Journal of Japanese Society of Reconstructive Microsurgery
Online ISSN : 2185-9949
Print ISSN : 0916-4936
ISSN-L : 2185-9949
Current issue
Displaying 1-9 of 9 articles from this issue
Special Feature Article: Microsurgery for critical limb ischemia: Indications and long-term outcomes
  • Yutaro YAMASHITA, Shinji NAGASAKA, Kazuhide MINEDA, Yoshiro ABE, Ichir ...
    2022 Volume 35 Issue 3 Pages 63-73
    Published: 2022
    Released on J-STAGE: September 26, 2022
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       Introduction: Microsurgery is indicated for the treatment of critical limb ischemia (CLI) for: (1) surgical revascularization (microsurgical distal bypass) or (2) endovascular treatment + free tissue transfer, or (3) free tissue transfer anastomosing into the bypass graft. 
       Results: In Group 1, there were 17 cases (20 limbs) . Patient undergoing hemodialysis was 75% (15 limbs) . The bypass patency rate was 52.3%, and the amputation-free survival rate was 67.2% at one year postoperatively. There were eight cases in Group 2. Patients undergoing hemodialysis was 62.5%. Free tissue survival rate was 88% with partial necrosis in 37.5%, and one case with total necrosis. Amputation-free survival rate was 60% at an average follow-up of 31.4 months. In Group 3, there were two male patients, and one of them was on hemodialysis. The free tissue survival rate was 100%; however, partial necrosis was observed in one patient. The amputation free survival rate was 0% at average follow-up of 12 months. 
       Conclusion: Microsurgery technique was useful in CLI treatment. However, composite free tissue transfer may be more prone to partial flap necrosis. The high rate of CLI patients undergoing hemodialysis may make the results worse.

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Special Feature Article :New Technology in Microsurgery
  • Hideki KADOTA
    2022 Volume 35 Issue 3 Pages 74-81
    Published: 2022
    Released on J-STAGE: September 26, 2022
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      Presently, robotic surgeries are increasing rapidly in the fields of urologic and general surgery. Surgical robots can reduce surgeon’s finger tremors and facilitate precise maneuvers, which are advantageous in microsurgery. In Europe, two types of surgical robotic systems were created for microsurgery, and they have begun to be used in clinical practice. 
      We have been working on the development of a new surgical robot specialized for microsurgery since 2017. Our goal was to make robotic hands with following accuracy of less than±0.01 mm and use a 3D monitor with 8K resolution in place of the surgeon’s eyes. In 2021, we succeeded in anasto-mosing an artificial vessel of less than 1 mm in diameter using our test model. We are aiming to complete the final product, which will be used to suture lymphatic vessels of less than 1 mm, by 2024. 
      The exoscope has begun to be introduced in the field of microsurgery as another option to the surgical microscope. By using the exoscope, surgeons can perform microsurgery with a wide working space and relaxed posture, which reduce the physical burden on microsurgeons. 
      The latest information and the pros and cons of these new devices are reviewed in this article.

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Special Feature Article :Preoperative and postoperative treatments of lymphedema
  • Yoshichika YASUNAGA, Yuto KINJO, Daisuke YANAGISAWA, Mayumi NAKAJIMA, ...
    2022 Volume 35 Issue 3 Pages 82-91
    Published: 2022
    Released on J-STAGE: September 26, 2022
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      [Background]We examined the efficacy of lower limb lymphaticovenular anastomosis (LVA) combined with postoperative reduction treatment (PORT) in reducing lymphedema during the first postoperative year. 
      [Methods]Female patients with unilateral leg lymphedema who had undergone leg LVA with 7 days of PORT were included. Patients were selected for whom body water volume data were available at six points in time: preoperatively; at discharge; and 1, 3, 6, and 12 months postoperatively. Patients were divided into two groups according to the change in postoperative water volume reduction in the affected leg: those with maintenance of body water volume below the preoperative level, termed as “maximum efficacy”, and those without. 
      [Results]Of the 28 eligible cases, 14 demonstrated maximum efficacy with LVA. The first peak of water volume reduction in cases with maximum efficacy was at the time of discharge, with a transient regression observed following discharge. Thereafter, the water volume decreased, reapproaching the discharge value. Greater preoperative leg water volume was a common factor for cases with maximum efficacy (odds ratio: 3.351, 95% confidence interval: 1.215-9.240, p = 0.019) . 
      [Conclusion]The leg water volume of LVA cases with maximum efficacy increased after discharge but returned to discharge values over the first postoperative year.

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Original Article
  • Noriaki KIKUCHI, Lisa TAMURA
    2022 Volume 35 Issue 3 Pages 92-97
    Published: 2022
    Released on J-STAGE: September 26, 2022
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      In head and neck surgery, the internal jugular vein has been the most reliable and one of the most frequently used recipient vessels. Recently, thrombosis of the vein has become a problem in head and neck microsurgical reconstruction. We report our experience of using cephalic vein transposition in seven patients with unavailable local veins for free flap anastomosis. Venous thrombosis after primary free flap reconstruction, or secondary microsurgical reconstruction was a reliable treatment option. A long pedicle can be taken to reach the mid-face. In patients with enucleated eyeball, without undue tension, coverage with a free flap was successfully achieved. At the chest wall besides the neck area, the cephalic vein can serve as a useful resource to save the venous depletion in cases of thoracic esophageal reconstruction with pedicled colon adding supercharge and superdrainage. The cephalic vein provided reliable and adequate flow for the free flap. The cephalic vein is located outside the ablative surgical or radiated field, and it was undamaged. As a last resource, using the cephalic vein should be considered at critical situation in head and neck reconstruction.

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  • Tomohiro KANO, Tatsuya HARA, Toshikazu KURAHASHI, Shiro URATA
    2022 Volume 35 Issue 3 Pages 98-102
    Published: 2022
    Released on J-STAGE: September 26, 2022
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      Traumatic finger amputations in children are relatively rare. In this study, we investigated replantation for traumatic finger amputation in children (aged < 12 years) at our hospital. This retrospective study included 11 consecutive children (12 fingers) who underwent finger replantation between 2006 and 2021. Of these, seven were boys and four were girls (mean age 6.1 years) , and mean follow-up duration was 24 months. 
      Mechanisms of injury included crush injuries (n = 8) , guillotine-induced injuries (n = 3) , and avulsion (n = 1) . Tamai’s classification zones I, II, III, IV, and V were observed (n = 1, 7, 2, 1, and 1 finger, respectively) . The overall survival rate was 50.0% (6 of 12 fingers) . We observed no signi-ficant differences in survival rate based on patient age, weight, the mechanism of injury, or Tamai’s classification. Replantation failure was secondary to arterial insufficiency (n = 3) , venous congestion (n = 1) , and unknown causes (n = 2) in six fingers. Artery-only replantation was performed (n = 9) . The external bleeding method was used (n = 8) . Salvage surgery for replantation failure was performed in four fingers using palmar pocket method, thenar flap, reverse island flap, and revision amputation.

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Case Report
  • Tetsu TSUBONE, Kazuhiro SAKAI, Sinsuke NAGAYOSHI, Hiroyuki KUBO
    2022 Volume 35 Issue 3 Pages 103-106
    Published: 2022
    Released on J-STAGE: September 26, 2022
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    Supplementary material

      A 71-year-old woman presented with a dislocated proximal humeral fracture. Arterial bleeding had occurred during the open reduction of her dislocated humeral head. A tissue-like vessel was ligated and separated to stop bleeding; however, arterial bleeding continued. As the bleeding source was a ruptured axillary artery diagnosed by the emergent angiography, it was considered impossible to embolize. Therefore, the injured part of axillary artery was exposed and clipped. The former ligated tissue was confirmed as a nerve after enable hemostasis, and it was sutured. We diagnosed iatrogenic musculocutaneous nerve injury, because she could not flex her elbow and recognize sensation of the lateral part of her forearm after the operation. Three and a half years later, her elbow had good motor function (MMT of elbow flexion 5) , and the sensation of her forearm had recovered to normal. We performed electrophysiological examination, which targeted sutured musculocutaneous nerves. Our case demonstrates good outcome of motor function of the biceps and sensation of the lateral forearm cutaneous nerve after nerve repair in an elderly patient.

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  • Kenichiro KAWAI, Soh NISHIMOTO, Yohei SOTSUKA, Masao KAKIBUCHI
    2022 Volume 35 Issue 3 Pages 107-115
    Published: 2022
    Released on J-STAGE: September 26, 2022
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    Supplementary material

      With significant advances in and wider availability of microvascular techniques, free flaps, such as anterolateral thigh flap, are preferred for head and neck reconstruction in most cases. However, pedicled flaps are thought to be safer, easier, and take less time than free flaps. When free flaps fail or there is a limitation of free flap usage, pedicled flaps, such as pectoralis major myocutaneous flap, have an important role in the treatment of certain head and neck defects. In this case report, we report our experience of multiple flap failure. We ultimately used a two-staged latissimus dorsi flap using a supercharge technique. Normally, this method is not recommended due to its requirement of multiple operations and a poor esthetic result; however, it may be worth considering this technique in patients with significant risk factors for free flap failure.

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  • Haruka KOGA, Hiroki MORI, Tsutomu HOMMA, Sayuri KATO, Naoya ISHIDA, Ke ...
    2022 Volume 35 Issue 3 Pages 116-121
    Published: 2022
    Released on J-STAGE: September 26, 2022
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      Norepinephrine is recommended to be administered via the central venous route. However, in the emergency field, norepinephrine is often given from the peripheral vascular route. The present case was a 59-year-old man with a history of chronic renal failure who had a shunt on his left forearm. Norepinephrine was injected through the peripheral vascular route of the right forearm because pyogenic spondylitis caused septic shock. On the 18th day after extravasation of norepinephrine, he was referred to our department. At the time of surgery, all extensor tendons were necrotic, and the joint capsule of his wrist was necrotic. The joint capsule was reconstructed using the tensor fascia lata, and the soft tissue was reconstructed using anterolateral thigh flap. Since there was no flexor tendon injury, certain activities of daily living were possible with the use of a wrist extension orthotic device. In this case, the antagonist phentolamine was not administered, leading to widespread soft tissue necrosis. Extravasation of drugs is an iatrogenic disorder and requires efforts to reduce the extent of damage as much as possible. Norepinephrine, which is the most frequently used vasoconstrictor, should be documented and all staff involved should be informed, including treatment with antagonists.

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Miscellaneous:Functional restoration of amputated fingers and limbs: How to set goals (fingers)
  • Hirotada MATSUI, Kentaro ONO
    2022 Volume 35 Issue 3 Pages 122-129
    Published: 2022
    Released on J-STAGE: September 26, 2022
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    Supplementary material

      In this study, 41 fingers with complete replantation were divided into two groups: a PIP joint preservation group (JP group) (n = 23 fingers) , and a PIP joint arthrodesis group (JA group) (n = 18 fingers) . We investigated the injury patterns and active joint range-of-motion of the replanted fingers and compared the two groups. In the JP group (compared to the JA group) , total active range-of-motion (TAM) was 138.9° (80.4°) , MP joint AM was 80.4° (74.4°) , and PIP joint + DIP joint AM was 58.5° (5.0°) . There were significant differences in TAM, and PIP joint + DIP joint AM between the two groups. Nine of the 23 fingers in the JP group underwent tenolysis to improve postoperative TAM. The effect of tenolysis was not constant, and the average improvement in TAM was 55.0° (20°-150°) . The two patients in whom TAM significantly improved were those in which joint contracture before tenolysis was not observed and those in which only flexor tenolysis was performed. The range-of-motion of the fingers that underwent Tamai zone 4 replantation was still poor. However, to minimize joint contracture, two-stage flexor tenolysis is recommended, which may greatly improve the range-of-motion of fingers that underwent Tamai zone 4 replantation.

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