Susumu Tamai, M.D. finished his Postgraduate Course in Orthopedic Surgery at Nara Medical University in 1964 and earned a Ph.D. with his thesis on “Experimental Surgery on Replantation of Amputated Limbs in Dogs”. During his 4 year course of study, he also mastered the technique of microvascular surgery for miniature blood vessels, which was initially developed by Jacobson and Suarez in 1960. On July 27th, 1965, a 28-year-old male amputated his left thumb at the MP joint level by a steel cutter. He was transferred to Nara Medical University Hospital 30 minutes after the injury. At the request of patient, the replantation team decided to attempt replantation of the thumb. Under brachial plexus block anesthesia and after applying a tourniquet on the arm, the MP joint was fused by two wires and the extensor tendon was repaired. The flexor tendon was not repaired as it was not routine procedure at that time. Two volar digital arteries were repaired using 8-0 monofilament nylon sutures and two dorsal veins were repaired with 7-0 braided silk under an operating microscope. Following recirculation, the thumb became pink and the skin was closed. The postoperative course was uneventful without complications.
History of development of double clamp designed by myself was described. Some clinical applications, such as replantation of digits, free flap transfer, free muscle graft and vascularized bone graft using microsurgical technique, in 1970s were described. Speculation in 1983 about microsurgery in future, such as stereoscopic microscope and microsurgery by intelligent robot, is also described.
In the treatment of acute severe limb injuries, prevention of deep infection is a key factor; thus, sufficient debridement and reconstruction with vascularized free tissue transfer are the mainstays of treatment. This was a retrospective study for 9 consecutive patients (8 men, 1 woman; mean age: 44 years) who underwent vascularized free tissue transfer for acute severe limb injuries with a mean follow-up period of 17 months. The clinical outcomes at the final follow-up were reviewed and analyzed. The types of injuries were as follows: forearm open fracture in 3 patients, forearm amputation in 1, and open tibia fracture in 5. The mean waiting time from injury to surgery was 36 days. The flap survival rate was 90%, and deep infection was observed in one patient. A correlation was found between the waiting time from injury to surgery and the length of hospital stay. The clinical outcomes of free tissue transfer for acute severe limb injuries were relatively favorable. Early reconstruction should be considered as a treatment option because it is particularly effective in improving the flap survival rate and reducing the duration of the treatment.
Purpose: This retrospective case series examined wound complications after Tamai zone V replantation, and describes a potential strategy to increase the finger survival rate and improve function. Methods: Nine patients (22 fingers) underwent Tamai zone V replantation at our institution between 2011/9 and 2017/5. We performed a detailed chart review to identify features of their postoperative soft tissue progress, finger loss rate and details of additional surgeries. Results: Four patients (10 fingers) lost all replanted fingers, whereas in five patients (12 fingers) , all fingers survived. In all four failure cases, tissue necrosis developed gradually in the replantation zone covering the vascular anastomoses, and vascular thrombosis and spasm were observed approximately 1 week after the first replantation. In contrast, 3 out of 5 patients did not develop tissue necrosis. The fingers of the remaining 2 patients were salvaged by performing timely flap coverage of the necrotic tissue overlaying the vascular anastomoses. Conclusion: Early flap coverage to the Tamai zone V replantation area may be effective in preventing vascular thrombosis and spasm leading to finger loss, and it made it easier to perform additional reconstructive surgeries.
We retrospectively evaluated severe extremity injuries with two free flaps at our hospital. There were 12 free flaps from 6 patients: 3 cases in the lower leg, and 1 each in the foot, forearm, and hand. Regarding the reasons for multiple flaps, 3 cases required reconstruction for tissue deficits, 2 cases were for free flap failures, and 1 was for delayed osteomyelitis. Three cases in which damaged vessels were used for the recipient vessels using the end-to-end technique had severe vascular spasms during surgery, and 2 of the 3 cases resulted in complete flap loss. Vessels with a greater than twice-the-size vascular mismatch were used in 7 anastomoses, including 4 arteries and 3 veins. Among them, 2 venous anastomoses required end-to-side anastomosis. We should carefully choose suitable recipient vessels for severe extremity injuries in order to avoid flap failure caused by refractory vasospasm. In addition, we believe that performing anastomosis using the end-to-side technique will maintain peripheral blood flow and minimize the need for dissection around vessels. This may preserve the anastomosis site for multiple tissue reconstruction.
We report reconstructive surgery using a flap based on the superficial palmar branch of the radial artery (SPBRA) , and evaluated the function of the wrist joint at the donor site. Four patients received free flaps from the SPBRA due to trauma and excision of tumors. The size of the flaps, length and diameter of the nutritional arteries, and survival rate were assessed. We also evaluated grip strength, DASH-JSSH, range-of-motion (ROM) of the wrist joint, and modified Mayo wrist score (MMWS) at the final follow-up. The mean size, diameter, and length of the nutritional arteries were 3.5 cm×1.9 cm, 1.2 mm, and 17 mm, respectively. In one patient, congestion occurred at the distal site of the flap. At the final follow-up, the mean ROM of the volar and the dorsal flexion were 71° and 78° , respectively. The mean DASH-JSSH score and MMWS were 7.1 and 86, respectively. Two patients complained of tenderness of the hypertrophic scar. The SPBRA flaps were useful for the reconstruction of defects of the volar skin without limiting the wrist motion, but attention should pay to partial necrosis at the distal site and hypertrophic scar formation.
The use the lower wing of the chicken as a training model has not been explored, and we propose a new training model for supermicrosurgery training by investigating an easily available and accessible model. Fifty fresh chicken wings were dissected. A total of four arteries and three veins were analyzed. We measured the external diameter and the dissection time for these seven vessels. The mean external diameter was 0.98 ± 0.07 mm for the ulnar artery, 0.63 ± 0.08 mm for the deep radial artery, 0.68 ± 0.07 mm for the ventral metacarpal artery, 0.35 ± 0.06 mm for the superficial branch of the ulnar artery, 1.01 ± 0.21 mm for the deep ulnar vein, 0.37 ± 0.08 mm for the accompanying vein of the ulnar artery and 0.36 ± 0.07 mm for the medial subcutaneous vein of the lower wing. All dissections were completed within two minutes. The vascular diameters of the deep radial artery, ventral metacarpal artery, superficial branch of the ulnar artery, accompanying vein of the ulnar artery and medial subcutaneous vein of the lower wing were considered to be most appropriate for supermicrosurgery training. Chicken wings are readily available and inexpensive, and easy to store, prepare and dissect.
Plastic surgical reconstruction of the perineum is often required after abdominoperineal excision of the rectum. Large perineal defects can occur after surgery for malignancy, particularly after adjuvant radiotherapy. Muscle and myocutaneous flaps can be used to close large defects, increase vascular supply to poorly healing wounds, and to reduce the incidence of major infection associated with perineal wound closure such as pelvic abscess. We report 3 cases in which gracilis flaps were used to repair large perineal defects. The defects were created after abdominoperineal resection and large perineum skin resection for rectal cancer (2 cases) and anal canal cancer. Although a mild pelvic abscess developed after the operation in one patient, it was controllable by drainage because the dead cavity of the pelvis was relatively small due to the filing effects of the gracilis flap. The gracilis flap is useful for both pelvic and perineal skin defects caused by extended resection of anorectal cancer invading the skin and pelvic organs.
The patient was a 1-year-old girl with ipsilateral polydactyly of the thumb, and hypoplasia of the thumb and thenar muscle. The radial thumb had no nail, and radiography revealed a proximal phalanx and metacarpal, but no distal phalanx. The ulnar thumb was a floating thumb, and a distal phalanx and an incomplete proximal phalanx were noted on radiography. On-top plasty was performed to reconstruct the morphology of the thumb and to preserve sensation. We transposed the ulnar floating thumb to the top of the radial thumb as a pedicle flap with the digital nerve and artery of the floating ulnar thumb. As angiospasm occurred during surgery, the operation was changed to a two-stage procedure. The postoperative course was uneventful, and function and morphology of the reconstructed thumb remain improved as of 2 years postoperatively. Radiography revealed bone union at the level of osteosynthesis. In such cases, hypoplasia of the vessels may warrant a two-stage procedure to reduce the risk of angiospasm and congestion.
A 49-year-old man was injured by a conveyor belt. His right arm, palm and thumb were severely scraped, resulting in his skin, flexor pollicis longus, thenar muscle and neurovascular bundle of his thumb becoming necrotic. After several rounds of debridement of the necrotic tissue, we performed skin reconstruction using a pedicled groin flap on the 18th day after injury. Adduction and flexion contracture of the thumb occurred despite aggressive rehabilitation. Five months after his injury, release of adduction contracture was performed by multiple Z-plasty and tenotomy, then an external fixator was placed on his right hand for two months. Seven months after his injury, the external fixator was removed and the thumb interphalangeal joint was fused. One year after the injury, his ability to pinch and grasp was improved, and he returned to his previous work. A few reports have suggested that surgical debridement and replacement by skin graft or flap are the best methods for heat-press injuries. The groin flap is well established method and large flaps can be harvested. In our case, contracture of the thumb occurred after the operation. However, gradual release by external fixator improved the hand contracture because the injured hand was reconstructed using a thin and flexible flap.
A 24-year-old man injured his right little finger when it was sandwiched by metal that was several hundred degrees. This heat press injury resulted in the loss of the dorsal part of the DIP joint, including its terminal tendon, and exposure of the DIP joint. To cover the defect, we performed one-stage reconstruction using the superficial palmar branch of the radial artery flap combined with the palmaris longus tendon. The donor site was closed primarily along the distal wrist crease. With additional vein anastomosis for postoperative congestion, the flap survived completely. One year after surgery, the DIP joint of the injured finger had an active ROM of －30° extension to 60° flexion. The patient responded to the 3.61 to 4.31 Semmes-Weinstein monofilament values in the flap. When the flap is designed with the volar part of the wrist, it can involve the palmaris longus tendon that is in the same operation field. Together, they can be used as a vascularized tendon flap. We suggest this flap as an effective method to restore function of the DIP joint after complex injuries of the skin and tendon defects.