秋田 新介

BACKGROUND: In microvascular breast reconstruction, the internal mammary vein (IMV) has emerged as the most common recipient vein. The open-Y technique can increase the vessel diameter via the bifurcation site. This study aimed to investigate the open-Y technique for IMV. METHODS: The characteristics and details of the operative procedure in patients who had undergone unilateral breast reconstruction with and without the open-Y approach for the free abdominal flap were compared. Differences in IMV anastomosis site (the bifurcation of the main duct or that of the perforator branch) were also compared in patients with the open-Y technique. The open-Y technique was performed on the IMV side. RESULTS: The open-Y and conventional groups included 127 and 62 patients, respectively. The main duct diameter of IMV was significantly smaller (median 2.5 vs. 3.0 mm, P < 0.001), and the rate of right-sided anastomosis (47.2 vs. 82.3%, P < 0.001) was significantly lower in the open-Y group. When comparing the main duct and perforator groups, the branch diameter (1.8 vs. 1.0 mm, P < 0.001) and the diameter after the open-Y technique (5.0 vs. 3.9 mm, P < 0.001) were significantly higher, and the angle of bifurcation (45° vs. 60°, P = 0.007) was significantly lower in the main duct group. CONCLUSIONS: Given a small venous diameter, the open-Y technique is superior, especially for left-sided breast reconstruction. Owing to the lower angle of bifurcation and large diameter, the open-Y technique at the main duct bifurcation of IMV causes less turbulence in the blood flow. TAKE HOME MESSAGE: The open-Y technique is especially effective for left-sided breast reconstruction. Considering the lower angle of bifurcation and large diameter, the open-Y technique at the main duct bifurcation of the internal mammary vein causes less turbulence in the blood flow.

"COVID toe," one of the extrapulmonary disorders of coronavirus disease 2019 (COVID-19), may result in toe necrosis. In this case, we successfully reconstructed a severe COVID-19-induced defect in the great toe by using an innervated hemi-pulp V-Y advancement flap. A 48-year-old woman was diagnosed with fulminant myocarditis due to COVID-19 and received intensive care. Even after the acute phase, a skin defect measuring 10 mm × 7 mm was noted, exposing the underlying bone on her right great toe tip. Because of ulceration, she was unable to start walking training. To continue rehabilitation, we reconstructed it with the innerved hemi-pulp V-Y advancement flap. The pain improved quickly, and rehabilitation was resumed. During the 6-month follow-up period, no cosmetic or functional complications were observed. Plantar pressure measurements demonstrated favorable loading on the great toe, and it was a favorable outcome in walking function. This flap is a valuable option as one of the innervated flaps for toe-end necrosis with preserved blood flow, which helps in implementing prompt gait rehabilitation.

The purpose of this study was to evaluate changes in mandibular position during midface distraction. Midface distraction was performed in patients with syndromic craniosynostosis to increase upper airway volume. Although this treatment resulted in changes in occlusion, the concomitant changes in mandibular position were poorly understood. In this retrospective study, three-dimensional (3D) cephalograms were obtained before and after midface distraction in 15 patients with syndromic craniosynostosis. Perioperative polysomnography scores and changes in maxillary and mandibular position, mandibular volume, and upper airway volume were analyzed. Results showed a significant improvement in apnea-hypopnea index (AHI) (from 20.6 ± 21.3 to 6.9 ± 5.1, p < 0.05) and upper airway volume (from 2951.65 ± 2286.38 to 5218.04 ± 3150.05 mm3, p < 0.001). When the lowest point of the sella turcica was set as the reference point, the mandible moved significantly in an anterior direction (from 47.9 ± 11.5 to 51.9 ± 9.8 mm, p < 0.05). Mandibular volume did not change significantly perioperatively (from 32530.19 ± 10726.01 to 35590.50 ± 14879.21 mm3, p = 0.10). There were positive correlations between the rates of improvement in AHI and the amount of mandibular movement in the anterior and inferior directions (both p < 0.05). Within the limitations of the study, it seems that the mandible moved in the anterior-inferior direction after midface distraction, and the amount of movement correlated with improvement in respiratory function. Therefore, it is important to consider the position of the mandible when determining the direction of midface distraction, as it may influence the therapeutic effect.