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Objective Concomitant chemoradiation therapy is a standard treatment for head and neck cancer. Thus, salvage surgery has become a necessary treatment. The aim of the study was to evaluate the results of salvage surgery by each site of the head and neck, especially the oropharynx, hypopharynx and larynx. Methods This was a retrospective, single-institute study. The primary endpoint was overall survival. Secondary endpoints were disease-free survival, the locoregional control rate after salvage surgery, the indication rate for salvage surgery, the reasons for contraindications to salvage surgery, the post-operative complication rate and the predictors of survival. Results Three-year overall survival after salvage surgery was 58.8% in the salvage surgery group and 8.59% in the other treatment group (P Conclusions Salvage surgery is effective for recurrent or residual cases after concomitant chemoradiation therapy. For oropharyngeal cancer, local control is important, and for oropharyngeal cancer and hypopharyngeal cancer, distant metastasis is important.

Goltz syndrome is a rare X-linked dominant multisystem disorder that presents with ectoderm and mesoderm-derived symptoms. Skin manifestations including congenital patchy skin aplasia, congenital nodular fat herniation, congenital hypo- or hyperpigmentation along Blaschko's lines, telangiectasia, and congenital ridged dysplastic nails are typical in this disorder. Almost all cases of Goltz syndrome correspond to female newborns and that hemizygosis makes the syndrome fetal in males. Triple X syndrome is a relatively common congenital disorder that presents with mild to no symptoms in the developmental and psychiatric realm. The patient reported here was born with multisystem anomaly affecting the eyes, craniofacial region, cardiovascular system, skin, and limbs. A G-banding chromosomal study revealed 47, XXX. She was diagnosed with Goltz syndrome owing to her distinctive skin manifestations. The congenital cervical skin defect healed with conservative treatment. The facial cleft, cleft lip-palate, and syndactyly were successfully treated with multiple surgical treatments. The combination of triple X syndrome and Goltz syndrome is very rare. We describe the expression of presenting with both syndromes simultaneously.

A 33-year-old man developed a left Achilles tendon rupture and skin necrosis. We reconstructed the defect using an anterolateral thigh flap and a tensor fasciae lata muscle flap in a chimeric fashion. he was able to stand on a toe of the operated foot without help 6 months postoperatively.

The use of growth factors and stem cells as the core treating agents is one step into creating a biocompatible Solid Lipid Nano Particles (SLNP) for treatments. Apart from obtaining these growth factors and stem cells from the patients, using the bi-product of the extraction process which is the lipid of the patient for the production of the SLNP assures the final product to be biocompatible and of a unique structure. The use of autologous cells and proteins from the patients makes the entire process medically ethical and more viable for treatment procedures. This article, thus discusses on the experimental process of developing such SLNP and the introduction of the relevant medical contraption designed uniquely for the procedure inclusive of a specified membrane.

Summary Background It is challenging to manage colorectal or urinary tract-related fistula. We typically treat colorectal or urinary tract-related fistula with a vascularized tissue transfer. This study aimed to analyze the outcomes of our surgical treatments for colorectal or urinary tract-related fistula. Methods This retrospective review included all patients who underwent surgical repair of a colorectal or urinary tract-related fistula at our institution from October 2004 to September 2019. Patients whose surgical outcomes could not be evaluated were excluded. The primary outcome was the overall cure rate. We also evaluated the complication rate and compared the outcomes for rectovaginal fistula with those for urorectal fistula. Results The final analysis included 38 cases, of which 17 were rectovaginal fistula and 16 were urorectal fistula. The transperineal approach was used in 28 cases and transperineal and transabdominal combined in nine cases. A gracilis muscle flap was used in 19 cases and a gluteal fold flap in 13 cases. Although a major leak occurred in nine cases, the fistula was finally cured successfully in 31 cases. A comparison of the outcomes for rectovaginal fistula and urorectal fistula showed that complications occurred in 5/17 cases of rectovaginal fistula and 10/16 cases of urorectal fistula (p = 0.056). Fistulae were cured successfully in 13/17 cases of rectovaginal fistula and 14/16 cases of urorectal fistula (p = 0.656). Conclusion Our surgical treatment for colorectal or urinary tract-related fistula succeeded in 31 of 38 cases. Thus, vascularized tissue transfer is useful for refractory colorectal or urinary tract-related fistula.

Activated cancer-associated fibroblasts (CAFs) and fibroblasts that have undergone the epithelial-mesenchymal transition (EMT) in cancer stroma contribute to tumor progression and metastasis. However, no reports have investigated the CAF phenotype and its clinicopathological relevance in cutaneous malignant tumors, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM). Here, we investigated the CAF phenotype in cutaneous malignant tumors based on their histology and immunohistochemical expression of CAF-related markers, including adipocyte enhancer-binding protein 1 (AEBP1), podoplanin, platelet-derived growth factor receptor α (PDGFRα), PDGFRβ, fibroblast activating protein (FAP), CD10, S100A4, α-smooth muscle actin (α-SMA), and EMT-related markers (Zeb1, Slug, and Twist). In addition, we assessed the role of the CAF phenotype in cutaneous malignant cancers using hierarchical cluster analysis. Consequently, 3 subgroups were stratified based on the expression pattern of CAF- and EMT-related markers. Subgroup 1 was characterized by low expression of AEBP1, PDGFRα, PDGFRβ, FAP and Slug, whereas subgroup 2 was closely associated with high expression of PDGFRβ, S100A4 and Twist. In addition, high expression levels of podoplanin, PDGFRβ, CD10, S100A4, α-SMA, Zeb1, Slug and Twist were observed in subgroup 3. High expression of CD10 was commonly found in all 3 subgroups. These subgroups were correlated with histologic subtypes, that is, subgroup 1, MM; subgroup 2, BCC; and subgroup 3, SCC. We suggest that the expression pattern of CAF- and EMT-related proteins plays crucial roles in the progression of BCC, SCC, and MM.

Background and objectives The choice of reconstructive technique for a segmental mandibular defect in elderly patients is controversial. The aim of this study was to establish an algorithm for selecting a method of mandibular reconstruction in elderly patients. Methods We retrospectively evaluated 121 patients aged ≥65 years who underwent immediate microvascular mandibular reconstruction after oncologic resection. Patients were divided into three groups based on method of reconstruction: vascularized bone graft (n = 49), mandibular reconstruction plate and soft tissue flap (n = 22), and soft-tissue flap (n = 50). We compared perioperative outcomes among groups and investigated factors affecting the choice of reconstructive technique. Results Rates of postoperative complications did not differ significantly among groups. Mandibular reconstruction plate was indicated only for anterior mandibular defects. Soft-tissue flap was indicated for posterior mandibular defects in patients aged ≥75 years or with a poor postoperative Eichner index. Conclusions Mandibular reconstruction plate and soft-tissue flap can be good alternatives to vascularized bone graft in the elderly. Our algorithm uses defect type, patient age, and postoperative Eichner index to determine reconstructive technique.

Introduction: The study aimed to present our experience of surgical treatment for urorectal fistulas (URF) that develop after cancer surgery. Materials and Methods: Fourteen patients with URF who were treated at our institution from 2005 through 2015 were retrospectively analyzed. Among these, 7 patients had previous surgical treatment of prostate cancer (PC) and the other 7 had been treated for rectal cancer (RC). The fistula was resected through a perineal incision, and the urinary and fecal defects were separately closed with the hinge flap method followed by interposition of a muscle flap transfer. Results: The overall fistula closure rate was 79%. Although the closure rate of the URF was lower in patients with previous RC surgery compared to the PC patients (57 vs. 100%), it did not reach statistical significance. Conclusions: URF treatment using an interposition muscle flap offers a high success rate of fistula closure. However, complicated fistulas occurring after RC surgery involving the prostate or the seminal vesicle might be difficult to repair by this surgery alone.

IntroductionThe aim of breast reconstruction (BR) is to improve patients’ health-related quality of life (HRQOL). Therefore, measuring patient-reported outcomes (PROs) would clarify the value and impact of BR on a patient’s life and thus would provide evidence-based information to help decision-making. The Satisfaction and Quality of Life After Immediate Breast Reconstruction study aimed to investigate satisfaction and HRQOL in Japanese patients with breast cancer who undergo immediate breast reconstruction (IBR).Methods and analysisThis ongoing prospective, observational multicentre study will assess 406 patients who had unilateral breast cancer and underwent mastectomy and IBR, and were recruited from April 2018 to July 2019. All participants were recruited from seven hospitals: Okayama University Hospital, Iwate Medical University Hospital, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Showa University Hospital, University of Tsukuba Hospital, Osaka University Hospital and Yokohama City University Medical Center. The patients will be followed up for 36 months postoperatively. The primary endpoint of this study will be the time-dependent changes in BREAST-Q satisfaction with breast subscale scores for 12 months after reconstructive surgery, which will be collected via an electronic PRO system.Ethics and disseminationThis study will be performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects published by Japan’s Ministry of Education, Science and Technology and the Ministry of Health, Labour and Welfare, the modified Act on the Protection of Personal Information and the Declaration of Helsinki. This study protocol was approved by the institutional ethics committee at the Okayama University Graduate School of Medicine, Dentistry, on 2 February 2018 (1801-039) and all other participating sites. The findings of this trial will be submitted to an international peer-reviewed journal.Trial registration numberUMIN000032177.

OBJECTIVE To evaluate the feasibility of postoperative intensity-modulated radiotherapy for head and neck cancer by investigating the patterns of failure after this therapy. METHODS A retrospective chart review was performed. RESULTS Between March 2006 and December 2013, 122 consecutive patients with head and neck squamous cell carcinoma were treated by surgery followed by postoperative intensity-modulated radiotherapy. In regard to the site of the primary tumor, 59 (48%) patients had cancer of the oral cavity, 31 (26%) patients had cancer of the hypopharynx, 14 (11%) patients had cancer of the oropharynx, 10 (8%) patients had cancer of the larynx and 8 (7%) patients had cancer of unknown primary. The median follow-up period of the surviving patients was 54 months (range, 25-115). Concurrent chemotherapy was administered in 76 patients (62%). The median prescribed radiation dose was 66 Gy. The 3-year overall survival, progression-free survival, distant metastasis free survival and loco-regional control rates were 59%, 48%, 52.4% and 71%, respectively. Of the 122 patients, 32 developed loco-regional recurrence as the initial recurrence, including in-field recurrence in 26 patients, marginal recurrence in five patients and out-field recurrence in seven patients. Of the five patients with marginal recurrence, four have had two or more surgeries before the intensity-modulated radiotherapy and three had oral cavity cancer. Severe adverse events were not frequent, occurring at a frequency of

The risk of surgical site infection (SSI) remains high after major reconstructive surgery of the head and neck. Clinical data regarding SSI in microsurgical tongue reconstruction are described at National Cancer Hospital in Japan, including discussions of unfavorable representative cases, the relationship between SSI and preoperative irradiation at Okayama University Hospital in Japan, and strategies for SSI control in head and neck reconstruction. Local complications are inevitable in patients undergoing reconstruction in the head and neck areas. The frequency of major complications can be decreased, and late postoperative complications can be prevented with the help of appropriate methods.

A 76-year-old Japanese woman had noticed an asymptomatic and palpable mass in her left parotid gland region for 20 years. The tumor had showed rapid growth during the last two months. Therefore, the tumor was clinically suspected of being a malignant tumor and was surgically resected. A histopathological examination revealed that the tumor consisted of two different histopathological neoplastic components accompanied by hyalinized fibrosis at the center of the tumor. The two-neoplastic components were squamous cell carcinoma and salivary duct carcinoma. The tumor was suspected to be a carcinoma ex pleomorphic adenoma after considering the clinical course and the histopathological findings, such as hyalinized fibrosis at the center of the tumor. There was no evidence of recurrence at 30 months after the surgical resection.

Flap reconstruction has become an essential component in soft tissue sarcoma treatment. However, the clinical features of local recurrence after soft tissue sarcoma resection and flap reconstruction remain unclear. The present study aimed to establish effective follow-up strategies after soft tissue sarcoma resection and flap reconstruction. Data from patients who underwent soft tissue sarcoma resection and immediate flap reconstruction were retrospectively reviewed. Follow-up after surgery included history taking and physical examination during every visit to the hospital. Magnetic resonance imaging to evaluate the primary site was performed six months after the end of treatment then annually for ten years. The methods of detection of local recurrence were assessed. A total of 229 consecutive patients were included in the present study. During a median follow-up period of 40 months, 33 patients (14.4%) developed local recurrence. Twenty-three recurrences that occurred on the margin of the transferred flap were detected as palpable mass prior to radiological assessment; among the remaining ten recurrences that occurred in the deep layer of the transferred flap, six were detected by abnormal clinical findings and four were clinically occult and detected by surveillance radiological assessment. Surveillance radiological assessment has an important role in early detection of local recurrence that develops in the deep layer of the transferred flap. Therefore, meticulous clinical assessment combined with routine radiological study should be performed during follow-up evaluation for local recurrence after soft tissue sarcoma resection and flap reconstruction.

Background and Objectives Lateral and superior oropharyngeal reconstruction is technically challenging and can be complicated by postoperative dysphagia. The aim of this retrospective study was to identify the predictive factors of dysphagia after lateral and superior oropharyngeal reconstruction with free flap transfer and to establish better management for cases with these predictive factors. Methods We performed a retrospective chart review of 109 patients who had undergone lateral and superior oropharyngeal reconstruction with free flap transfer for oropharyngeal cancer. Preoperative, operative, and postoperative variables were examined, and possible predicative factors for dysphagia were subjected to univariate analysis and multivariate logistic regression analysis. Results Dysphagia occurred in 16 patients (14.7%). Multivariate logistic regression analysis identified extensive tongue base resection, postoperative radiotherapy, and history of radiotherapy to the head and neck region as independent factors contributing to dysphagia after lateral and superior oropharyngeal reconstruction. Of these factors, extensive tongue base resection was the most important. Conclusions Early intervention to minimize the risk of dysphagia should be performed for patients identified with these predictive factors. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

Background Reconstruction of extensive axillary defects after sarcoma resection presents a challenging problem in reconstructive microsurgery. The purpose of this report was to investigate the feasibility of the free anterolateral thigh (ALT) flap for oncologic axillary reconstruction. Methods The extensive axillary defects in six patients with sarcoma was reconstructed using a free ALT flap. The defect size ranged from 15 × 11 to 28 × 25 cm2. Five patients had recurrent cases and the ipsilateral latissimus dorsi flap had been already used in three patients. Two patients with a full-thickness defect underwent chest wall reconstruction with the iliotibial tract. Results All flaps survived completely and the wounds healed without complications in all patients. Conclusions The free ALT flap is an ideal flap for axillary reconstruction after extensive sarcoma resection. It can be tailored to the requirements of the individual's defect and provides durable coverage for the axillary neurovascular bundle and intrathoracic structures. Flap harvesting in the lateral decubitus position enables a two-team approach. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

For recurrent cases or residual cases following concomitant chemo-radiation therapy (CCRT), salvage surgery is a frequently used treatment options. A swallowing disorder is one of the major complications of CCRT. The purpose of the present study was to evaluate the effect of CCRT on swallowing function in patients who underwent salvage total pharyngo-laryngo-esophagectomy (TPLE), and to evaluate the importance of pharyngeal constriction in patients who underwent TPLE. Between 2008 January and 2014 May, 54 patients were treated with salvage TPLE following CCRT or TPLE at the National Cancer Center Hospital East, Chiba, Japan and were included in the present study. A total of 14 patients underwent salvage TPLE following CCRT for recurrence or residual tumor (the salvage TPLE group), and 40 patients underwent TPLE as initial treatment (the TPLE group). The pharyngeal constriction score and the post-swallowing oropharyngeal residue rate were evaluated, and inadequate velopharyngeal closure was assessed by videofluorography. The pharyngeal constriction score of the salvage TPLE group was poorer than that of the TPLE group (P0.99). The results of the present study indicate that the swallowing function of patients who undergo salvage TPLE may be affected by CCRT.

Background:. Free jejunal transfer (FJT) is a standard method of reconstruction after total pharyngo-laryngo-cervical esophagectomy (TPLE) in patients with advanced head and neck cancer. However, it is related to various degrees of postoperative swallowing dysfunction. This study aimed to assess whether the tensed and straight FJT method results in a reduced rate of postoperative dysphagia compared with historical controls. Methods:. Patients who were undergoing FJT after TPLE for squamous cell carcinoma of the hypopharynx or cervical esophagus were enrolled. The primary endpoint was the rate of not developing dysphagia within 6 months of the surgery, and we compared this value with that obtained from historical data of patients who underwent FJT. The secondary endpoint was the rate of developing surgical complications. Results:. Although 128 patients were registered between August 2012 and July 2015, 7 were excluded based on the exclusion criteria. Of the remaining 121 patients, FJT with the craniocaudally tensed and straight method was performed in all patients. The rate of not developing dysphagia and its 95% confidence interval (CI) were 66.1% and 57.0–74.5%, respectively. The lower limit of the CI was higher than the prespecified threshold value of 50.0%. The rate of developing complications of total necrosis of the jejunum was 3.3%, cervical infection was 9.9%, and major anastomotic leakage was 4.1%. Conclusions:. Our findings revealed that the proportion of postoperative dysphagia decreased in patients who underwent tensed and straight FJT. This method may become the standard surgical method in reconstruction of defects after TPLE.

Summary Introduction Indications for flow-through latissimus dorsi (LD) flaps have been limited for reconstructing distal extremities. In addition, there has been little discussion in regard to the question of which branch is most suitable as a distal runoff of the flow-through anastomosis. The aims of this study were to investigate the feasibility of flow-through LD flaps in various areas in the body and the rationale for branch selection for the distal runoff vessel. Methods This retrospective study included 33 patients who underwent reconstruction of an oncology-related defect with a free flow-through LD flap. Defect locations, branches used for the distal runoff, and postoperative complications were investigated. Results The defect location was in the lower extremity in 13 patients, the scalp in seven, the upper extremity in six, the pelvis in six, and the chest in one. In 19 of the 33 patients, the defects were located in areas other than the distal extremities. The circumflex scapular artery (CSA) was most frequently used as the distal runoff vessel (24 patients) followed by the serratus anterior branch (SAB) (five patients). All flaps were transferred successfully without anastomotic failure. Conclusions The flow-through LD flap is a reliable option for reconstruction in many areas of the body. It can provide high success rates not only for extremity reconstruction but also for scalp and pelvic reconstruction. The CSA matches well with the workhorse recipient vessels. The SAB is suitable when there is a vascular defect of the recipient artery.

Background Functional reconstruction of extensive soft-palate defects is challenging for microsurgeons. The versatility of the combination of a free anterolateral thigh flap and a superiorly based pharyngeal flap for oncologic soft-palate reconstruction was investigated. Methods The combination of flaps was used for immediate reconstruction after total or subtotal resection of the soft palate in five consecutive patients from 2006 to 2011. Results All flaps survived completely. Palatal fistula and miniplate infection each developed in one patient but healed conservatively. Follow-up period ranged from 21 to 66 months. All patients tolerated a regular diet without significant aspiration or nasal regurgitation. Speech intelligibility was excellent in all patients, and none required a palatal prosthesis. Conclusions The combination of an anterolateral thigh flap and a superiorly based pharyngeal flap is a versatile option for reconstructing extensive soft-plate defects. This method is simple and achieves reproducible results with limited donor-site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Objective Free flap transfer is an essential part of limb-sparing surgery for leg sarcoma; however, this procedure is associated with a high failure rate. The aim of this study was to identify factors that contribute to microvascular compromise and flap failure for leg free flap transfer, while focusing on anastomotic techniques (end-to-end, end-to-side, and flow-through anastomoses). Patients and methods Data from 56 consecutive patients who underwent leg free flap transfer after oncologic resection were retrospectively reviewed. Of these patients, flow-through anastomosis was performed with the artery in 29 and the vein in 24, whereas conventional techniques were performed in others. The variables contributing to microvascular compromise and flap failure were statistically analyzed. Results Venous thrombosis (four patients, 7.1%) was more frequent than arterial thrombosis (one patient, 1.8%) and (4 patients, 7.1%) resulted in flap loss. All anastomotic failures occurred in end-to-end anastomoses. All flow-through anastomoses achieved patency both for the artery and vein. No anastomotic failure or flap loss occurred in 22 flaps which were transferred with flow-through anastomosis for both the artery and vein. Flow-through venous anastomosis tended to have a lower rate of microvascular compromise and flap loss than conventional techniques (P = 0.13 and 0.25, respectively). Conclusion The key to successful leg free flap transfer is to prevent venous failure; thus, flow-through venous anastomosis may be a breakthrough solution. Preferential use of flow-through anastomosis for both the artery and vein can provide predictable results in leg free flap transfer. © 2015 Wiley Periodicals, Inc. Microsurgery 35:536–540, 2015.

Backgrounds Although a vascularized fibular graft (VFG) is the favored method for mandible reconstruction, only few functional reports have been published. In this study, surgical outcomes and functional results after mandible reconstruction were analyzed. Patients and methods From 1999 through 2010, oromandibular defects after segmental mandibulectomy were reconstructed with VFG in 101 patients. Operative outcomes and subjective functional evaluation was performed. Of these, 44 patients could be evaluated for functional outcomes, and bite force was measured with an occlusal force meter in 24 patients. Results Major surgical complications required secondary revisional surgery developed in four patients. A normal diet was possible in 37 patients (84.1%), and a soft diet was possible in 7 patients (15.9%). Conversational ability was rated as excellent in 42 patients (95.5%). The mean bite force on the nonaffected side of the mandible was 187.7 N, and bite force decreased as the number of osteotomies in the VFG increased. Furthermore, bite force was significantly lower (P = 0.001) on the affected side (58.2 N), compared to nonaffected side (191.9 N). Conclusions Although masticatory force decreases as the number of osteotomies increases, oral function after mandible reconstruction is satisfactory in most cases. Transfer of a VFG is a safe and reliable method for functional mandible reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Reconstruction of complex knee defects including the popliteal artery presents a challenging problem in reconstructive microsurgery. Reconstruction of the popliteal artery and soft-tissue coverage should be performed simultaneously for limb salvage. We present the one-stage reconstruction of a complex knee defect including the popliteal artery using a free flow-through anterolateral thigh (ALT) flap as a bypass flap in two patients with sarcomas. In both patients, the popliteal artery and vein were reconstructed using branches of the lateral circumflex femoral arterial system. The flaps survived without vascular compromise and the limbs were preserved successfully. Free flow-through ALT flap enables simultaneous leg revascularization and soft-tissue coverage with a single free flap. The lateral circumflex femoral arterial system has many branches with large diameters, making it suitable for reconstruction of multiple infrapopliteal arteries.

Objective Mandibular reconstruction with a mandibular reconstruction plate (MRP) and free flap transfer can involve serious plate-related complications. The aim of our study is to present our new “no-touch-technique” which keeps an MRP not contaminated to saliva during the entire operation for the reduction of plate-related complications. Patients and Methods Data were retrospectively collected on 29 patients who had undergone segmental mandibulectomy for head and neck tumor and mandibular reconstruction with an MRP and free flap transfer from 2004 to 2013; 12 patients were reconstructed with our no-touch-technique from 2010 to 2013 (no-touch-technique group), and 17 patients with the conventional technique from 2004 to 2009 (conventional group). A rectus abdominis musculocutaneous flap or anterolateral thigh flap was transferred in all patients. The rates of perioperative recipient site complications including total flap necrosis, partial flap necrosis, wound infection, fistula formation and wound dehiscence, and reoperation for complications were compared between the groups. Results All flaps were successfully transferred although one venous thrombosis formation occurred in the conventional group. The rate of wound infection in the no-touch-technique group (8.3%) was significantly lower than that in the conventional group (47.1%) (P = 0.04). Additionally, the rate of fistula formation in the no-touch-technique group (8.3%) tended to be lower than that in the conventional group (29.4%) (P = 0.35). Conclusion The results of our study showed that our no-touch-technique may be a safe and effective procedure for the prevention of perioperative plate-related complications for mandibular reconstruction with an MRP and free flap transfer. © 2015 Wiley Periodicals, Inc. Microsurgery 36:115–120, 2016.

Rotationplasty is used most often as a function-preserving salvage procedure after resection of sarcomas of the lower extremity; however, it is also used after infection of prosthetic knee joints. Conventional vascular management during rotationplasty is to preserve and coil major vessels, but recently, transection and reanastomosis of the major vessels has been widely performed. However, there has been little discussion regarding the optimal vascular management of rotationplasty after infection of prosthetic knee joints because rotationplasty is rarely performed for this indication. We reviewed four patients who had undergone resection of osteosarcomas of the femur, placement of a prosthetic knee joint, and rotationplasty with vascular reconstruction from 2010 to 2013. The mean interval between prosthetic joint replacement and rotationplasty was 10.4 years and the mean interval between the diagnosis of prosthesis infection and rotationplasty was 7.9 years. Rotationplasty was successful in all patients; however, in one patient, arterial thrombosis developed and necessitated urgent surgical removal and arterial reconstruction. All patients were able to walk independently with a prosthetic limb after rehabilitation. Although there is no consensus regarding the most appropriate method of vascular management during rotationplasty for revision of infected prosthetic joints, vascular transection and reanastomosis is a useful option.

The posterior thigh flap is a workhorse flap for reconstruction in the gluteal region. The main vascular pedicle of the flap is commonly the descending branch of the inferior gluteal artery, although it is at risk for transection during sarcoma resection. We report successful reconstruction of an infragluteal defect resulting from sarcoma resection with a venous-supercharged freestyle posterior thigh flap in the absence of the descending branch of the inferior gluteal artery. A 77-year-old man underwent sarcoma resection in the infragluteal region. The descending branch of the inferior gluteal artery was sacrificed. We found a sizable perforator through the long head of the biceps femoris and harvested a posterior thigh flap on the basis of that perforator with a freestyle approach. The flap gradually developed a congestive appearance after transfer. We therefore anastomosed the vein of the second perforator to an accompanying vein of the sciatic nerve at the recipient site. The complete flap survived, and the postoperative course was uneventful. We believe that combined use of the freestyle approach and the perforator-supercharging technique can enhance the versatility and the safety of pedicled perforator flap transfer.

Free flaps have rarely been used to reconstruct lumbosacral defects, primarily because of the lack of suitable recipient vessels in this region. We propose the novel use of the superior rectal artery as a recipient vessel for free flap transfer after partial or total sacrectomy. We transferred free flow-through latissimus dorsi musculocutaneous flaps, with the superior rectal vessels as recipient vessels, to reconstruct defects after partial sacrectomy in 2 patients with sacral chordoma. The flaps survived completely, and the wounds healed uneventfully in both patients. The superior rectal artery is easier to dissect and anastomose than are gluteal vessels and is less affected by patients' postoperative postural change than are extraperitoneal vessels. We believe that the superior rectal artery is a versatile recipient vessel for free flap transfer to reconstruct sacrectomy defects.

Summary:. A postoperative aerodigestive fistula is one of the rare but critical complications after esophagectomy, and management is challenging. The essential keys to successful treatment of these fistula are thorough debridement and complete closure followed by separation of the respiratory and digestive tract. We present a case of a recurrent bronchoesophageal fistula between the left main bronchus and neo esophagus, which was successfully treated through a contralateral approach. The fistula was debrided and closed primarily through a right thoracotomy, and the interposition of a pedicled latissimus dorsi musculocutaneous flap from the right side was carried out. The patient was able to resume oral feeding at 16th postoperative day.

Introduction Donor site seroma formation and prolonged drainage duration are common complications of using latissimus dorsi musculocutaneous (LDMC) flaps. The present retrospective study aimed to investigate the effect of types of back flap harvest on drainage duration and seroma formation rates. Methods Adult patients (n = 155) who underwent reconstruction with a latissimus dorsi flap from January 2010 to October 2015 were included in the study, of which 54 patients underwent breast reconstruction with a pedicled LDMC flap (LD breast group), 80 patients underwent an LDMC flap transfer for purposes other than breast reconstruction (LD nonbreast group), and 21 patients underwent soft tissue reconstruction with a thoracodorsal artery perforator (TAP) flap (TAP group). Flap size, drainage durations, and seroma formation rates at donor sites were compared among the 3 groups. Results Flap sizes significantly differed between the LD nonbreast group (median value, 185.5 cm) and the other 2 groups (119 cm in the LD breast group. 127.5 cm in the TAP group), with no significant difference observed between the LD breast and TAP groups. The mean drainage duration was 11.6 days for the LD breast group. 9.82 days for the LD nonbreast group, and 4.81 days for the TAP group. Drainage durations significantly differed among the groups. Seroma formation rate of the LD breast group (42.6%) was significantly higher than those of the other groups. Conclusions The type of back flap harvest used significantly affected drainage duration and seroma formation rate in the present study. Lumbar fat extension with the use of a LDMC flap for breast reconstruction may lead to seroma formation. Thoracodorsal artery perforator flaps are associated with minimal risks of seroma formation and significantly shortened drainage duration compared with LDMC flaps.

Suitable recipient vessels for free-flap transfer are hard to find in the posterior thigh. To investigate the versatility of accompanying artery of sciatic nerve as a recipient vessel in this region, we performed computed tomographic angiographic study of 20 consecutive healthy thighs in 10 patients. The presence and internal diameter of the accompanying artery were studied. The accompanying artery of the sciatic nerve was present in 11 thighs (55%) and the internal diameter of the artery at the mid-thigh level ranged from 2.1 to 3.2 mm. We used this artery as a recipient vessel for free flaps transferred to reconstruct extensive thigh defects in three patients with sarcomas. In all patients the flaps survived without vascular compromise. No sensory or motor dysfunction in the sciatic nerve distribution occurred in any patients. We believe that the accompanying artery of the sciatic nerve may be a recipient vessel for free-flap transfer in selected patients. © 2014 Wiley Periodicals, Inc. Microsurgery 35:284–289, 2015.

Background Tracheal necrosis is a severe complication of total pharyngolaryngectomy (TPL). The purpose of this retrospective study was to identify risk factors for tracheal necrosis after TPL. Methods We performed a retrospective chart review of 177 patients who had undergone TPL. The preoperative, operative, and postoperative variables were examined, and possible risk factors for tracheal necrosis were subjected to univariate analysis and multivariate logistic regression. Results Tracheal necrosis occurred in 35 patients (19.8%), and tracheoesophageal fistula subsequently developed in 3 of these patients. Multivariate logistic regression analysis identified total esophagectomy and diabetes mellitus as significant risk factors for tracheal necrosis after TPL. Conclusion The findings of this study will be useful for assessing the risk of tracheal necrosis after TPL. In patients at high risk for tracheal necrosis, efforts should be made to preserve the tracheal circulation and to prevent life-threatening sequelae if tracheal necrosis occurs. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1207–1210, 2015

Surgical site infections (SSIs) occur at a rate exceeding 40 % after head and neck reconstruction and are due in part to the clean-contaminated surgical field, in which cutaneous fields interact with oral or pharyngeal fields. The aim of this study was to clarify the most important risk factors for SSI and to identify effective strategies for preventing SSI. In 2011 and 2012, 197 patients who underwent head and neck reconstructive surgery were studied at National Cancer Center Hospital East, Japan. The SSI rate, risk factors for SSI, and biological aspects of SSI were evaluated prospectively. A total of 42 patients (21.3 %) had SSIs, and 62 bacterial species were identified at infection sites. Significant risk factors for SSI identified with multivariate analysis were hypoalbuminemia [P = 0.002, odds ratio (OR) = 3.37], reconstruction with vascularized bone transfer (P = 0.006, OR = 3.99), and a poor American Society of Anesthesiologists Physical Status score (P = 0.041, OR = 3.00). Most bacteria identified were species that persist around cutaneous and pharyngeal fields, but multidrug-resistant bacteria were rare. The SSI rate at our hospital is lower than rates in previous studies. To minimize SSI, intervention to improve the patient’s perisurgical nutritional status and a more appropriate mandible reconstructive strategy should be considered.

Resection of malignant bony tumours of the pelvis creates large bone and soft-tissue defects, and is frequently associated with complications such as wound dehiscence and deep infection. We present the results of six patients in whom a rectus abdominis myocutaneous (RAM) flap was used following resection of a malignant tumour of the pelvis. Bony reconstruction was performed using a constrained hip tumour prosthesis in three patients, vascularised fibular graft in two and frozen autograft in one. At a mean follow-up of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection of a malignant tumour of the pelvis to provide an adequate volume of tissue to eliminate the dead space, cover the exposed bone or implants with well-vascularised soft tissue and to reduce the risk of complications. Cite this article: Bone Joint J 2014;96-B:270–3.

Soft-tissue defects after wide resection of groin sarcomas have been reconstructed with well-characterized flaps, such as rectus abdominis, gracilis, and anterolateral thigh flaps. To our knowledge, the use of superficial femoral artery perforator (S-FAP) flaps for this purpose has not been reported. We report on three female patients in whom groin defects after sarcoma resection were reconstructed with pedicled S-FAP flaps. The dimensions of the skin defects ranged from 13.5 × 11 to 16 × 14.5 cm. Sizable perforators from the superficial femoral arteries were identified preoperatively around the apex of the femoral triangle with computed tomographic angiography or color Doppler ultrasonography. The lengths of the flaps ranged from 17 to 19 cm. The main perforator penetrated the sartorius muscle in two patients and emerged between the sartorius and the adductor longus muscles in the other patient. The postoperative course was uneventful, and results were satisfactory in all patients. The main advantages of the S-FAP flap over more commonly used flaps are that it is easier to harvest and is associated with less donor-site morbidity. We believe that the S-FAP flap may be a versatile option for the coverage of groin defects. © 2014 Wiley Periodicals, Inc. Microsurgery 34:470–474, 2014.

Secondary reconstruction of thoracic esophageal defects is a challenging problem for microsurgeons. Because of previous surgeries and coexisting disease, gastric pull-up, and creation of a pedicled colon conduit are often impossible. Transfer of a supercharged pedicled jejunum flap or free jejunal interposition is usually the last resort; however, identifying appropriate recipient vessels and adequately covering the reconstructive conduit are often difficult. We performed secondary thoracic esophageal reconstruction with combined use of the cephalic vein as a recipient vein and the pectoralis major muscle flap for coverage in three patients. Two patients underwent transfer of a supercharged pedicled jejunum flap, and the other patient underwent free jejunal interposition. No wound complications occurred, and all patients could resume oral intake. The cephalic vein is a more reliable recipient vein than is the internal mammary vein. The skin graft-covered pectoralis major muscle flap provides secure external coverage to prevent anastomotic leakage even in complicated cases. Combined use of the cephalic vein and the skin graft-covered pectoralis major muscle flap is a versatile option for secondary thoracic esophageal reconstruction.

Background Few studies have performed a multiple factor analysis to assess the factors associated with successful mandibular reconstructions in a large number of subjects. The purpose of this study is to evaluate the functional outcome in mandibular reconstruction by means logistic regression analysis. Methods Since April 2005 to September 2009, 126 patients underwent segmental resection of the mandible for cancer ablation and mandibular reconstruction with free flaps at 6 Japanese institutions. The patients' charts were reviewed retrospectively. Twelve patients were excluded for the reconstruction was with double flaps, or they went under secondary reconstruction. With logistic regression analysis in 114 subjects, we assessed multiple factors influencing postoperative speech intelligibility, feeding ability, and postoperative complications of mandibular reconstruction. Results The use of a reconstruction plate with a soft-tissue free flap only was showed to have a deleterious effect on postoperative feeding. The strong association in the level of statistical significance between the use of a reconstruction plate with soft-tissue free flaps only and the occurrences of major complications was indicated. It was also statistically revealed that the postoperative presence of opposing teeth contributed to both speech intelligibility and oral intake. Conclusions In our research, osteocutaneous flaps were superior to reconstruction plates with soft-tissue free flaps regard to the postoperative feeding ability and major complication rate. © 2013 Wiley Periodicals, Inc. Microsurgery 33:337–341, 2013.