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When resecting the internal jugular veins bilaterally in surgery for head and neck cancer, it is necessary to perform neck dissection in two stages or to reconstruct the internal jugular veins in one stage. Reconstruction of the internal jugular vein using grafting or direct anastomosis to the external jugular vein have both been reported. We report the case of a 53-year-old man with accidental injury to the left internal jugular vein after resection of the right internal jugular vein for supraglottic cancer. The left internal jugular vein was damaged near the inflow of the subclavian vein, making vein grafting difficult. Therefore, internal jugular venous return was reestablished by end-to-side anastomosis of the left internal jugular vein to the left external jugular vein system. In this surgical procedure, by incising the internal jugular vein obliquely, it was not necessary to match the calibers of the internal jugular vein and the external jugular vein system, and a smooth hemodynamic body was reconstructed. In addition, we were able to reconstruct the internal jugular vein while preserving blood flow in the external jugular vein system. End-to-side anastomosis of the internal jugular vein to the external jugular system is an option for internal jugular vein reconstruction.

Background: There is a need for quick skin blood flow tests that can be performed in the wound healing field. Antera 3D® is a compact scanner using multispectral imaging. It can perform quick assessment of skin conditions. The purpose of the present study was to investigate the ability of the Antera 3D® to assess skin blood flow in comparison with transcutaneous partial pressure of oxygen (TcPO2) measurements. Methods: This study was conducted on 13 patients with a history of lower extremity ulcers. Measurements of hemoglobin average level (hereafter, Hb score) measured by Antera 3D® and TcPO2 measured by a transcutaneous blood gas monitor were obtained at the same sites on the dorsal foot and lower leg. Differences in Hb score and TcPO2 were analyzed by t-test for each measurement site and for the presence of peripheral arterial disease (PAD). The correlation between TcPO2 and Hb score was analyzed by Pearson’s correlation coefficient. Results: Twenty-four limbs were tested. Hb score was higher (P < 0.001) and TcPO2 was lower (P = 0.056) in the dorsal foot compared to the lower leg. In the dorsal foot, Hb score was higher (P = 0.023) and TcPO2 was lower (P = 0.046) in patients with PAD compared to those without PAD. A significant negative correlation (r = –0.68; 95% confidence interval –0.85 to –0.38, P < 0.001) between TcPO2 and Hb score was observed in the dorsal foot. Conclusion: The negative correlation between TcPO2 and Hb score may reflect compensatory peripheral vasodilation due to occlusion or stenosis of central arteries. This study showed that Hb score measured by Antera 3D® may be related to skin blood flow.

Myelomeningocele is the most common form of neural tube anomalies. Early reliable skin coverage should be achieved to reduce central nervous system infections. The keystone flaps are gaining popularity for myelomeningocele defect reconstruction. However, the use of a traditional keystone flap is limited in very wide or transversely oriented myleomeningocele defects with inadequate lateral tissue laxity. In this study, we present our successful experience using modified rotation advancement keystone flaps for closure of the transversely oriented myelomeningocele defects.Between April 2019 and April 2020, the modified rotation advancement keystone flap was used for reconstruction of transversely oriented myelomeningocele defect in 7 patients (5 males and 2 females) with average age of 14 days. The localization of the lesions was lumbosacral in 5 patients and thoracolumbar in 2 patient. The average myelomeningocele defect width was 6.4 cm, whereas the average defect length was 5.7 cm. The following information was evaluated: the flap dimensions, operative time, and postoperative complications.All patients had uneventful operations, except for 1 case of superficial epidermolysis over flap tip, which settled with conservative wound management. Immediate venous congestion was detected in 2 patients that completely resolved. Otherwise, all wounds healed without any evidence of complications. The mean follow-up was 4 months.Although the conventional keystone flap seems to have geometric constraints to close a transversally oriented myelomeningocele defect, the modified rotation advancement keystone flap serves as a superior alternative and effective option for closure transversally oriented defect.

Background: Although head and neck reconstruction using free flaps has become a common procedure, flap complications remain a concern. This study aimed to analyze the risk factors of free flap complications and to identify the causes of these complications. Methods: We studied 97 patients with head and neck cancer with intraoral defects who underwent reconstruction using free flaps at Tottori University Hospital between 2011 and 2020. We used a retrospective cohort study design to investigate whether flap complications, including flap necrosis (total and partial) and flap dehiscence, were related to various factors, including the underlying disease condition, treatment status, and surgical factors. Results: Of the 97 patients analyzed, total flap necrosis was observed in one patient (1.0%). The incidence rate of flap complications, including flap necrosis and flap dehiscence, was 29.9%. When the time taken to perform one vascular anastomosis, including preparation of the recipient vessel and flap vessel, exceeded 30 min, the incidence rates of flap necrosis (total and partial) (odds ratio, 8.30; 95% confidence interval, 1.91-36.00; P = 0.005) and flap dehiscence (odds ratio, 3.46; 95% confidence interval, 1.05-11.36; P = 0.041) increased significantly. Conclusion: The time taken to perform one vessel anastomosis was the factor that contributed the most to the incidence of flap complications. Reconstructive surgeons should reduce the incidence of flap complications by keeping the known risk factors of the surgery in mind and by aiming to complete a vascular anastomosis time, including the time taken for the preparation of vessels, of ≤ 30 min per vessel during surgery.

[Background] Technical issues in free flap transfer, such as the selection of recipient vessels and the positioning and method of anastomosis of the vascular pedicle, have been the subject of vigorous debate. Recent developments in computational fluid dynamics (CFD) have enabled the analysis of blood flow within microvessels. In this study, CFD was used to analyze hemodynamics in a microanastomosis. [Methods] In the fluid calculation process, the fluid domain modelizes microvessels with anastomosis. The inlet flow conditions were measured as venous waveform, and the fluid is simulated as blood. Streamlines (SL), wall shear stress (WSS), and oscillatory shear index (OSI) at the anastomosis were visualized and analyzed for observing effects from the flow field. [Results] Some flow disruption was evident as the SL passed over the sutures. The maximum recorded WSS was 13.37 Pa where the peak of a suture was exposed in the lumen. The local maximum value of the OSI was 0.182, recorded at the base of the anastomosis on the outflow side. [Conclusion] In the ideal anastomosis, the SL is disrupted as little as possible by the sutures. The WSS indicated that thrombus formation is unlikely to occur at suture peaks, but more likely to occur at the base of sutures, where the OSI is high. Tight suture knots are important in microanastomosis.

Pressure injuries in people with spinal cord injury or dysfunction (SCI/D) are known to have a high recurrence rate. As a countermeasure, we perform surgery after adjusting the wheelchair and cushion with the intervention of a seating expert. The effectiveness of seating interventions in postsurgical recurrence prevention was examined.In this retrospective analysis, the participants were 19 patients with SCI/D who underwent pressure injury surgical treatment in the gluteal region from 2005 to 2018. The patients with conventional rehabilitation were assigned to Group 1 (n = 8), and those with seating intervention by experts in addition to conventional rehabilitation were assigned to Group 2 (n = 11). The main outcome measure was the presence or absence of recurrence 3 years after the surgery. The recurrence rate was compared between the two groups.The recurrence rates were 18% with seating intervention and 75% without; there was a significant difference (p = 0.025). The recurrence odds ratio was 13.5.This study suggests that presurgical seating evaluation and assessment by experts, postsurgical rehabilitation based on presurgical evaluation and assessment, and routine follow-up and seating adjustment according to changes are efficacious for preventing postsurgical pressure injury recurrence in patients with SCI/D.

Reconstruction of bone and soft-tissue defects in the forearm is a surgery that often proves unsuccessful. Free fibular osteocutaneous flaps are a useful material for reconstruction that enable simultaneous reconstruction of bone, skin, and soft tissues. However, in free fibular osteocutaneous flaps, the fibula, skin, and vascular pedicle are tightly bound together by the posterior intermuscular septum and the perforators that pass through the septum, giving the disadvantage of a low degree of freedom when setting these structures in place. We take into account the 3-dimensional structure of the free skin flap when selecting which lower leg to use as the donor. We report here the case of a 61-year-old man with defects in the radius, skin, and soft tissues after resection of spindle cell carcinoma of the right forearm, which was reconstructed using a free fibular osteocutaneous flap harvested from the left lower leg. Two years postoperatively, recovery has been uneventful with no complications. Donor-side selection of free fibular osteocutaneous flap is an important factor for safely completing composite radius reconstruction.

Objectives: Liposuction is now applied to harvest autologous adipose-derived regenerative cells in the regenerative medicine. Although liposuction is highly safe for females who generally have larger fat deposits, liposuction has some potential risks for donor-site complications in the case of aged male patients. The purpose of our study was to review the complications of liposuction of the aged male patients who have undergone cell therapy for stress urinary incontinence. Methods: Sixteen male patients (mean age, 74 years old) with persistent stress urinary incontinence were included in this study. Approximately 250 mL of adipose tissue was harvested using a syringe attached to the cannula. Postoperative complications were recorded and graded according to the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. Results: Average liposuction time was 57.4 min. No major complications were observed. However, there were some minor complications: bruising, numbness, contour irregularities, firmness, and scarring. These complications were CTCAE Grade 1 in all cases. The complications, except for the scarring, became unnoticeable within 6 months in all cases. Conclusion: Liposuction takes time and has some minor donor-site complications for stem cell therapy in aged male stress urinary incontinence patients. Keywords: Aged patients, Donor-site complications, Liposuction, Male, Stress urinary incontinence

The tapering technique is one of the useful methods of anastomosing 2 vessels with large discrepancies during microanastomoses. When the tapering technique is used, a three-point suture is always present. The authors analyzed the most appropriate suture technique for this using computational fluid dynamics. This aspect has not previously been addressed. Three different suture techniques were simulated: (1)Three single-knot sutures (Type I);(2)Two single-knot sutures forming an X-shape (Type II); and(3)A single continuous ligature through the vascular wall (Type III). Vascular models of these 3 types were created. The streamline, wall shear stress, and oscillatory shear index at the anastomosis site were measured using a previously prepared venous model. Streamline disruption was most severe for Type II. In all 3 types, the highest wall shear stress was recorded at the suture peak protruding into the vessel. The maximum oscillatory shear index was highest in Type II, and lowest in Type III. The present results suggest that Type III is the best three-point suturing method for the tapering technique.

[Background] Subcutaneous injection of tumescent solution, which contains local anesthetic, adrenaline, and saline, before split-thickness skin graft harvesting, shows a significant hemostatic effect. This method can reduce the initial bleeding from the donor site. The aim of this study is to assess the benefits of controlling the bleeding from donor sites by tumescent injection. A randomized, controlled trial was performed to compare the wound healing of split-thickness skin graft donor sites treated with or without tumescent injection. [Methods] This randomized, controlled trial examined donor site healing days as the main measure of outcome. postoperative pain, donor site ulceration, and scar quality were evaluated as secondary outcome measures. Patients planned for split-thickness skin graft harvest were randomly assigned to receive either pre-harvest subcutaneous injection of local anesthetic, adrenaline, and saline solution (tumescent solution) (Group 1) or post-harvest application of adrenaline solution-soaked gauze to the skin graft donor sites (Group 2). Donor sites were treated with calcium alginate dressings after graft harvesting. On the 10th postoperative day, the dressings were removed and donor site healing were measured. Follow-up evaluation of scar quality was performed 6 months after surgery. Postoperative pain was evaluated on the 1st day after operating. [Results] Forty-five patients (26 males; average age 61.8 years) completed the late follow-up evaluation (6 months postoperatively), with 26 patients in group 1 and 19 in group 2. There were no significant differences between the two groups in any of the outcome measures. [Conclusion] Tumescent technique provides sufficient hemostasis in split skin graft donor sites, especially the initial bleeding just after graft harvesting, without any negative effects. Larger series should be studied to evaluate the effect in donor site wound healing.

In the present study, we have established a novel transgenic mouse and transgenic rats with dual reporters of EGFP and ELuc. In these transgenic (Tg) rodents, both GFP fluorescent and luciferase luminescent signals were ubiquitously detected in the heart, liver, kidney and testis, while only the GFP signal was detected in the brain. This expression system is based on a P2A linked EGFP/ELuc protein allowing both signals to be generated simultaneously. Microscopy experiments, FCM, and luciferase assays showed strong expression in freshly isolated ADSCs from Tg rodents upon transplantation of Tg rat-derived ADSCs into wild-type-mice. The ELuc transgene signal was observed and traced in vivo, and EGFP positive cells could be recovered from ELuc positive tissues in engraftment sites of wild-type mice for multiple analysis. These dual reporter Tg rodents are a useful reconstituted model system of regenerative medicine and are a valuable tool to study stem cells., Highlights • Establishment of dual reporter transgenic mice and rats, which express luciferase and GFP in all organs. • Both luciferase and GFP signals were detected by in vivo imaging using their respective antibodies. • Isolated mesenchymal stem cells from transgenic rodents showed both luciferase and GFP signals. • Implantation of transgenic mesenchymal stem cells enables cell tracking in vivo.

Background A successful free flap transfer is achieved, in part, by having a thorough understanding of vascular anatomy and blood flow dynamics. We previously reported that vascular resistance differs by type of free flap. To test the hypothesis that the difference reflects the proportion of tissue components within free flaps, we calculated blood flow and vascular resistance for free flaps in which we determined the volume of each tissue component. Methods Measurements and calculations were made for 40 free flap transfers performed at our hospital: 7 radial forearm flaps, 14 anterolateral thigh flaps, and 19 rectus abdominis myocutaneous flaps. Results The vascular resistance of free flaps was inversely related to the volume of each tissue component. Univariate regression analysis revealed that muscle volume correlated most closely with resistance ( r = 0.881), followed by skin ( r = 0.622), and fat ( r = 0.577). Multiple regression analysis confirmed the relationship between combined muscle and fat volume and resistance ( R 2 = 0.865). Conclusions A strong inverse correlation exists between vascular resistance and combined muscle and fat tissue volume in flaps. It may be helpful to consider these relationships when making decisions regarding choice of free flap and recipient vessels.

Introduction Cell sheets using myoblasts have been developed for the treatment of heart failure after myocardial infarction (MI) bridging to heart transplantation. Stem cells are supposed to be better than myoblasts as a source of cells, since they possess a potential to proliferate and differentiate into cardiomyocytes, and also have capacity to secrete angiogenic factors. Adipose-derived stem cells (ASCs) obtained from fat tissues are expected to be a new cell source for ASC sheet therapies. Administration of angiotensin II receptor blockers (ARBs) is a standard therapy for heart failure after MI. However, it is not known whether ARBs affect the cell sheet therapy. This study aimed to examine ameliorating effects of ASC sheets on heart failure and remodeling after MI, and how pretreatment with ARBs prior to the creation of MI and ASC sheet transplantation modifies the effects of ASC sheets. Methods ASCs were isolated from fat tissues of wild-type rats, and ASC sheets were engineered on temperature-responsive dishes. In in vitro studies using cultured cells, mRNA levels of vascular endothelial growth factor (VEGF) in ASCs were determined by RT-PCR in the presence of angiotensin II and/or an ARB, irbesartan, under normoxia and hypoxia; mRNA and protein levels of angiotensin II receptor type 1a (AT1aR), type 1b (AT1bR) and type 2 (AT2R) were also determined by RT-PCR and western blotting. In in vivo studies using a rat MI model, effects of transplanted ASC sheets and/or irbesartan on cardiac functions and remodeling after MI were evaluated by echocardiography, histological analysis and molecular biological techniques. Results In the in vitro studies, ASCs expressed higher levels of VEGF mRNA under hypoxia. They also expressed mRNA and protein of AT1aR but not AT1bR or AT2R. Under normoxia, angiotensin II increased the level of VEGF mRNA in ASCs, which was abolished by irbesartan. Under hypoxia, irbesartan reduced the level of VEGF mRNA in ASCs regardless of whether angiotensin II was present or not. In the in vivo studies, ASC sheets improved cardiac functions after MI, leading to decreased interstitial fibrosis and increased capillary density in border zones. These effects of ASC sheets were abolished by oral administration of irbesartan before MI and their transplantation. Conclusions ASC sheets ameliorated cardiac dysfunctions and remodeling after MI via increasing VEGF expression, which was abolished by pretreatment with irbesartan before the creation of MI and transplantation., Highlights • ASC sheets ameliorated cardiac dysfunctions and remodeling after MI in rats. • ASC sheets could protect hearts after MI through activation of AT1aR. • Pretreatment with an ARB, irbesartan, abolished ameliorating effects of ASC sheets. • We need to pay attention to the attenuating effect of ARBs on cell sheet therapy.

OBJECT Intracranial revascularization surgeries are an effective treatment for moyamoya disease and other intracranial vascular obliterative diseases. However, in some cases, wound-related complications develop after surgery. Although the incidence of wound complication is supposed to be higher than that with a usual craniotomy, this complication has rarely been the focus of studies in the literature that report the outcomes of revascularization surgeries. Here, the relationship between intracranial revascularization surgeries and their complications is statistically assessed. METHODS Between October 2004 and February 2010, 71 patients were treated using cerebral revascularization surgeries on 98 sides of the head. The relationship between wound complications and operative technique was retrospectively assessed. Multivariate logistic regression analysis was performed to identify the risk factors of wound complication, including operative technique, age, sex, diabetes mellitus (DM), hypertension, hyperlipidemia, and smoking history. RESULTS In total, there were 21 (21.4%) operative wound complications. Of these 21 complications, there were 14 (66.7%) minor complications and 7 (33.3%) major complications. No statistically significant relationship was found between wound complications and any surgical procedure. A trend toward severer complications was demonstrated for the procedures that used both STA branches (“double” procedures) in comparison with the procedures that used only 1 STA branch (“single” procedures, p = 0.016, Cochran-Armitage trend test). Multivariate logistic regression analysis also revealed that double procedures demonstrated a significantly higher incidence of wound complications than single procedures (OR 3.087, p = 0.048). DM was found to be a risk factor for wound complication (OR 9.42, p = 0.02), but age, sex, hypertension, and hyperlipidemia were not associated with the incidence of complications. Even though the blood supply to the scalp is abundant due to 5 arteriovenous systems, sometimes cutaneous necrosis develops after intracranial revascularization surgeries. The galeal blood supply is thought to be crucial for preventing wound-related complications. Special care is also thought to be required for DM patients. CONCLUSIONS Revascularization surgeries seemed to demonstrate a higher risk of wound-related complications. Double-type procedures, which use both branches of the STA, and a history of DM were found to be risk factors for wound-related complications. Attention should be paid to the design of the galeal incision and vessel harvest line. Also, special attention should be paid to patients with DM.

The objective of this study was to clarify the outcomes of craniofacial resection for locally advanced maxillary sinus carcinoma classified as T4 and to present methods for managing cases involving the skull base.Case series with chart review.Tertiary university hospital.We performed anterolateral craniofacial resection in en bloc fashion for locally advanced maxillary sinus carcinoma at stage T4. Participants comprised 40 patients with T4 maxillary sinus carcinoma treated between 1992 and 2011. Surgical outcomes were analyzed retrospectively.Forty patients with stage T4a (n = 26) or stage T4b (n = 14) were included in this study. Five-year overall and disease-free survival rates for the 40 patients with T4 maxillary sinus carcinoma were 62.7% and 52.6%, respectively. Cavernous sinus involvement correlated significantly with worse prognosis (P = .012). In 35 cases without cavernous sinus involvement, previous treatment (P = .017) and positive margins (P = .019) correlated significantly with worse prognosis, and 5-year overall and disease-free survival rates were 72.4% and 55.3%, respectively.This study only included cases of locally advanced maxillary sinus carcinoma classified as T4. Considering the advanced stage, our study suggests relatively favorable outcomes and the importance of managing the cavernous sinus in en bloc resections of malignant skull base tumors. Craniofacial resection in en bloc fashion achieved good survival rates.

Introduction Most often used for reconstruction at superficial sites, a muscle flap recently was reported to promote clinical wound healing in a duodenal defect. We therefore examined whether a muscle flap could promote wound healing comparably to an omental flap in rats with gastric wall defects. Methods After perforation of the centre of the anterior gastric wall, rats were divided into 2 groups. In the muscle group, a muscle flap was fixed to the defect; in the omentum group, an omental flap was placed over the defect. We histopathologically compared tissue responses during gastric wall healing. Results While stratified villi had completely covered the defect by day 7 in both groups, scar maturation differed. Scar tissue persisted in the muscle group, but was gradually replaced by adipose tissue in the omentum group. Discussion Both muscle and omental flaps accelerated gastric wall wound healing. Conclusion A muscle flap is an excellent alternative for repair of gastric defects when no omental flap is available.

BACKGROUND Impaired wound healing as one of the complications arising from diabetes mellitus is a serious clinical issue. Recently, various cell therapies have been reported for promotion of wound healing. Skin-derived precursor cells (SKPs) are multipotent adult stem cells with the tendency to differentiate into neurons. We investigated the potency of promoting diabetic wound healing by the application of SKPs. METHODS Skin-derived precursor cells isolated from diabetic murine skin were cultured in sphere formation medium. At passage 2, they were suspended in phosphate-buffered saline (PBS), and applied topically to full-thickness excisional cutaneous wounds in diabetic mice. Application of PBS served as controls (n = 21 for each group; n = 42 total). Time to closure and percentage closure were calculated by morphometry. Wounds were harvested at 10 and 28 days and then processed, sectioned, and stained (CD31, α-smooth muscle actin, and neurofilament heavy chain) to quantify vascularity and neurofilaments. RESULTS Wounds treated with SKPs demonstrated a significantly decreased time to closure (18.63 days) compared with PBS-control wounds (21.72 days, P < 0.01), and a significant improvement in percentage closure at 7, 10, 14, and 18 days compared with PBS-control wounds (P < 0.01). Histological analysis showed that the Capillary Score (the number of vessels/mm2) was significantly higher in SKP-treated wounds at day 10 but not at day 28. Nerve Density (the number of neurofilaments/mm2) had increased significantly in SKP-treated wounds at day 28 compared with control group. Some applied SKPs were stained by neurofilament heavy chain, which demonstrates that SKPs directly differentiated into neurons. CONCLUSIONS Skin-derived precursor cells promoted diabetic wound healings through vasculogenesis at the early stage of wound healing. Skin-derived precursor cells are a possible therapeutic tool for diabetic impaired wound healing.

Meningiomas occasionally display aggressive behavior, but the mechanisms of malignant transformation remain unclear. We encountered the case of a 65-year-old man with a 10-year history of recurrent meningioma. The patient had undergone multiple tumor resections, radiotherapy treatments, and reconstructive surgeries due to wound infection. After the third resection of the tumor and reconstruction with an omental flap, the tumor demonstrated rapid growth and lung metastasis. The final pathological diagnosis was anaplastic meningioma. Because the drastic change of the tumor was observed after omental flap transposition, we investigated the effect of the omentum on tumor cells and performed histopathological analyses of meningiomas using a mouse model. We found that meningioma cells have a high affinity to the omentum and show a growth advantage when co-cultured with adipocytes. Immunohistochemical staining revealed that meningioma cells adjacent to the omentum strongly expressed fatty acid-binding protein 4, a lipid transfer protein, in both mouse and human. Our results suggest that tumor cells can receive lipid supply from omental adipocytes, and the surrounding tissues may induce tumor progression. We conclude that although omental tissue is an ideal material for reconstruction surgery, close follow-up is recommended in meningioma patients when used for cranioplasty.

Background The purpose of this study was to assess the usefulness and accuracy of preoperative 3D virtual simulation of anterolateral craniofacial resection in cases of advanced sinonasal sinus carcinoma. Methods Seven patients with advanced (T4 classification) sinonasal sinus carcinoma who underwent anterolateral craniofacial resection in our hospital between 2011 and 2013 were included in this study. Postsimulation CT images were fused with postoperative CT images and differences between the planned and actual osteotomy were measured in 3 regions of the skull base. Results The differences ranged from 0 mm to 5.8 mm (average, 3.1 mm) at the inferior wall of the cavernous sinus, from 0.8 mm to 8.3 mm (average, 3.5 mm) at the inferior wall of the sphenoid sinus, and from 0 mm to 13.6 mm (average, 2.3 mm) in the palatine bone. Conclusion Preoperative 3D virtual surgical simulation and postoperative feedback can contribute to training for surgeons. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

Recipient vessel selection in head and neck reconstruction using free flap transfers has to be standardized. However, the recipient vessel selection based on the type of neck dissection has yet to be investigated. We describe the relationship between the type of neck dissection and recipient vessel.Records of 107 consecutive patients who had undergone head and neck reconstruction using free flap transfers from 2011 to 2015 were reviewed retrospectively. Ninety-five were men and 12 were women, with a mean age of 65.6 years. Patients were divided into 5 groups based on the type of neck dissection: no neck dissection (NND, n = 17), upper jugular neck dissection, (UJND, n = 1), supraomohyoid neck dissection (SOND, n = 18), jugular neck dissection (JND, n = 39), and modified radical neck dissection (mRND, n = 32). We details the number of recipient vessels we selected for free tissue transfer in head and neck reconstruction depending on the type of neck dissection.The overall patency rate was 100%. The superficial temporal artery was used most frequently in NND; the superior thyroid artery in SOND; the transverse cervical artery in JND; and the transverse cervical artery in mRND. The superficial temporal vein was used most frequently in NND; The internal jugular vein in the SOND; and The external jugular vein in mRND.Microsurgeons should remember that proper recipient vessel selection depending on the type of neck dissection is important. We believe proper recipient vessel selection should improve results of head and neck reconstruction using free flap transfer.

Because omental flaps are useful for flap prefabrication and the cambium layer of the periosteum can be osteogenic, we examined whether calvarial periosteum grafted onto greater omentum of rats was osteogenic and suitable for a flap. Distal omentum was wrapped with calvarial periosteum and so the cambium faced the omentum. Grafted omentum was harvested at 1 to 9 days. In other rats, grafted omentum was elevated as a pedicled flap and moved to the abdominal subcutis, to be harvested later at 1 to 5 months after the initial surgery. Bone formation was evaluated histologically, histochemically, and radiographically. On day 3, osteoid had formed. From day 4, calvarial periosteum was revascularized by omentum and bone was forming. New bone was maintained after grafting to subcutis for 5 months. Thus, bone formed by periosteum on the omentum could be used to reconstruct defects of the bone.

Lymphangioma localized to the bones of the skull base is rare. The authors report herein the case of a 5-year-old boy who presented with lymphangioma of the bone, localized to the skull base and leading to cerebrospinal fluid (CSF) rhinorrhea with meningitis. Neuroimaging demonstrated lytic destruction with a cyst in the right middle skull base. The patient was successfully treated with resection of the tumor and prevention of CSF leakage. Histopathological examination revealed a lymphangioma. An enlarging lymphangioma can lead to bone destruction. A differential diagnosis of a lytic lesion for a cyst at the skull base is important for proper case management.

Background: The free vascularized fibular bone graft, first described in 1975, has become one of the most commonly used bone grafts. It is useful for reconstructing mandibular and traumatic long bone defects and defects following tumor resection. This flap, however, does not have a long pedicle and does not have very much volume. The authors report a solution to these problems through the use of an omental flap as a bridge. Methods: Over a 3-year period, nine patients were treated by means of a free fibular osteocutaneous flap with an omental flap. These cases required bone reconstruction without suitable recipient vessels that existed near the defect. The nine patients had the following disorders: two femoral pseudoarthrosis, two tibial pseudoarthrosis, two malignant femoral tumors, one maxillary defect after tumor resection, and one femoral and tibial osteomyelitis. Results: All flaps were transferred successfully. In one case, an additional skin graft was performed because of partial omental necrosis that occurred within 2 weeks. Fibular synostosis developed in eight cases, but amputation was performed in one case because of failed fibular synostosis. In one case, femoral amputation was performed because the femoral artery became obstructed 3 months postoperatively. Conclusions: An omental flap has a long pedicle for use as a bridge flap. It is useful as a vascular flap. A combined fibular osteocutaneous and omental flap is useful for bone reconstruction without satisfactory recipient vessels that exist near the defect. Furthermore, the flap is useful for infected wounds.

Free flaps are becoming the preferred method of choice for head and neck reconstruction. However, many patients who have undergone radiotherapy and radical neck dissection or who require treatment for recurrent tumor, often present difficulty in choosing recipient vessels. The authors have noted a potential recipient vein coursing vertically along the anterior ridge of the trapezius muscle. They used this vein as the recipient vein in two patients; the two free flaps were transferred successfully without complications. This vein, which they provisionally named the posterolateral cervical vein (PLCV), is considered an important option as a recipient vein in head and neck reconstruction when more commonly used recipient cervical veins are unavailable.

While the free fibular osteocutaneous flap is indispensable for mandibular reconstruction, reliable setting is often difficult because relative positions of the bone, skin island, and vascular pedicle are critical. We have an algorithm for donor-side selection of free fibular osteocutaneous flap. From July 2002 to March 2004, we performed 15 mandibular reconstructions using free fibular osteocutaneous flaps. We retrospectively classified these procedures as follows. In type I (flap harvested ipsilaterally to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle emerged from the anterior aspect of the fibula. In type II (flap contralateral to defect, n = 5), the skin island was fixed to the oral cavity, and the vascular pedicle arose from the posterior aspect. In type III (flap contralateral to defect, n = 4), the skin island was fixed to the facial skin and the vascular pedicle arose from the anterior aspect. In type IV (flap ipsilateral to defect, n = 1), the skin island was fixed to the facial skin and the vascular pedicle arose from the posterior aspect. Flaps took completely except in 1 group II case with partial necrosis. Close attention to geometric characteristics of a free fibular osteocutaneous flap facilitates reconstruction of mandibular defects and selection of donor side.

頭蓋底の再建では，頭蓋と鼻腔との確実な閉鎖が求められる。通常は遊離腹直筋皮弁などの遊離皮弁にて再建することが多い。しかし中頭蓋底のように奥深く複雑な欠損を死腔なく充填することは難しい。われわれは，中頭蓋底再建に遊離大網移植を行い有用であったので報告する。最近の5年間にわれわれの施設で行った中頭蓋底再建は8例で，側頭窩下腫瘍が3例，外耳道腫瘍が2例，上顎癌の頭蓋底侵潤が1例，副咽頭間隙腫瘍が1例，斜台腫瘍が1例であった。再建に用いたのは大網が5例，腹直筋が3例であった。大網移植を行った5例のうち1例で髄液瘻を認めたが，保存的に治癒した。腹直筋皮弁にて再建した3例のうち2例において感染し，1例は保存的に治癒したが，1例では遊離大網移植を行うことで治癒した。大網は，volumeの調節がしやすく，柔軟性があるため，狭い部分にも充填しやすく，複雑な欠損となる中頭蓋底の再建に有用であると考えられた。

Microstomia is a term used to describe a small oral aperture. Most of the reported cases are caused by scar contracture after facial trauma, burn injury, and tumor excision. We experienced a rare case of microstomia in a patient with antilaminin 332 mucous membrane pemphigoid, which was an acquired autoimmune disease and showed blisters and erosive lesions mainly on the mucous membranes. The patient had recurrent aphthous stomatitis and presented microstomia caused by scar contracture of oral mucosa. We surgically corrected microstomia by 5-flap Z-plasty for commissuroplasty and 2 Z-plasty of both upper and lower lips for an enlargement of oral aperture. The patient could achieve an enough oral aperture and was satisfied with the result. There was no recurrence of microstomia for 2 years.

Background: Although we have seen tremendous advancement in microsurgery over the last 2 decades and free tissue transfer has become standard for head and neck reconstruction, surgeons still struggle to prevent postoperative complications. We examined the relationship between body mass index (BMI) and postoperative complications in patients undergoing rectus abdominis free flap transfer after anterolateral craniofacial resection. Methods: This was a retrospective review of reconstructive surgery using rectus abdominis musculocutaneous free flap in patients with locally advanced maxillary sinus carcinoma from 2003 to 2014 (n = 35, 27 men and 8 women; average age, 60.9 ± 7.8 years). All patients underwent craniofacial reconstruction after anterior and middle cranial fossa skull base resection and maxillectomy (class IV, subtype a) with palatal resection. Patients were categorized based on sex, BMI, and other parameters. Results: Recipient-site infection occurred in 11 patients (31.4%), cerebrospinal fluid leakage in 6 (17.1%), partial flap necrosis in 2 (5.7%), total flap necrosis in 1 (2.9%), and facial fistula in 4 (11.4%). Women showed partial flap necrosis significantly more frequently (P = 0.047), probably owing to poor vascular supply of the subcutaneous fat layer. Patients with low BMI (

Objective. We investigated the efficiency of laser speckle flowgraphy for evaluating blood flow in free flaps used for plastic surgery.Methods. We measured blood flow using a visual laser meter capable of providing two-dimensional color graphic representations of flow distribution for a given area using a dynamic laser speckle effect. Using laser speckle flowgraphy, we examined the blood flow of 20 free flaps applied following the excision of head and neck tumors.Results. After anastomosis of the feeding and draining blood vessels and sewing the flap, musculocutaneous (MC) flaps showed significantly lower blood flow than jejunal or omental flaps (P<.05). The ratio of blood flow decrease from the edge to the center was significantly greater in MC flaps than in jejunal or omental flaps (P<.001).Conclusion. Laser speckle flowgraphy is useful for the perioperative measurement of blood flow in free flaps used in plastic surgery. This method is a highly useful, practical, and reliable tool for assessing cutaneous blood flow and is expected to be applicable to several clinical fields.

Tissue engineering of bone is an interesting field of research. Many approaches to bone tissue engineering such as from bone marrow stromal cells in vitro have been reported. Furthermore, a model of vascularized tissue-engineered bone flap has been reported. However, there has been no report of bone tissue engineering using omentum. We present a study of tissue engineering of bone from omentum in a rabbit model. The omentum, which was elevated based on the right gastroepiploic vessels, was wrapped by the periosteum from cranial bone in the abdomen of rabbits. We harvested the omentum thus wrapped 1, 2, 4, 6, 8, 12, or 24 weeks after surgery. Within 1 week after surgery, woven bone was formed and clusters of osteoblasts were observed. At 8 weeks, medullization, including the presence of granulocytes, was confirmed. This technique might prove useful for creating tissue-engineered bone flaps for reconstructive surgery.

In free-flap transfer, blood flow in the transferred flap contributes to wound healing and to resistance against infection in the recipient site. Successful reconstructions using free tissue transfers may be required to define and choose flaps with abundant blood flow in necessary cases. We investigated blood flow in the flap by transit-time ultrasound flowmeter in 58 free-flap transfers. Flow volume was compared between flap tissues as vascular resistance in the flap was calculated. Fasciocutaneous and osteocutaneous flaps had relatively low blood flow volume, myocutaneous flaps had more, and intraperitoneal flaps had still higher blood flow volume. These differences were statistically significant. Vascular resistance significantly decreased in the same order of comparison. Our findings will help in selecting the most suitable flaps for reconstructive surgery.

Lymphangioma localized to the bones of the skull base is rare. The authors report herein the case of a 5-year-old boy who presented with lymphangioma of the bone, localized to the skull base and leading to cerebrospinal fluid (CSF) rhinorrhea with meningitis. Neuroimaging demonstrated lytic destruction with a cyst in the right middle skull base. The patient was successfully treated with resection of the tumor and prevention of CSF leakage. Histopathological examination revealed a lymphangioma. An enlarging lymphangioma can lead to bone destruction. A differential diagnosis of a lytic lesion for a cyst at the skull base is important for proper case management.

Free flaps are used increasingly in reconstructive surgery. However, many patients lack a satisfactory recipient vessel near the defect because of radiotherapy, post-traumatic infection, or treatment for recurrent tumor. We usually use a venous graft in such cases, but when both long arterial and venous segments are needed, we use the gastroepiploic vessels because they include extensive, viable arterial and venous segments. Between 1998 and 2006, we used gastroepiploic vessels as grafts in the 13 cases analyzed here. All defects lacked satisfactory recipient vessels nearby. Patients included 10 men and 3 women; mean age was 51.2 years (range, 14 to 82 years). Demographic and clinical background, results, and complications were analyzed retrospectively. Mean length of gastroepiploic vessels was 13.3 cm (range, 10 to 17 cm). All outcomes were satisfactory. A complication, abdominal wound infection secondary to harvesting of the gastroepiploic vessels, occurred in one case. Although the number of gastroepiploic vessels used as grafts analyzed here is relatively small, this experience confirms their clinical usefulness.

We report the case of a 71-year-old woman with a chondrosarcoma originating in the first metatarsal of the left foot. We performed a wide resection and reconstructed the first and second metatarsals with a free vascularised double-barrelled fibular graft. Her limb was successfully salvaged with functional and aesthetic results. Two years after surgery, the patient is able to walk without any ortho-prosthetic devices and has returned to farm work. The details of the technique applied in this case have been described in this article.

Treatment of empyema after pneumonectomy is challenging. We treated 4 patients with postpneumonectomy empyema using a free rectus abdominis myocutaneous flap together with a pedicled pectoralis major muscle flap. The pectoralis major flap was used to fill the apical portion of the cavity, while the rectus abdominis flap was used to fill the caudal portion and occlude any bronchial fistula present. All empyemas were treated successfully without recurrence. This method has the advantage of filling apical and caudal parts of the space at once, making effective use of the combined volume of the two flaps.

Radical resection of tongue and oropharyngeal carcinomas often results in complex defects that are challenging to reconstruct. Furthermore, remaining function should not be disturbed by the reconstruction. We introduce a new flap design and monitored swallowing and speech following reconstruction of complex oral defects. The new design consists of four lobes on a single pedicle. The first reconstructs the tongue, the second the tongue base, the third the oral floor, and the fourth the lateral wall. The records of cases performed between July 2002 and December 2006 were reviewed. Twenty-three patients (17 men and 6 women) with an average age of 60 years underwent immediate reconstruction using a free flap after radical resection of a malignant carcinoma of tongue or oropharynx using a free flap. Postoperative swallowing and speech were rated using a self-report questionnaire. Moreover, the functional outcome in patients with and without a tongue base defect was compared. All free flaps took entirely, and postoperative function was largely satisfactory. Swallowing in patients with and without a tongue base defect was similar, but speech was more impaired in patients who had a tongue base defect. Our new design is effective for reconstructing intraoral defects three-dimensionally. However, further refinement is required to preserve speech.