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It is impossible to predict underlying anomalies in acute large vessel occlusion and it could be a problem when performing mechanical thrombectomy (MT). We report a case of MT for occlusion of the fenestrated middle cerebral artery (MCA) M1 segment. A 49-year-old woman presented to our hospital with dysarthria and left hemiparesis. Acute ischemic stroke due to right occluded MCA was diagnosed. During performing emergent MT, a part of the M1 segment was revealed to be slit-shaped by digital subtraction angiography, suggesting a fenestrated MCA. The aspiration catheter could not be advanced through the narrow limb of the fenestration, and the distal thrombus was retrieved using a stent retriever, additionally. Postoperatively, the patient's symptoms improved without complications. When occlusion of the fenestrated MCA is suspected, it is necessary to consider converting the strategy from an aspiration catheter alone to the combined use of a stent retriever.

Background:. The effectiveness of conservative treatment for congenital auricular deformities depends primarily on the plasticity of the auricular cartilage. However, the effect remains uncertain due to various confounding factors such as differences in the characteristics of the deformity and timing of treatment initiation. In this study, we investigated the optimal timing for initiation of conservative treatment. Methods:. We investigated the age at treatment initiation and surgical avoidance rate among 158 children with congenital auricular deformities who were treated with corrective devices at our hospital. In addition, we conducted and analyzed questionnaires containing items assessing treatment satisfaction and characteristics. Results:. Surgical avoidance rates decreased markedly among those starting treatment after 5 months of age, and satisfaction was significantly higher in the surgical avoidance group. Multivariate analysis showed that the only factor affecting the treatment effect was the age at treatment initiation. Conclusions:. This study suggests that the initiation of conservative treatment with corrective devices within 5 months of age for congenital auricular deformities may lead to avoidance of surgery and increased satisfaction. However, we should not judge the indication for conservative treatment solely based on age in months. Bearing in mind the effectiveness of initiating treatment within the first 5 months of age, we should initiate treatment at the earliest appropriate age with consideration of the individual patient's type and severity of deformity and cartilage elasticity.

Summary:. Giant congenital melanocytic nevus (GCMN) is a skin condition characterized by an abnormally dark, noncancerous skin patch. Two main issues with GCMN are aesthetics and malignant transformation. Various methods of treatment are reported, but each method has its own disadvantages, such as risk of recurrence or restriction in the treatable area. We report three cases of GCMN treated with full-thickness excision and immediately covered with cultured epidermal autograft (CEA) combined with split-thickness skin graft (STSG). This is a single-center, single-arm, retrospective report of three cases. The nevus was excised at full skin thickness. Meshed STSG taken from scalp was grafted to the defect, and CEA was grafted over simultaneously. Two weeks later, CEA was applied again as a booster. The same procedures were performed until all nevi were excised. In all cases, nearly complete epithelialization was achieved at several weeks after operation. The reconstructed skin was elastic, and there was no persistent joint contracture. Vancouver Scar Scale score was 4–8. Mesh-like appearance was observed. A hypertrophic scar appeared in the area without meshed STSG. An intractable keloid was observed in one patient. No recurrence of the nevus was observed during the follow-up period. The donor site scar on the scalp was well hidden by the hair. Our method enables full-thickness resection and reconstruction of a wider area in a single operation while improving the take rate of CEA, with reasonable degree of scarring compared with conventional methods.

Summary:. As carbon ion radiotherapy (CIRT) was developed only recently, reports of CIRT-induced ulcers requiring plastic surgery are still rare, but the number of such cases is expected to increase. Here, we describe a case of a CIRT-induced ulcer to aid the treatment of such ulcers. An 82-year-old man had a sacral chordoma (12 × 7.5 × 7.5 cm), which extended from the fourth to fifth sacral vertebrae. He underwent CIRT (70.4 Gy). An ulcer developed 30 months after the treatment. The ulcer enlarged to 13 cm × 7 cm. Debridement, negative-pressure wound therapy, and antibiotics were used. We tried to avoid injuring the rectum and sciatic nerve, and covered the ulcer with a delayed superior gluteal artery perforator flap. Wound healing was difficult to achieve in the lower half of the flap. Further debridement was appropriate, but we considered that it was likely to cause complications. Once a post-CIRT ulcer develops, its progression and the required extent of debridement can be roughly predicted based on the radiotherapy treatment plan. In this case, the rectum and sciatic nerve were irradiated, but there were no related symptoms. Therefore, we performed surgery to preserve these structures. However, there was very thick scar tissue surrounding these structures, making debridement difficult, and the wound was slow to heal. It is desirable to use a flap with good blood flow, such as a myocutaneous flap, for covering post-CIRT ulcers.

Summary:. Accurate burn depth assessment is essential to decide an appropriate surgical procedure. However, most cases of burn depth are diagnosed with subjective judgment by an experienced plastic surgeon. There is a need for a simple, noninvasive, and accurate diagnostic method. Here, the authors present two burn cases in which burn depth was predicted using high-frequency power Doppler ultrasonography. In case 1, the patient showed partial deep burn area prediagnosed by clinical inspection in dorsal area. However, pulsatile microcirculation was detected in the deep dermal layer using high-frequency power Doppler ultrasonography, and we rediagnosed it as deep dermal burn. Tangential excision was performed to debride necrotic tissue, preventing excessive removal of viable dermal tissue. In case 2, the patient showed anterior chest burn covered eschar. Pulsatile microcirculation was detected in the dermis using high-frequency power Doppler ultrasonography. The authors diagnosed the area as superficial dermal burn and opted for conservative treatment. Dermal microvascular damage is a more sensitive indicator of tissue injury. Hence, the burn depth can be assessed using dermal microcirculation. To the best of the authors’ knowledge, there are no reports on the evaluation of blood flow in burn wounds using high-frequency power Doppler ultrasonography. In this case report, the authors introduce the possibility of using high-frequency ultrasonography to assess burn depth.

Summary:. We present a technique for treating orbital floor fractures using three-dimensional (3D) printing technology and a preoperative template based on the mirror image of the unaffected orbit. Our patient, a 56-year-old man, experienced persistent diplopia in the upward direction and left enophthalmos after previous open reduction internal fixation surgery. To address these complications, we used a simulation of the ideal orbital floor from computed tomography images and used a 3D printer to create a template. Subsequently, an absorbable plate was molded intraoperatively based on this template. Notably, the plate fit seamlessly into the fracture site without requiring any adjustment, reducing the operation time. Postoperative computed tomography scans confirmed successful reduction, improved visual function, and the absence of complications. Our method offers a precise and efficient approach to reconstructing fractured orbital floors. By leveraging 3D printing technology and preoperative templates, surgeons can enhance postoperative outcomes and minimize patient burden. Further investigations are warranted to assess the long-term effectiveness and cost-effectiveness of this technique. Our findings highlight the potential of this approach to improve treatment strategies for patients with orbital floor fractures.

Summary:. First branchial cleft fistulas are congenital malformations that result from the incomplete closure of the ectodermal portion of the first branchial cleft. These fistulas typically appear as small pits or subcutaneous masses in the upper neck and cheek and can cause pain due to infection and inflammation. Surgical excision is the most effective treatment, but special attention is necessary to avoid facial nerve injury due to the proximity of the lesion to the nerve and variations in their arrangement. Here, we report the successful treatment of a first branchial cleft fistula piercing through the main trunk of the facial nerve in a 3-year-old girl. Intraoperative findings revealed that the fistula in the parotid gland opened into the cheek area from the ear canal. Identification of the facial nerve trunk was challenging due to the malformation of the lower end of the auricular cartilage, which is an anatomical landmark of the facial nerve. The trunk of the facial nerve was divided proximally by the fistula and merged just past the fistula. Preoperative magnetic resonance is important for determining the fistula location, surrounding anatomical variations, and fistula-facial nerve arrangement. Furthermore, early surgical treatment should be considered to prevent tissue scarring and adhesion due to infection, which can lead to facial nerve injury.

Summary:. Chronic expanding hematoma (CEH) is a rare type of hematoma that expands slowly and continuously without compromising coagulation. Its etiology is often unknown. However, we experienced a rare case of CEH, in which an epidermal cyst was thought to be the cause. A 57-year-old man had developed a painless soft-tissue tumor in his left buttock 45 years earlier, which slowly grew to 11 cm in diameter. Preoperative magnetic resonance imaging suggested a large cyst containing several masses. Surgery revealed a hematoma and keratin debris surrounded by a white fibrous cyst wall and a fibrous nodule measuring 4 cm in diameter. On histopathological examination of the white fibrous wall, an epidermal component was observed contralateral to the superficial punctum, but the epidermal component was absent from most of the wall, including the fibrous nodule. Based on a pathological examination, the CEH was suggested to have been caused by partial rupturing and inflammation of an epidermal cyst. To the best of our knowledge, there are no reports of epidermal cysts causing CEH. In addition, the large fibrous nodule protruding from the CEH cyst wall was considered to be rare. This was considered to be a rare CEH that may have originated from an epidermal cyst.

Background:. Lumbar sympathetic nerve block (LSNB) improves blood flow in the lower limbs and relieves pain involving the sympathetic afferents. This study examines the use of LSNB, but there are no reports of its use for the purpose of wound healing. Therefore, the authors planned the following study. Methods:. An ischemic limb ulcer was created on both lower limbs using a rat model (N = 18). The rats were divided into three groups, namely, A, B, and C. Group A received LSNB on one side (N = 6). Group B was sprayed with basic fibroblast growth factor preparation (trafermin/fiblast) on one side (N = 6). Group C was used as a control (N = 6). Lower limb temperature and the ulcer area were measured over time in each group. Furthermore, the correlation between the ulcer temperature and the ulcer area reduction rate was analyzed. Results:. Group A had higher skin temperature on the LSNB-treated side than on the nontreated side (P = 0.0022 < 0.05). Regarding the correlation between the average temperature and the ulcer area reduction rate, the correlation coefficient was as high as 0.691 in group A. Conclusions:. In the LSNB group, the skin temperature increased and the ulcer area decreased significantly. Conventionally, LSNB has been used for pain relief purposes, although the authors consider that it will be useful in the treatment of ischemic ulcers and that it is a potential treatment option for future chronic limb ischemia/chronic limb-threatening ischemia cases.

A 62-year-old woman presented with a tumor in the right kidney. A right partial nephrectomy was performed, and the tumor was diagnosed as clear cell renal cell carcinoma (RCC) on histopathological examination. A right ovarian tumor was detected on follow-up computed tomography (CT) 5 years after partial nephrectomy and pathology proved RCC metastasis. RCC rarely metastasizes to the ovaries. There is limited information on the radiological features of ovarian metastasis in RCC. In this case report, we presented the CT and magnetic resonance images of ovarian metastasis of RCC. In addition, we also presented a literature review with special emphasis on the imaging features of ovarian metastasis of RCC.

We report a case of vertebral artery dissecting aneurysm (VADA) that developed with subarachnoid hemorrhage and was found to be occluded based on subsequent digital subtraction angiography. Few reports have been published on ruptured VADA in which ipsilateral vertebral arteries are occluded. The proper management of this type of aneurysm is controversial. A 44-year-old woman developed a sudden onset headache. Computed tomography and three-dimensional computed tomography were immediately performed and showed subarachnoid hemorrhage and VADA distal to the right posterior inferior cerebellar artery bifurcation. We decided to treat the VADA immediately and performed digital subtraction angiography but found the VADA had spontaneously occluded. We performed coil embolization, including the aneurysm and the parent artery, with reference to the findings of three-dimensional computed tomography. On Day 16, recurrence was considered due to the finding of dilation of the distal end where the coil was embolized. An additional embolization was performed via the posterior communicating artery. No cases of endovascular treatment have been reported in VADA cases in which the rupture site is spontaneously occluded. In such cases, the treatment may be incomplete, so strict follow-up is required.

Summary:. We encountered a 51-year-old male patient who was not immunocompromised. Thirteen days before his admission, his right forearm was scratched by his pet cat. Swelling, redness, and purulent discharge appeared at the site, but he did not seek medical attention. He developed a high fever and was hospitalized with a diagnosis of septic shock, respiratory failure, and cellulitis on plain computed tomography. After admission, the swelling on his forearm was relieved with empirical antibiotics, but the symptoms spread from his right axilla to his waist. We suspected necrotizing soft tissue infection and made a trial incision in the lateral chest up to the latissimus dorsi, but were unable to prove it. However, an abscess was later found under the muscle layer. Second incisions were made to allow the abscess to drain. The abscess was relatively serous, and no tissue necrosis was observed. The patient’s symptoms improved rapidly. In retrospect, the patient probably already had the axillary abscess on admission. It may have been detected at this point if contrast-enhanced computed tomography had been performed, and early axillary drainage may have accelerated the patient’s recovery, which could also have prevented the formation of the latissimus dorsi muscle abscess. In conclusion, the Pasteurella multocida infection on the patient’s forearm induced a very unusual presentation and caused an abscess to form under the muscle, unlike necrotizing soft tissue infections. Early contrast-enhanced computed tomography may aid earlier and more appropriate diagnosis and treatment in such cases.

Osteoporotic acetabular fractures in elderly patients have recently been increasing, but the best treatment remains uncertain due to the difficulty in stabilizing these fractures with osteosynthesis. We performed total hip arthroplasty with an impacted bone graft on the acetabula of 3 elderly patients with comminuted acetabular fractures after confirming acetabular callus formation via radiographic imaging 2 months following the patients’ initial injuries. Two of the patients presented in the subacute phase after conservative treatment, and 1 patient had no history of trauma or quadrilateral surface destruction. Two patients achieved good functional results at the 3-year follow-up. Furthermore, no loosening of the prosthesis components or subsidence of the acetabular cemented cup was evident on radiographic imaging in any of the patients.

Summary:. We report the clinical course of a patient who developed a sacral radiation ulcer 19 years after treatment for cervical cancer. The patient’s postoperative course after a free latissimus dorsi muscle flap transfer was favorable, but various late radiation complications, including rectal perforation, a rectal fistula, sacral necrosis, a rectointestinal fistula, and sacroiliac joint osteomyelitis, occurred within 11 years. Plastic surgeons who treat such ulcers need to know that patients may develop other serious radiation-related complications. Being aware of these complications will allow appropriate measures to be taken and aid decisions regarding future surgical strategies. More careful assessment of sacral necrosis and bone resection may have ameliorated some of the complications. When encountering similar patients, we believe that careful magnetic resonance imagery (MRI) and intraoperative evaluation are warranted, as sacral necrosis may be detectable in some patients.

Background:. No standards for the assessment of axillary odor intensity and the effects of therapy for osmidrosis have been established. This study presents an objective method for assessing odor severity in patients with osmidrosis and investigates the volatile odorants and skin flora. Methods:. The odor intensity was measured pre- and postoperatively using an industrial odor sensor in 79 patients with osmidrosis. Cultures of the axillary skin were obtained during skin flap surgery. Volatile odorants of the patients were assessed using an odor-sensor gas chromatograph mass spectrometer, and samples collected from clothing worn by the patients before and after surgery. The skin pH of the axilla was measured before and after surgery. The locations of odorants and bacteria in the skin were observed using electron microscopy. Results:. The mean patient age was 28.8 years, and the male-to-female ratio was 4:3. The odor significantly decreased from 52.6 preoperatively to 20.5 postoperatively (P < 0.001). The bacterial flora on the skin included mostly Staphylococcus. Multiple causative substances (volatile proteins) were identified on gas chromatography. The mean preoperative axillary skin pH was 6.21, which was significantly different than that of patients without osmidrosis (5.92; P < 0.01). Conclusions:. An odor sensor accurately assesses odor intensity in patients with osmidrosis. The neutralization of axillary pH may promote the production of odorants by creating the optimal pH for bacterial growth. Odor sensor and pH values can be used pre- and postoperatively as objective assessment measurements for patients with osmidrosis.

Summary:. For large lower lip defects, a thin flap combined with a tendon is the standard reconstructive option. However, this method can result in flap ptosis, which occurred in two of our patients. To correct the ptosis, we transplanted costal cartilage into the reconstructed lower lips, which produced good or moderate results. We report our experience based on long-term follow-up. In case 1, reconstruction was performed with a latissimus dorsi myocutaneous flap. Within 10 years of the first cartilage transplant, two additional surgeries were required due to cartilage/screw breakage. These problems may have been triggered by the bulkiness of the flap and/or the angle at which the cartilage was anchored in place. There have not been any further problems for 3 years. In case 2, reconstruction was performed with a free anterolateral thigh flap. The skin around the flap had poor extensibility, and the patient had marked Class II occlusion. We grafted cartilage without fixing it to the mandible. However, temporary interference with the maxillary dentition was observed. In conclusion, costal cartilage grafts are effective against flap ptosis after free flap reconstruction of the lower lip in patients without Class II occlusion. To achieve long-term stability, the optimal angle and positioning of the cartilage and the extensibility of the skin must be thoroughly investigated before surgery, and a thick piece of cartilage must be firmly fixed in place.

Background:. Skin contracture after skin grafting is undesirable. It is generally accepted that full-thickness skin grafts contract less than split-thickness skin grafts. However, unexpected secondary skin-graft contracture sometimes occurs after full-thickness skin grafting. We tried to elucidate the causes of skin contracture from the viewpoint of the orientation of collagen fibers to find a way to reduce skin-graft contracture. Method:. First, we examined the collagen fiber orientation of the skin over the whole body in Sprague-Dawley rats. Next, two pieces of skin (width: 30 mm × 30 mm; thickness: ca. 2 mm) were stripped off a rat for grafting. The pieces were grafted to different sites so that the collagen fibers of the graft and surrounding skin ran parallel or perpendicular to each other. The collagen fiber orientation before and after the skin grafting was determined using Osaki’s microwave method, a mechanical method, and scanning electron microscopy. Results:. The rat skin exhibited marked variations in collagen fiber orientation among different sites. The direction of the collagen fiber orientation corresponded to that of minimal mechanical strain. We found that the collagen fiber orientation in skin grafts remained almost unchanged after skin grafting. Conclusions:. Mismatched collagen fiber orientation between grafts and the surrounding skin is considered to be a cause of secondary contracture after skin grafting. We propose that skin grafts that minimize the difference in collagen fiber orientation between the skin graft and the surrounding skin should be selected.

Summary:. Abdominal hernias are often repaired using prosthetic mesh, which is susceptible to infections. Normally, it is necessary to remove the mesh. However, successful mesh salvation with negative-pressure wound therapy (NPWT) has recently been reported. We encountered Mycobacterium(M) mageritense infection after hernia repair using the mesh. M. mageritense is classified as a fast-growing nontuberculous mycobacterium, but few cases have been reported. Nontuberculous mycobacterium can cause rare chronic infections. Skin and soft-tissue infections by nontuberculous mycobacterium involving localized abscess formation and chronic abscesses under various situations have been reported. We report an 85-year-old woman in whom a ventral hernia repair-related M. mageritense mesh infection was treated with NPWT without mesh removal. The hernia was repaired using Bard Ventralex mesh. Pus discharge was seen on the seventh postoperative day, and there was a small area of necrosis under the mesh. From the 13th postoperative day, NPWT was performed for 4 weeks. On the 29th postoperative day, a M. mageritense infection was diagnosed, which was resistant to multiple drugs. After the NPWT, most of the wound showed good granulation tissue formation. In conclusion, the mesh used to repair a hernia became infected with M. mageritense, but NPWT was able to salvage it. In cases of mesh infection involving small necrotic areas, performing NPWT under the guidance of an infectious disease expert may make it possible to preserve the mesh.

One of the rare complications of low-grade pancreatic neoplasms is fistulization into nearby structures. This often does not present clinically, but is incidentally identified in patients who have been imaged serially to monitor the progression of the disease. In this report, we present an uncommon complication of an intraductal papillary mucinous neoplasm, which developed a spontaneous gastropancreatic fistula in a patient who was conservatively managed. The clinical course, imaging features, and management of this case are discussed. Keywords: Intraductal papillary mucinous neoplasm, Gastropancreatic fistula

Summary. We treat infected cysts on a daily basis, but it is difficult to diagnose similar lesions produced by inflammatory conditions that are not primarily caused by bacteria. Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory disease that results in disfiguring, painful, and purulent lesions. It often takes a long time to diagnose. The pathophysiology of DCS remains unclear. Various treatments for DCS have been proposed, depending on the severity of the disease. However, none of these treatments are clearly superior to the others. If DCS spreads to the entire occipital region, aggressive surgical treatment may be beneficial in terms of the patient’s quality of life. However, surgical interventions, such as drainage, are not effective at preventing the progression of the disease. Herein, we report the case of a young female patient who developed a cyst in the occipital region. We initially suspected that the lesion was a normal infected trichilemmal cyst. However, DCS was subsequently suspected because the lesion exhibited an unusual course after drainage and debridement. We consider that we made a diagnosis relatively early, but if we had sufficient knowledge about DCS we could have made a diagnosis even earlier by performing debridement sooner. Minocycline was administered for 5 months, which caused the lesion to disappear. After 2 years, no recurrence had been observed.

Summary:. Cryptotia is a congenital auricular deformity. Common methods of surgical reconstruction involve creating an auricular temporal groove using local flaps and/or a skin graft. However, it can be difficult to determine which method is most suited to the unique 3-dimensional (3D) structure of each cryptotic ear. Here, we showed that creating 3D ear models of a cryptotic ear with a 3D camera and printer and using these models to simulate surgery with two different flap methods (cat’s-ear and square) allowed selection of a reconstruction method that led to good outcomes after the actual surgery. The patient was a 7-year-old girl with left cryptotia. A 3D camera was used to acquire 3D data for the ear. After structural analysis, a home 3D printer was used to print the data into 3D ear models using an elastic material. These models exhibited good plasticity. After subjecting the models to simulated cat’s-ear and square flap surgeries, the cat’s-ear flap method was considered to better reproduce the healthy side of the ear compared with the square flap method for this particular case. Ear morphology during and after the actual surgery closely resembled the model-ear morphology during and after the simulated cat’s-ear flap surgery. We successfully created a full-scale 3D model with good plasticity using a 3D camera and 3D printer. This allowed easy, noninvasive preoperative evaluation and identification of the most suitable operation for the specific case, facilitating easier, more successful surgery.

Background:. Treatment of cranial deformity is often performed during infancy in cases such as craniosynostosis and deformational plagiocephaly. To acquire morphologic standards for the treatment goals of these conditions, we created cranial average models and elucidated the growth patterns of the cranium of healthy infants in 3-dimension (3D) using homologous modeling. Methods:. Homologous modeling is a technique that enables mathematical analysis of different 3D objects by converting the objects into homologous models that share the same number of vertices with the same spatial relationships. Craniofacial computed tomographic data of 120 healthy infants ranging in age from 1 to 17 months were collected. Based on the computed tomographic data, we created 120 homologous models. Six average 3D models (20 individuals each for 6 different age groups) were created by averaging the vertices of the models. Three-dimensional growth patterns of the cranium were clarified by comparing the 6 average models. Results:. We successfully created 6 average models and visualized the growth patterns of the cranium. From 1-month-old to 5-month-old infants, the entire cranium except for the occipital region grows, and the cranium tended to be brachycephalic (cephalic index at 4–5 months: 87.1–97.3), but the growth was thereafter localized to specific areas. Conclusions:. Three-dimensional growth patterns of the cranium of healthy infants were clarified. These findings will support the understanding and treatment of the conditions that cause cranial deformity. To our knowledge, this is the first report to visualize the growth patterns of the entire cranium of healthy infants in 3D.

Summary:. In dialysis patients, peripheral venous hypertension–induced hand ulcers are rare. We report a case in which a severe hand ulcer was treated with skin grafting after shunt ligation. The patient was a 60-year-old woman who been undergoing dialysis for 13 years. Twelve years ago, a shunt was created in her right wrist via a side-to-side anastomosis. Swelling and congestion occurred in the right hand, and skin ulcers developed on the dorsal proximal portions of the index, middle, ring, and little fingers. No central vein obstruction was apparent. The right wrist shunt was explored, and the distal vein was ligated. A new shunt was created at the right elbow, but the proximal end of the vein that was used for the wrist shunt had to be used, resulting in complete cephalic vein occlusion from the wrist to the elbow. The swelling extended to the entire forearm. Four weeks after the wrist and elbow shunts were ligated, conservative treatment had resulted in granulation tissue formation in the ulcers. Debridement and full-thickness skin grafting from the abdomen were performed. Overall, skin graft survival was 75%. In conclusion, in this patient, side-to-end anastomosis of the proximal vein might be appropriate for shunt creation. When venous hypertension is suspected, ensuring an appropriate alternative shunt, promptly detecting the cause of the problem, and appropriate treatment are important. Venous hypertension must be completely resolved before surgery for ulcers.

Background: The present study aimed to elucidate the safety and effectiveness of a noble and unique airway management technique in which a pediatric intubation tube is used in adult patients with atrial fibrillation (AF) undergoing catheter ablation (CA) under continuous deep sedation. Methods: In total, 246 consecutive patients with AF (mean age, 65±10 years; 60 women) underwent CA under dexmedetomidine-based continuous deep sedation. A 4-mm pediatric intubation tube guided by a 10-French intratracheal suction tube was inserted smoothly, and the tip of the tube was located at the base of the epiglottis. The maximum shifting distance of the heart (MSDH) was measured with the 3D mapping system (Ensite NavX system) before and after inserting the pediatric intubation tube. Results: At baseline, the MSDH of patients under continuous deep sedation was 23±14 mm. The pediatric intubation tube reduced the MSDH to 13±6 mm (mean reduction from baseline, 38.4±21.7%; P

Background Eosinophilic cholecystitis (EC) is a rare condition that presents in a manner comparable to acute cholecystitis. The diagnosis is based on classical symptoms of cholecystitis with excessive eosinophilic infiltration within the gallbladder. EC has been reported alone or in combination with manifestations, such as eosinophilic gastrointestinal tract inflammation. However, association with airway inflammation in patients with EC is rare. Case Presentation: We report the case of a 65-year-old man who had refractory eosinophilic chronic rhinosinusitis with bronchial asthma. A second endoscopic sinus surgery (ESS) was performed as treatment for recurrent nasal polyps. EC occurred while inhaled corticosteroids were reduced after ESS. Pathologic examination of the excised gallbladder demonstrated submucosal infiltration with a number of eosinophils. Furthermore, immunohistostaining revealed many galectin-10-positive cells in both the gallbladder mucosa and the paranasal sinus mucosa. Galectin-10 is a major constituent of human eosinophils, also known as the Charcot–Leyden crystal protein, which has been linked with eosinophilic inflammation. Interestingly, nasal polyps were reduced without any additional treatments 1 month after the cholecystectomy. Conclusions We experienced a rare case wherein EC onset occurred in a patient with refractory eosinophilic airway inflammation during inhaled corticosteroid tapering. Galectin-10 might help diagnose rare cases of eosinophilic inflammation in multiple organs.

Background:. Cryptotia is an auricular muscle abnormality that causes the superior and posterior auricular area to be buried under the temporal skin. Surgical treatment approaches can be divided into skin grafts and local flaps. Complex cases also require cartilage/muscle modification. In this study, we treated one case each with the Square flap method and the Cat’s Ear flap method. The aim was to help surgeons select the most appropriate surgical procedure on a case-by-case basis. Methods:. Two typical cryptotia cases were treated with the Square or Cat’s Ear flap method. Finite element analysis was performed with ADINA v8.9 software, a PC (Windows 7, CPU: Core i7, Memory: 8 GB), and a hyperelastic skin model (skin diameter 20 cm; thickness 2 mm). The model scales were about 500 nodes and 500 elements (tetrahedron). Results:. The Square flap method involved advancing the square flap between the two triangular flaps. Switching then generated dog-ears that created a big valley. In the Cat’s Ear flap method, the two triangular flaps were rotated in the same direction, whereas a square flap was advanced slightly on the opposite side. This created a large dog-ear. Conclusions:. This study suggested that the Cat’s Ear flap method may be particularly useful for cryptotia patients whose posterior auricular groove is shallow when the buried helix is pulled out. The Square flap method may be suitable for other cases because it effectively extrudes the buried helix with comparatively small excision.

Summary:. We report a case, function preservation of the upper lip after tumor resection was possible using residual orbicularis oris muscle and attached levator labii superioris alaeque nasi. Patient was 67-year-old male with squamous cell carcinoma at the vermilion border. The tumor was resected with an 8-mm margin, leaving the oral mucosa as intact as possible. To reconstruct the red lip, we used the oral mucosa as a rotational transposition flap. The white lip was reconstructed with a cheek rotation flap. A levator labii superioris alaque nasi muscle flap, which was attached to the remaining orbicularis oris muscle, was used to increase marginal lip volume. The movement of the reconstructed lip was good. At 9 postoperative months, induration of the red lip was palpable, and we suspected that the blood supply to the levator labii superioris alaque nasi was borderline insufficient. Slight drooping of the reconstructed lip occurred. We dissected this was caused by dissection of mid facial muscles from orbicularis oris muscle to ease downward rotation of the cheek flap and obscure the original nasolabial fold. Although some drooping and induration of the lip occurred, the white and red lip were reconstructed in a single-stage procedure, which resulted in good movement and preserved the function of the orbicularis oris muscle.

Summary:. Reconstruction of the anterior neck requires attention to both aesthetic and functional outcomes. In general, skin grafts are not suitable for anterior neck reconstruction in Asian patients, even when artificial dermis is used before skin grafting. Therefore, we have employed various types of thin flaps for anterior neck reconstruction, including the cervico-pectoral flap. However, we have realized that, to fully release neck contractures and therefore achieve the full range of neck extension, the skin pedicle must be sufficiently wide. Therefore, we have started reconstructing anterior neck scar contractures using wide, thin, and long flaps that are harvested from the anterior chest wall. In this article, we describe the case of a 71-year-old man who presented with a neck contracture and tracheal fistula after receiving extensive burns. A transposition flap bearing the internal mammary artery perforator was harvested from the anterior chest wall to repair the neck wounds that were left after removing the scar. At the same time, the tracheal fistula was covered by the flap. The aesthetic and functional results were acceptable. The effectiveness of supercharged transposition flaps from the anterior chest wall for reconstructing anterior neck scar contraction is discussed.

Summary:. It is difficult to totally reconstruct the lip, achieving good functional and aesthetic results. There have been few reports of reconstructing complete lip defects. Moreover, upper and lower lip necrosis by purpura fulminans has not been reported. We present a case of a 60-year-old male purpura fulminans patient with upper and lower lip necrosis. Fortunately, our patient had retained his oral commissure function. We reconstructed this defect with an orbicularis oris muscle-skin-mucosal pedicled flap derived from the region between the nasolabial folds for upper lip; a similar bipedicled flap for the lower lip and the donor site was closed with a dual-skin paddled anterolateral thigh flap. Postoperative results were satisfactory, that is, no lip tightness or aperture restriction was seen, and symmetry had been achieved. The new lips exhibited complete sensory recovery. Drooling was minimal during rest and feeding. We could select a method that combined the advantages of local and free flaps. We consider our method for this defect is superior to those described in previous studies, in that the restoration of lip sensation and oral sphincter function can be achieved to some extent in 1 stage while preserving the oral commissure function.

Background: The safety and efficacy of radiofrequency hot balloon catheter (Toray-Satake balloon [TSB]) ablation for the treatment of atrial fibrillation (AF) was evaluated in a 3-center pilot study. Methods: Thirty patients (24 men; age, 61±8 years) with drug-resistant AF (paroxysmal, n=24; persistent, n=6) were evaluated in this study. The pulmonary veins (PVs) and PV antrum were isolated using the TSB under general anesthesia (n=12) or deep sedation (n=18). Results: Complete PV isolation was achieved in 110 (92%) of 120 PVs, and decreased PV potentials were observed in the right superior PV in 4 patients (13%), left superior PV in 4 patients (13%), and left inferior PV in 2 patients (7%). The mean total procedure time was 104±27 min. The mean total fluoroscopic and total application times were 32±14 min and 12±2 min, respectively. After a single session, 22 (73%) and 20 (67%) of the 30 patients were free from AF after 6 and 11.4±2.2 months of follow-up, respectively. There were no device-related severe complications such as stroke, esophageal fistula, symptomatic PV stenosis, phrenic nerve palsy, or pyloric spasm. Conclusion: TSB catheter ablation might be a promising approach for the treatment of drug-resistant AF.

Background: There is limited data regarding the outcomes after stepwise ablation for persistent atrial fibrillation (AF) in patients with heart failure (HF). Methods and results: Patients without structural heart disease undergoing stepwise ablation for persistent AF (continuous AF≤1 year) were studied (n=108; age, 61±10 years) and 32 patients had a history of HF. The HF patients were further grouped on the basis of left ventricular ejection fraction (LVEF)≤45% (n=15) and >45% (n=17). During a median follow-up period of 2.2 years, repeated ablations were necessary in 65 patients. The proportion of patients that were arrhythmia free 1 year after the last ablation was 67% in patients with LVEF≤45%, 86% in LVEF>45%, and 91% in no HF (p=0.0009). In patients with LVEF≤45%, the AF burden was reduced to less than one paroxysmal episode per month, and patients with and without recurrences both showed significant increases in LVEF over the follow-up period (38±7% to 60±10% and 37±6% to 53±10%, respectively). Conclusions: HF patients with LVEF≤45% had lower chances to remain free from arrhythmias after stepwise ablation for persistent AF than those with LVEF>45%. Nevertheless, LVEF also improved in patients with recurrences, reflecting the observed reduction in AF burden and emphasizing the benefits of ablation.

Summary: When treating a giant ovarian cyst, management of inferior vena cava (IVC) syndrome, bleeding, abdominal competence, and cosmetic appearance are difficult. The details of abdominoplasty for patients with such a cyst have not been discussed. We present a patient requiring 85,000 ml of fluid evacuation before surgery.

A 39-year-old man with a seemingly non-remodeled, small heart suffered persistent atrial fibrillation (AF). Extensive isolation of the pulmonary vein, superior vena cava, and posterior left atrium, in conjunction with right atrium focal ablation, was performed to ablate multiple AF foci during two catheter ablation sessions. Sinus arrest occurred suddenly during follow-up, despite the absence of recurrent AF, ultimately necessitating pacemaker implantation. This case underscores the necessity of careful follow-up after catheter ablation, highlighting the risk of sudden, severe sinus node dysfunction, even in young AF patients with small hearts.

Abstract: Keloids are a dermal fibroproliferative disorder and can arise from trauma, acne, vaccination, and herpes zoster. Pyoderma gangrenosum (PG) is a painful ulcerative skin disorder that is associated with neutrophilic dysfunction. However, the pathophysiologies of keloids and PG are not fully understood. The authors encountered an unusual case of a 24-year-old woman who presented with an anterior chest keloid that bore an ulcer. The keloid was resected along with the ulcer, and histology revealed the ulcer to be a neutrophilic PG ulcer. A year after surgery, another ulcer developed in the scar. The ulcer met the PARACELSUS criteria of a postsurgical PG ulcer. After treatment with systemic prednisone and adalimumab for 250 days, the ulcer re-epithelialized. However, relapsed keloids were then observed at the PG site. Corticosteroid taping may be the safest therapy for patients with a history of PG. Conversely, if there is suspicion that a patient is prone to keloid development, diagnostic biopsies and surgical management of PG ulcers should be avoided or conducted with care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

We have used the developing chicken to determine if ornithine decarboxylase (ODC) activity is altered in fetuses chronically exposed to the opiate N-desmethyl-l-alpha-acetylmethadol (NLAAM) or rendered abstinent by acute injection of naloxone (Nx). Exposure to NLAAM from day 3 of embryogenesis did not significantly change brain ODC activity in 15, 17 or 19-day-old fetuses. Acute treatment of 17-day-old fetuses with a motility suppressant dose of NLAAM did not differentially affect ODC activity in NLAAM-dependent fetuses, but an additional treatment with Nx, which precipitated withdrawal, resulted in a significant increase in ODC activity in this group. We conclude that withdrawal can alter fetal ODC activity which otherwise appears normal, even though fetuses have been chronically exposed to and dependent upon an opiate.

The structures of purified rat liver and heart plasma membranes were studied with the 5-nitroxide stearic acid spin probe, I(12,3). ESR spectra were recorded with a 50 gauss field sweep, and also with a new technique which "expands" the spectrum by (1) recording pairs of adjoining peaks with a smaller field sweep and (2) superposing the common peaks. The hyperfine splittings measured from the "expanded" spectra were significantly more precise than those obtained from the "unexpanded" spectra. Both procedures were used to study the effects of various I(12,3) probe concentrations on the spectra of liver and heart membranes, as well as the effects of temperature and CaCl2 additions on the spectra of liver membranes, and revealed the following: The polarity-corrected order parameters of liver (31 degrees) and heart (22 degrees) membranes were found to be independent of the probe concentration, if experimentally-determined low I(12,3)/lipid ratios were employed. The absence of obvious radical-interaction broadening in the unexpanded spectra indicated that "intrinsic" membrane properties may be measured at these low probe/lipid ratios. Here, "intrinsic" properties are defined as those which are measured when probe-probe interactions are negligible, and do not refer to membrane behavior in the absence of a perturbing spin label. At higher I(12,3)/lipid ratios, the order parameters of liver and heart membranes were found to substantially decrease with increasing probe concentration. The increase in the "apparent" fluidity of both membrane systems is attributed to enhanced radical interactions; however, an examination of these spectra (without reference to "low" probe concentration spectra) might incorrectly suggest that radical interactions were absent. For the membrane concentrations employed in these studies, the presence of "liquid-lines" (or "fluid components") in the unexpanded ESR spectra was a convenient marker of high probe concentrations. A thermotropic phase separation was observed in liver membranes between 19 degrees and 28 degrees. Addition of CaCl2 to liver plasma membrane [labelled with "low" I(12,3) concentrations] increased the rigidity of the membrane at 31 degrees and 37 degrees, without inducing a segregation of the probe in the bilayer. Previously reported data are discussed in relation to these results, and suggested minimal criteria for performing membrane spin label studies are included.

Injection of l-alpha-noracetylmethadol (NLAAM), the active des-methyl metabolite of l-alpha-acetylmethadol, into chicken eggs on the 3rd day of embryonic development produced no deficits in body or brain weight, or brain nucleic acid and protein content in the 20-day check embryo. NLAAM decreased embryo viability in a dose-dependent manner as early as day 4. At this time measureable levels of radiolabeled NLAAM could be detected in the embryo; further sampling of whole embryos or embryo brains demonstrated continual exposure to NLAAM throughout development. The present report describes the utility of an avian model in studying the direct effects of prenatal opiate exposure on development.

Fetal chicks were made opiate-dependent by injections of N-desmethyl-1-alpha-acetylmethadol into the chorioallantois on day 3 of embryogenesis. The injections had no effect on subsequent hatchability; however, spontaneous fetal motility was significantly depressed. Injection of naloxone caused a significant increase in the motility of the opiate-exposed fetuses but had no effect on control fetuses. That naloxone's effect was an expression of opiate withdrawal and not due to antagonism of depressed motility is also supported by the observation that naloxone significantly reduced the hatchability of opiate-exposed chicks and not of control chicks. Thus the withdrawal of a developing organism from a narcotic may be more deleterious to its survival than continued exposure.