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In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.

Background: In the setting of the reconstruction for a large defect, we must make the maximum use of the limited human tissue with the minimum damage. In this article, we report on reconstruction using a combination of three-skin paddle latissimus dorsi and a scapular flap for a large defect after soft tissue sarcoma resection to minimize donor site morbidity., Methods: From 2000 to 2012, six patients underwent primary reconstruction using free or pedicled triple-lobe combined latissimus dorsi and scapular flap after wide resection of soft tissue sarcoma. There were five male patient and one female, and their average age was 66.8 (range, 49-80 years). The location of the defects was the thoracic wall in three, the thigh in one, the knee in one, and the shoulder in one. The average size of the defect was 18.8 × 13.9 cm., Results: The average size of the ascending scapular flap and the skin paddle of the latissimus dorsi flap was 6.8 × 13 cm and 7.3 × 14.7 cm. One patient had partial necrosis of the skin paddle of the latissimus dorsi flap, which was treated conservatively. The triple-lobe combined latissimus dorsi and scapular flaps survived completely in five cases. Neither anastomosis complications nor infections were encountered. The average follow-up period was 63.67 months. All patients were satisfied functionally and esthetically with the reconstruction outcomes at the end of follow-up., Conclusion: In conclusion, the triple-lobe combined latissimus dorsi and scapular flap is one of the options for reconstruction of a large defect after sarcoma resection to minimize donor site morbidity., (© 2020 Wiley Periodicals LLC.)

Background: Patients with facial fracture or head and neck surgery sometimes suffer from infraorbital nerve injury. This injury results in severe hemilateral numbness in the midfacial area. The infraorbital nerve ends with two major branches; the infra nasal branch (INB) and superior labial branch (SLB). In this study, we assessed the feasibility of cross-nerve transfer of the INB and SLB based on a cadaver study., Methods: The INB/SLB from a total 20 sides of 10 cadavers (2 men and 8 women; average age, 79.9 years) were dissected. The distribution patterns of the INB and SLB, the distance between the INB/SLB and the piriform aperture, and the shortest distance between the INB/SLB were estimated., Results: Three distribution patterns of the INB and SLB were observed, that is type A (65%); only the INB is thick enough for a nerve transfer, type B (20%); only the SLB is thick enough for a nerve transfer, and a combination of types A and B (15%). The distance between the INB, SLB and the piriform aperture was on average 8.61 and 10.81 mm in each. The shortest distance between the INB and SLB was on average 11.34 ± 3.7 mm., Conclusions: The INB and SLB existed in all the specimens and could be found approximately 1 cm below the piriform aperture. The average distance between the INB and SLB was approximately 11 mm. These results imply the feasibility of a cross-nerve transfer of the distal part of the infraorbital nerve.

We encountered a very rare condition where the patient had a lymphocele under the skin envelope of the breast following mastectomy during the course of breast reconstruction with a tissue expander. The incidence rate of axillary lymphoceles is reported as 2.2-50% in breast cancer patients, but there have been no reports mentioning lymphoceles under the breast skin during the course of breast reconstruction with a prosthesis. The patient had a lymphocele in the lower lateral part of the breast following mastectomy and had multiple cellulitis-like inflammations. These inflammations were treated with conservative therapy such as administration of antibiotics, resting, and cooling. After 6 months of the initial surgery, the patient underwent complete resection of the lymphocele, preventative elimination of a possible lymphatic leakage, and breast reconstruction using a prosthesis combined with a capsular flap. The capsular flap is a transposition flap that uses capsular tissue around the expander to cover adjacent thinned skin. There were no postoperative complications such as breast skin necrosis, exposure of the prosthesis, or recurrence of the lymphocele and cellulitis. The patient had a successful breast reconstruction even though a lymphocele of the breast was observed. Even though a patient may have a lymphocele in the breast following mastectomy, with careful resection of the lymphocele, complete elimination of possible lymphatic leakage, and by performing the capsular flap technique, complete breast reconstruction with a breast prosthesis may be successful.

Objective: The aim of this study was to identify the risks and benefits of the stepladder V-Y advancement medial thigh flap for vulvovaginal reconstruction in comparison to direct skin closure., Methods: Fifty-four patients with vulvar cancer treated in our hospital between 1992 and 2013 were enrolled in this study. The cohort group (group A) consisted of 25 patients who underwent surgery from August 2006 until April 2013. During this period, we changed our surgical paradigm to incorporate reconstructive plastic surgery immediately following surgery for vulvar cancer performed by gynecologic oncologists. The control group (group B) consisted of 29 patients treated between 1992 and August 2006. During this period, our surgical approach was limited to direct skin closure with no reconstructive plastic surgery. Perioperative findings and clinical outcomes were compared retrospectively., Results: Patient characteristics and surgical procedures, other than the reconstructive surgery, were the same for the 2 groups. The mean blood loss and operative times were similar, and there were no major complications in either group; however, the average length of hospital stay was significantly shorter in group A (P = 0.04)., Conclusions: Stepladder V-Y advancement medial thigh flap lowers posttreatment morbidity and improves quality of life for patients with vulvar cancer. Rapid recovery from surgery is reflected in the short hospital stay, and it enables immediate induction of adjuvant therapy. It may possibly contribute to improved treatment outcome.

We present the current perspective on reconstructive surgery for soft tissue tumors, especially in the extremities, based on our large series. A total of 1,813 patients with bone and soft tissue sarcomas underwent surgery at our hospital between 1978 and 2011. Reconstructive operations were performed by plastic surgeons. In such reconstructive surgery, to achieve better quality of life for the patient, great effort was made not only for limb salvage but also for functional reconstruction. Although a few surgeries resulted in limb amputation due to multiple tumors, recurrence, or advanced age of the patient, the rate of limb salvage and/or functional recovery has been increasing dramatically using the method of flap surgery and vascular reconstruction. In fact, over more than 30 years, the limb salvage rate at our hospital has increased from 71.6 % around 1980 to 90.5 % around 2010. In this article, we describe our experience in plastic and reconstructive surgeries after operation for bone and soft tissue sarcomas.

The defects following soft-tissue or bone malignancies resection tend to be wide and composite at the region of ankle, and reconstruction of the defects is a difficult task. Between 1982 and 2007, we performed reconstruction for the defects of the ankle region in seven patients. All of the patients underwent free tissue transfer, and the selected methods are different for each case. No perioperative complications have occurred in any patients. All flaps survived completely. Two patients had local recurrence and amputation was carried out. Functional and aesthetical improvement is desirable for reconstruction of the ankle. We consider it important to select reconstructive options based on the size and volume of the defects and tissue deficiency; and free tissue transfer is useful for the reconstruction of the wide and composite defects at the ankle region., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

In free tissue transfers, preventing microvascular thrombosis is the first priority to achieve a successful result. Numerous protocols exist for preventing thrombosis postoperatively. We performed continuous local intraarterial infusion of anticoagulants in 11 patients undergoing wide resection of malignant soft tissue tumors, followed by primary microvascular reconstruction in the lower limb. A catheter designed for epidural anesthesia was inserted into the femoral artery and connected to a syringe pump. A daily dose of 100 ml comprising 2,000 U of heparin and 40 microg of prostaglandin E(1) was administered by means of continuous infusion for seven consecutive days as a standard regime. There were no cases of thrombosis during the continuous local intraarterial infusion of anticoagulants. There were no serious systemic complications. Although we have described limited cases and supporting data are lacking, we feel that this procedure might be useful for microsurgical reconstruction of the lower limb., ((c) 2010 Wiley-Liss, Inc.)

Many surgical procedures have been reported for vulvoperineal reconstruction following cancer resection. These include the use of skin grafts, local skin flaps, muscle flaps and fasciocutaneous flaps. Among them, V-Y advancement flap from the medial thigh region has been widely used. However, at times a scar contracture occurs, caused by the long, straight suture line. From September to October 2007, we performed vulvoperineal reconstruction following cancer resection using stepladder V-Y advancement medial thigh flaps in three patients. All flaps survived completely and no scar contracture was observed in all the patients. No surgical revisions were needed. This flap is reliable, easy to be elevated and allows immediate repair of deep defects. This technique can be useful for the reconstruction of the vulvoperinela region because zigzag scars are inconspicuous, diminish the postoperative scar contracture and achieve normal urination.

In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 years, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours after operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cancer. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancer if there are no metastatic lesions in other organs.

Forehead recontouring in endoscopic surgery is presented. Eleven cases of protruded forehead deformity caused by benign tumor and one case of concave deformity caused by depressed frontal bone fracture were treated. All lesions were approached through incisions made in the hair-bearing area and operated on endoscopically. This method left no scars on the forehead, and the results were satisfactory. It is considered to be an excellent procedure with regard to cosmetic results.

The size of detects in scalp for which primary wound closure can be applied is limited. Cases with a scalp defect for which primary wound closure is difficult to perform are frequently seen. In these cases, an attempt is made to close the wound by extending the margin of an incision produced by extensive subgaleal undermining or galeal incisions. However, its effectiveness is limited. We performed in such cases intra-operative scalp expansion with a tissue expander for primary wound closure, and this technique has yielded good results. A case with craniosynostosis and five cases with cranioplasty received this procedure. Four of these cases had a previous history of undergoing surgery for carvarial bone defect three to five times from the same incision. The scalp at the carvarial bone defect had a scar and was atrophic with great depression. It was expected that the expansion of cranium resulting from cranioplasty would make it difficult to perform primary wound closure. During the surgery, a tissue expander was placed subgaleally in an osseous area prior to the bone operation, and intermittent air expansion was carried out for 20 to 30 minutes by means of air inflation and deflation to expand the scalp. In all of these cases little tension was generated by the wound closure despite the lapse of time during the bone operation. In consequence, primary wound closure was accomplished easily, and the reliable closure of the galea made it possible to prevent the scar widening. This is a simple and easy technique combining primary wound closure of the scalp with intra-operative scalp expansion. We believe that the technique should be considered for cases for whom primary closure of compression deformity is difficult or in whom there is a wound at the carvarial reconstruction site. The technique and typical cases are reported.

The latissimus dorsi musculocutaneous flap can provide a large, reliable flap for reconstruction of various areas of the body. This flap can also be extended quite some way over the anterior and upper border of the muscle, although its width is limited to between 10 cm and 12 cm if direct closure of the donor site defect is required. This paper presents a sliding-shaped modification of the latissimus dorsi flap that enables the flap to be used efficiently in covering a wide defect as well as in correcting the donor site defect.

We performed endoscope-assisted rectus abdominis muscle flap harvests on 2 patients with anterior chest wall defects. For the procedure, a spindle-shaped anterior fascia and the upper two-thirds of the rectus abdominis muscle were elevated endoscopically from an incision at the umblicus and transferred to the chest wall defect through a subcutaneous tunnel. Endoscopic harvest of the rectus abdominis muscle flap minimizes postoperative scarring caused by cutting off the flap, affording expectations of good cosmetic results. Furthermore, this surgical procedure is less invasive, relieves postoperative pain, and enables reduction of donor site morbidity.

Lipomas were extracted with an ultrasonic suction scalpel, assisted by an endoscope, with good results. The combined surgical technique is described in this paper. Preoperative clinical findings and diagnostic imaging of the patients provided a preoperative diagnosis of lipomas. For the procedure, the endoscope was inserted through a small incision immediately above the tumor. The tumor was endoscopically confirmed and then extracted with an ultrasonic scalpel. Complete lipoma extraction was achieved in all patients without recurrence. The patients had good cosmetic results with only minimal postoperative scarring. The endoscopic extraction of lipomas with an ultrasonic scalpel is proven to be highly useful, especially for large tumors, and permits a less invasive and more reliable surgical operation.

The endoscopic excision of a forehead osteoma is reported. This method leaves no scars in the forehead, results in positive excision of the tumor, and involves no complications such as nerve damage or vascular injury with direct endoscopic vision. It is considered to be an excellent procedure with respect to cosmetic results.

Using percutaneous endoscopic surgery, we achieved good results in patients with frontal sinus cyst. The surgical procedure is described and discussed. The endoscopic system consisted of a needle-shaped rigid fiberscope (direct-vision and angle-vision types [30 degrees, 90 degrees]) 1.7 mm in diameter with a light source. A small incision was made at the eyebrow, the sinus was cleaned, and an opposite hole was made through the existing wound. This procedure permitted less invasive surgery under direct view of the surgical field compared with conventional percutaneous transnasal frontal sinus procedures. Postoperative patency of the sinus was also satisfactory. This percutaneous endoscopic procedure was designed for surgical maneuvers in the frontal sinus through a small, 3- to 5-mm incision. This technique is considered effective for the treatment of inflammatory disorders of the frontal sinus caused by positional abnormalities after trauma or recurrence after conservative transnasal surgery.

Two cases are presented in which a scapular osteocutaneous flap and a latissimus dorsi musculocutaneous flap were applied as combined flaps with a single pedicle, to repair massive soft-tissue defects resulting from tibial hemisection in the lower limb. In each case, the oval-shaped donor site was divided into two parts (an ascending scapular flap and a latissimus dorsi flap, respectively) to repair the resected area, using a vertically designed, combined flap from the dorsolateral region. Consequently, after flap elevation, the donor site could be closed primarily and functions of the affected limb could be completely reconstructed. For reconstruction of defects too large to be covered with a single flap, the vertical double flap design of a combined ascending scapular and latissimus dorsi flap is a good alternative. It has the merits of easy dissection, broad area skin coverage and it also provides a composite flap that contains a scapular bone graft. Moreover, it allows a simple microsurgical anastomosis, as well as direct closure of the donor site. In addition, when the recipient site is on the lower leg, flap elevation can be carried out simultaneously with surgery at the recipient site. This means that the operative time can be shortened.

Luhr miniplate is used for temporary fixation and adjustment so that ideal occlusion and fracture alignment can be achieved. In this procedure, the lower edge of the mandible is first temporarily fixed, and precise bone alignment is achieved through dynamic compression using the temporary miniplate. Afterward, one or more miniplates are attached on the ideal line to maintain structural integrity during bone restoration. This method is a simple restoration technique that allows temporary auxiliary fixation to assist precise attachment of the manipulative miniplate. No special instrument or devices are required. It is, therefore, quite beneficial as an auxiliary technique for reconstructive surgery of this type.

Rigid internal fixation using mini/micro plate has become a frequent application in cranio-maxillo-facial surgery. In order to make plate fixation easier and reduce operative time, the TM HAKEN plate, a kind of micro plate, was devised which has a thorny HAKEN like an ice pick and applied to cranio-facial surgery. The plate is made of titanium, and th HAKEN and screw are made of titanium alloy. These allow contoured engagement in all three dimensions due to the flexibility of titanium, and firm fixation due to the physical strength of titanium alloy, resulting in minimized artifact on CT scan and MRI images. The fixation is accomplished by just driving in the plate with a hammer, and using screws. In the case of wide operative field, the plate is driven in directly, while in the case of small field, the plate is driven in with an impactor. TM HAKEN plate has been used for osteosynthesis in 39 cases of craniofacial surgery at the Department of Plastic and Reconstructive Surgery of Toho University Hospital between September 1992 and September 1994. Of the 39 cases, 19 were cranioplasty using frozen preserved auto-carvarial bone, 9 were midface fractures, 6 were fixation of free bone grafting, and 5 were fixation of artificial bone (hydroxyapatite-tricalcium phosphate composite ceramics) grafting. Satisfactory results were obtained in all cases without any difficult complications such as infection, exposure or migration. In addition, reliable post-operative evaluations and follow-ups were possible with reduced artifact on CT scan and MRI images.(ABSTRACT TRUNCATED AT 250 WORDS)

This report describes a case of radial club hand which was reconstructed by a proximal growth plate of the fibula supplied by the reverse anterior tibial artery. A brief discussion on epiphyseal transfer of the fibula is included.

Preoperative therapy effects, resected margin and local radicality were investigated in 40 cases of soft tissue sarcoma in which preoperative therapy (mainly radiation therapy) had been given. The results indicated that there was no effect upon prognosis due to postponement of surgery in order to perform preoperative treatment. In cases in which radiation therapy was used for preoperative treatment, even when a surgical margin resulted with in a tumor, no recurrence was found. However, histologically there was concern that some portion of the living tumor cell in marginal area of the tumor might have remained. Thus, at the present stage in cases having undergone initial treatment, radiation limited to the specific area of the resected margin causing non-curative margin should be given. If combined with preoperative radiation therapy, surgical intervention involving "wide margin" can be considered radical. On the other hand, cases having undergone surgery before and receiving preoperative therapy that show good response nevertheless show numerous recurrences. These recurrences, however, invariably occur outside of the irradiated area, and may be attributed to the fact that tumor cell dissemination from the earlier surgery was not within the radiation field. Hence, it was considered that the area for radiation in the case of a recurrence should extend well beyond the scar area.