Introduction: Contouring the breast shape is one of the most time-consuming procedures in autologous breast reconstruction. We conventionally shape the breast during the last part of the operation through two separate procedures: envelope formation and flap volume adjustment. We performed envelope formation before the vascular anastomosis as predictive contouring, and were able to shorten the operation time.
Methods : The time from the end of vascular anastomosis to the end of the operation was measured as the contouring time in 236 autologous breast reconstruction procedures between June 2008 and October 2017. The predictive contouring group and the non- predictive contouring group were compared.
Results : The breast-shaping time was a median of 244 min in 42 in the non-predictive contouring group and a median of 170 min in 9 in the predictive contouring group for one-stage reconstruction (p<0.01), and a median of 234 min in 39 in the non-predictive contouring group and a median of 137 min in 27 in the predictive contouring group for second-stage reconstruction (p<0.01).
Conclusion : Predictive contouring can shorten the operation time. A free operative field can be obtained irrespective of anastomosed vessels, which allows for simultaneous flap elevation and envelope preparation.

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Reconstruction is necessary for chest wall defects from wide resection of malignant tumors. As the resection time is long, the time required for reconstruction must be as short as possible. We focused the time of reconstruction for large chest wall defects using a pedicled latissimus dorsi flap.
We report four cases of pedicled latissimus dorsi flaps for chest wall defects. The clinical course and findings are presented. Case 1 was for a defect after resection of chondrosarcoma in a 50-year-old man. Case 2 was for a defect after resection of a recurrent malignant peripheral nerve sheath tumor in a 73-year-old man. Case 3 was for a defect after resection of myxofibrosarcoma in a 70-year-old man. Case 4 was for a defect after resection of leiomyosarcoma in a 66-year-old man. The mean time of resection was 349.8 min and the size of defects was 197.8 cm² on average. All flaps survived and no skin graft was required for the donor site.
We conclude that pedicled latissimus dorsi flaps are useful for large chest wall defects and the time of reconstruction is shorter using these flaps. Moreover, skin grafting was not needed at donor sites in our cases.

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症例は70歳，男性．前医にて仙骨浸潤，膀胱浸潤および骨盤内膿瘍を伴う高度進行直腸癌の診断で，当院へ紹介となった．横行結腸双孔式人工肛門造設術を行い，化学療法としてmFOLFOX6+panitumumabを10コース施行した．原発巣の著明な縮小を認めたため，conversion surgeryとして，仙骨合併骨盤内蔵全摘（郭清:D3，LD3），回腸導管造設，S状結腸人工肛門造設，横行結腸人工肛門閉鎖術を施行した．術後，骨盤死腔炎を発症し，開創術による膿瘍ドレナージのみでは改善に乏しく，局所陰圧閉鎖療法を開始したところ，良好な創傷治癒が得られた．術後82病日に退院となった．消化器外科領域においても，創感染に対する局所陰圧閉鎖療法の有用性を示す報告は散見され，創傷治癒や入院期間の短縮に寄与する可能性が示されている．骨盤内蔵全摘後の難治性骨盤死腔炎に対しても局所陰圧閉鎖療法は有効な治療法であった．

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上下顎骨の著しい不調和を生じる骨格性不正咬合に対し，顎矯正手術を伴う外科的矯正治療が適応となる．この顎矯正手術では咬合の機能的改善のみならず，顔貌の形態不調和の改善も重要である．本研究では，非被曝かつ短時間で三次元撮影が可能であるハンディタイプ3Dカメラを用いて上下顎移動術前後の鼻口唇形態の変化について検討することを目的とした．対象は骨格性下顎前突の診断のもと顎矯正手術を行った女性患者10名とし，3Dカメラを用いて手術前後の顔面軟組織形態を測定し，その変化について統計的な処理を行った．その結果，鼻翼幅の増加，鼻孔の長径の減少およびNasolabial angleの増加などを有意に認め，顎骨の移動に伴い外鼻形態の変化が生じることが明らかとなった．今後，コーンビームCT（以下，CBCT）を用いた術前のシミュレーションと合わせて3Dカメラによる軟組織の分析評価を併用することで，患者の主訴の改善および，より精度の高い外科的矯正治療が可能となることが期待される．

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Background : Deep inferior epigastric artery perforator ( DIEP ) free flap has become one of the good options for breast reconstruction due to its advantage of less donor site morbidity. We experienced a rare complication of intraoperative perforator avulsion and spasm and attempted to salvage this situation using the intravascular stenting ( IVaS ) method.
Case reports : A 64-year-old woman who underwent breast reconstruction using a DIEP free flap accidentally suffered perforator avulsion, and a 40-year-old woman had persistent perforator spasm due to a previously formed abdominal scar during flap harvesting procedures. In these two cases, the IVaS method was performed to salvage these situations.
Result : Although the salvage procedures using the IVaS method in these two cases were performed successfully, there was extensive flap loss in the former case and partial flap loss in the latter case. In the former case, progressive venous thrombosis occurred three days postoperatively, and in the latter case, repeated temporary flap ischemia occurred due to unstable blood flow of the salvaged perforators.
Discussion : The IVaS method is supposed to be a technically reliable technique to overcome perforator difficulties, but careful postoperative care is necessary for such patients due to the fragility and instability of the salvaged perforators.

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われわれはPubMedデータベースを用いて1997年から2017年までに報告された英語論文をもとに, 乳頭温存乳房切除術後の乳癌患者における乳頭・乳輪再発リスクに関する論文のシステマティックレビューを行ったので報告する。

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症例は68歳，男性．慢性C型肝炎で通院中に膵頭部腫瘍を指摘され，精査で膵膿瘍と診断された．肝膿瘍も併発し，度重なる膿瘍再燃のため当院へ紹介された．通院開始2カ月後，十二指腸潰瘍術後の創瘢痕中央部が自壊し，膿汁を伴った漏出液と周囲の皮膚炎を認め，漏出も多く，緊急入院とした．CTで膵頭部と自壊部は連続し，漏出液のアミラーゼ値は47,360IU/dlと高値で膵液皮膚瘻と診断した．ガーゼ保護では皮膚炎は悪化．第2病日にソマトスタチンアナログ投与を開始したが，副作用で第6病日に中止となった．治癒には膵液の持続ドレナージが必要と考え，第9病日に局所陰圧閉鎖療法（negative pressure wound therapy:以下NPWT）を開始．皮膚炎は速やかに軽快し，開始4週間後には膵液皮膚瘻も閉鎖した．1カ月後，軽度の再燃を認めたが，1週間のNPWTで治癒し，以降の再燃は認めなかった．膵液皮膚瘻の治療にNPWTも有用である可能性が示唆された．

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Background : In our quest to perform safe and reliable breast reconstruction using autologous free flap transfer, we hereby introduce the concept of lean breast reconstruction ( LBR ).
Method : The LBR concept consists of the following three approaches : avoiding any complicated arrangement or placement of the flaps, using deep inferior epigastric artery perforator free flaps or MS2 transverse rectus abdominis musculocutaneous free flaps based on the safety of the flap-harvesting procedures, and using lateral thoracic vessels as the first-choice recipient vessels for microvascular anastomoses whenever appropriate. We compared two patient groups : the conventional reconstructive surgery group and the LBR surgery group.
Results : The cases of 16 patients were reviewed in this study. The reconstruction time did not change significantly after the introduction of the LBR concept, although it tended to be shorter. However, the patients' postoperative hospital stay was significantly reduced, and the perioperative complications rate improved.
Discussion : As the LBR concept is simple, and easy to understand and perform, it can improve the learning curves of surgeons, assistants, and other medical staff. Thus, the LBR concept might enable reliable breast reconstruction to be performed in more patients and improve the surgical outcomes of such reconstructive procedures.

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  We performed a clinical analysis of 145 children younger than 15 years who had oral and maxillofacial traumatic injuries treated at the Department of Oral and Maxillofacial Surgery, Asahikawa Medical University during the past 5 years (April 2004 to March 2009). The following conclusions were made:
  The ratio of male to female patients was 1.8:1. As for the age distribution, 1-year-old children had the highest incidence of injuries. Analysis of the monthly frequency of injuries showed that September was highest month, and February was the lowest month. Forty percent of the patients visited our hospital on a Saturday, Sunday, or national holiday. The highest proportion of injuries occurred between 15:00 and 18:00. About 87% of the patients visited our hospital directly, and 88.2% of the patients visited our hospital on the day of injury. The causes of injury were falls and drops (66.2%), traffic accidents (8.9%), and sports (7.5%). The most common site of soft tissue injury was the lip, and the most common site of tooth injury was the maxillary anterior primary teeth. Half of the patients were observed without any surgical treatment.

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症例は72歳の肥満女性で，左卵巣腫瘍に対して当院産婦人科にて腹式子宮全摘術，両側付属器切除術，大網切除術が施行された．術後創感染を来したため創開放，デブリードマンを行ったが，創離開を来して腸管が完全に腹腔外へ脱出したため当科に相談があり，再手術を行った．一期的縫合閉鎖での閉腹術では再離開の可能性が高いと判断し，アイソレーションバッグ^®をトリミングして人工腹膜に見立てて腹壁に縫合固定し，感染を伴う腹壁欠損部に対して自動洗浄機能を付加した陰圧閉鎖療法を行った．創は徐々に縮小し，再手術後39日目にアイソレーションバッグ^®を除去し，53日目に陰圧閉鎖療法を終了，55日目に退院した．再手術後6か月では痂皮がわずかに残存する程度となり，治癒が得られたと判断した．今回，アイソレーションバッグ^®と陰圧閉鎖療法を併用することにより創感染，腸管脱出を伴う創離開を安全に治癒しえたため報告する．

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乳房再建において, 左右の対称性の再現は重要なゴールの1つである。患者の希望がある場合, 当院では, 再建手術の前後に対側乳房の縮小・固定術を施行している。今回, 乳房縮小・固定術施行症例の左右の乳房形態を3D画像撮影解析装置VECTRA® BODY (以下ベクトラ) を用いて評価した。

2017年1月〜2020年8月に再建前に乳房縮小・固定術を施行した11症例の術後乳房形態をベクトラを用いて評価した。

平均年齢は48.9歳, インプラント再建が8例, 自家組織再建が3例であった。術後の乳房幅, 胸骨切痕から乳頭までの距離, 乳房下溝から乳頭までの距離, 乳房容量で評価した。各値を再建側／縮小・固定術側の割合で評価すると, 平均107.0%, 96.7%, 105.6%, 101.2%であった。

再建術と乳房縮小・固定術の順序に関してはまだ検討の余地があるが, 当科では主として再建前に縮小・固定術を行っている。本検討において術後の左右対称性は比較的良好であり, 再建前の乳房縮小・固定術による一定の効果が示唆された。

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