Objectives: The face is an important factor for an individual to create an impression and engage in social activities such as seeing, talking, laughing, and eating. Treatment for people with blepharoptosis is covered under public health insurance in Japan. Many surgeons report that the operation improves patients' health-related quality of life (HRQOL); however, no patient-reported outcome (PRO) measures regarding the face and eyelids are available in Japanese. Therefore, this study developed the Japanese versions of the Eye and HRQOL Modules of FACE-Q Aesthetics and analyzed their validity and reliability.

Methods: We translated FACE-Q Aesthetics following the procedure established by the copyright department of Q-Portfolio after obtaining permission to develop the Japanese version. Subsequently, we validated the translated modules by surveying 50 patients with blepharoptosis. Data were collected in the following three waves: preoperatively, 6 months postoperatively, and 2 weeks after the second phase. Data were analyzed to identify floor and ceiling effects, internal consistency, test-retest reliability, and concurrent validity.

Results: No problematic floor or ceiling effects were identified. The non-response rate for all items was ≤10%. Cronbach's alpha coefficients were >0.7 for all scales. Moreover, the intraclass correlation coefficient between the first and second postoperative responses was also >0.7 for all scales. Several correlations were observed among the other PRO measures, which are available in Japanese.

Conclusions: This study developed and validated the Japanese versions of the Eye and HRQOL Modules of FACE-Q Aesthetics. These versions were sufficiently valid, reliable, and in line with Japanese culture.

Reports of frontal and nasal bone-involving composite midfacial bone defect reconstruction after anterior skull base tumor resection remain scarce. Here, we present the case of a 75-year-old man with recurrent ethmoid sinus carcinoma who underwent combined transcranial and endonasal endoscopic resection. The resulting defects included the anterior skull base and frontal and nasal bones. A pericranial flap was used for skull base closure, achieving rigid midfacial reconstruction in a single stage using the split outer and inner cranial bone tables harvested during craniotomy. Titanium plates were used for fixation. The medial canthal ligaments were reattached with intracranially placed sutures and embedded within the pericranial flap to reduce the risk of infection. One month postoperatively, the esthetic result was favorable, with no midfacial depression. Although the patient died from disease recurrence three months postoperatively, this method potentially offers a practical and cosmetically effective option for anterior skull base reconstruction.

Treatment of nasal septal defects or hypoplasia requires careful, long-term planning. We report a case of a 20-year-old male with congenital nasal septal cartilage hypoplasia who underwent auricular cartilage grafting at age 5 and costal cartilage transplantation at age 11. At adult evaluation, the nasal root was low, and the previously reconstructed L-strut was undersized for the matured facial skeleton, resulting in a short nose deformity. Revision surgery used re-harvested costal cartilage for dorsal and L-strut reconstruction and auricular dermochondral grafts for lining and rim support. Costal cartilage was readily available from the prior donor site, while auricular cartilage was limited due to previous use and donor-site concerns. Two years postoperatively, nasal aesthetics and facial balance improved markedly, with high patient and family satisfaction. This case underscores the importance of anticipating postpubertal facial growth, planning early reconstruction accordingly, selecting grafts strategically, and recognizing the likely need for secondary reconstruction in adulthood.

Compartment syndrome (CS) is a rare but serious complication following fibula flap harvest. We report a 72-year-old man who developed donor-site CS on postoperative day 3 without pain but with edema, blisters, and paresthesia. Serum creatine phosphokinase rose to 17,677 IU/L, indicating its diagnostic utility. Immediate wound release, debridement, negative pressure therapy, and skin grafting achieved sensory and motor recovery with independent ambulation at 9 months. Review of eight previous cases showed a mean skin paddle width of 4.16 (3-5) cm. Seven donor sites were primarily closed under tight or slightly tight tension, and one was left open. The mean onset was postoperative day 5.62 (0-14). Clinical manifestations were dominated by cutaneous or motor changes, while pain was uncommon. CS may occur irrespective of skin paddle width and without pain, delaying recognition. Vigilant monitoring for cutaneous or neurologic signs and early intervention are essential to minimize sequelae.

General anesthesia for cleft palate surgery carries significant risks, with most complications occurring during induction. We report the case of a 17-month-old boy with complete bilateral cleft lip and palate who developed bronchial obstruction during induction of general anesthesia for cleft palate surgery due to food residues. The foreign body was promptly removed via bronchoscopy. Severe bradycardia, hypoxemia, and atelectasis in the right upper lung field were observed but subsequently resolved. Although such residues rarely pose a problem during induction of general anesthesia, they can lead to serious complications and warrant careful perioperative management.

Upon reviewing this case, we identified the risks associated with the induction of general anesthesia in cleft palate surgery and emphasized the importance of perioperative management. Even with adequate preoperative management, it is crucial to check for any foreign bodies in the oral and nasal cavities during induction of general anesthesia to prevent airway obstruction.

Objectives: To evaluate the clinical effectiveness of small intestinal submucosa-extracellular matrix (SIS-ECM) in the conservative treatment of traumatic fingertip injuries without residual tissue.

Methods: We conducted a retrospective analysis of 11 patients (12 fingers) treated with SIS-ECM between 2022 and 2024. No surgical reconstruction or skin grafting was performed. Wound size, exposed tissue, wound conditions, healing duration, scar quality, sensory recovery, and patient satisfaction were recorded. Scar formation was assessed using the Vancouver Scar Scale, and sensory outcomes were evaluated with the Semmes-Weinstein Monofilament Test (S-W test).

Results: All wounds achieved complete epithelialization, with a mean healing time of 42.8 days (range, 26-71). Small defects (≤1.5 cm²) healed in an average of 34.3 days (about five weeks), while medium-sized defects (1.6-3.0 cm²) required slightly longer (39.2 days). In contrast, large defects (>3.0 cm²) showed markedly prolonged healing (60.0 days) and more pronounced scarring. Cases with bone exposure also demonstrated delayed healing and inferior scar quality. No cases required secondary surgical intervention, and overall patient satisfaction was high.

Conclusions: SIS-ECM appears to be a safe, effective, and minimally invasive alternative to skin grafting or flap procedures for fingertip injuries up to approximately 3 cm² or without bone exposure. However, larger defects or those with bone exposure may require careful consideration due to the risk of delayed wound closure and inferior cosmetic results. The findings should be interpreted with caution given the lack of a control group.

Objectives: An aesthetically pleasing nasal side profile is a must for a successful rhinoplasty result. We offer a simple technique for accurate measurement of the desired reduction limit of the nasal hump and thus avoiding over- or under-reduction, plus obtaining a single long piece of cartilage that can be used as a graft in the operation.

Methods: A prospective randomized intervention study compared 20 patients: group A (conventional hump reduction) versus group B (tool-assisted reduction). Outcomes were assessed via Likert scales (1-5) at 6 weeks, 3 months, and 6 months postoperatively.

Results: Group B showed significantly higher median satisfaction scores for hump reduction (p = 0.006 at 6 weeks, p = 0.003 at 6 months) and overall rhinoplasty outcomes (p < 0.001). The tool enabled precise resection while preserving cartilage for grafts.

Conclusions: This technique improves reproducibility and patient satisfaction, offering a cost-effective alternative to three-dimensional imaging/artificial intelligence planning.

Objectives: Traumatic enophthalmos is a common complication of orbital wall fracture. Costal cartilage grafting is the preferred surgical approach for traumatic enophthalmos. However, widely used clinical guidelines have not been established regarding the optimal volume of costal cartilage grafts required to correct enophthalmos. This study aimed to quantitatively evaluate the changes in the orbital volume (OV) and enophthalmos before and after surgery in patients who underwent costal cartilage grafting, and to analyze the relationship between them.

Methods: The medical records of 12 patients with unilateral orbital wall fractures who underwent costal cartilage grafting between June 2012 and October 2020 were retrospectively analyzed. The OV and enophthalmos were measured using pre- and postoperative computed tomography scans. The OV difference (OVD) and OV ratio (OVR) between the affected and unaffected sides were calculated to assess their correlation with enophthalmos.

Results: Among the nine patients in whom the OV was accurately measured, all demonstrated postoperative reductions in OVD, OVR, and enophthalmos. A significant positive correlation was observed between the OVR and enophthalmos postoperatively: R = 0.931 (p = 0.021). The analysis suggested that a volume of the transplanted costal cartilage that achieves a postoperative OVR of approximately 88% justly corrects the enophthalmos.

Conclusions: This study quantitatively confirmed that costal cartilage grafting reduces OVR and improves enophthalmos. The OVR may serve as a potential predictive metric for enophthalmos and facilitate graft volume planning for reconstructive surgery.

A 53-year-old woman underwent breast reconstruction using a free omental flap following the resection of a phyllodes tumor in the right breast. Postoperative volumetric analysis was retrospectively conducted over 5 years using computed tomography and three-dimensional imaging software. The omental flap demonstrated a 157% increase in volume compared with the immediate postoperative size. A positive correlation (r = 0.93) was observed between body weight and flap volume. Our report is just a single case; therefore, further studies are required to elucidate our hypothesis.

To the best of our knowledge, this is the first report to describe this association in an omental flap used for breast reconstruction. These findings may support appropriate surgical planning and postoperative follow-up in reconstructive breast surgery.

Objectives: Although collecting lymphatic vessels are known to run beneath the superficial fascia, its ultrasonographic features, particularly in lymphedematous limbs, remain poorly understood. This study aimed to evaluate the structure of the superficial fascia and its relationship with lymphatic vessels.

Methods: We analyzed the patients with secondary lower extremity lymphedema who underwent lymphaticovenous anastomosis under local anesthesia. Ultrasound images were obtained at four anatomical sites: 5 cm and 10 cm distal to the saphenofemoral junction and the popliteal fossa. Sites where lymphatic vessels could not be visualized by ultrasound were excluded. The superficial fascia was scored for clarity (0-4), and the number of fascia was counted. Measurements included the superficial fascia depth (shallowest and deepest), amplitude of undulation, and the depth and relative position of lymphatic vessels.

Results: Of the 42 limbs (168 sites) in 21 patients, 158 sites were included. The superficial fascia was more clearly visualized in the thigh than in the calf, with visibility decreasing as lymphedema severity advanced. Lymphatic vessels were located at a mean depth of 7.0 mm, also increasing with severity, while the vessel-fascia distance (mean, 1.1 mm) showed no association. The number of fascial layers averaged 2.6, more in the thigh than in the calf, and 96.2% of lymphatic vessels lay beneath the first or second fascial layer.

Conclusions: Lymphatic vessels are typically located just beneath the first or second superficial fascial layer, and ultrasound evaluation of fascia provides practical landmarks for preoperative mapping in lymphedema.

Objectives: The aim of this study is to present a new method for creating a deep umbilicus in pediatric umbilical hernias.

Methods: A retrospective chart review of patients who underwent umbilicoplasty using anterior rectus sheath flaps from 2010 to 2021 was conducted. Surgical technique: after performing an umbilical hernia repair through a cruciate incision within the umbilical fossa, umbilicoplasty was carried out. Anterior rectus sheath flaps measuring 7 × 20 mm were created 15 mm cranially and caudally from the umbilicus. These flaps were elevated, inverted, and threaded through two slits in the opposite anterior sheath, then sutured back into their original position. This procedure allowed the approximation of the bilateral anterior rectus sheaths. Finally, the cruciate incised skin was sutured at the base of the umbilicus. Measurements of the distance between the rectus muscles and the thickness of subcutaneous fat were taken using ultrasound preoperatively and at the final follow-up.

Results: The study comprised 31 patients-14 males and 17 females-with a mean age at surgery of 4 years and an average follow-up duration of 13 months. In all cases, a deep umbilicus was successfully created and maintained. Ultrasound examinations revealed a reduction in the distance between the rectus muscles at five peri-umbilical points and an increase in subcutaneous fat thickness (p < 0.05).

Conclusions: The use of anterior rectus sheath flaps enabled the creation of a deep umbilicus that was sustainable over an extended period.

Objectives: This study aimed to evaluate the accuracy and simplicity of a preoperative vascular assessment method with Viewtify^® for perforator flap elevation.

Methods: To evaluate the accuracy and simplicity of this new method, we compared it with an existing reliable method based on the same contrast-enhanced computed tomography (CT) images. The evaluation included the deviation of the deep inferior epigastric artery (DIEA) course and the position of the perforators, as well as the time required for evaluation. CT images were acquired from 20 female patients who underwent DIEA perforator flap reconstruction. A third-year plastic surgery resident, new to flaps and the software, was the candidate for this new method and hand-drew a schematic diagram from three-dimensional computer graphics (3DCG) images reconstructed with Viewtify^®. After receiving only short instructions on how to operate the software, she began the evaluations. The comparison was made with reference images that had been created by a board-certified surgeon using a reliable method from the same CT images.

Results: The average age and body mass index (BMI) of patients were 48.1 ± 7.5 years and 24.2 ± 3.3 kg/m², respectively. Deviations in the DIEA pathway were within 7.4 ± 3.2 mm, and perforator positions matched the reference images. Evaluation times decreased significantly, stabilizing below 10 min in 5 patients. The average evaluation time across all patients was approximately 8 minutes.

Conclusions: Viewtify^® enables accurate and efficient preoperative vascular assessment, even for inexperienced surgeons, demonstrating a rapid learning curve. This method may offer an alternative approach for the surgical planning of perforator flap elevation.

Background: Breast cancer related lymphedema (BCRL) is a distressing problem in breast cancer survivors. Chang and colleagues attempted to develop evidence based statements and recommendations for physiological technique is superior to another in lymphedema treatment and no procedure is more effective than others.

Objectives: This study aimed to evaluate the results of the physiologic techniques to develop an algorithm for use in the management of breast cancer-related lymphedema.

Methodology: This was a prospective case series study conducted on 23 patients. First, all patients underwent duplex ultrasonography (US) to detect the main component of the edema. If fluid was predominant, Indocyanine Green (ICG) lymphography was performed to choose which technique would be used after proper compression decongestive therapy.

Results: In this study all cases showed postoperative significant improvement in International Society of Lymphology (ISL) staging, cellulitis attacks, and quality of life, as well as improvement in circumference measurements. This study showed that cases with dermal backflow better to be managed with Vascularized Lymph Node Transfer (VLNT), while those showing a linear pattern by ICG better managed by Lymphaticovenular Anastomosis (LVA).

Conclusion: Physiologic operations are effective in downstaging lymphedema, improving social quality of life, and decreasing or preventing cellulitis attacks. Our algorithm integrates clinical assessment and staging, ICG staging, and ultrasound findings, which allows a tailored management plan for each patient, achieving the greatest gains in functional outcome and cosmesis.

Major upper extremity replantation in pediatric patients remains a challenge despite advances in techniques and surgical devices. We present the case of a one-year-old child from an underserved rural area who sustained a traumatic transhumeral amputation caused by a farming machine. Replantation was performed within four hours of the injury, followed by staged reconstructive microsurgery. The initial surgery focused on vascular, musculoskeletal, and soft tissue repair, with delayed nerve reconstruction performed under intraoperative neurophysiologic monitoring (IONM). Sural nerve grafts were used for neurorrhaphy of the median, ulnar, and musculocutaneous nerves. At the three-year follow-up, the patient achieved a Chen Grade three functional outcome. This case highlights the value of IONM as an innovative tool in pediatric nerve reconstructive microsurgery, offering a potential novel dimension of intraoperative precision that may enhance surgical decision-making and improve functional outcomes in replantation.

This paper introduces a novel approach to breast reconstruction in ptotic breasts undergoing nipple-sparing mastectomy (NSM). The technique integrates single-stage mastopexy with a broad-based inferior dermal pedicle and immediate reconstruction, inspired by the Boston Modified Robertson technique. It addresses the concerns of nipple viability as well as postoperative aesthetics compared with conventional mastopexy techniques.

The case report describes a 41-year-old woman diagnosed with left breast carcinoma who underwent a left NSM, followed by single-stage mastopexy with a broad-based inferior dermal pedicle and immediate pedicled transverse rectus abdominis myocutaneous flap reconstruction.

The approach resulted in favorable outcomes, including preserved nipple viability, high aesthetic satisfaction, and minimal complications.

Advantages over traditional methods include elimination of a vertical scar component, avoidance of free nipple grafting, and precise control of the distance between the nipple-areolar complex and inframammary fold, thereby enhancing breast shape.

Objectives: The nose is the most prominent part of the face. The postoperative evaluation of the nose is vital to check if the desired surgical result was achieved. The scarcity of standardized scales/scores for nasal assessment inspired us to develop an entirely new scoring system (Surendrakumar and Sukhen Nasal After Rhinoplasty Evaluation Score [SSNARES]), which is universally applicable to people of all ethnic groups, ages, and genders, and yields a valid, reliable result.

Methods: SSNARES consists of a questionnaire of 10 parameters that assesses the nose aesthetically, functionally, and psychologically. Patient's responses are graded between 0-4 scores per parameter. The addition of all scores yields the final score, which is correlated with a satisfaction grade (a quantitative measure of patient satisfaction after surgery). SSNARES was thoroughly analyzed by an interdisciplinary panel of experts and underwent stringent statistical analysis to prove its validity and reliability upon pilot testing on 20 patients.

Results: The item content validity index and score content validity index of SSNARES were both 1 (excellent). Bartlett's Test of Sphericity showed a p-value of <0.001, indicating a highly significant test. The Kaiser-Meyer-Olkin test value for the overall score is >0.9 (marvelous category). The construct validity of SSNARES was tested by exploratory factor analysis, and questions with loadings >0.4 were considered significant to represent a specific factor. The confirmatory factor analysis of SSNARES showed a p-value of <0.001, indicating a high significance level and strong correlation. The Cronbach's α coefficient of SSNARES is 0.9646, which highlights excellent reliability.

Conclusions: This cost-effective, efficient, easy-to-use, patient-oriented new score will be of prime significance for patients, clinicians, and researchers for score computation, decision-making for reintervention, and research purposes.

Objectives: Voriconazole is a broad-spectrum antifungal agent known to be associated with cutaneous squamous cell carcinoma (cSCC) in White organ transplant recipients; however, such cases are rarely reported in Asian populations. This study aimed to examine the epidemiology and treatment outcomes of Japanese patients without a history of organ transplantation who developed invasive cSCC during voriconazole therapy.

Methods: This retrospective observational study analyzed data from six Japanese male patients who were treated at our hospital between the years 2013 and 2023. All patients had Fitzpatrick skin type IV and were undergoing long-term voriconazole therapy for pulmonary aspergillosis. The diagnosis of invasive cSCC was confirmed via skin biopsy. Clinical, pathological, and treatment data were collected and analyzed descriptively.

Results: Fifteen facial lesions were identified (nine at initial presentation and six during follow-up). The median duration of voriconazole treatment before cSCC diagnosis was 66.5 months. Tumors had a median diameter of 17 mm, with an estimated growth rate of 6 mm per month. Most lesions demonstrated deep invasion (Clark level IV or V), and some exhibited perineural or perivascular infiltration. All lesions were surgically excised, except for one that was treated with radiotherapy. No regional recurrence or distant metastasis was observed during a median follow-up period of 9 months.

Conclusions: Prolonged voriconazole therapy may increase the risk of aggressive cSCC in Japanese patients, even in the absence of prior transplantation. Early identification of phototoxic skin changes and prompt intervention are crucial to prevent deep tissue invasion and improve clinical outcomes.

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a systemic inflammatory disease that involves mandibular osteomyelitis with diffuse sclerosis in 10% of cases. Drug therapy is the primary treatment choice; however, severe deformity resulting in restricted mouth opening requires mandibular reconstruction. We report a rare case of mandible reconstruction in a patient with SAPHO syndrome, using a vascularized fibular flap with long-term follow-up. One year after surgery, a fistula developed in the chin region following a rash on both lower extremities as a skin manifestation of SAPHO syndrome. Bone scintigraphy showed uptake in the remaining right mandible, although there was no uptake in the transplanted fibula bone. Five years after the surgery, the mandibular fistula was closed by removing the titanium plate. The transplanted vascularized fibula achieved osteosynthesis; however, further follow-up is required to identify early symptoms of relapse and determine the need for additional medications.

Upper lip trauma with tissue loss due to dog bites is relatively common; however, reports of replantation of amputated lip tissue remain rare. Even fewer studies have documented long-term changes in graft tissue or the implementation of revision surgery after replantation. We present a case of upper lip replantation after a dog bite, with follow-up and subsequent revision surgery conducted. Despite the absence of venous anastomosis, graft survival was achieved using medicinal leeches. Revision surgery was eventually performed after a follow-up period of 2 years and 8 months. Because replanted tissue may undergo changes over time, long-term follow-up observation with consideration for revision surgery is necessary to achieve optimal outcomes.

Objectives: The Foreign Technical Intern Training Program, established in 1993, has undergone three revisions, and the number of foreign workers in Japan (as of October 2024) is expected to reach a record high of 2.3 million and continue to grow. In Nagasaki Prefecture, foreign residents account for more than 1% of the prefecture's population, and the number of foreign patients visiting plastic surgery departments is also increasing. We investigated the trends of foreign patients who underwent surgery at our hospital's plastic surgery department over the past 15 years and analyzed the results.

Method: Foreign patients who underwent surgery at our hospital's plastic surgery department between April 1, 2010, and March 31, 2024, were retrospectively identified from medical records. The following factors were examined: 1) Patient background (nationality, employment type), 2) Clinical findings at the first consultation (mechanism of injury, disease name).

Results: A total of 31 foreign patients underwent surgery. The number of patients increased sharply after 2017, when the Foreign Technical Intern Training Act came into effect, with Vietnamese patients accounting for the majority (55%). Seventy-one percent of surgical patients were foreign technical intern trainees, and most cases (61%) were work-related accidents.

Discussion and Conclusion: With the increase in foreign residents, especially technical intern trainees, the number of foreigners undergoing plastic surgery has also risen. Many cases involved work-related accidents among foreign technical intern trainees, more than 80% of whom were from Southeast Asia. As the number of foreign residents increases, the number of foreign surgical patients is also expected to rise. However, work-related accidents are likely to decrease as the working environment improves.

Objectives: In Japan, Karate is widely practiced as a traditional martial art. In a kumite (contact fighting) competition, as in other martial arts, the outcome of the contest is judged by the effectiveness of punches and kicks, which naturally makes it difficult to prevent injuries. The present retrospective observational study aimed to clarify the epidemiology of injuries sustained by Karate athletes to improve the safety of the sport.

Methods: Data on sex, university year, injury site (head and neck, face, trunk, upper limbs, lower limbs), injury type, and examination and treatment details of individuals who were injured while performing Karate were extracted from the rescue records of the Karate competitions of the Kanto University Karate Federation between 2000 and 2014.

Results: Records of 67 tournaments and medical interventions for 597 male and 156 female patients were identified. The number of interventions for injuries to the head and neck, face, trunk, upper limbs, and lower limbs was 85, 337, 22, 105, and 164, respectively. Sixty-two patients, with 23 and 25 injuries in total to the head and neck area and the face, respectively, required transport by ambulance.

Conclusions: The present study revealed that male competitors suffered more injuries, that the most common site of injury was the face, and that injuries to the head and neck area and the face were most likely to be severe. The high frequency of facial injuries in combat sports warrants greater involvement of plastic surgeons in their treatment and prevention.

Epidermal cysts are common benign tumors typically treated through surgical excision, which may result in significant scarring. Moreover, larger cysts are associated with increased surgical invasiveness and a greater burden on the patient. This report presents a case of successful treatment of a large epidermal cyst using a small-incision technique combined with suction-assisted negative pressure. The method involved a minimal incision, aspiration of cyst contents using a suction cannula, and removal of the cyst wall. Incorporating magnetic resonance imaging into the preoperative planning further enhanced the precision of the treatment. A 16-cm cyst was completely cured without recurrence over a follow-up period exceeding 5 years. This approach minimized scarring and simplified the surgical procedure.

Objective: The objective of this study was to compare the surgical treatment of gynecomastia using circumareolar excision versus transverse skin excision.

Methods: Thirty-six male patients with unilateral or bilateral gynecomastia participated in this prospective randomized study at our institution. Participants were divided into two groups: Group A received circumareolar skin excision, and group B received transverse skin excision. Patients were evaluated for surgical and postoperative complications, patient satisfaction, and cosmetic outcomes.

Results: There were no intraoperative complications or blood transfusions. The average operative time was 150 minutes for group A and 110 minutes for group B. Hospital stays ranged from one to two days. Both groups had a 5.56% incidence of hemostasis-related issues and wound infections. Seromas appeared in 11.11% of cases and resolved spontaneously. Wound dehiscence was observed in 16.67% of group A and 5.56% of group B, with no statistically significant difference. Hypertrophic scars occurred in 16.67% of group B, while none were reported in group A (p = 0.07).

Conclusions: The circumareolar technique requires longer surgical time and may lead to a less optimal chest contour. However, it provides superior cosmetic results for the nipple-areola complex. Both techniques demonstrate comparable rates of postoperative complications.

Objectives: Necrotizing soft tissue infections (NSTIs) caused by group A streptococcus (GAS) are life-threatening diseases with high morbidity and mortality rates. Early diagnosis is of paramount importance because a delay in diagnosis results in a significant reduction in survival rates. Recent studies have shown that the use of a rapid antigen detection test for GAS (GAS-RADT) at the time of NSTI diagnosis facilitates timely identification and simplifies surgical decision-making through small incision-based interventions. This study aimed to evaluate the accuracy of rapid diagnosis using a puncture method and to describe the associated procedure.

Methods: We evaluated the accuracy and reproducibility of GAS-RADT performed using a less invasive and simpler puncture method compared to conventional sampling from small incision wounds and outlined the diagnostic procedure. The study population included 19 patients who underwent GAS-RADT using the puncture method at our hospital between 2019 and 2023.

Results: The concordance rate between GAS-RADT and wound culture was 100%; Cohen's kappa coefficient was 1.0, indicating extremely high concordance.

Conclusions: As GAS-RADT performed with puncture sampling is a minimally invasive and rapid testing method that helps determine treatment strategies, it can be considered an extremely useful diagnostic method for detecting GAS-NSTI, which has been on the rise in recent years.

Dystrophic epidermolysis bullosa (DEB) causes extensive blisters and erosions due to a genetic abnormality, significantly reducing patients' quality of life. Recently, transplantation of reversion-mutated mosaicized skin has shown promise as a radical cure. In 2019, the use of cultured epithelial autograft for DEB was approved in Japan.

Meanwhile, the Meek micrografting technique, first described in 1958 by Dr. Cicero Parker Meek in the United States of America, was reintroduced in 2019 as a new device for split-thickness skin grafting. This system can harvest skin grafts more efficiently than conventional methods.

In this case report, we report on our successful treatment of DEB using the Meek technique and cultured epithelial autografts.

Hypophosphatasia is a relatively rare congenital bone metabolic disease, occurring in approximately 1 in 100,000 to 150,000 births. It is diagnosed in infancy by low bone calcification, rickets-like symptoms visible on X-ray, and decreased serum alkaline phosphatase (ALP) levels in the blood. Prognosis varies by type, and while treatment has not been long established, ALP enzyme replacement therapy has been developed and has achieved improved outcomes since 2015. Pan-craniosynostosis, as an unfavorable side effect of this symptomatic therapy, is not well known even among experienced craniofacial surgeons, likely because it is often regarded as part of the bone transformation process, especially when the unusual discrepancy between a hard cranium and fragile limb bones is observed, or is overlooked due to poor prognosis. The author's purpose is to present rare experiences of two cases of pan-craniosynostosis considered to be iatrogenic after the therapy for hypophosphatasia. Some reports in Japan indicate that this iatrogenic complication may appear in 15.3% of cases after treatment. As craniofacial surgeons, we need to recognize this causal relationship between hypophosphatasia treatment and craniosynostosis.

The global population of older adults is expanding at an unprecedented rate, demanding greater focus on their health care needs. Older individuals are particularly susceptible to burn injuries, and complications are more likely to develop in these patients. Therefore, accurate assessment of burn severity is essential. Among the various scoring systems used worldwide to predict mortality in patients with burns, the burn index (BI) and Prognostic BI (PBI) have been routinely applied in Japan since the 1980s. However, with both overall life expectancy and healthy life expectancy steadily increasing in Japan, the PBI may now overestimate mortality risk in today's older adults. Here, we review BI, PBI, and global burn severity assessment tools to highlight their differences and discuss their applicability in older patients, drawing in part on the authors' clinical experience.

Preoperative Indocyanine Green (ICG) angiography is often used to confirm lymphatic vascular circulation; however, in advanced edema, ICG may be unable to confirm circulation. We use contrast-enhanced ultrasound to confirm the course of lymphatic vessels before lymphaticovenous anastomosis (LVA).

We performed ICG angiography and lymphatic contrast-enhanced ultrasound using perflubutane before surgery. The intraoperative detection rate of lymphatic vessels was compared between cases in which only ICG imaging was performed preoperatively and cases in which ICG and contrast-enhanced ultrasound were performed.

When comparing the use of ICG alone with the use of ICG in combination with contrast ultrasound, the detection rate of lymphatic vessels in total (72.6% vs 82.8%) and in areas exhibiting a diffuse pattern (54.5% vs 74.0%) was significantly increased.

Using this method, we will be able to perform LVA more safely, reliably, and time-efficiently, even in patients with severe lymphedema showing a diffuse pattern on ICG imaging.

Breast cancer remains a leading public health issue in low- and middle-income countries (LMICs), where 5-year survival rates range from 12% to 53%. Although post-mastectomy breast reconstruction is a key part of cancer care, its uptake remains low in LMICs. This review identifies the main barriers limiting reconstruction access to inform potential interventions. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were searched for English-language, peer-reviewed articles published between January 2013 and October 2023 on challenges to post-mastectomy breast reconstruction. Eligible studies were original research. Two reviewers extracted and categorized findings into socio-cultural, structural, and financial themes, summarized through descriptive analysis. The search identified 15 papers from 11 countries across four continents. Of the included studies, 73% (n = 11) mentioned barriers under two or more categories; 20% (n = 3) mentioned only structural barriers, and 7% (n = 1) mentioned only socio-cultural factors. Ten studies (67%) described socio-cultural barriers, with the most prevalent themes being the perception of reconstruction as purely aesthetic (47%), fear of anesthesia and recovery time (33%). Thirteen studies (87%) described structural barriers, with the most prevalent structural barrier being a lack of patient awareness, especially before mastectomy (47%). Limited numbers of practicing plastic surgeons (40%), urban-clustered tertiary treatment facilities (33%), and low surgeon referral rates (27%) reduced reconstruction utilization. Twelve studies (80%) described financial barriers with self-payment cited as the most significant limitation to reconstruction and the most significant barrier overall (60%). Reconstruction in LMICs faces intertwined socio-cultural, structural, and financial barriers that limit access and patient willingness.

Postpartum mastitis is common, but immunological changes specific to the postpartum period can exacerbate the inflammation. We report a case of methicillin-resistant Staphylococcus aureus-associated mastitis that rapidly progressed, leading to breast necrosis and symptoms resembling toxic shock syndrome. Postpartum mastitis can result in severe symptoms, so early detection and intervention are important.

A 46-year-old male patient had been undergoing treatment for hidradenitis suppurativa for over 10 years and had undergone surgical treatment 9 and 7 years before visiting our hospital and subsequently received only conservative treatment. The patient had a history of diabetes mellitus and was diagnosed with stage III hidradenitis suppurativa according to Hurley's classification. He had scars and fistulas, particularly, on the buttocks, and had severe anemia. This anemia appeared to be associated with bleeding from the lesions and chronic inflammation. A colostomy was performed, which eliminated the need for regular blood transfusions, and his hemoglobin level improved to within normal limits after two-stage excisional surgeries, followed by reconstruction with split-thickness skin grafting. Although colostomy can help manage anemia, a serious complication of hidradenitis suppurativa, aggressive surgical intervention, including colostomy, may be necessary for patients with refractory disease to prevent deterioration of their general condition.

Congenital lip sinus is known to occur in the upper lip, lower lip, or oral commissure, but a midline sinus of the upper lip is extremely rare. This report describes a 5-year-old boy who was born as a dizygotic twin at a gestational age of 33 weeks and 6 days, weighing 2,118 g. He was noted at birth to have a subcutaneous mass with an opening in the philtrum of the upper lip. Magnetic resonance imaging at 1 year of age revealed a teardrop-shaped cyst with high intensity on T2-weighted images beneath the upper lip. Surgical excision was performed due to the gradual enlargement of the mass. The sinus tract was removed using a combined intraoral and extraoral approach. Histopathology showed cystic dilation of the epithelial lining. The postoperative course was uneventful with good aesthetic results. Early diagnosis and excision are essential for the successful management of this rare congenital anomaly.

Objectives: Lymphedema is a chronic condition characterized by fluid accumulation and limb swelling, often accompanied by pain. While complete decongestive therapy may reduce pain, some patients experience persistent symptoms. Lymphaticovenous anastomosis (LVA) is a minimally invasive procedure that has shown promise in alleviating pain, but the types of pain most responsive to LVA remain unclear.

Methods: This retrospective study included 14 patients (12 women, 2 men; mean age 55.6 years) with lower limb lymphedema and pain who underwent LVA between August and December 2023. A total of 25 limbs were treated. Pain was assessed using a visual analog scale (VAS, 0-10), and pain characteristics were categorized. Limb circumference was measured at six points and summed. Preoperative and postoperative data were compared using paired t-tests. The mean follow-up duration was 268.4 days.

Results: The mean preoperative VAS score was 3.1, which improved slightly to 2.9 postoperatively (p = 0.23); 5 patients (35.7%) experienced pain reduction, 6 (42.9%) had no change, and 3 (21.4%) reported worsening pain. Limb circumference improved significantly from 205.5 cm to 200.5 cm (p < 0.01). Pain improvement showed moderate correlation with changes in limb circumference (r = 0.42) and postoperative weight loss (r = 0.49). Subgroup analysis revealed greater pain reduction in patients who described their pain as "sharp" or "throbbing," whereas all patients who experienced worsening pain reported "heaviness."

Conclusions: LVA may provide meaningful pain relief in selected patients with lower limb lymphedema, particularly those with sharp or throbbing pain. Limb volume reduction and postoperative weight loss appear to be associated with greater pain improvement.

A keloid scar is a benign fibroproliferative disorder that is characterized by excessive tissue growth beyond the original wound. The psychosocial and surgical challenges that arise can present potentially devastating long-term consequences for patients, particularly in demographics with a high incidence of keloid scar formation. Considering the high incidence of keloids with an estimated 11 million cases annually, particularly in those of Asian and African backgrounds, an understanding of their exact pathophysiology remains challenging. Piercing-induced keloids of the ear are a common cause of ear keloids, yet the exact mechanism and optimal treatments are of considerable debate. This narrative review aims to evaluate current treatment modalities for ear keloids, focusing on their association with ear piercings and the implications for management.

A systematic review of Medline, Embase, and Mendeley identified 26 studies, covering a range of surgical and non-surgical treatment methods, indicating a considerable recurrence rate, with an average of 20.3%. Surgical excision remained the primary treatment modality, which was often accompanied by adjunctive therapies such as steroid injections and radiotherapy. Fractional carbon dioxide laser therapy may also be a useful treatment modality with fewer potential complication risks.

Overall, the findings identified significant variability in treatment protocols and outcomes, underscoring the need for personalized approaches based on keloid characteristics and patient preferences. Ultimately, the review highlights the importance of further research to establish standardized treatment protocols for ear keloid scars and to understand the role of piercing-specific pathophysiology in improving patient outcomes.

We report the first case of endoscope-assisted deep inferior epigastric perforator (E-DIEP) flap breast reconstruction in Japan. A 46-year-old woman underwent skin-sparing mastectomy with immediate reconstruction using a DIEP flap. Intramuscular perforator dissection was performed using an open approach, followed by pedicle harvesting using an endoscopic totally extraperitoneal technique. Consequently, a 14-cm pedicle was successfully obtained through a 3.5-cm fascial incision. Microsurgical anastomosis was performed via a mastectomy incision. Recovery was uneventful and the patient was discharged on postoperative day six without complications. This hybrid approach combines the advantages of minimal donor site morbidity and a long pedicle length, enabling tension-free anastomosis and safety. E-DIEP flap harvesting may serve as a practical and less-invasive alternative to robot-assisted techniques, particularly, in facilities where robotic systems are unavailable. This case demonstrated the feasibility and potential benefits of E-DIEP flap for clinical breast reconstruction.

Parotid gland arteriovenous malformation (AVM) may present as a parotid mass. Most parotid masses are benign, and the majority of these are pleomorphic adenomas; therefore, the initial diagnosis of vascular malformations can be challenging without the pathognomonic turkey-wattle sign. We present a case of a parotid gland AVM that was initially misdiagnosed as a parotid gland cyst. The clinical and radiological findings are also discussed here. The AVM was managed with surgical intervention and sent for histopathological study to confirm the diagnosis.

Extensive pelvic resection often results in complications, making flap reconstruction essential for managing pelvic defects. We report a case of successful reconstruction using a pedicled vastus lateralis myocutaneous flap following abdominoperineal resection for anal canal cancer. The flap was transferred through an intermuscular and subcutaneous tunnel into the pelvic cavity. Its anteroposterior extensibility allowed effective filling of the defect. Advancement of the posterior portion of the muscle into the deep pelvis compensated for the limited pedicle length. Preservation of the motor nerve may have helped maintain muscle volume, particularly on the intrapelvic side, with minimal postoperative atrophy observed. These technical strategies demonstrate that the pedicled vastus lateralis myocutaneous flap provides adequate volume, reach, and durability, and may represent a valuable option for extensive pelvic floor reconstruction, especially when motor innervation is preserved.

Smith-Magenis syndrome (SMS) is caused by a deletion in the 17p11.2 region or abnormalities in the RAI1 gene. Clinically, it is characterized by distinctive facial features, sleep disturbances, and neurobehavioral traits such as self-injurious behaviors and developmental delays. It may also be accompanied by ophthalmologic, ear, nose, and throat (ENT), and cardiovascular abnormalities. The prevalence of cleft lip and palate in SMS is reported to range from 0% to 25%; however, there are no detailed reports on speech therapy or speech evaluations following surgery in such patients. Given the significant individual variability in developmental delays among patients with SMS, careful consideration is necessary when determining surgical indications for cleft palate. We conducted regular language assessments, including evaluations of mental development, with a speech therapist, and determined that the patient was a candidate for cleft palate surgery when pre-linguistic speech with meaningful elements was confirmed. Herein, we report a case of SMS in which palatoplasty was performed.

We report the first case of penile sensory reconstruction in a patient with spina bifida in Japan. A 27-year-old man presented with congenital sensory loss in the perineal region owing to spina bifida. His myelomeningocele was repaired immediately after birth. He was unable to recognize bladder fullness and required urinary self-catheterization. Emotional erection and ejaculation were possible, and his gait was normal. We elected to perform the TOMAX procedure (i.e., TO MAXimize sensation, sexuality, and quality of life) to reconstruct penile sensation. Microsurgical sensory nerve anastomosis between the ilioinguinal nerve and the dorsal nerve of the penis was performed bilaterally under general anesthesia. No complications occurred. Penile sensation was noted 3 months after surgery. At the 1-year follow-up, the patient could detect the blue filament on Semmes-Weinstein testing. The TOMAX procedure can provide sensory recovery in patients with spina bifida and improve their quality of life.

Objectives: Treatment of congenital facial paralysis is often postponed because patients exhibit only mild dysfunction and inconspicuous facial asymmetry at rest. Surgical facilitation of smiling has significant implications for the quality of life and the physical and mental development of patients. We describe facial reanimation using modified lengthening temporalis myoplasty (LTM) in patients with congenital incomplete facial nerve palsy who first presented to our institution after the age of 10 years.

Methods: Three patients (age, 12-26 years; two males and one female) underwent facial reanimation with modified LTM using an extended S-shaped incision. In two cases, T-shaped fascial grafts were simultaneously applied to the lower lip. Evaluation was conducted using a simple and objective method to assess smile symmetry.

Results: The postoperative follow-up period ranged from one to nine years. Postoperatively, the oral commissure remained symmetrical at rest in all three cases. Good symmetry was observed during voluntary smiling in all three cases and during spontaneous smiling in two cases.

Conclusions: Modified LTM, a technique that does not require microsurgery and leaves no facial scarring, is a useful option for smile reconstruction in patients with congenital incomplete facial nerve paralysis.

An external dental fistula is a skin perforation caused by spontaneous drainage of pus from odontogenic lesions and is often misdiagnosed due to its resemblance to other conditions. This report describes an 84-year-old man who presented with left cheek swelling and pus drainage. Although an external dental fistula was initially suspected, the diagnosis was delayed due to the edentulous state of the left maxilla. After multiple referrals to various specialties and several misdiagnoses, a computed tomography scan revealed a fistulous tract linked to a retained tooth fragment. The dental fragment was surgically removed, leading to resolution of the abscess and closure of the fistula. This case highlights the importance of considering external dental fistulas even in edentulous patients, as a retained tooth fragment can be the underlying cause.

The palm is prone to skin contractures due to Dupuytren's contractures or trauma. To cover skin defects after contracture release and prevent re-contracture, surgeons prefer flaps to skin grafts. The perforator propeller flap is one of the best local flaps; however, there are few reports on this method. In a perforator mapping study in healthy volunteers, color Doppler ultrasonography showed that the perforator vessels were located around the metacarpophalangeal joints. Five patients with Dupuytren's contracture and one with post-traumatic scar contracture underwent novel perforator propeller flap reconstruction using perforator vessels around the metacarpophalangeal joint in the second, third, or fourth intermetacarpal spaces. Flap sizes ranged from 11 × 22 to 16 × 50 mm², and all flaps survived completely. Our propeller flap is useful for the reconstruction of distal palmar skin defects, especially those less than 16 mm in width.

Electrical injury refers to sustained trauma to the skin or internal organs caused by direct contact with an electric current. Progressive necrosis caused by vascular endothelial damage is a defining feature of electrical injuries. Given this endothelial damage, careful attention is required during reconstruction after such injuries. We present a case of upper extremity reconstruction following an ultra-high-voltage electrical injury (275,000 volts), using an abdominal distant flap with planned vascular anastomosis. Many cases of electrical injury require extremities amputation; however, we were able to salvage the upper extremity. Therefore, this reconstruction method can be an effective technique for managing high-voltage electrical injuries.

A comprehensive apocrine glandectomy with a high certainty of treating axillary osmidrosis is described. Two semicircular subcutaneous disks that include all glands are dissected, starting with the backside. By deftly using every finger, the entire procedure can be performed alone. In the dissected specimens, the completely removed apocrine glands are prominent as elastic, reddish granules surrounded by loose, light-yellow fat tissue.

This is a rare case report in which a third free flap was used to restore metachronous mandibular defects. Significant functional and aesthetic losses may result from segmental mandibular excision in cases of oral cancer. The fibula flap is the gold standard for reconstructing these defects, which is essential for regaining shape and function. Reconstruction attempts become more complex when individuals experience metachronous malignancies or recurrence. We present a rare instance in which a third free flap was required for restoration following 2 metachronous mandibular defects. Mandibular continuity was effectively restored using a free chimeric scapular with latissimus dorsi myocutaneous flap, yielding positive functional and cosmetic results. This case report shows that even after prior reconstruction, patients can successfully undergo an additional free flap procedure, improving their quality of life. It further underscores the adaptability and effectiveness of this reconstructive technique in correcting complex mandibular defects.

A Spigelian hernia is a rare abdominal wall herniation that occurs within the Spigelian fascia, located between the semilunar line and the outer border of the rectus abdominis muscle. A 2-year-old boy was brought to our medical facility because of a longstanding bulge in his right lower abdominal quadrant. Computed tomography revealed the presence of a spinal hernia, right undescended testicle, and right kidney defect. Given the potential association of Spigelian hernias with an undescended testis, a comprehensive examination of the scrotal region at the time of diagnosis is warranted. In the absence of intestinal obstruction or hernia abruption, surgical intervention is recommended on a standby basis. Furthermore, concurrent treatment of any undescended testicle is advised to alleviate patient burden.

This case report presents a rare instance of distal sciatic nerve injury caused by bone fragments from a blast injury. It provides valuable insight for plastic reconstructive surgeons, offering guidance on the management of complex sciatic nerve injuries. Sciatic nerve injuries often have a poor prognosis and require long-term management. Due to limited research and established guidelines, management can vary based on surgeon expertise. Initial treatment focused on limb salvage, with the nerve injury initially overlooked. Nerve conduction studies confirmed the extent and level of the nerve injury, leading to surgical exploration, removal of bone fragments within the nerve, neurolysis, and neurorrhaphy.

Hemifacial microsomia has been reported as the second most common congenital craniofacial malformation. The aim is to present a representative case of a patient who underwent both surgical procedures for the integrated care of hemifacial microsomia. The surgical technique for dynamic facial reanimation was a two-stage procedure due to masseter function impairment. The first one consisted of a cross-facial nerve graft, which was coapted to the masseteric nerve on the contralateral side, and the second stage consisted of a gracilis muscle transfer, in which the obturator nerve was coapted to the masseteric nerve on the ipsilateral side (a dual-innervated free functional gracilis flap). Mandibular distraction was performed a year after the second stage of facial reanimation. At the five-year follow-up, the patient had sustained a satisfactory, aesthetic, and pleasant result. No further secondary or revision procedures have been needed. Objectively, we observed bite-force enhancement, as demonstrated by electromyography. In our experience, we recommend performing microsurgical facial reanimation first, followed by mandibular distraction, and finally, autologous ear reconstruction.

Objectives: To evaluate the effect of resonance tube therapy (RTT) for velopharyngeal inadequacy (VPI) of patients with cleft palate (CP± L), submucous cleft palate (SMCP), and congenital velopharyngeal incompetence (CVPI).

Methods: Thirteen patients were diagnosed with mild or moderate VPI due to either repaired CP± L (7), repaired SMCP (1), or CVPI (5) who had articulation errors. We trained these 13 patients in RTT and performed cephalometry before and after training. Roentgen lateral cephalograms during phonation were used to measure the velar height (mm) and the distance of the narrowest segment of the velopharynx (mm).

Results: After RTT, the velum was significantly elevated, and the velopharynx was narrowed during phonation of /a/ (p< 0.01). Additionally, the velum was significantly elevated, and the velopharynx was more markedly narrowed during phonation of /ɯ/ with tube (tube phonation /ɯ/) than during phonation of /a/ (p < 0.01). The velopharyngeal function (VPF) of all 13 patients was improved by RTT. Ten of 13 showed improved speech and velopharyngeal function. Our findings suggest that RTT is effective in improving velar mobility and velopharyngeal function.

Conclusions: The use of roentgen lateral cephalography during phonation provides quantitative objective findings that distinguish between velar mobility before and after RTT. We propose that RTT is effective for improving velar mobility and velopharyngeal function in patients with and without cleft palate (CP).