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Objective: In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT. Method: We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (75%). Results: When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of Conclusion: Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.

Early excision and skin grafting is the principle treatment for a burned hand although there are occasions when it cannot be done such as severe general condition, delayed consultation, and the lack of a definitive assessment of burn depth. This study analyzes the factors that affected function after a delayed excision and skin graft for hands with a deep dermal burn. This study retrospectively evaluated 43 burned hands that required a delayed excision and split-thickness skin graft on the dorsal side. Cases were required to only have split-thickness skin grafting from the dorsum of the hand and fingers distally to at least the proximal interphalangeal joint at least 8 days after the injury. The hands were divided into two functional categories: Functional category A, normal or nearly normal joint movements, and functional category B, abnormal joint movements. Demographic data were assessed statistically by a univariate analysis following a multiple regression analysis by a stepwise selection. A significant difference was observed between the groups in the number of days from grafting to complete wound healing of the graft site and with or without an escharotomy in the analysis. These parameters were statistically significant predictors of functional category B. The functional outcome of a burned hand after a delayed excision and split-thickness skin graft on the dorsal side became degraded depending on the number of days from grafting to complete wound healing. Cases that underwent an escharotomy also showed deterioration in function.

Objective: To clarify the surgical indications and the appropriate perioperative management of ischial pressure ulcers (PUs). Method: A two-year prospective, nationwide registry study was carried out across 26 medical institutions in Japan. All participating institutions managed ischial PUs according to the standardisation of total management and surgical application for the refractory decubitus (STANDARDS-I) perioperative protocol. Analysis was conducted on a range of clinically or statistically important variables for the achievement of primary or secondary endpoints: complete wound healing and hospital discharge at three months, and complete wound healing at one month after surgery, respectively. Results: A total of 59 patients took part in the study. All patients underwent surgery for ischial PUs during the study period. Patients who had achieved the primary endpoint had a higer preoperative functional independence measurement (FIM score), a higher ‘G’ score in the DESIGN-R scale and were more likely to have healed by primary intention. Patients who had achieved the secondary endpoint were more likely to have spastic paralysis, preoperative physiotherapy and localised infection of the wound, among other variables. Conclusion: This survey suggests that preoperative physiotherapy increases the speed of wound healing, and good granulation of the wound bed preoperatively increases the likelihood of woundless discharge from hospital, whereas the existence of comorbidities negatively influences the likelihood of woundless discharge from hospital. The study also suggests that the existence of spastic paralysis, preoperative infection of the wound, or surgical reduction of the ischial tubercle speeds up the healing of the wound. However, the wound failed to heal significantly more often in patients with increasing white blood cell count after surgery.

Maggot debridement therapy (MDT) has long been used to treat various wounds or ulcers. Although the mechanisms underlying MDT are not completely understood, laboratory studies have clarified the various effects of larval secretions/excretions. The most noticeable change in maggot-treated wounds is debridement. Other characteristics include microbial death (disinfection) and accelerated wound healing (growth stimulation). Recently, it has been reported that the amino acid-like compounds present in maggot excretions/secretions may mediate wound healing by stimulating angiogenesis. In the clinical setting, MDT for critical limb ischemia has been reported to lead to an increase in skin perfusion pressure, which serves as an index of peripheral circulation in the skin and subcutaneous tissue. Laboratory and clinical findings to date suggest that ischemic ulcer is a good candidate for MDT.

Summary Background There is no agreement regarding a staging system and optimal treatment of Merkel cell carcinoma. Some centres have reported results from larger series of patients, but these do not include Asian or Japanese centres. Objective The purpose of this study was to retrospectively review our experience with the surgical treatment of MCC of the face in the Japanese and to study its management and outcome using the staging system described by Clark et al. Methods We report our experiences with 16 cases between 1991 and 2004. Patients and tumour characteristics, treatment variables and outcome were analysed. Results The follow-up periods ranged from 1 to 180 months. The average was 32.6 months and the median was 17.5 months. The relapse-free survival for all patients was 51% at 2 years. The relapse-free survival was 80% for the patients with Stage I and 33% with Stage II at 2 years. Conclusion This staging system was suggested to reflect prognosis although the number of patients in this series was small. Sentinel lymph node biopsy should be considered to determine the accurate nodal staging, and patients with MCC of the head and neck may be treated according to the revised staging system by Clark et al.

Background The reused skin-graft technique can be used to treat chronic gluteal hidradenitis suppurativa, but long-term outcomes and the reliability of the technique have not been reported. Methods In a retrospective review of 18 men with chronic gluteal hidradenitis suppurativa (age range, 18–68 years) treated with a reused skin graft between June 2004 and March 2012, we evaluated disease severity (Hurley classification system), skin-graft thickness, the need for an additional normal skin graft, histological findings and recurrence rate at the surgical site. Results The mean duration of follow-up was 61.3 months (range, 17–113 months). Five cases were classified into severity group I, 12 cases into severity group II and one case into severity group III. The range of skin-graft thicknesses was 0.013–0.020 inches. An additional donor site was unnecessary in 10 cases (three cases in group I (60%) and seven cases in group II (58.3%)). Histological examination indicated that a buried epidermal cyst could cause chronic gluteal hidradenitis suppurativa recurrence, although none of the patients experienced recurrence at the surgical site during follow-up. Conclusion The reused skin-graft technique is reliable for chronic gluteal hidradenitis suppurativa resection, and it shows promising long-term outcomes.

33歳男性。1年前から臍窩に腫瘤が出現し, 徐々に増大してきた。尿膜管遺残症を疑いMRI検査を施行したが尿膜管遺残症は否定された。切除生検を施行し悪性黒色腫と診断され, 3週間後に拡大切除術を施行した。再建した臍から5cm離し, 下床は腹直筋膜を含めて切除し腹膜も約1cmの幅で切除した。転移が示唆された左腋窩リンパ節郭清術を行い, sentinelリンパ節生検を施行した。左右の腹直筋を中央で合わせ, 皮膚欠損部は両側からのVY伸展皮弁で再建した。sentinelリンパ節生検の結果陽性だった右腋窩と右鼠径のリンパ節郭清術を2週間後に施行した。本症例をpT4bN3M0, Stage IIIcと診断し, DAV-feron化学療法を5クール施行した。術後1年6ヵ月後に腰椎L4棘突起に転移を認め, 整形外科で切除手術を行い, DAC Tam療法を2クール施行した。しかしながら初診から2年2ヵ月後に癌性リンパ管症で死亡した。

Angiosarcoma of the scalp is a relatively rare malignant endothelial tumor. We experienced a case of angiosarcoma treated by wide local excision. An 85-year-old man was admitted to our hospital with a tumor which had appeared 1 month before on his left temporal region. The diagnosis of angiosarcoma was made based on the clinical features and histopathological finding of the lesions on the skin by a former institution. We performed wide local excision immediately circumferentially to a distance of more than 3-5cm from the tumor margin. At present, 13 months after surgery, no recurrence or metastasis has been observed. [Skin Cancer (Japan) 2003; 18: 51-55]

We reported two cases of trichoblastoma misdiagnosed as basal cell carcinoma. Case 1 was a 36-year-old woman with a normal skin-colored mass of 5×5mm on the left nasal ala. Case 2 was a 62-year-old man with an 18×13×5mm mass on the right upper eyelid. The results of histopathological examinations of both patients indicated basal cell carcinoma, and extensive resections were performed. The diagnosis was corrected to trichoblastoma based on the results of a subsequent detailed examination. [Skin Cancer (Japan) 2002; 17: 135-140]

We report an 84-year-old Japanese woman who presented with a pedunculated malignant melanoma of the vaginal mucosa. Mucosal melanoma is believed to be more common in Japan than other countries, but such tumors of the vulvovaginal region are quite unusual. In our patient, three tumors were connected by a narrow pedicle. Three black tumors measuring 5-10 mm in diameter with a common pedicle were seen on the vaginal mucosa at five o'clock from the cervix. The tumors were hanging from the narrow pedicle. On histologic examination, they were diagnosed as malignant melanoma. Resection was done with a distal margin of 3 cm from the tumors and a margin of 1 cm from the cervix. The patient has had no evidence of local recurrence or distant metastasis. In our patient, the three main tumors had a common pedicle, which seems to be a unique finding. Since pedunculated malignant melanomas are rare, making a clinical diagnosis is difficult. Although pedunculated melanomas are recognized as having a high malignant potential because these lesions are generally thick, a relatively good outcome is sometimes reported. In our patient, there was no tumor infiltration into the dermis of the pedicle, and this may be one reason for the good outcome at present. There has been no previous report of a mucosal melanoma consisting of three tumors like those in the present patient.

Malignant skin tumors are known to develop in areas of chronic radiodermatitis. We experienced a patient with multiple basal cell carcinomas that developed about 50 years after irradiation. The patient was a 77-year-old man who underwent radiotherapy in his twenties for caries in the left shoulder joint. The dose given was unknown. Black skin tumor appeared initially about 10 years before the first consultation. The skin around the tumor began to erode about six months before presentation. Biopsy of the tumor was done at another institution and revealed basal cell carcinoma(BCC), so the patient was referred to our department. In addition to the BCC measuring 35×20mm in the left shoulder, BCC measuring 17×20mm and 15×15mm were found on the chest and the left axilla, respectively. The lesions were excised with a margin of 5mm from the radiodermatitis, and the resultant skin defects were covered with latissimus dorsi flaps. All three tumors were basal cell carcinomas. The patient died of an unrelated disease six years after surgery and there was no recurrence of his tumors.

We reported a case of 67-year-old man with malignant fibrous histiocytoma (MFH). He noticed a subcutaneous tumor on the right lateral lower leg three years ago. Tumor was totally excised by a primary physician about two years ago, and histological examination revealed the tumor to be MFH. The lesion recurred one year ago and he presented us on february 24, 1994. Physical examination revealed 45×45mm, well-demarcated, elastic hard, subcutaneous tumor with pain. A detailed evaluation showed no evidence of metastatic disease, however a invasion to the peroneus muscle was suggested. Surgical resection of the tumor was carried out along clinically 3cm normal skin margin, including peroneus longus, brevis and soleus.Postoperative radiation therapy was performed before the reconstructive surgery for fear of microscopic subclinical residual tumor. The defect was reconstructed with a free LD flap. Two years and six months postoperatively, there has been no sign of recurrence. We think that the free flap transfer is useful for the defect after tumor excision.

We recently treated case of Merkel cell carcinoma of the right cheek. The patient, an 83-year old japanese woman, complained of a nodule on her left cheek measuring 40×40×10mm. The tumor was a cutaneous nodule with reddish-purple overlying skin. Histologically, the tumor invaded the dermis and subcutaneous tissue and did not exend into the epidermis. The tumor cells were small sized and showed a monotonously uniform appearance. They had round nuclei and scant cytoplasm. We performed wide local excision, radical neck dissection and used the radial forearm flap for reconstruction of the right cheek.

We report three cases of eccrine porocarcinoma seen at our hospital.Case 1: A 77-year-old female had a 40×35 mm clearly-demarcated erythema on the lateral aspect of her left thigh, with a 15×17 mm region of erosion in its center. The lesion was locally excised deeply to the fascia, and circumferentially to a distance of 3cm beyond the tumor margin. Histopathologically, the lesion was diagnosed as an eccrine porocarcinoma. Swelling of the inguinal lymph nodes was observed at 14 months after surgery, and lymph node dissection was performed. Two years have now elapsed since the original surgery, and no recurrence or metastasis has been observed.Case 2: A 74-year-old female had a black-brown swelling of about 12×10 mm with an irregular surface on the medial side of the left lower eyelid. A basal cell epithelioma was suspected, and the lesion was excised circumferentially to a distance of 5 mm from the tumor margin. Histopathologically, the lesion was diagnosed as an eccrine porocarcinoma. At present, two years after surgery, no recurrence or metastasis has been observed.Case 3: A 70-year-old female had a slightly prominent, 13×8 mm, red plaque with a central erosion on the posterior aspect of her left leg. The lesion was excised deeply to the fascia, and circumferentially to a distance of 3 cm from the tumor margin. At present, 27 months after surgery, no recurrence or metastasis has been observed. Histologically, all lesions showed clearly demarcated encapsulated nests, the tumor cells were dysplastic, there was no tendency for keratinization, and ductal structures were observed in the tumor foci.

We report 11 cases of dermatofibrosarcoma protuberans (DFSP) . A mean follow up period is 2 years and 6 months with a range of 5 months to 6 years 2 months.4 patients were males and 7 patients were females. The average age was 35.4 years. The youngest was 16 years old girl and the oldest was 67 years old women. Tumors had from 4 month to 15 years clinical course. The tumor size ranged from 5×4mm to 8×4.5×3cm. The location of the tumor were two head and neck regions, two arms, six trunks and one thigh. Two patients had experienced bruise before the ocurrence of the tumor.All patients were treated surgically. We excised the tumors widely. No recurrence was seen in all cases under the follow up period of 5 months to 6 years.

We obtained cosmetically satisfactory results by using diverse flaps for reconstruction after excision of basal cell carcinoma of the face.Wide local excision is necessary for surgical treatment of malignant skin tumors, asin the case of facial areas. In general case, skin grafting is temporarily applied, andfullscale recontruction is performed after it has been confirmed that there is noreccurence or matastasis. However, since the face is an exposed part, we cannotobtain cosmetically successful results by using skin grafting in many cases.Basal cell carcinoma is a malignant skin tumor we encounter most frequently, butdistant metastasis seldom develop. It therefore seems possible for us to apply technique which is superior in the cosmetic aspect, such as using flaps from the biginning. For small defects, local flaps with good texture match and color match are usuallyapplied. On the other hand, micro surgery is applied when the defect become largeror nerve or bone is exposed.It is important to remove the tumor completely without any remainings when usingflaps. We conduct rapid pathologic diagnosis during the operation or check pathologically for remainings by coating the wound with Biobrane® before reconstructive surgery.With this method, we have obtained satisfactory results in both clinical and cosmetic aspects thus far.

We report 2 cases of presacral squamous cell carcinoma. In these cases, it was suspicious that the tumor disseminated to the internal iliac nodes through the direct pathway called the neurovascular lymphatic space (NVLS) around the superior/inferior gluteal vessels or sciatic nerve bypassing external iliac nodes. NVLS was initially reported as accessory pathway which follows the major vessels forming a sheath like structure with an actual or potential space between the vessel wall and the enveloping membrane. NVLS has been reported to be observed as a tubular shadow within the neurovascular sheath by lymphangiographies of lymphedema patients using oil-based contrast material. These cases provide insights into the potential pathway through which a cutaneous tumor disseminates.

22歳女性。2歳時の水痘罹患後の左腰部の瘢痕部に母指頭大の結節が生じ次第に増大してきた。昭和63年12月末, 結節中央部に潰瘍を形成した。平成元年2月2日当科初診。左腰部, 腸骨稜に中心に潰瘍を伴う硬結を4×6cmの範囲に認めた。切除生検の結果Epithelioid sarcomaと診断され, 局部拡大切除および連続的鼠径リンパ節郭清術施行後, 化学療法を3クール施行した。現在, 再発・転移を認めていない。

For microtia correction we have been inserting a cartilage framework and reconstructing the tragus at the first operation in one stage, using part of the microtic ear. This procedure is started with transposition of the lower two-thirds of the microtic ear to make a lobule. The upper third of the microtic ear is elevated as a chondrocutaneous flap which is then transposed downwards to the conchal cavity to make a tragus. The cartilage of the chondrocutaneous flap is anchored, using a bolster to pull it back and outwards. Using this technique, we have reconstructed 34 microtic ears. Adequate positioning of the auricle and tragus has been achieved and a natural auricle obtained even when observed from a frontal oblique direction.

Neurofibromatosis is a genetic disorder that primarily affects the cell growth of neural tissue. The disorder can cause tumors to grow on the nerves at any location at any age. The most common type, neurofibromatosis 1 or NF-1 (previously known as von Recklinghausen’s neurofibromatosis or peripheral neurofibromatosis), is an autosomal dominant disorder affecting about 1 in 4000 individuals. Multiple hyperpigmented areas (cafe-au-lait macules) and neurofibromas are characteristic findings in affected individuals.1 Tumors are often removed for cosmetic reasons or to control unexpected active bleeding. However, NF-1 resection is frequently complicated due to factors such as size, location, hypervascularity, and tissue friability, which make achieving complete hemostasis a challenge. In addition to intraoperative hemorrhage, bleeding often occurs during the postoperative period and may be life threatening. This report describes the application of the method using the Tsukisui device, which is conventionally used to pass wires through bone in facial fracture surgeries, to NF-1 resection, aiming at minimal blood loss.

Congenital infantile fibrosarcoma is a rare soft-tissue malignant tumor that usually presents as a mass involving the arm or leg. We report a case of congenital fibrosarcoma on the right hand of a newborn infant. The patient was a 12-day-old male. From the time of delivery, he had a red tumor on his dorsal right hand. The tumor was initially associated with bleeding within a hemangioma and compressed. The course was observed. It appeared that the tumor might be malignant because it increased in size to 10 × 8 × 3 cm, and ulceration and bleeding appeared on the surface after 10 days. A biopsy suggested a fibrosarcoma. The tumor was resected 32 days after birth at the narrow margin in consideration of preservation of function. However, a recurrence was observed under the graft after 2 weeks and another resection was performed. Because the tumor had passed through the interosseous muscle and invaded the palm of the hand, the middle finger, ring finger, and little finger had to be amputated. One year and 7 months postoperatively, no recurrence or metastasis has been observed.

Prefabricated free flaps using an expansion technique were used for four reconstructive cases, including two leg reconstructions and two facial reconstructions. In this series, the prefabricated free flaps created by using the expander were classified into two types: the expanded flap based on the conventional vascular pedicle, which is called the expanded flap with primary vascularization; and the expanded flap based on the vascular pedicle in the carrier, which is called the expanded flap with secondary vascularization. The expanded flap with primary vascularization that is created iii the trunk has a good indication for leg reconstruction, because it provides an wide and thin flap with minimal donor site morbidity. The expanded flap with secondary vascularization created in the pectoral region has a good indication for facial reconstruction, because it provides good color and texture matches. Although there are some disadvantages in the tissue expansion technique, the prefabricated free flaps using the expander are very effective in facial and leg reconstruction.

Congenital ectopic nails are quite unusual and characterized by development of nail-like tissue on the tips of one or more fingers. We present the case of a boy with congenital ectopic nails on both little fingers. To prevent tapering of the fingertips following surgery, we used subcutaneous pedicle flaps and obtained a satisfactory cosmetic result.