秋田 新介

下顎骨再建用のサージカルガイドの作成法と利用法を報告した。切除範囲が術前に決定している場合(タイプ1)、二期再建の場合(タイプ2)および切除範囲が変更になる可能性がある場合(タイプ3)に分類し、それぞれのタイプごとに2症例ずつ全6症例に対して、本サージカルガイドを使用して手術を行った。再建の評価法として、術前術後の患側関節突起先端部中心点の偏差を計測した。全症例で良好な形態を再建できた。1例は術後感染により皮弁壊死を認めた。その他は全例合併症なく、良好な咬合、開口を獲得できている。術前術後の患側関節突起先端部中心点の偏位距離はタイプ1が6.1〜6.5mm、タイプ2が9.2〜10.9mm、タイプ3が6.6〜7.7mmであった。

BACKGROUND: Shingles (localized zoster) and disseminated zoster are caused by the reactivation of latent varicella zoster virus (VZV). Reactivation of VZV is related to impaired cell-mediated immunity. Extensive burns affecting a patient result in burn-related immunosuppression and cytokine storm. Despite immunosuppression in burn patients, the reactivation of VZV is extremely rare, whereas eczema herpeticum, caused by reactivation of latent herpes simplex virus (HSV), is common. We have found only 1 published case of VZV reactivation during burn treatment in the literature. CASE PRESENTATION: A 51-year-old man was burned in a fire, which affected 60% of his total body surface area (TBSA), and also received inhalation injury (day 0). Despite fluid resuscitation, he showed persistent renal failure. Continuous hemodialysis and filtration (CHDF) combined with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) therapy was used for cytokine modulation. Autologous and allogeneic skin grafting was performed. On day 15, multiple-drug-resistant Pseudomonas aeruginosa (MDRP) was detected from a blood specimen, and the patient developed multiple organ failure (MOF). On day 31, compact aggregations of small vesicles appeared on the intact skin of his left knee and left buttock. The vesicles were located within the 4th lumbar (L4) spinal dermatome. From day 32 to day 34, similar new vesicles arose on his intact skin and epithelializing skin-graft donor sites. We diagnosed disseminated zoster, based on the patient's age, the characteristic occurrence of the initial vesicles within a limited area of intact skin in the left L4 dermatome, and a positive Tzank smear. Serologic testing on day 36 showed a high level of anti-VZV immunoglobulin (Ig)G with low levels of anti-VZV IgM, anti-HSV IgG, and anti-HSV IgM. The patient was isolated in a negative-pressure room to avoid air-borne spread of VZV. On day 52, the patient died. CONCLUSIONS: To the best of our knowledge, our patient is the second case of reactivation of VZV during burn treatment. It is unclear why reactivation of VZV is rare in patients with burn-related immunosuppression, whereas HSV reactivation is common. Cytokine modulation throughout the treatment period using CHDF combined with PMX-DHP might have been related to the rare reactivation of VZV in our patient. Our case provides an additional information on the relationship between the immune status of a patient with extensive burns and reactivation of latent VZV or HSV.

日本形成外科学会認定施設全318施設にアンケートを行い、36施設から回答を得た。リンパ浮腫の診察を実施していると答えたのは35施設(97%)で、検査の内容は、メジャーによる周径測定が32施設(91%)、インドシアニングリーン蛍光リンパ管造影(ICG-LG)が27施設(77%)、インピーダンス法が13施設(37%)、リンパシンチグラフィが13施設(37%)、SPECT-CTリンパ管造影が4施設(11%)、MRIリンパ管造影が1施設(3%)、CTリンパ管造影が1施設(3%)であった。このうちICG-LGを実施している施設のみを対象とし、「ICG溶液の濃度」「注射部位」「副作用」などについて調査した。結果、ICG溶液の濃度は1.25mg/mLが2施設(7%)、2.5mg/mLが14施設(52%)、5.0mg/mLが5施設(19%)、6.25mg/mLが2施設(7%)、不明4施設であった。注射部位を明記していた施設は、上肢12施設(44%)、下肢13施設(48%)であり、上肢における注射部位の1ヶ所目は第1指間が7施設(58%)、第2指間が5施設(42%)、下肢における1ヶ所目は第1趾間が11施設(85%)、第2趾間が2施設(15%)であった。過去に経験した副作用は、気分不良など軽度の全身症状を1施設(4%)で1件、注射部位の発赤など軽度の局所症状を1施設(4%)で3件経験していた。

Methods for quantitative analysis of long distance lymphatic transport of nanoparticles in live animals are yet to be established. We established a mouse model for analysis of time-dependent transport just beneath the abdominal skin to investigate lymph node-to-lymph node trafficking by in vivo imaging. For this purpose, popliteal lymph nodes (PLNs) as well as efferent and afferent lymphatic vessels, marginal veins, and feeding blood vessels were surgically resected to change the lymphatic flow from footpad injections. Using this model, we observed a novel lymphatic flow from the footpad to the proper axillary lymph node (ALN) via the inguinal lymph node (ILN). This drainage pathway was maintained over 12 weeks. Time-dependent transportation of 1,1′-dioctadecyltetramethyl indotricarbocyanine iodide-labelled liposomes from the footpad to the ILN was successfully quantified by an in vivo imaging system. Moreover, congestion and development of a new collateral lymphatic route was visualised under a lymphedema status. Histological analysis of abdominal skin tissues of this model revealed that PLN resection had no effect on the abdominal lymphatic system between the ILN and ALN. These data indicate that this model might be useful to clarify the mechanisms of lymphedema and study direct transportation of lymph or other substances between lymph nodes.

© 2018 The Japan Society of Applied Physics. We aim to develop an ultrasonic tissue characterization method for the follow-up of healing ulcers by diagnosing collagen fibers properties. In this paper, we demonstrated a computer simulation with simulation phantoms reflecting irregularly distributed collagen fibers to evaluate the relationship between physical properties, such as number density and periodicity, and the estimated characteristics of the echo amplitude envelope using the homodyned-K distribution. Moreover, the consistency between echo signal characteristics and the structures of ex vivo human tissues was verified from the measured data of normal skin and nonhealed ulcers. In the simulation study, speckle or coherent signal characteristics are identified as periodically or uniformly distributed collagen fibers with high number density and high periodicity. This result shows the effectiveness of the analysis using the homodyned-K distribution for tissues with complicated structures. Normal skin analysis results are characterized as including speckle or low-coherence signal components, and a nonhealed ulcer is different from normal skin with respect to the physical properties of collagen fibers.

Background: In a deep epigastric artery perforator (DIEP) flap breast reconstruction, the necessity of additional anastomosis of the superficial inferior epigastric vein (SIEV) should be determined intraoperatively. The purpose of this pilot study is to propose a method to detect venous congestion intraoperatively using the blood glucose measurement index (BGMI). Methods: In 70 DIEP flaps of 67 patients for breast reconstruction, the ratio of blood glucose content in the flap to systemic blood glucose (BGMI) was measured immediately after wound closure. Eight flaps in which BGMI was less than 0.8 were categorized into the low BGMI group, and additional venous anastomosis using SIEV was conducted. The other 62 flaps were categorized into the normal BGMI group. Perioperative objective color difference of the flap calculated using the L*a*b* color coordinate scale was recorded simultaneously. Correlation between BGMI and color difference was analyzed. Results: In all flaps in the low BGMI group, SIEV diameter was increased after additional anastomosis, the BGMI significantly improved (from 0.71 ± 0.05 to 0.94 ± 0.05, P &lt .01). There was a significant correlation between BGMI and color difference (P =.04). The determination coefficient was 0.265. When a BGMI of less than 0.8 was assumed to be a true positive, the area under the curve of color difference in the receiver operating characteristic curve was 0.82. Conclusion: BGMI immediately after wound closure may be useful to detect initial signs of venous congestion. Intraoperative objective color difference also reflects venous congestion however, it is not highly accurate.

Background: Poststernotomy deep sternal wound infections are persistent and occasionally fatal, especially in cases involving prosthetic grafts, because of their complicated structure and virtual impossibility of removal. We aimed to verify the influence of cooperation with plastic surgeons and our novel strategy for treating deep sternal wound infection after aortic replacement on cardiovascular surgery outcomes. Patients and Methods: Nine hundred eighty-three consecutive patients were divided into two groups: an early group (2012–2013) and a late group (2014–2015). The late group had received cooperatively improved perioperative wound management: our novel strategy of deep sternal infection based on radical debridement and immediate reconstruction decided by reference to severities of the patient's general condition and widespread infection by early intervention of plastic surgeons. The groups were analysed retrospectively. Binary variables were analysed statistically with the Fisher exact test and continuous variables with the Mann–Whitney U test. Inter-group differences were assessed with the chi-square test. Results: Twenty of 390 cases in the early group and 13 of 593 cases in the late group were associated with deep sternal infection. Morbidity rates of deep sternal wound infection and associated mortality rates 1 year after reconstruction surgery were significantly less (p &lt 0.05 for both) in the late group. Conclusions: Intervention by plastic surgeons improved perioperative wound management outcomes. Our treatment strategy for deep sternal wound infection also reduced associated mortality rates. Facilities should consider the early inclusion of plastic surgeons in the treatment of patients undergoing aortic replacement to facilitate better outcomes.

Background Vascularized nerve grafting is normally associated with a good outcome, but can be difficult to use for nerve reconstruction in patients with long defects of the sciatic nerve given the graft thickness. We report 3 cases of large defect sciatic nerve reconstruction using the bilateral sural nerves of the lower legs harvested together with the fascia and lesser saphenous vein to form a vascularized flap. Methods The subjects were 3 patients who required the reconstruction of a 10-cm or longer segment of the sciatic nerve. Priority was given to restoring sensation in the plantar region such that reconstruction of the sensory nerves corresponding to the tibial region. Results Two patients were followed up for long term. There was some persistent perceptual deficit in the foot, minimal protective sensation had been achieved. Conclusions We were able to selectively reconstruct the sensory nerves to achieve sensation in the soles of the feet by using sural nerve grafts from both legs. As the prognosis for the underlying condition in cases necessitating this procedure is often poor, the costs and benefits of reconstruction should always be weighed carefully for each individual patient.

Background: Following vascularized lymph node (VLN) transfer (VLNT), the VLN may be at a risk for sclerosis because of efferent lymphatic vessel obstruction. We developed a new technique to prevent VLN sclerosis via a prefabricated lympho-venous (LV) shunt. This study compared the treatment outcomes of single VLNT with prefabricated LV shunt, conventional multiple VLNTs, and conventional single VLNT. Methods: Overall, 47 limbs of 45 patients that underwent VLNT for lower-extremity lymphedema (LEL) in late clinical stage II/III were divided into 3 groups: conventional single VLNT group (control 21 limbs where 4 had primary LEL), multiple VLNTs group (13 limbs where 3 had primary LEL), and prefabricated LV shunt group (13 limbs where 4 had primary LEL). In the prefabricated LV shunt group, lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated VLN were performed simultaneously with VLNT. Results: Although venous thrombosis at the anastomosis site was observed in 1 case, it was salvaged by re-anastomosis, and all VLNs survived. No other complications were observed. The LEL index significantly improved in the prefabricated LV shunt group compared with that in the control group (28.0 ± 1.7 vs 20.9 ± 1.5, P = 0.02). In the prefabricated LV shunt group, all VLNs survived functionally, and the average size of the transferred lymph nodes was significantly larger than that of the control group (5.7 ± 0.1 vs 4.3 ± 0.2 mm, P &lt 0.01). Conclusions: Prefabricated LV shunt may improve the efficacy of VLNT.

リンパ浮腫などを罹患した皮膚組織において、初期の線維化や炎症程度を超音波定量診断法により指標化することを目指している。本報告では、摘出正常ヒト皮膚(n=3)と重度リンパ浮腫(n=1)からのRFエコー信号を自作スキャナと15、25MHz(中心周波数)の単一凹面振動子を用いて計測し、エコー振幅包絡像の特徴を整理した。さらに、組織構造の差を指標化するために、後方散乱係数および統計分布を用いた信号解析法を適用した。組織構造の評価パラメータとして、Homodyned-K分布のパラメータμおよび1/(κ+1)、後方散乱係数の積分値(IB)に着目した。特に25MHz振動子での解析結果では、エコー強度に関連する評価パラメータの算出結果に差がみられた[中央値(四分位範囲):μ=0.71(0.43-1.16)、IB=4.32(2.20-10.3)×10^-3sr-1mm-1(正常皮膚)およびμ=2.03(1.32-2.89)、IB=13.0(6.49-23.4)×10^-3sr-1mm-1(リンパ浮腫)]。正常皮膚に比して、リンパ浮腫組織が高散乱体密度かつ後方散乱波のエネルギーが大きいと想定される。病理像を用いて作成した膠原線維の数密度が異なる媒質モデルに対し、エコーシミュレーションを検討した結果においても、低散乱体密度なモデルに比して高散乱体密度なモデルの評価パラメータが高いことから、実信号解析の結果を裏付けることができた。(著者抄録)

Background: Although early detection is valuable for secondary lymphedema treatment, existing screening tests are not popular. This study aimed to propose a novel method of screening lymphedema patients based on the thickness of the subcutaneous fat measured with perioperative computed tomography (CT) and present the results from evaluation of patients who underwent those examinations was performed. Method: The medical records of 96 gynecological cancer patients and 189 breast cancer patients, whose lymphatic function was assessed with indocyanine green lymphography, were reviewed. In gynecological cancer patients, the perioperative temporal subcutaneous fat thickness index (T-SFTI) was calculated from presurgical and follow-up CT data, and in breast cancer patients, the postoperative crosswise subcutaneous fat thickness index (C-SFTI) was calculated. In lower extremity lymphedema patients, the effect of lymphaticovenular anastomosis (LVA) was also evaluated using T-SFTI. Results: Perioperative T-SFTI was assessed in 180 lower extremities, and it was significantly higher in 46 lymphatic dysfunction limbs (1.21 +/- 0.08) than in 134 normal lymphatic function limbs (1.03 +/- 0.08), (P < .01). Postoperative C-SFTI was assessed in 53 upper extremity, and it was significantly higher in 11 lymphatic dysfunction limbs (1.31 +/- 0.21) than in 42 normal lymphatic function limbs (1.01 +/- 0.06), (P < .01). In lower extremity lymphedema patients, T-SFTI improved significantly after planned conservative treatments and LVA (P = .04). Conclusion: Assessment of subcutaneous fat thickness using CT is useful for screening early stage lymphedema. If the efficacy of this method is validated, patients worldwide may be assessed using the same criterion.

Background The contribution of simultaneous breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap to the efficacy of vascularized groin lymph node transfer (LNT) for breast cancer-related lymphedema (BCRL) was investigated. Methods Patients were divided into two groups: the first group underwent groin LNT + DIEP flap surgery for simultaneous breast reconstruction (groin LNT + DIEP flap group) and the second group underwent groin LNT only (groin flap alone group). Patients with BCRL were evaluated based on indocyanine green lymphography findings. LNT was indicated only in advanced-stage BCRL cases, and groin nodes nourished by superficial circumflex iliac artery (SCIA) were used as donors. The side for the vascular pedicle(s) was decided based on our algorithm. In patients with pendulous breast, the flap was vertically transferred on the chest. Lymphatic function was assessed after LNT using imaging tests, and transferred lymph nodes were evaluated using ultrasonography. Results In this study, 27 patients with advanced-stage BCRL underwent LNT. Of them, 13 belonged to the groin LNT + DIEP flap group and 14 belonged to the groin flap alone group. Although reduction volume was not significantly different between the groups, the number of patients in whom lymphatic function was improved and the need for compression therapy could be reduced was significantly higher in the groin LNT + DIEP flap group than in the groin flap alone group. Conclusion When a patient with advanced-stage BCRL undergoes LNT based on SCIA, simultaneous breast reconstruction using DIEP flap may reduce the need for compression therapy.

Oto-palato-digital syndrome type 1 (OPD1) is an X-linked recessive disorder comprising characteristic facial appearances and skeletal alterations. The authors report OPD1 in a mother and her 2 sons who had multiple common congenital anomalies. Both of the brothers were born with mild hearing impairment, frontal bossing with prominent supraorbital ridges, downslanting palpebral fissures, dental malocclusion, and palatal clefts. They underwent a series of aesthetic surgeries for their facial malformations with good cosmetic results. The mother had a milder phenotype with less prominent craniofacial defects that did not require surgical correction. The older brother required a 2-jaw surgery whereas the younger brother required a surgically assisted rapid palatal expansion. In the second series of operations, both brothers underwent scraping of their prominent supraorbital ridge. They have been free of complications throughout their 16-year follow-up. The authors also screened the family for possible genetic etiologies and identified mutations in the causative gene of OPD1 on Xq28 in all 3 patients. In conclusion, the authors have identified 3 patients with OPD1, performed surgical treatments on the affected brothers and have obtained good reconstructive results. There are no reports involving OPD1 patients who have received good surgical treatment. With careful examination and identification of patients with characteristic facies and skeletal abnormalities, it is our opinion that the authors can help more patients with this disease through surgical management.

Background: Patients with secondary lower extremity lymphedema often develop suprapubic lymphedema. The authors developed a novel surgical method of shaping the lower abdomen and debulking suprapubic lymphedema with simultaneous reconstruction of lymphatic flow in case of lower extremity lymphedema. Methods: A fleur-de-lis skin incision pattern was performed for horizontal and vertical abdominal skin and fat resection. A caudally based isosceles triangular flap was created on the central suprapubic region to reduce wound tension at the intersection of the horizontal and vertical incisions. After resection and debulking of the suprapubic region, a lymphaticovenular anastomosis between the efferent lymphatic vessel of the groin node and the superficial inferior epigastric vein was created or vascularized lymph node transfer to the groin region was performed to restore lymphatic flow. Lymphaticovenular anastomosis and lymph node transfer were also performed at the lower extremities to improve lower extremity lymphedema. Perioperative change in limb volume was evaluated using the lower extremity lymphedema index, and lymphatic function was evaluated by lymphoscintigraphy. Results: Simultaneous abdominoplasty and reconstructive lymphatic microsurgery were performed in 11 patients. The lower extremity lymphedema index improved perioperatively, with a significant difference (p &lt 0.01). In eight patients who underwent lymphoscintigraphy before and after surgery, the lymphatic function was found to have not deteriorated in any limb. Conclusions: When simultaneous lymphatic microsurgical procedures and careful observation for complications were performed, abdominoplasty resulted in good outcomes in patients with lower extremity lymphedema and suprapubic lymphedema without worsening of lymphedema.

皮膚潰瘍の治癒状況や感染発症の有無を非侵襲かつ定量的に診断する手法が求められている。新規診断法の可能性として、超音波による組織性状診断技術の応用を検討しており、その定量診断技術の基礎となる信号解析法を検討した。信号解析法として生体組織の散乱特性を考慮した統計分布を用い、エコー信号の振幅分布を数学モデル化することで、皮膚潰瘍からのエコー信号の散乱特性を評価した。さらに、組織病理学的評価により組織の空間的特徴を観察し、主に非感染および感染組織の構造に着目した。動物実験について、臨床用の超音波診断装置と中心周波数8.9MHZのリニアアレイプロープを用いて、皮膚潰瘍を有する3種のラットモデル(非感染・表層感染・深層感染モデル)からのRFエコー信号を取得した。まず、実測と推定された統計分布間の一致度を評価することで、数学モデル化精度の高い統計分布を確認した。さらに、数学モデル化精度の高い統計分布のパラメータを用いて、非感染および感染組織の差を指標化した。結果、感染をモデル化したラットにおいてのみ、干渉信号のパワーに関係する統計分布のパラメータが感度を示し、そのパラメータの空間分布の特徴は、対応する断面の組織病理像の特徴と一致した。(著者抄録)

The deep layers of the nasoethmoid region comprise a thin-walled lacrimal bone, a paper-thin ethmoid plate, and ethmoidal cells, forming an extremely fragile and easily crushed structure. In a nasoethmoid complex fracture where the support structure itself is destroyed, epithesis and immobilization are difficult and can lead to residual saddle nose deformities. Therefore, bone grafts are often necessary at a later date. Recently, the authors occasionally see reports of nasoethmoid complex fractures that are treated with Halo distraction devices. Advantages of this device are that it applies constant traction to maintain the shape of the structures until the ruptured nasoethmoid bone and mucosa are repaired, thus minimizing relapse. There is no need for rigid fixation with a plate, no limitations on how much distraction is possible, and no major skin incisions are required for the approach. The authors treated a 30-year-old man who suffered a severe and widespread depressed facial deformation due to a nasoethmoid fracture that included a midface comminuted fracture using a Halo-type distraction device. A gentle traction was maintained on the nasoethmoid bone and part of the maxilla pulling it forward, and resulted in an extremely good outcome both esthetically and functionally. This method is believed to be extremely useful and effective, requiring only minimally invasive surgery for comminuted midface fractures involving a nasoethmoid fracture with a depressed frontal process of the maxilla. Below, the authors provide a detailed description of their experience with this device.

Background: Tissue oximetry is a useful tool for postoperative free flap monitoring. Reported criterion values have been accurate; however, there are various complicated author-dependent criteria, and sometimes it is too late for flap salvage. The authors offer a new, simple criterion for faster and accurate detection of perfusion problems. Methods: Intraoperatively, perfusion areas of various free perforator flaps were assessed by both indocyanine green angiography and regional oxygen saturation. The elevated flap was categorized into the early-stained area, the delayed-stained area, and the no-stained area by indocyanine green angiography. The regional oxygen saturation index (regional oxygen saturation on the flap on the control nondissected portion) of each area was calculated. Postoperative continuous flap monitoring was conducted, recording the value of the regional oxygen saturation index at the early-stained area. The blood glucose measurement index was also recorded periodically. Results: In 60 cases of perforator-based free flaps, intraoperative indocyanine green areas were significantly correlated with the values of regional oxygen saturation index. The postoperative regional oxygen saturation index showed very stable values in various types of perforator flaps, provided that no vascular problem occurred, and it never went below 0.75. When vascular problems occurred, the regional oxygen saturation index dropped below 0.75 in all three cases before the blood glucose measurement index and the absolute value of regional oxygen saturation dropped below the criterion value. Conclusion: The regional oxygen saturation index may be a simple and fast criterion for detecting vascular problems following free flap reconstruction compared with existing criteria.

CaseThe patient was a 3-year-old with hypospadias. Urethroplasty was performed as a two-stage procedure, but a severe urethral stricture occurred due to a postoperative infection and the patient was virtually in urinary retention. An emergency cystostomy was performed, and thereafter urethral reconstruction was performed. A large urethral diverticulum had formed in the scrotum. The inner wall of the diverticulum was found to be completely epithelialized and well vascularized. Therefore, it was elevated as a skin flap and a neourethra was reconstructed up to the glans region using the diverticular tissue. OutcomePostoperative complications were not observed, and micturition was satisfactory. ConclusionA urethral diverticulum is one of the often encountered complications of hypospadias surgery. However, there are only a few literature reports related to the treatment of urethral diverticulum. In addition, there are almost no reports on reconstructions using urethral diverticular tissue. In this report, we describe such a treatment experience.

Vascularized lymph node transfer (VLNT) has become a popular surgical option for extremity lymphedema however, this surgical technique requires a longer hospital stay than lymphaticovenular anastomosis (LVA), and has a risk of donor site morbidity. VLNT is suitable for patients with International Society of Lymphology late stage II or more severe lower extremity lymphedema, because greater average volume reduction can be achieved with VLNT than with LVA. Patients who desire simultaneous total or partial breast reconstruction and surgical treatment for upper extremity lymphedema are also candidates for VLNT. They can obtain both symmetrical breasts and a non-edematous arm simultaneously. However, patients should be fully informed about the risks of a lymphatic function disorder at the donor site. Careful surgery is necessary to avoid impaired lymphatic flow at the donor site. A definitive technique for VLNT has not yet been standardized, and some problems remain.

Background: Upper extremity edema following surgical treatment for breast cancer does not always result in chronic breast cancer-related lymphedema. Changes in the findings of indocyanine green lymphography and upper extremity volume following breast cancer surgery were observed prospectively to understand the early changes in lymphatic function and to establish a new strategy for early diagnosis and treatment of breast cancer-related lymphedema. Methods: Lymphatic function for 196 consecutive breasts was examined using indocyanine green lymphography and bilateral upper extremity volume before surgery and 1, 3, 6, 9, and 12 months after surgery. When a "stardust," " diffuse," or " no flow" pattern was observed, patients were diagnosed with lymphatic disorder and subsequently underwent conservative treatments such as compression sleeve therapy. Result: In 35 patients, lymphatic disorder was observed after a mean of 5.2 +/- 3.0 months after surgery. In 21 of these patients, no significant limb volume change was observed. In 14 patients, lymphatic disorder and volume change appeared simultaneously. In 11 of 35 patients, lymphatic function improved later, and compression therapy was discontinued. Lymph node dissection, radiation therapy to axillary lymph node, and the use of docetaxel chemotherapy were significant risk factors for lymphatic disorder. No patients experienced cellulitis during the study period. Conclusions: Lymphatic function disorder could be detected before volume changes. By early intervention with conservative treatments, lymphatic function improved in just under one-third of cases. Indocyanine green lymphography for high-risk patients may be useful for detecting lymphatic disorder early, thereby increasing the chance for disease cure.

顔面の萎縮や先天性の成長障害を伴う疾患に対する治療の1つに、脂肪注入移植術がある。我々もこのような患者数人に脂肪注入術を行い、約1年経過を追うことができた患者3名につき報告する。2名は限局性強皮症、症例3はhemifacial microsomiaの診断であった。結果として、移植脂肪の生着に関しては個人差がみられたが、概ね良好であった。Hemifacial microsomiaの症例では、患者の体重の増加と共に移植部の増大がみられた。また、萎縮した皮膚に色素沈着のみられた限局性強皮症の患者で、術後、色素沈着の改善がみられた。さらに、吸引した脂肪よりもメスで採取して細片化した脂肪の方が、生着が良好である印象であった。(著者抄録)

異物の移植後には、いつも感染の危険性が伴う。我々は、鼻へのシリコンプロテーゼ移植後30年経過した後に、鼻尖部の発赤をきたし、感染が疑われた1症例を経験した。症例は58歳の女性で、来院時、鼻尖部の僅かな腫脹と発赤がみられたため、感染を疑い摘出術を考えた。しかし、自発痛や圧痛はなく、X線所見では、プロテーゼ周囲に石灰化がみられ、鼻柱上部にカルシウムと思われる物質の沈着があったため、異物による反応と考え、穿刺吸引を試みた。沈着した物質は16G針を用いても吸引できなかったが、その針穴から、クリーム状の物質が圧出された。その後、発赤などは消失し、プロテーゼの抜去を行わずに済んだ。しかし、その8年後に高度の石灰化が原因と考えられる鼻の変形を訴えたため、最終的には、プロテーゼの抜去を行った。(著者抄録)

BackgroundAn examination of the vascular anatomy of the iliotibial tract (IT) has not been previously reported. Because a flap resists infection better than an avascular graft, a vascularized IT graft is useful for reconstructive surgeries pertaining to infected wounds or wounds in contact with artificial material. The purpose of this study was to examine the vascular anatomy of the IT. Materials and MethodsThe study sample consisted of 39 limbs of freshly frozen cadavers. The study was divided into three parts. The ascending and transverse branches of the lateral circumflex femoral artery (LCFA) of all cadavers were injected with latex. Distance from the tensor fasciae latae muscle and the most distal point at which the vessel on the IT was stained by latex was recorded. A microscopic observation was performed for these limbs. The deep femoral artery (DFA) or superior lateral genicular artery (SLGA) was also observed. ResultsThe length of the IT fed by the LCFA was 162.336.2 mm. The IT vascularity was located between the layered structure of the fascia and there was a vascular source for the IT within 1 mm above the IT by optical microscopy. The vascularity derived from the DFA or SLGA was not confirmed in any specimens. ConclusionsBlood supply of the IT was derived from the LCFA and a vascularized IT graft could be elevated in length to approximately 16 cm. This knowledge may be useful for improving the safety of surgery when transferring an IT flap. (c) 2015 Wiley Periodicals, Inc. Microsurgery 36:325-329, 2016.

This study examined a combination of artificial dermis and basic fibroblast growth factor (bFGF) to treat skin defects in clinical Cases, and it histopathologically examined the effects on the conditions of recipient beds. Materials and Methods. The subjects were 11 patients with skin defects from burn ulcers or traumatic ulcers. In each subject, debridement was performed and subsequently artificial dermis was applied to the defect. The bFGF was used on 1 side (combination therapy) of the artificial dermis and not used on the other side (artificial dermis monotherapy). A histopathological examination was performed on the granulation tissue collected from the recipient bed. The authors also measured skin hardness 6 months after the skin graft. Results. Histologically, the combination therapy site had more extensive capillary angiogenesis than the monotherapy site. The combination therapy site. also had capillary walls consisting of thick, large endothelial cells; fibroblast proliferation and activation; and more severe infiltration of inflammatory cells. Skin hardness after the graft was also much softer in the combination therapy. Conclusion. The results suggest the usefulness of this combination therapy in the preparation of skin graft beds to improve skin hardness after skin grafts in clinical cases.

UNLABELLED: Carotid-cavernous sinus fistula (CCF) is a rare complication occurring after the Le Fort osteotomy. We aimed to elucidate the cause of CCF in the Le Fort osteotomy. METHODS: Eleven fresh cadavers were used. After craniotomy, a Le Fort III bipartition osteotomy was then performed. On the left side, both the lateral wall of the maxilla and the pterygomaxillary junction (PMJ) were divided, in addition to the conventional osteotomy line. On the right side, those parts were kept intact. After the osteotomy, a tensiometer was fixed to the skull base. The sensor was linked with the wall of the carotid artery in the cavernous portion. A down-fracture was then performed initially from the left, followed by the right. Tensile force data of both sides were recorded. RESULTS: In all cases, a higher tensile load was observed on the right side compared to the left side. In right side, two skull base fractures complexed with high pterygoid process fractures, and nine pure high fractures of the pterygoid process were identified. CONCLUSIONS: During down-fracture, the wall of the carotid artery experiences significant tensile load. The tensile load on the arterial wall may collapse the fine branches of the carotid artery in the cavernous portion.

Background: The critical issue related to breast-conserving therapy (BCT) is that cosmetic outcomes deteriorate with long-term follow-up. There is little research for breast density as a predictor of cosmetic outcomes at the late stage after BCT. To improve the long-term quality of life after BCT of breast cancer patients, the correlation of volumetric breast density (VBD) and cosmetic outcome at the late stage after BCT was evaluated. Study design: Breast volume, fibroglandular tissue volume, adipose tissue volume, and VBD were calculated on mammography using image analysis software (Volpara (R)) in 151 patients with BCT. Furthermore, the correlation of breast density and the change of breast volume over time was analyzed on mammography in 99 patients who were followed-up long-term after BCT. Results: On multivariate analysis, VBD was a predictor of cosmetic outcome after BCT with percent breast volume excised (PBVE). Decreased adipose tissue volume and increased fibrosis were more common in patients with VBD < 15%. Furthermore, remnant breast volume continued to decrease over time in low breast density patients during long-term follow-up. 93% of patients with VBD >= 15% and PBVE < 10% had a better cosmetic outcome, while 60% of patients with VBD < 15% and PBVE >= 10% had a worse cosmetic outcome after BCT. Conclusions: While PBVE was involved in cosmetic outcome at the early stage after BCT, VBD was associated with cosmetic outcome at the late stage after BCT. Thus, a combination of VBD and PBVE could predict cosmetic outcome after BCT and contribute to the selection for the appropriate BCT. (C) 2016 Elsevier Ltd. All rights reserved.

In most general thoracic operations performed via standard posterolateral thoracotomy, such as for descending aortic aneurysms and lung cancer, the latissimus dorsi (LD) muscle is divided. However, division of the LD can hamper reconstructive surgery because the initial operation creates unstable blood flow to the divided LD. We conducted this study to assess blood flow in a divided distal LD muscle flap using intraoperative indocyanine green-fluorescence angiography (ICG-FA) with the Hyper Eye Medical System(A (R)) (Mizuho Medical Co., Ltd., Tokyo, Japan). The subjects were 11 patients who underwent posterolateral thoracotomy with reconstructive surgery using a divided distal LD and other peripheral muscle flaps. Intraoperative ICG-FA was conducted to assess blood flow to the LD. Intraoperative ICG-FA revealed that at least two intercostal perforators from the sixth to the tenth intercostal spaces were preserved as feeding vessels to the divided distal LD. There were no major complications associated with inadequate blood flow to the muscle flaps. Intraoperative ICG-FA proved extremely useful for assessing altered blood flow of the divided LD and for selecting preserved intercostal perforators.

Currently the distraction technique could be very useful for posterior expansion in syndromic craniosynostosis. Even for fronto-orbital advancement (FOA), it is thought that distraction has the definitive advantage over the conventional technique. The authors describe the appropriate indication of distraction for FOA in our series of craniosynostosis patients. Since 1998, FOA by distraction has been used for 61 cases of simple and syndromic craniosynostosis. Among these, seven severe cases were extracted with a conspicuous craniofacial deformity with a multiple honeycomb appearance in 3DCT views. Early surgery for FOA by distraction to the extent possible was performed and a retrospective study was conducted. Seven children were identified. All of them exhibited a severe craniofacial deformity. Pfeiffer syndrome in 5 children and clover-leaf skull in two unidentified children were diagnosed. Mean age at surgery for FDA by distraction ranged 10-18 months. Mean operative time: 3-3.5 h. Blood loss: 230-320 mL. The mean advancement by distraction: 20-27 mm. We conclude FDA by distraction when a large amount of advancement is required for early severe cases as our series can be definitely one of the most appropriate candidates beyond the conventional technique, despite disadvantages. (C) 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Background: To achieve an unnoticeable postoperative scar in patients with little abdominal skin laxity for breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, we devised a new design called the low-rise scar DIEP flap; the skin paddle of this flap is located lower with a smaller vertical width, and more adipose tissue is elevated to obtain enough volume. The purpose of this report is to evaluate the utility of the low-rise scar DIEP flap compared with that of the conventionally designed flap. Methods: Twelve patients who underwent low-rise scar DIEP flaps (study group) and 11 patients who underwent conventionally-designed DIEP flaps (control group) were included in the present study. The distance from the umbilicus to horizontal scar was divided by the patient's height. The length of the scar was divided by the abdominal circumference. These ratios were compared between groups. Results: All flaps survived completely and no recipient site complication was observed, except for one case in the control group with small-range fat necrosis. No donor site complication was observed in either group. The distance ratio was significantly larger in study group (<0.01, 0.049 +/- 0.004, and 0.028 +/- 0.005, respectively). The length ratio was significantly smaller in the study group <0.01, 0.42 +/- 0.02 and 0.36 +/- 0.02, respectively). The weight of the flap used for reconstruction was 338.8 +/- 127.7 g in the study group and 320.5 +/- 63.0 g in the control group Conclusions: A low-rise scar DIEP flap leaves a lower and shorter postoperative scar. (C) 2015 Wiley Periodicals, Inc.

Poor survival is a major problem of adipocyte transplantation. We previously reported that VEGF and MMPs secreted from transplanted adipocytes are essential for angiogenesis and adipogenesis. Pretreatment with low-dose (5 Gy) radiation (LDR) increased VEGF, MMP-2, and HIF-1 alpha mRNA expression in human ceiling culture-derived proliferative adipocytes (hccdPAs). Gene expression after LDR differed between adipose-derived stem cells (hASCs) and hccdPAs. Pretreatment with LDR improved the survival of hccdPAs under hypoxia, which is inevitable in the early stages after transplantation. Upregulation of VEGF and MMP-2 after LDR in hccdPAs is mediated by HIF-1 alpha expression. Our results suggest that pretreatment with LDR may improve adipocyte graft survival in a clinical setting through upregulation of VEGF and MMP-2 via HIF-1 alpha. (C) 2015 Elsevier Inc. All rights reserved.

Background Vascularized lymph node transfer has become a popular surgical option to improve lower extremity lymphedema (LEL), although potential donor sites are limited. The free supraclavicular flap with deep cervical lymph nodes has been recently associated with a minimal risk of secondary lymphedema caused by donor site dissection. However, the effectiveness of this procedure has not yet been evaluated. Methods Vascularized supraclavicular lymph node transfer (VSLNT) was performed for patients with International Society of Lymphology late stage II or more severe LEL. The results were compared with lymphaticovenular anastomosis (LVA) performed for patients with the same stages of severity. To evaluate improvement in lymphatic function, indocyanine green lymphography and lymphoscintigraphy were performed. Results Vascularized supraclavicular lymph node transfer was performed in 13 limbs of 13 patients. The results were compared with 43 limbs of 33 patients who underwent multiple LVA. No severe complications were observed in either group. Improvement in lymphatic function, as measured by the LEL index, was 26.5 4.4 and 21.2 +/- 2.0 in the VSLNT and LVA groups, respectively. Lymphatic function was improved in 7 cases in the VSLNT group and 10 cases in the LVA group. Conclusions Vascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage LEL. Lymphaticovenular anastomosis is also effective, but to a lesser degree than VSLNT. However, LVA is less invasive and requires a shorter hospital stay.