was found in 6 cases, skin flap blood flow was reevaluated by ultrasonography. The results of ultrasonography were similar with those by Venue 40® in all 6 cases with abnormalities. Several methods have been reported for evaluating blood flow after free flap transplantation, but a reliable and objective method has not been established. As Venue 40® can be repeatedly employed at the bed side by the doctor or medical staff, it may be useful for monitoring flaps.
Glomus tumors are rare neoplasms of the hand. Seventeen patients (11 females and 6 males) underwent surgical excision of glomus tumors. Their mean age was 53 years (46 to 77 years). Seven of the 17 patients had been managed under a different diagnosis and 4 were diagnosed as normal at their prior hospital. In 6 of the 17 patients, plain radiographs revealed cortical scalloping of the affected phalanx. The lesion was visualized by magnetic resonance imaging in all patients. Fifteen patients underwent surgical excision in winter. The transungual approach was employed for 16 patients, and the lateral subperiosteal approach was used for 1 patient. Complete pain relief was achieved in all patients, and 2 patients who were treated with the transungual approach had postoperative nail deformities. During the procedure, especially at the time of tumor extirpation and repair of the nail bed, microscopy was useful to obtain a good operation field. No complications or tumor recurrence occurred during the follow-up period. Patients with glomus tumors are often misdiagnosed. Surgical excision of the tumor results in rapid symptom relief. Clinical findings, including pain, cold sensitivity, and nail deformities, and imaging methods are helpful for diagnosing glomus tumors, and facilitate the detection and precise localization of small lesions.
This study was performed to evaluate the usage of full-scale three-dimensional (3D) bone models in vascularized fibula graft surgery. Vascularized fibula inlay grafting with a 3D bone model was performed for 3 patients, including a 43-year-old woman with pseudoarthrosis of the tibia, a 56-year-old man with pseudoarthrosis of the tibia, and a 43-year-old man with an open comminuted metacarpal fracture. A standard triangulated language (STL) file for each bone model was constructed from CT data using commercially available computer software. After inputting the STL file, a 3D printer was used to print a 3D bone model made of polylactic acid resin. The model was sterilized with ethylene oxide and used during surgery. For each patient, transplantation of the vascularized fibula graft was facilitated by the 3D bone model and the operating time was reduced. With conventional surgery, several attempts are generally required to fit the vascularized fibula graft into the graft bed. However, repeated fitting trials increase the risk of injury to the fibula graft, especially to the periosteum. Our method employing a 3D bone model was able to minimize injury to the graft.
A medial plantar fasciocutaneous flap provides structurally similar tissue to the plantar foot with thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue, and plantar fascia. During the past 2 years, 4 patients (3 men, 1 woman) with skin and soft-tissue defects after resection of malignant skin tumors over the plantar forefoot were treated. They ranged in age from 58 to 76 years (mean, 67.5 years). The medial plantar flap was transposed to the defects in a reverse flow manner. Flap sizes varied from a width of 5.0 to 6.0 cm and a length of 7.0 to 11.0 cm. The follow-up period ranged from 4 to 20 months (mean, 13 months). Partial flap loss was observed in one patient. However, no revision or re-grafting was performed. Hyperkeratosis was observed in two patients. All patients achieved normal gait within 2 months after surgery, and none noted recurrence of ulceration or tumors. Durable coverage of the defects was achieved in all patients. If the communicating vessels in the forefoot are preserved, we consider this flap to be useful for forefoot reconstruction after resection of skin tumors.
After microsurgical free flap transfer to the foot and ankle, an external fixator is often necessary to offload and protect the foot and the flap. Although modern circular ring fixators based on the original Ilizarov design are widely used, they are complex and time-consuming to construct. A combination frame consisting of an ordinary unilateral external fixator and a skeletal traction bow (Kirschner bow) was conceived at our institution. The unilateral external fixator is applied to the tibia and attached to a frame constructed with a kickstand to suspend the limb. To prevent equinus deformity, a skeletal traction bow is placed in the forefoot and fastened to the external fixator frame to complete the combination. The simplicity and ease of application reduce the surgical burden and time required after free flap transfer. Most trauma centers are equipped with the required components, a unilateral external fixator and skeletal traction bow. By uncoupling the two components, ankle movement exercises can be easily performed by rehabilitation staff. The results of free flap transfer to the foot and ankle with this hybrid frame were satisfactory. All flaps survived completely and all patients achieved plantigrade walking.
We report two patients with large soft tissue defects on the weight-bearing heel that were reconstructed with a distally based sural flap, with a literature review. [Case 1] A 69-year-old man had a large area of necrotic skin on his sole secondary to severe crush injury due to a motorcycle accident. Reconstruction with a sural flap was performed, and the patient is now able to walk using plantar inserts. He has reacquired good activity of daily life without obstacles, such as ulcer formation, despite a loss of sensation. [Case 2] A 52-year-old man with poorly controlled diabetes developed a severe infection of the sole due to minor injuries that resulted in an extensive tissue defect of the heel after debridement of the infected necrosis tissue. Reconstruction with a sural flap was performed, and the patient regained the ability to walk with normal shoes using a plantar insert plate. The distally based sural flap is one of the most commonly used flaps for reconstructing tissue defects around the lower leg and ankle joints. Sufficient thickness to withstand load walking and sufficient volume to wear commercially available shoes were achieved in both patients, suggesting this to be a useful method.
We report 2 cases of femoral shaft nonunion that were successfully treated using pedicled vascularized medial femoral epicondyle bone grafts. Case 1 was in a 66-year-old woman with rheumatoid arthritis. Her roentgenograph demonstrated breakage of all 3 screws proximal to the fracture site 8 years after plate fixation with bone grafting, indicating femoral shaft fracture nonunion. Therefore, plate fixation was converted to intramedullary nailing and bone grafting with a pedicled vascularized medial femoral epicondyle bone. Case 2 was in a 36-year-old man. He exhibited nonunion of the femoral shaft for over 2 years after 2 surgeries for an open fracture. The intramedullary nail was replaced and grafting with a pedicled vascularized medial femoral epicondyle bone was performed. In both cases, bone union was uneventfully achieved within several months after the surgery. Pedicled vascularized bone grafting for the treatment of femoral shaft nonunion is indicated for patients with a lesion in the distal half of the femur. However, the length of the vascular pedicle may not be sufficiently long to reach the nonunion site. Thus, preoperative evaluation of the pedicle length using contrast-enhanced CT is recommended.
Post-traumatic radio-ulnar synostosis is a rare complication of forearm fracture. We report two cases of adult post-traumatic radio-ulnar synostosis treated by synostosis excision and radial forearm adipofascial flaps. Synostosis excision and pedicled radial forearm adipofascial flap interposition to prevent recurrence resulted in good functional outcomes and no recurrence. The best treatment for post-traumatic radio-ulnar synostosis remains controversial. Several interposition materials have been used to prevent the reformation of bone between the radius and ulna after synostosis excision. The advantages of pedicled radial forearm adipofascial flaps are reliable vascularity and flap elevation using the same synostosis excision approach.
Treatment of recurrent ulnar nonunion with moderate bone defects in the presence of inadequate vascularity of surrounding tissues requires a vascularized bone graft (VBG). We report a case of recurrent ulnar nonunion that was treated successfully with a radius graft pedicled on the anterior interosseous artery (AIA) branches. A 48-year-old female presented with recurrent ulnar nonunion following ulnar shortening osteotomy with 5-mm bone defects at 5 cm proximal to the wrist. We elevated the VBG with a 2, 3 intercompartmental supraretinacular artery and 4th extensor compartmental artery, and gently inserted the VBG into the recipient site, enabling stable osteosynthesis. X-ray imaging revealed consolidation after 4 months without restriction of the range of motion of the wrist or extensor paralysis. As the recipient site was located in the proximal area, none of the posterior interosseous nerve motor branches were sacrificed to elevate the VBG with AIA branches. Anatomical information regarding the vascular pattern of the AIA and its relation to posterior interosseous nerves provides reliable solutions for recurrent ulnar nonunion through a distal radius graft pedicled on AIA branches.
A right-sided aortic arch is a rare congenital abnormality. Anatomical displacement of the intrathoracic cavity must be addressed when performing surgery for such patients. Here, we report a case of free jejunal transfer for reconstruction of an esophago-cutaneous fistula after resection of esophageal cancer in a patient with right-sided aortic arch. The patient was a 67-year-old male who had upper thoracic esophageal perforation due to invasion of esophageal carcinoma. The thoracic esophagus was resected and reconstruction was carried out with a gastric tube via the posterior sternal route. However, an esophago-cutaneous fistula developed after the operation and the patient consulted our department. A CT scan revealed that the gastric tube was crushed between the sternum and the aortic arch, which likely caused the circulatory impairment of the gastric tube. Surgery was planned to close the fistula. First, the sternum was partially resected to widen the reconstructed digestive route, and the defect in the esophagus was replaced with a free jejunal flap. The postoperative course was uneventful. In the present patient, anatomical displacement in the surgical area caused the complication in the primary operation. It is important to consider individual anatomical features when treating such patients.