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BackgroundNear-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of changes in the tissue levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) and can identify the severity of chronic venous diseases. Here we investigated the predictors of post-thrombotic syndrome (PTS) using NIRS in patients with a first episode of deep venous thrombosis (DVT).MethodsThe study enrolled 129 patients with DVT. Risk factors in each patient were assessed at presentation. Venous abnormalities confirmed by ultrasound and parameters derived from NIRS were evaluated at 6 months after DVT. On standing, increases in O2Hb and HHb (ΔO2Hbst and ΔHHbst) and the times taken for each concentration to become maximal (TO2Hbst, and THHbst) were measured. During 10 tiptoe movements, O2Hb showed a continuous decrease (ΔO2Hbex), whereas venous expulsion (ΔHHbEex) and subsequent retention (ΔHHbRex) were observed. The oxygenation index (HbD; HbD = O2Hb − HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex). Final clinical manifestations were evaluated at 6 years, and PTS was considered to be present if the Villalta score was ≥5.ResultsThirteen patients were excluded and 116 patients were finally included. Of these, 19 (16%) developed PTS. Among various NIRS-derived parameters, TO2Hbst had the highest area under the curve (0.88; 95% confidence interval [CI], 0.80-0.93; P < .01) with the best cutoff value (TO2Hbst ≤48 seconds). On univariate analysis, variables associated with greater risk for development of PTS were stroke (odds ratio [OR], 5.59; 95% CI, 0.74-42.41; P = .06), idiopathic DVT (OR, 4.13; 95% CI, 1.36-12.55; P < .01) and iliofemoral DVT (OR, 4.31; 95% CI, 1.48-12.60; P < .01) at initial presentation, venous occlusion combined with reflux (OR, 4.24; 95% CI, 1.50-12.00; P < .01), and NIRS-derived TO2Hbst ≤48 seconds (OR, 43.03; 95% CI, 9.04-204.81; P

Near-infrared spectroscopy (NIRS) provides continuous noninvasive monitoring of changes in the levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) in tissues. The purpose of this study was to investigate changes in calf muscle O2Hb and HHb levels during standing and exercise in the follow-up of deep venous thrombosis (DVT).Forty-three patients with a first episode of unilateral proximal DVT were included. Final clinical manifestations were evaluated at a mean follow-up point of 53 months after diagnosis of DVT, and post-thrombotic syndrome (PTS) was considered to be present if the Villalta score was5. Moreover, to assess the severity of PTS, the revised Venous Clinical Severity Score (VCSS) was employed. NIRS was used to measure changes in the levels of O2Hb and HHb in calf muscle. On standing, increases in O2Hb and HHb were calculated by subtracting the baseline value from the maximum value (ΔO2Hbst and ΔHHbst). The times taken for the O2Hb and HHb concentrations to become maximal (TO2Hbst, and THHbst) were also measured. During 10 tiptoe movements, the relative change in O2Hb was calculated by subtracting the value measured at the end of exercise from the value measured at the beginning of exercise (ΔO2Hbex). On the other hand, 10 tiptoe movements produced venous expulsion (ΔHHbEex) and a subsequent retention (ΔHHbRex). The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex).Among the 43 limbs evaluated, 21 had PTS. On standing, the ΔHbDst was significantly decreased in patients with PTS relative to the patients without PTS (12 ± 8, 22 ± 11 μmol/L; P = .001). The TO2Hbst was also significantly reduced in patients with PTS relative to those without (43 ± 41, 107 ± 58 seconds; P = .001). During 10 tiptoe movements, the ΔHHbEex was significantly reduced in patients with PTS relative to those without (-2 ± 1, -3 ± 3 μmol/L; P = .016). Similarly, the ΔHHbRex was significantly increased in patients with PTS relative to those without (8 ± 7, 3 ± 2 μmol/L; P = .001). Furthermore, falls in ΔHbDex were more pronounced in patients with PTS (-10 ± 16, 10 ± 10 μmol/L; P .001). NIRS-derived TO2Hbst (r = -0.568; P .001) and ΔHbDex (r = -0.645; P .001) showed strong inverse correlations with VCSS. Similarly, NIRS-derived ΔHHbEex (r = 0.409; P .01) and ΔHHbRex (r = 0.476; P .01) showed moderate positive correlations and ΔHbDst (r = -0.422; P .01) had a moderate inverse correlation with VCSS.Changes in O2Hb and HHb concentrations differ between patients with and without PTS. The reduced TO2Hbst may indicate impairment of the venoarteriolar reflex in patients who have PTS. Furthermore, severe falls in HbD in patients with PTS might reflect the pain of venous claudication. These findings may have implications for investigations of the microcirculation in the context of post-thrombotic sequelae.

Background Lymphatic malformations (LMs) are low-flow congenital lesions that consist of cysts of varying size. Sclerotherapy with intralesional bleomycin and OK-432 has been reported to yield dramatically beneficial results for this disorder. However, inflammation-related symptoms are often seen after treatment with these sclerosing agents. On the other hand, polidocanol (POL) is reportedly associated with fewer allergic and inflammatory reactions. Up to now, however, very few reports have documented the use of POL microfoam for treatment of LMs. This study was performed to assess the efficacy and safety of POL microfoam sclerotherapy for LMs. Methods Between 2003 and 2016, cases were identified from a prospectively compiled database on low-flow congenital vascular malformations before undertaking a retrospective electronic chart review. Patients were included if they had LMs that had been treated by POL microfoam sclerotherapy. The location, size, and type of LMs were assessed using ultrasound and magnetic resonance imaging. Twenty-gauge venous catheters were inserted into the lymphatic space under ultrasound visualization. The LMs were then fully aspirated if they were macrocystic in form. Microfoam composed of 3% POL was then injected under ultrasound guidance. Microcystic LMs were treated by direct injection with POL microfoam under ultrasound guidance. The outcome was assessed by clinical examination combined with findings of postsclerotherapy imaging using ultrasound and magnetic resonance imaging. Results During a 13-year period, 32 patients met the inclusion criteria. These were 11 (34%) male patients and 21 (66%) female patients with a mean age of 18 years. The LMs were localized to the head and neck (47%), the trunk (38%), and the extremities (15%). The lesions were subdivided into macrocystic (56%), mixed macrocystic and microcystic (31%), and microcystic (13%) LMs. The average lesion size was 6.6 × 4.6 × 3.0 cm. The mean number of treatment sessions was 2.8 (range, 1-15), with a mean foam volume of 4.6 (range, 1-10) mL. Excellent (47%) and moderate (41%) responses were seen in 88% of the patients. Notably, half of the patients achieved excellent or moderate resolution with a single treatment session. Intralesional hemorrhage occurred in four patients (13%) but resolved spontaneously. Only one patient with mixed macrocystic and microcystic LMs developed post-therapy infection. However, the other patients did not develop any post-therapy inflammation-related symptoms, including fever, pain, and marked swelling. Conclusions Percutaneous sclerotherapy using POL microfoam appears to be safe and effective for treatment of LMs. Ultrasound-guided POL microfoam sclerotherapy should be considered for such lesions, particularly those that are exclusively macrocystic.

Objective Klippel-Trenaunay syndrome (KTS) is a condition defined by the association of three physical features: capillary malformation, varicosities, and hypertrophy of bony and soft tissues. However, KTS is characterized by congenital vascular malformations (CVMs) that are difficult to classify. Therefore, the present study was undertaken to analyze the various CVMs in patients with KTS. Methods Sixty-one patients with KTS were enrolled, and their CVMs were divided into predominantly venous defects, predominantly lymphatic defects, and mixed vascular defects using the Hamburg Classification. Capillary malformations were subdivided into port-wine stain, telangiectasia, and angiokeratoma. Truncular and extratruncular vascular malformations were detected using duplex ultrasound and magnetic resonance imaging. Reflux in the superficial and deep venous systems was also evaluated. Results Forty-five patients (74%) had predominantly venous defects, four (6%) had predominantly lymphatic defects, and 12 (20%) had mixed vascular defects. Capillary malformations were detected in 54 patients (89%), among which port-wine stain was the most predominant (40 patients, 66%), followed by telangiectasia (31 patients, 51%) and angiokeratoma (18 patients, 30%). Extratruncular venous malformations were detected in 47 patients (77%). In contrast, truncular venous malformations were found in 50 patients (82%). Among these, embryonic lateral marginal vein showed the highest occurrence, accounting for 53% (32 patients). However, reflux in this vein was detected in only nine patients (15%). Twelve patients (20%) had reflux in the great saphenous vein, and four (7%) had reflux in the small saphenous vein. Deep vein hypoplasia was found in seven patients (12%), and only five patients (8%) had deep vein aplasia. Extratruncular lymphatic malformations were found in 13 patients (21%) and truncular lymphatic malformations in 17 (28%). Conclusions Patients with KTS have a variety of CVMs, but both extratruncular and truncular venous malformations continue to be targets for intervention.

Objective To assess whether the preoperative level of deoxygenated hemoglobin (HHb) in the calf muscle during light-intensity exercise is useful for identifying patients at risk of developing deep vein thrombosis (DVT) after total knee or hip arthroplasty. Methods Sixty-eight patients undergoing total knee or total hip arthroplasty were enrolled. The Caprini risk assessment model was used to stratify patients into Caprini 5 to 6, Caprini 7 to 8, and Caprini >8 groups. The preoperative diameter of each venous segment was measured, and the time-averaged velocity (TAV) and time-averaged flow (TAF) of the popliteal vein (POPV) were assessed. Moreover, the prevalence of venous reflux in the POPV was evaluated preoperatively. Near-infrared spectroscopy (NIRS) was used to measure the calf muscle HHb level. The calf venous blood filling index (FI-HHb) was calculated on standing, and then the calf venous ejection index (EI-HHb) was obtained after one tiptoe movement and the venous retention index (RI-HHb) after 10 tiptoe movements. All patients received low-dose unfractionated heparin preoperatively and fondaparinux for postoperative thromboprophylaxis. Patients with arterial insufficiency, those who had preoperative DVT, and those who developed bilateral DVT after surgery were excluded from the study. Results Four patients were excluded on the basis of the exclusion criteria. Among the 64 patients evaluated, 14 (21.9%) were found to have DVT postoperatively. Among the risk factors for DVT, only the previous DVT was significantly predominant in patients who developed DVT (P = .001). The diameter of the popliteal vein was significantly smaller in patients who developed postoperative DVT than in those who did not (P = .001). Similarly, the diameter of the gastrocnemius vein was significantly larger in patients with postoperative DVT than in those without (P = .010). TAV and TAF were significantly increased in the popliteal vein in patients who developed postoperative DVT (P = .043, 0.046, respectively). Both groups showed a similar prevalence of reflux in the POPV (P = .841). The preoperative NIRS-derived RI was significantly increased in patients who developed DVT relative to those who did not (P = .004). The RI increased as the Caprini score progressed; however, there were no statistically significant differences between the three categories. Using ultrasound- and NIRS-derived parameters of significance as a unit of analysis, an optimal RI cut-off point of >2.3 showed the strongest ability to predict postoperative DVT, followed by a cut-off point >0.25 cm for the diameter of the gastrocnemius vein (GV). Conclusions NIRS-derived RI >2.3 may be a promising parameter for identifying patients at risk of developing postoperative DVT despite pharmacologic DVT prophylaxis. A GV diameter of >0.25 cm also seems to contribute to the development of postoperative DVT. These results might be helpful to physicians for deciding which patients require more intensive thromboprophylaxis.

Introduction In burned sheep, we showed more than a 10-fold increase in bronchial blood flow following smoke inhalation. It was previously reported that sclerosis of the bronchial artery prior to smoke exposure reduces the pathophysiology of the inhalation insult. We hypothesized that sclerosis of the bronchial artery after insult attenuates smoke/burn-induced acute lung injury. Methods Through an incision at the 4th intercostal space, a catheter was placed via the esophageal artery into the bronchial artery such that the bronchial blood flow remained intact. Acute lung injury was induced by a 40% total body surface area, 3rd degree cutaneous burn and smoke inhalation. Adult female sheep ( n = 18, 35.6 ± 1.0 kg) were divided into three groups following the injury: (1) sclerosis group: 1 h after injury, 4 mL of 70% ethanol was injected into bronchial artery via bronchial catheter, n = 6; (2) control group: 1 h after injury, an equal dose of saline was injected into bronchial artery via the bronchial catheter, n = 6; (3) sham group: no injury and no treatment, n = 6. The experiment was conducted in awake animals for 24 h. Results Bronchial blood flow, measured by microspheres, was significantly reduced after ethanol injection in the sclerosis group. Pulmonary function, evaluated by measurement of blood gas analysis, pulmonary mechanics, and pulmonary transvascular fluid flux, was severely impaired in the control group. However, pulmonary function was significantly improved by bronchial artery sclerosis. Conclusion The results of our study clearly demonstrate a crucial role of enhanced bronchial circulation in thermal injury-related morbidity. Decreasing bronchial circulation using pharmacological agents may be an effective strategy in management of burn patients with concomitant smoke inhalation injury.

Background: We have previously reported the importance of adequate and precise arterial anastomosis and the hypothesis that, up to subzone III, fingertip amputation salvage can be achieved on arterial anastomosis alone. These findings were reported during the meeting of the Japanese Society of Reconstructive Microsurgery. This is our follow-up report with insight and opinion on the limitations of complete fingertip amputation salvage on arterial anastomosis alone. Methods: We examined 67 fingers (59 patients) with fingertip amputations presenting to our hospital between January 2005 and December 2008. Amputation levels and whether these injuries received only arterial or both arterial and venous anastomoses were noted. Fisher exact test was used to examine statistical differences between the groups. Results: Amputation levels were 11 in subzone I, 20 in subzone II, 17 in subzone III, and 19 in subzone IV. Successful replantation was achieved in 87% (58 of 67) of fingers. There was no statistically significant difference between fingers receiving arterial alone versus both anastomoses in amputations of subzones I, II, and III. Conclusions: We found that with proper postoperative congestion care, no statistically significant difference in replantation success of fingers receiving arterial anastomosis alone versus both arterial and venous were noted up to subzone III. However, in subzone IV, regardless of the postoperative congestion, compete necrosis rates are high; thus, it is speculated that a venous anastomosis is necessary for successful replantation. It is preferable to perform as many anastomoses as possible, but we believe that it is also desirable for the procedure to be fast and less invasive. In cases that have no adequate vein, fingertip replantation can be achieved on arterial anastomosis alone up to subzone III.

Summary Background In harvesting free fibula composite flaps, preoperative knowledge of the lower limb vascular anatomy is essential to prevent ischaemic complications or flap failure. Magnetic resonance angiography (MRA) allows imaging of the septocutaneous perforators (≤1–2mm diameter) of the peroneal artery used in the free fibula flap. Methods We investigated seven patients undergoing the free fibula flap preoperatively with high-resolution MRA images to study the following: 1) tibio-peroneal anatomy, 2) peripheral artery disease, 3) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum and 4) the cutaneous distribution of the perforators, and to compare them to surgical findings. Results MRA demonstrated tibio-peroneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease, detected septocutaneous perforators arising from the peroneal artery coursing in the posterolateral intermuscular septum and determined the skin terminus of the septocutaneous perforators. All septocutaneous perforators found during surgery were detected prospectively on high-resolution MRA. Conclusion Lower leg vascular anatomy assessment with high-resolution MRA determined the location of the septocutaneous perforators of the peroneal artery preoperatively with accuracy and precision. This anatomical knowledge provides for a safer procedure and the opportunity to plan surgical details preoperatively.

The authors devised a novel bronchial artery catheterization technique to deliver agents directly into bronchial circulation with preserved blood flow in an awake ovine model. A polyurethane catheter was inserted into bronchial artery via an incision into the 4th intercostal space. Regional blood flow of the airway was measured by fluorescent microspheres before cannulation, after cannulation, and 7 days after the operative procedure. The blood flows were also measured in a sham group (no cannulation, no ligation, n = 6), cannulation group (bronchial artery cannulation, n = 5), and ligation group (bronchial artery ligation, n = 5) at baseline and 6 hours after burn and smoke inhalation injury. The regional blood flows decreased slightly after cannulation in proximal bronchi, but recovered after 7 days. The regional blood flow increased 10-fold after inhalation injury in bronchi of the sham group. Bronchial artery ligation significantly attenuated the increase of blood flow. However, cannulation preserved regional blood flow and did not prevent the blood flow increases after burn and smoke inhalation injury, thus constituting a novel bronchial artery catheterization technique.

Several previous reports have documented arteriovenous malformations associated with anomalies of the arterial tree. We report two cases in which a malformation on the foot coexisted with arterial variants of the popliteal artery. Careful therapeutic planning was required to avoid jeopardising perfusion to the distal area.

Summary Introduction We conducted semi-closed reduction of isolated tripod fractures of the zygoma through only a brow incision under intraoperative assessment with ultrasonography. Methods Twenty-three patients with unilateral, non-comminuted tripod fractures of zygoma were selected for application of this method at Tokyo Women's Medical University and Tokyo Metropolitan Hiroo General Hospital between April 2002 and April 2006. Patients with orbital floor blowout fractures were excluded. A skin incision was made only at the lateral brow region and the reduction was performed by inserting an elevator beneath the zygomatic arch. The bone alignment was intraoperatively assessed by ultrasonography. When the reduction was accurate, the frontozygomatic suture was immobilised with a mini-plate under direct visualisation and transmaler Kirshner wire fixation was performed. The accuracy of the reduction and postoperative movement were evaluated by computed tomography (CT) scans taken at 1 and 6 months. In five cases, the DICOM (Digital Imaging and Communication in Medicine) data from the CT were analysed with 3D imaging software (V-works, CyberMed Co., Korea). Results In all cases, accurate reduction was obtained. The analysis of the 3D imaging data revealed that postoperative movement of bone fragment was minimal. Conclusions When the accurate reduction was obtained under intraoperative assessment, the semi-closed reduction and one-plate fixation with transmaler Kirshner wire is enough to treat the simple tripod fractures of zygoma. This method is minimally invasive and takes less operative time.

ObjectiveTo compare the proportion of foam sclerosant that enters deep veins between multiple injections of 0.5ml foam per injection.Design & methodsOne hundred and seven patients with superficial venous incompetence were randomised to receive either multiple injections of 0.5ml 1% POL-foam per injection (few injections) for the treatment of varicose tributaries. All patients then received ultrasound-guided foam sclerotherapy for refluxing great saphenous vein (GSV) using 3% POL-foam. Only a single session was allowed per patient in order to standardise treatment. Qualitative ultrasonographic inspection of the foam was carried out during a 5-min period before compression was applied. Post-sclerotherapy surveillance was done at day 3, 2weeks, 1month, 3months, and 6months.ResultsFifty-six limbs in 53 patients were treated with multiple injections and the remaining 56 limbs in 54 patients were treated with a few injections. There were no significant differences in age or male:female ratio between the groups. The mean volume of 1% POL-foam was 2.2 S.D. 0.6ml (range: 0.7–4.0ml) in the multiple injections group and 2.5 S.D. 0.6ml (range: 1.0–4.0ml) in the few injections group (p=0.003). The mean volume of 3% POL was 1.5ml (range: 0.7–3.0ml) and 1.4ml (range: 0.7–3.0ml), respectively (p=0.137). Ultrasonographic inspection immediately after sclerotherapy demonstrated that foam was distributed significantly more commonly in the deep veins of patients treated with a few injections (p=0.0003). Two (4%) of the patients treated with a few injections developed migraine during the procedure, but recovered quickly with no further complications. There was no significant difference in the success rate between the groups at 6months (p=0.257).ConclusionsThese findings suggest that multiple small-dose injections can reduce the amount of foam sclerosant and the risk of foam sclerosant entering the deep veins in patients with superficial venous insufficiency.

Summary A major drawback of the DIEP flap is the compromised venous drainage in the distal area, which is the rationale behind the creation of additional venous anastomoses for better flap survival. Although venous congestion is defined as an increase in the venous pressure, the effect of vascular augmentation on the venous pressure has not been elucidated. We investigated the effects of arterial supercharge and venous superdrainage on the venous pressure and the flap survival area in a rat abdominal perforator flap model. An abdominal perforator flap was raised in each of 30 Wistar rats, with the contralateral superficial inferior epigastric artery (SIEA) and vein (SIEV) isolated for pressure measurements. The changes in the SIEV pressure were recorded while proximal sites of these vessels were opened and closed. Thereafter, the animals were divided into three groups: a control group ( n =10, both the SIEA and SIEV were ligated), an enhanced arterial inflow (EAI) group ( n =10, the SIEA was left intact) and a supplemental venous outflow (SVO) group ( n =10, the SIEV was left intact). The flap survival area was determined 7 days after surgery. The SIEV pressure without vascular augmentation was only 13.2±5.9mmHg. Compared with the control group, the flap survival area was significantly larger in the EAI group, but not in the SVO group. An extremely high venous pressure was noted when the SIEA was opened and the SIEV was occluded, but there was great variation among the individual animals (range: 21.2–79.6mmHg). The necrotic area in the EAI group correlated well with the SIEV pressure (r=0.861). These findings indicate that the major factor contributing to distal necrosis in this rat perforator flap model is arterial insufficiency rather than venous congestion. The results suggest that, as long as the arterial inflow is secure, the venous pressure is a reliable parameter for deciding the necessity of venous superdrainage.

Purpose: To assess whether preoperative screening using venous duplex scanning (VDS) of the bilateral lower extremities is useful for identifying patients at risk of developing postoperative venous thromboembolism (VTE). Materials and Methods: Three hundred fifty-two consecutive referral patients at high or highest risk for postoperative VTE according to the guidelines of the American College of Chest Physicians were studied. After VDS, all patients re- ceived low-dose unfractionated heparin for postoperative thromboprophylaxis. Patients were then followed for 3 months after surgery for investigation of clinically significant VTE. Results: Three hundred thirty patients were finally enrolled. Of these, orthopedic surgery patients were most common (140 patients, 42.4%), followed by general surgery (104 patients, 31.5%) and gynecologic (42 patients, 12.7%) surgery patients. Preoperative VDS identified 66 (20.0%) patients with deep vein thrombosis (DVT). Twenty-three (7.0%) pa- tients had proximal DVT and the remaining 43 (13.0%) had distal DVT. Postoperative symptomatic VTE was found in 26 (7.9%) patients who had no evidence of preoperative DVT. Twenty-two patients developed calf DVT, two developed proximal DVT and two developed pulmonary embolism. In contrast, no propagation of DVT or new thrombus formation was found after surgery in patients who had preoperative DVT. Multivariate analysis showed that an age of >75 years (OR 2.57, 95% CI 1.14-5.82, p = 0.023) was the only significant predictor of postoperative VTE.

ObjectiveTo evaluate the efficacy and haemodynamic effects of great saphenous vein (GSV) sparing surgery – valvuloplasty combined with axial transposition of a competent tributary vein (A-VACT).Materials and methodsEighty-five limbs in 74 patients with isolated GSV incompetence were selected for GSV sparing surgery. After angiographic valvuloplasty, the competent tributary vein was exposed and cut 1.5cm distal to its insertion point on the GSV. The transected vein was anastomosed end-to-side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Venous valve competence were screened by serial postoperative duplex examination, and venous haemodynamic changes were analyzed using venous filling index (VFI) measured by air plethysmograph pre- and postoperatively. The follow-up period was 5-years.ResultsSixty-seven patients were included in whom 76 limbs were treated. There was a statistically significant reduction in the vein diameter at the SFJ after 5-years (0.83 S.D. 0.29cm to 0.46 S.D. 0.12cm, p=0.0002, Wilcoxon). Similarly, significant reduction was found in the GSV at the 5-year follow-up point (0.63 S.D. 0.19cm to 0.39 S.D. 0.11cm, p

A higher incidence of failure has been reported for free flaps transplanted to the lower extremities. However, the physiological background of this phenomenon has not been elucidated. We reviewed the 3-day postoperative hemodynamic data for 103 free flaps, including the in situ venous pressure (N = 103), arterial pressure (N = 53), and surface blood flow (N = 42). The cases were divided into two groups based on the recipient site, i.e., lower extremity (the LE group: N = 29) and the other (non-LE group: N = 74). The venous pressure was significantly higher in the LE group (26.6 +/- 2.2 vs. 14.8 +/- 1.2 mmHg), whereas the arterial pressure immediately after surgery was lower than the non-LE group. The hemodynamic data within the transferred tissues demonstrated significant differences between groups, especially in the early postoperative period. There is a possibility that the high venous pressure may aggravate the poor perfusion in tissues transferred to the lower extremities.

WOS: 000256454200005, PubMed ID: 18547178, BACKGROUND At present, various hyaluronic acids are being used to rejuvenate facial skin. There is no comparative study of single cross-linked hyaluronic acid (SCHA) versus double cross-linked hyaluronic acid (DCHA). The objective of our study is to compare the effectiveness and complications of SCHA versus DCHA in the treatment of glabellar lines. METHODS Ten female patients were enrolled in this randomized, evaluator-blind study. One side (left vs. right) of each patient's glabellar lines was treated with SCHA and the other side was treated with DCHA. Two independent blinded observers reviewed the clinical photographs at 3, 6, 9, and 12 months after the treatment and assessed for degree of improvement as well as complications. RESULTS The two products were equally effective in producing an optimal cosmetic result, although at 6, 9, and 12 months posttreatment, a higher proportion of patients showed over 50% improvement with DCHA than with SCHA. At 12 months posttreatment, DCHA was considered superior in 70% of patients, whereas SCHA was superior in 10% of patients. CONCLUSIONS Both SCHA and DCHA are equally effective in producing an optimal cosmetic result. DCHA provides a more durable esthetic improvement when compared to SCHA in the treatment of glabellar lines.

Currently, various nonablative skin resurfacing techniques are being used to rejuvenate facial skin, including lasers and intense pulsed light (IPL). There are few direct comparison studies between IPLs and lasers. The objective of our study is to compare the effectiveness of intense pulsed light versus a long-pulse pulsed dye laser (LPDL) in the treatment of facial skin rejuvenation. Ten Asian patients with Fitzpatrick skin types III-IV were enrolled in this study. One half of the face was treated with IPL (6 treatment sessions) and the other side was treated by LPDL (3 treatment sessions). An LPDL with a wavelength of 595 nm and spot size of 7 mm was used. Utilizing the compression method, lentigines were treated using a PDL with a fluence between 9-12 J/cm and a pulse duration of 1.5 ms. Wrinkles were treated with fluences between 10 to 12 J/cm and a pulse duration of 20 ms, using a pulse-stacking technique. An IPL with a type B handpiece was used. Lentigines and wrinkles were treated with fluences between 27 to 40 J/cm and a pulse duration of 20 ms. The improvement of lentigines was 62.3% and 81.1% for IPL and LPDL respectively. There was no significant difference between IPL and LPDL in wrinkle reduction. There was no scarring or pigmentary change seen with either device. Both IPL and LPDL are effective for facial skin rejuvenation in Asians, but LPDL treatment is significantly better than IPL treatment in the treatment of lentigines. The use of the compression technique may allow this LPDL to be used effectively for facial rejuvenation and with fewer treatment sessions, when compared with the IPL.

This is an account of 2 male surfing enthusiasts who recently sought care at our hospital after developing tumorous masses on their chins. Although the lesions appeared grossly benign, establishing a definitive treatment plan was perplexing because of the insidious nature of the protuberances. The lesion in the first patient was managed surgically. The approach was modified for the second patient because of information learned from the first. While the technical aspects of care management were simple, once the histologic structure of the tumor was defined, establishing an accurate clinical diagnosis before surgery was troublesome. The histologic findings for the lesion removed from the first patient consisted of primarily parenchymal fibrosis without concomitant structural abnormalities in overlying epidermis, suggesting that repetitive blunt trauma to the chin area while paddling the surfboard was probably the factor responsible for the pathogenesis of tumor formation. These findings and our experience in managing the 2 patients have formed the basis of this report.

BACKGROUND AND OBJECTIVE The 595-nm long-pulsed dye laser (LPDL) has been used for the treatment of vascular lesions, and although it is well absorbed by blood, it is also well absorbed by melanin. To utilize this device for the treatment of facial lentigines, we attached a glass window to the tip of the laser's handpiece, allowing compression of the skin during treatment. This prospective study aims to evaluate the efficacy and complications of using a LPDL delivered with compression for the treatment of facial lentigines in Asian persons. MATERIALS AND METHODS Fifty-four Asian patients with facial lentigines were enrolled in this study. The laser settings included fluences between 9 and 13 J/cm2 and a constant pulse duration of 1.5 ms. Cryogen spray cooling was not used. RESULTS Thirty-eight patients showed excellent results, 14 patients showed good results, and 2 patients showed fair results. Hyperpigmentation was seen in 1 patient. CONCLUSION LPDL delivered with the compression method is effective in the treatment of facial lentigines in Asian patients, and the side effect profile is minimal. The compression technique allows the traditional “vascular” LPDL to be used for treating a variety of pigmented lesions.

BACKGROUND The conventional pulsed dye laser (PDL), operating at a wavelength of 585 nm and a pulse duration of 0.45 ms, usually does not achieve complete clearance in the majority of port-wine stains (PWSs). OBJECTIVE In this study, we demonstrate the efficacy of a variable-pulse pulsed dye laser (VPPDL) equipped with cryogen spray cooling (CSC) in the treatment of PWS that have become resistant to PDL treatment. METHODS Forty Asian patients with Fitzpatrick skin types III to IV were enrolled in this study. All patients had previously been treated by the PDL at least eight times (mean, 12.8±5.9) and had reached a treatment plateau. A VPPDL with a wavelength of 595 nm and a spot size of 7 mm was used. The patients were treated with fluences between 9 and 15 J/cm2 and pulse durations of 1.5 to 10 ms. Four treatments were administered at 8-week intervals for each lesion. Three months after the last treatment, all patients were evaluated for the degree of improvement by two independent clinicians. RESULTS Eight patients had excellent improvement, 9 had good improvement, 11 had fair improvement, and 12 had poor improvement. No complications were observed during the course of laser treatment. Vessels larger than 30 μm were not seen in the biopsy specimens obtained after the final treatment. CONCLUSION The VPPDL is more effective than the PDL and the VPPDL should be used for treating PDL-resistant PWSs. Nonetheless, vessels less than 30 μm in diameter are resistant to both PDL and VPPDL treatment.

A 1-year-old boy had grayish pigmentation on the left side of his face over the area supplied by the mandibular branch of the trigeminal nerve. Upon further examination, the lesion was also found on the left side of the neck, shoulder, upper arm, right lower back and buttock. The pigmentation was uniform in intensity. This case report demonstrates that Mongolian spots can occur on the face in the area supplied by the mandibular branch of the trigeminal nerve. These spots should not be misdiagnosed as nevus of Ota.

Background: Disruption of venous outflow can lead to tissue necrosis. Thrombosis of a venous channel at the coaptation site in instances of free tissue transfer could cause death of the transplanted tissues. Although various techniques have been used to monitor the viability of transferred tissues, there has been no technique designed specifically to check the flow within and the patency of the venous channel. The authors have devised an approach with which to monitor the changes in venous pressure in a composite tissue transferred by means of microsurgical technique for bodily reconstruction. Methods: The status of the venous system in various composite tissue grafts was monitored at the time of surgery or for 3 days after the completion of surgery by placing a small-caliber catheter in the vein within the transferred tissue. A total of 52 patients participated in the study. Results: The venous pressure noted in grafts with a patent venous channel remained constant within a range between 0 and 35 mmHg. Venous insufficiency was detected in three of the 52 cases, with unmistakable findings of an elevated venous pressure of over 50 mmHg. Conclusions: The technique of measuring the venous pressure by means of an indwelling venous catheter to monitor changes was found to accurately assess the patency of the venous channel and, by inference, the viability of the transferred tissue. No morbidity was associated with the technique.

Recent refinements of magnetic resonance angiography (MRA) allow imaging vessels as small as the septocutaneous perforators (< or = 1 to 2 mm diameter), but a Medline review reveals no report of septocutaneous vessel imaging for free flap surgery. Challenges in fibula free flap preparation include knowledge of: (1) tibioperoneal anatomy, (2) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum, and (3) the cutaneous distribution of the perforators. Questioning whether high-resolution MRA could image these, we studied the lower extremities of nine healthy volunteers. MRA demonstrated tibioperoneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease and showed septocutaneous perforators arising from the peroneal artery and coursing in the posterolateral intermuscular septum to the skin. High-resolution MRA provided anatomic and clinical information that conventionally has been impossible to obtain preoperatively or has required multiple tests, often of an invasive nature.

Although the structural integrity of the hypopharynx can be readily restored in individuals who have undergone laryngopharyngoesophagectomy by transferring a segment of the jejunum by a microsurgical technique, rehabilitation is often hindered by voice loss. The outcomes achievable with conventional approaches of artificial voice box reconstruction have been, generally speaking, unsatisfactory. A new reconstructive technique was devised to create a connection between the tracheal stump and the neo-hypopharynx to shunt airflow for phonation. The technique consisted of modifying one of two jejunal segments nourished by a single vascular pedicle to make a side mucosal tube resembling an elephant's trunk. With the larger end of one segment connected to the tracheal stump, the side arm having a smaller calibre was connected to the neo-oesophagus which was reconstructed with the second jejunal segment. Upon recovery from the surgery, the patient was trained for phonation by shunting the airflow into the neo-pharyngoesophagus. A total of 39 individuals underwent the elephant trunk shunt procedure for voice restoration at our hospital during the past 10 years. Although phonation was restored in 28 patients who had survived the original disease, the speech was assessed in 11. The mean duration of follow up was 5.6 years. The quality of speech was considered to be adequate in all. The rehabilitation of individuals who had undergone laryngopharyngoesophageal resection was enhanced and the quality of life was improved by voice restoration. That objective is attainable by incorporating a jejunal segment that shunts airflow to the jejunal pouch, thereby enabling phonation.

Objective: To compare different duplex-and air plethysmography (APG)-derived parameters between patients with relatively early and those with advanced chronic venous insufficiency (CVI), and to investigate the indicative parameters reflecting the progression of CVI. Methods: Design: Prospective study at the University Hospital. Patients: In total 686 limbs in 574 patients at various clinical stages of CVI were included. The clinical manifestations were categorized according to the CEAP (clinical, aetiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups: group I (C1-3EP,SAS,D,PPR,O, relatively early stage of CVI) and group II (C4-6EP,SAS,D,PPR,O, advanced CVI). The distribution of venous insufficiency including the sapheno-femoral junction (SFJ), great saphenous vein (GSV), sapheno–popliteal junction (SPJ), common femoral vein (CFV), femoral vein (FV), popliteal vein (POPV), thigh perforators (TPV) and calf perforators (CPV) was determined by duplex ultrasound. The main duplex-derived parameters assessed were the reflux time (RT; s), peak reflux velocity (PRV; cm/s) and peak reflux flow (PRF; mL/s). The venous reflux was assumed to be present if the duration of reflux was ≥0.5 s. The data obtained by APG were on VV (mL), VFI (mL/s), EF (%) and RVF (%). Results: There was no significant difference in overall superficial venous reflux between the groups ( P=0.331). The frequency of deep and perforating vein incompetence differed only when superficial reflux was included in group II. The VFI and RVF were significantly higher in secondary CVI than in primary CVI ( P=0.0001, 0.003, respectively). In the secondary CVI, patients with reflux and obstruction showed significantly higher RVF than those with reflux alone ( P=0.003). The RT did not improve the discrimination power between the groups. In contrast, the PRV had significant discrimination power at the SFJ ( P Conclusions: This present study has suggested the importance of superficial venous insufficiency in the development of advanced CVI. In the secondary CVI, obstruction affects the RVF alone. The PRV and PRF are better parameters than the RT for discrimination of clinical severity in both superficial and deep venous insufficiency, and should be used to quantify venous valvular insufficiency.

Background and Objective Fractional resurfacing is a new concept of cutaneous remodeling whereby laser-induced zones of microthermal injury are surrounded by normal untreated tissue. The aim of this study is to compare the efficacy and complications of Fraxel laser treatment when using different fluences and density settings. Study Design/Materials and Methods Thirty female Asian patients were enrolled in the study. Group 1 (n = 10); half of the face was treated with eight passes at 125 MTZ/cm2 at an energy setting of 8 mJ. The other half of the face was treated with eight passes at 250 MTZ/cm2 at an energy setting of 8 mJ. Group 2 (n = 10); half of the face was treated with eight passes at 125 MTZ/cm2 at an energy setting of 8 mJ. The other half of the face was treated with eight passes at 125 MTZ/cm2 at an energy setting of 16 mJ. Group 3 (n = 10); half of the face was treated with eight passes at 125 MTZ/cm2 at an energy setting of 16 mJ. The other half of the face was treated with eight passes at 250 MTZ/cm2 at an energy setting of 8 mJ. Ice pack cooling was used during and after laser treatment. The patients were evaluated for clinical efficacy and treatment-related side effects. Results Pain, erythema, and swelling were observed to be significantly more evident or persisted longer in patients treated with higher densities and fluences (P

Laser therapy of port-wine stains (PWS) using the extended pulse pulsed-dye laser (EPPDL) is accepted as the optimal approach because the thermal relaxation time for the vessels in PWS is actually 1-10 msec. The purpose of this study is to elucidate the purpuric threshold using the EPPDL for treatment of PWS. One hundred and seventy-seven Japanese patients with PWS were recruited for this study. All the patients were dark-skinned with skin phototype III (n = 103) and IV (n = 74). PWS were treated with the EPPDL with a pulse duration ranging 1.5-10 msec, fluence ranging 9-15 J/cm(2), and a spot size of 7 mm. Cryogen spray cooling (CSC) was fixed to 30 msec of delay and 30 msec of spray duration. Patients returned to our clinic within 1 week after their initial laser therapy and the treatment sites were examined for the evidence of purpura formation. Of the 177 patients, 108 developed purpura. The lowest fluences that caused purpura and were seen in more than 50% of patients were 10 J/cm(2) with a pulse duration of 1.5 msec, 12 J/cm(2) with a pulse duration of 3 msec, 13 J/cm(2) with a pulse duration of 6 msec, and 13 J/cm(2) with a pulse duration of 10 msec. The fluence and pulse duration thresholds were 12.5 J/cm(2) and 1.65 msec, respectively. Because purpura is one of the treatment endpoints when using a pulsed-dye laser for PWS, higher fluences are necessary when using a long pulse duration.

Summary. Background: To investigate patterns of venous insufficiency and changes in calf muscle deoxygenated hemoglobin (HHb) levels after an acute deep vein thrombosis (DVT). Methods: A total of 78 limbs with an acute DVT involving 156 anatomic segments were evaluated with duplex scanning and near-infrared spectroscopy (NIRS) at 1, 3, 6 and 12 months. Venous segments were examined whether they were occluded, partially recanalized, and totally recanalized, and the development of venous reflux was noted. The NIRS was used to measure calf muscle HHb levels. Calf venous blood filling index (HHbFI) was calculated on standing, then the calf venous ejection index (HHbEI), and the venous retention index (HHbRI) were obtained after exercise. Results: The segments investigated were the common femoral vein (CFV; 38 segments), femoral vein (FV; 37), popliteal vein (POPV; 44), and calf veins (CV; 37). At 1 year, thrombi had fully resolved in 67% of the segments, 27% remained partially recanalized, 6% were occluded. The venous occlusion was predominant in the FV (24%) at 1 year. On the contrary, rapid recanalization was obtained in CV than proximal veins at each examination (P

Clinical signs and symptoms such as swelling, pain, and redness are unreliable markers of deep vein thrombosis (DVT). Because of this venous duplex scanning (VDS) has been heavily used in DVT detection. The purpose of this study was to determine if a combination of D-dimer testing and pretest clinical score could reduce the use of VDS in symptomatic patients with suspected DVT.One hundred seventy-four consecutive patients with suspected DVT were prospectively evaluated using pretest clinical probability (PCP) score and D-dimer testing before VDS. After calculating clinical probability scores developed by Wells and associates, patients were divided into low risk (or= 0 points), moderate risk (1 to 2 points), and high risk (or=3 points) PCP.One hundred fifty-eight patients were enrolled. The prevalence of DVT in this study was 37%. Thirty-eight patients (24%) were classified as low risk, 64 (41%) as moderate risk, and 56 (35%) as high risk PCP. DVT was identified in only one patient (2.6%) with low risk PCP. In contrast, DVT was found in 22 (34%) with moderate risk, and 35 (63%) with high risk PCP. In the high and moderate risk PCP groups, positive scan patients had a markedly higher value of D-dimer assay than negative scan patients (p=0.0001 and p=0.0057, respectively). In the low risk PCP patients, D-dimer testing provided 100% sensitivity, 46% specificity, 4.8% positive predictive value, and 100% negative predictive value in the diagnosis of DVT. Similarly, in the moderate risk PCP, the D-dimer testing showed 100% sensitivity, 45% specificity, 49% positive predictive value, and 100% negative predictive value. In the high risk group, D-dimer testing achieved 100% sensitivity, 57% specificity, 80% positive predictive value, and 100% negative predictive value in the diagnosis of DVT. These results suggested that 36 of 158 patients who had a non-high PCP (low and moderate PCP) and a normal D-dimer concentration were considered to have no additional investigation, so VDS could have been reduced by 23% (36/158).A combination of D-dimer testing and clinical probability score may be effective in avoiding unnecessary VDS in suspected symptomatic DVT in the low and moderate PCP patients. The need for VDS could be reduced by 23% despite a relatively high prevalence of DVT.

BACKGROUND:The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis.STUDY DESIGN:Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated.RESULTS:The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (pRESULTS

Bilateral buccal mucosal flaps were used for a pushback operation of the nasal mucosa as well as the oral mucosa.Two flaps from the buccal mucosal areas were inserted into the nasal mucosal raw surface at the hard and soft palatal border to achieve nasal mucosal pushback. Forty-four children with cleft palates were retrospectively studied to investigate the velopharyngeal function, articulation, and craniofacial morphology following primary palatoplasty using the modified Kaplan method.72.7% showed good velopharyngeal function. Articulation disorders were found in 26 of the 44 subjects (59.1%). A craniofacial morphological analysis revealed no major changes in the SNA (sella-nasion point A angle) and SNB (sella-nasion point B angle) and no cases of a marked loss of maxillary mandibular balance. In addition, no significant differences were observed in the maxillary length and width.The results of these palatoplasties by the modified Kaplan method indicated that the use of bilateral buccal mucosal flaps for the pushback of the nasal mucosa was effective in preventing the contraction of the maxillary and mandibular corpal lengths.

The planning of an operation based on three-dimensional imaging has been used mainly in orthognathic surgery. It is a useful way to plan the preoperative treatment as well as to make the postoperative evaluation. We used this technique in breast reconstruction. For the evaluation of breast volume and contour, we used three-dimensional photography by laser scanner, and these were analysed intraoperatively. Three-dimensional data obtained during the operation gave us precise information about the volume and contour of the breast.

Hypothermia is a common complication in patients with extensive burns, receiving massive volumes of fluid for resuscitation at ambient temperature. It is therefore important to maintain the body temperature of patients with extensive burns. The present study was performed to evaluate the usefulness of warm fluid for burn injury resuscitation. Ten dogs were used in this study. Full-thickness burns, involving 40% of the body surface, were generated in the backs of the animals. In the control group (n = 5), the fluid temperature was maintained at about 23 degrees C, while in other group (n = 5), the temperature of the fluid was maintained at 39 degrees C with a warming device. Cardiac output and urinary output were measured in both groups for up to 24 hours. The cardiac output decreased in all animals during the first two hours following injury. The cardiac dynamics remained depressed in the control group. By contrast, in animals treated with warm fluid, the cardiac output returned to the baseline level within 4 hours of resuscitative measures and then decreased slightly for the subsequent 20 hours. The urinary output was better in animals treated with warm fluid, indicating the improved hemodynamic state in these animals. These results suggested that the hemodynamic state in acute burn shock was ameliorated by the use of warm fluid. Therefore, warmed fluid resuscitation might be useful to perform immediate excision and grafting for the patients with extensive burns in acute burn shock.

There have been many case reports of thumb reconstruction using wraparound flaps, toe-to-thumb transfer, and twisted toe flaps but, to the authors' knowledge, there have been no previous reports of reconstruction of total ring finger deficit. In this report, they present a case of successful reconstruction of the ring finger amputated proximal to the proximal-interphalangeal joint, using a twisted toe flap and simultaneous application of a free groin flap to the donor site. Use of the modified twisted toe flap is suggested to be a cosmetically useful method for reconstruction of the ring finger.

Background and Objectives Attempts at using the pulsed dye laser (PDL) operating at 585 nm wavelength and 0.45 milliseconds pulse duration to treat leg veins have been notably unsuccessful. The aim of this study is to evaluate the efficacy and complications of the 595 nm long PDL in the treatment of leg veins. Study Design/Patients and Methods Fourteen patients with 38 lesions were treated using a long PDL equipped with a cryogen spray cooling (CSC) device. Variable pulse durations ranging from 1.5 to 20 milliseconds and energy fluences from 10 to 20 J/cm2 were utilized depending on the size of treated vessels. All patients received two laser treatments at an interval of 2 months. Results Of patients with veins type 1A and type 1, 6 (100%) and 3 (13%) had complete clearing, respectively. Of patients with veins type 1 and type 2, 18 (78.3%) and 2 (22.2%) lesions showed excellent response, respectively. Hyperpigmentation was the only observed complication lasting several months in 57.9% of treated sites. Conclusions The long PDL operating at 595 nm is a safe and effective treatment for leg veins, especially in type 1A and type1 vessels. Lasers Surg. Med. 35:62–67, 2004. © 2004 Wiley-Liss, Inc.

PURPOSE. To compare the preliminary results of hemodynamic changes between duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy. METHODS. Seventy Seven limbs in 77 patients with isolated greater saphenous vein incompetence were treated with duplexguided sclerotherapy. Thirty Seven limbs were treated with duplex-guided foam sclerotherapy and the remaining 40 limbs were treated with duplex-guided liquid sclerotherapy. Pretreatment exam was performed using a color duplex scanner and air plethysmography. The sclerosing foam was produced by Tessari’s method using 1% and 3% polidocanol. The varicose vein was injected with 2 mL of 1% polidocanol or 1% polidocanol foam, and then 1 mL of 3% polidocanol or 3% polidocanol foam was injected into the greater saphenous vein under duplex guidance. Venous obstruction and recanalization were screened by serial posttreatment duplex examination, and posttreatment air plethysmography analysis was performed 3, 6, 9, and 12 months after the sclerotherapy. RESULTS. Duplex scanning demonstrated complete occlusion in the greater saphenous vein for duplex-guided foam sclerotherapy in 25 limbs (67.6%), which was a significantly higher proportion than for the duplex-guided liquid sclerotherapy (7 limbs, 17.5%, po0.0001). Recurrent varicose veins were found in 3 patient (8.1%) in the duplex-guided foam sclerotherapy group and 10 (25%) in the duplex-guided liquid sclerotherapy group at 1-year (p 5 0.048). In duplex-guided foam sclerotherapy, venous filling index values remained normal during the subsequent follow-up examinations, whereas in duplex-guided liquid sclerotherapy, venous filling index began to increase, and there was a significant difference at 6 months between duplexguided foam sclerotherapy and the duplex-guided liquid sclerotherapy (po0.0005). At 9 months, there was a significant difference in the residual venous fraction between the two groups, and the residual venous fraction value continued to improve in duplex-guided foam sclerotherapy (p 5 0.033). CONCLUSIONS. Duplex-guided foam sclerotherapy could have greater promise compared to duplex-guided liquid sclerotherapy in the treatment of superficial venous insufficiency.

10th Japan-Society-of-Plastic-and-Reconstructive-Surgery Research Council Meeting -- OCT 18-19, 2001 -- Tokyo, JAPAN, WOS: 000189207200001, PubMed ID: 14673552, The present study was designed to determine whether a fasciovascular flap as a vascular carrier could be used to revascularize the undescended testis for avoiding the hazardous effects of the Fowler-Stephens procedure, high division of the spermatic vessels, and for bringing high-undescended testes into the scrotum. A total of 25 Wistar rats were divided into five groups of five rats each. In each group, surgical procedures were performed bilaterally, i.e. ten testes in each group, as follows: sham-operated controls (group 1), undescended testes (group 2), high division of the spermatic vessels (group 3), vascular induction with immediate division of spermatic vessels (group 4), and with delayed division of spermatic vessels (group 5). Evaluations were done by measuring the testicular weight and volume, testicular blood flow, and testicular biopsy scores and by microangiography. A moderate to severe decrease in testicular weight and volume in all experimental groups was observed compared with the sham-operated controls (group 1), but this was significantly less in groups 2 and 5. High division of the spermatic vessels in groups 3 and 4 resulted in a significantly greater decrease in the testicular blood flow, but this did not occur in group 5. Microangiographically, an impaired vascular supply from the deferential artery in group 3 and insufficient revascularization from the fasciovascular carrier in group 4 were observed. However, efficient revascularization stemming from the superficial epigastric artery of the fasciovascular flap was found in group 5. The testicular biopsy scores of groups 2 and 5 were significantly greater than those of groups 3 and 4. The results of the present study demonstrate that the fasciovascular flap as a vascular carrier revascularizes the testis through spermatic vessels after delayed division and provides an adjuvant treatment modality or first-stage procedure in a salvage operation for high-undescended testis during staged orchiopexy.

Background. Phacomatosis pigmentovascularis (PPV) consists of a capillary malformation with a variety of melanocytic lesions, which involve various regions of the body and are difficult to treat with conventional therapeutic tools. Objective. We described two cases with PPV (type IIa and IIb) that were successfully treated with different lasers. Methods. The areas involved by both melanocytic lesions and port-wine stains were treated using the Q-switched ruby laser, the Q-switched Alexandrite laser, and the flashlamp pumped pulsed-dye laser. Results. Removal of a good portion of cutaneous and vascular lesions using combined multiple laser approach was achieved after 6 sessions in the first case under general anesthesia and after 31 sessions under local anesthesia in the second case. Conclusion. PPV type II can be treated successfully by laser treatment. We prefer to start combined multiple laser treatment of PPV in childhood period under general anesthesia because it will reduce the number of treatment, improve the patient's quality of life, and increase the cost-effectiveness of the treatment.

Background and Objectives Nevus of Ota is a form of dermal melanocytic hamartoma that appears as a bluish discoloration in the trigeminal region. Although Q-switched lasers provide effective treatment, the appropriate age at which to start that treatment is not known. Our aim is to compare the clinical efficacy and safety of Q-switched ruby laser (QSRL) in the treatment of nevus of Ota in different age groups. Study Design/Materials and Methods Our study included 46 children and 107 adults with nevus of Ota, which had been treated with QSRL that achieved excellent (75% or more) to complete response. The laser parameters were 694-nm wavelength, 30 nanoseconds pulse duration, 4-mm spot size, and 5–7 J/cm2 fluence at 3–4 month intervals. We assessed the mean number of treatment sessions and the degree of complications in the two age groups of patients. Results The mean number of treatment sessions to achieve significance to complete clearing was 3.5 for the younger age group and 5.9 for the older age group (P = 0.0001). The complication rate for the younger age group was 4.8% as compared to 22.4% for the older age group. Conclusions The use of QSRL for the treatment of nevus of Ota in children can achieve an excellent result in fewer sessions and at a lower complication rate than later treatment. The risk of recurrence is a concern, however, and further long-term study is necessary to address this issue. Lasers Surg. Med. 32:391–395, 2003. © 2003 Wiley-Liss, Inc.

Applying negative pressure to wounds may speed the formation of granulation tissue, decrease the amount of localized edema, increase blood flow, and accelerate healing. In the present study, we treated ten patients with stage IV chronic pressure ulcers using this negative pressure dressing technique. The long (A) and short (B) diameters of each ulcer were measured to determine size, and the vertical distance from the skin to the deepest point of the ulcer was measured to determine depth. Lesions were measured initially and at weekly intervals. The area of each lesion was taken to be 3.14 x A/2 x B/2 (cm(2)). When we compared the area of ulcer before and after the treatment, the area had been reduced in all cases, and the average reduction was 55.1%. The depth of ulcer also decreased in all cases, and the average reduction was 61.2%. Over the period of evaluation, the method was considered markedly effective in reducing the size and depth of ulcers.

The present study was designed to evaluate the efficacy of fosfomycin used in combination with drugs that were found to be less effective against methicillin-resistant Staphylococcus aureus (MRSA). Twelve different antibiotics were tested against 32 strains of MRSA isolated from the wounds of burn patients admitted to the Burn Unit at Tokyo Women's Medical University Hospital. These antibiotics - fosfomycin (FOM), flomoxef sodium (FMOX), imipenem (IPM), cefotiam (CTM), cefmetazole (CMZ), ampicillin (ABPC), sulbactam/cefoperazone (SBT/CPZ), minocycline (MINO), ofloxacin (OFLX), and panipenem (PAPM) - were used either alone or in combination. Arbekacin (ABK) and vancomycin (VCM) were used for comparing efficacy in controlling bacterial growth. While both ABK and VCM were, as expected, found to be effective in suppressing in vitro bacterial growth, all ten other agents when used alone were found to be ineffective. In contrast, these agents, when used in combination with FOM, showed remarkable efficacy against all strains of MRSA tested. Based upon the in vitro findings, it is suggested that FOM, in combination with other antimicrobial agents, such as IPM, PAPM, CMZ, and SBT/CPZ may be used instead of ABK and/or VCM to curtail the emergence of Staphylococcus aureus strains that are resistant to these latter two drugs.

WOS: 000179149100008, PubMed ID: 12439014, The effect of the normal-mode ruby laser (NMRL) and the combined (normal mode plus Q-switched) ruby laser on congenital melanocytic nevi (CMN) was evaluated, and the degree to which both laser treatment regimens remove melanocytes was compared in 15 patients. Each nevus was marked to designate half of the lesion for the NMRL treatment and half of the lesion for combined ruby laser treatment. The efficacy of each laser treatment was correlated with the degree of clinical improvement determined by photographic assessment, histological examination, and melanin reflectance spectrometry before and 3 months after laser treatment. A single treatment using the NMRL with energy fluences of both 20 J per square centimeter and 30 J per square centimeter resulted in a slight, but not significant, improvement in lightening of pigmentation (42.61% and 30.38%, respectively). A better clinical response (excellent to good) and higher percentage of lightening (64.45%-72.43%) was noted in the combined ruby laser-treated areas than the NMRL-treated areas. Histological results showed that the combined ruby laser provided a marked decrease in the number of the nevomelano-cytic nests in both the junctional area and the papillary and reticular dermis, whereas the NMRL (with energy fluences of either 20 J per square centimeter or 30 J per square centimeter) caused a decrease in the junctional area and the papillary dermis. None of the nevi had complete clearance of the pigmentation after a single treatment. Therefore, multiple (four to five) treatment sessions are needed to cause complete removal of nevomelanocytic nests in CMN. In conclusion, the combined ruby laser is more effective than the NMRL alone in the treatment of CMN without scarring or textural change of the skin.

619, 622, BACKGROUND:New sclerosing foam is considered to have the advantage of causing more damage on the intima than liquid form. Therefore we recently applied duplex-guided foam sclerotherapy in a patient with venous malformations of the face.METHODS:A 20-year-old man was referred to our institute for the evaluation and treatment of vascular malformations of the face. Preoperative duplex scanning and magnetic resonance imaging (MRI) revealed subcutaneous and intramuscular venous malformations. The sclerosing foam was produced by Tessari's method using 1% polidocanol, and the duplex-guided foam sclerotherapy was performed under general anesthesia. A 20-gauge plastic needle was inserted into the venous space using ultrasound guidance and a total of 5 ml of sclerosing foam was infused followed by immediate tie-over dressing.RESULTS:The venous malformations were successfully reduced in size and postoperative MRI showed significant reduction of the venous malformations.CONCLUSION:Although further collective study is necessary to ensure the validity of this treatment, duplex-guided foam sclerotherapy could have great promise in the treatment of symptomatic venous malformations.