The aspect ratio of the palpebral fissure as a new blepharoptosis parameter

Although the margin reflex distance (MRD) is widely used to assess blepharoptosis, it has some drawbacks (e.g. inaccuracy in severe ptosis). A new parameter is desired. We digitally analyzed pre- and post-operative photographs of 95 patients with blepharoptosis. We set a rectangle with the vertical sides at the lateral and medial canthus and the horizontal sides at the highest and lowest points of the eyelids. We calculated the percentage of the vertical side (height) to the horizontal side (width) and defined this value as the vertical percentage of the palpebral fissure. The MRD and the vertical percentage values were strongly correlated (correlation coefficient 0.766). In the 77 bilateral cases, both sides showed significant improvement in vertical percentage (from 28.9 to 37.3%, right) and (28.7 to 36.1%, left). In the 18 unilateral cases, the affected side showed significant improvement in vertical percentage (from 29.6 to 38.7%), while the unaffected side showed no change. In the eight patients who underwent re-operation, the revised side's vertical percentage was not improved after the first operation (from 28.0 to 31.3%), and the revision significantly changed the vertical percentage to 39.0%. In the re-operated patients, the difference between the right and left sides decreased significantly from 6.7 to 1.9% post-revision. The aspect ratio of each palpebral fissure (the percentage of height to width) reflected the progression of blepharoptosis and the post-operative changes. The aspect ratio thus has the potential to be a new parameter for blepharoptosis.

Variability in the development of synkinesis in a rabbit facial nerve axotomy model

OBJECTIVE

Weakness and synkinesis (involuntary cocontraction of different muscle groups) are common sequelae after facial nerve injury. We describe a rabbit model of facial nerve axotomy and repair, which can be used to study such sequelae and propose a grading tool to assess the facial movement outcomes. Using this rabbit model, we assess the effect of delaying facial nerve repair on the quality of the clinical result.

METHODS

A total of 15 rabbits (30 facial halves) were divided into 4 groups: control, facial nerve main trunk axotomy and immediate repair, axotomy and repair at 2.5 weeks as well as axotomy, and repair at 2 months. Functional recovery was graded according to the observable criteria. We performed retrograde fluorescence labelling of the distal facial nerve branches and assessed the distribution of tracers in the facial nucleus.

RESULTS

A consistent model of weakness and synkinesis was produced in all rabbits after immediate axotomy and repair. A grading tool was used to clinically grade the quality of the recovery. The somatotopy of the facial nucleus was disrupted, with axons projecting from the facial nucleus to incorrect facial muscle groups. Varying the denervation time before repair affected the quality of the recovery. The worst result was noted when repair was delayed for 2 months. Subtle changes in the pattern and severity of synkinesis was noted among the different treatment groups.

CONCLUSION

A slight delay in nerve repair by 2.5 weeks as well as contralateral facial paralysis (analogous to botulinum toxin (BTX) injection) appear to improve eye recovery and reduce synkinesis. Because of the large size of the rabbit, such variability in synkinesis severity can be graded.

Convolutional neural networks for wound detection: the role of artificial intelligence in wound care

OBJECTIVE

Telemedicine is an essential support system for clinical settings outside the hospital. Recently, the importance of the model for assessment of telemedicine (MAST) has been emphasised. The development of an eHealth-supported wound assessment system using artificial intelligence is awaited. This study explored whether or not wound segmentation of a diabetic foot ulcer (DFU) and a venous leg ulcer (VLU) by a convolutional neural network (CNN) was possible after being educated using sacral pressure ulcer (PU) data sets, and which CNN architecture was superior at segmentation.

METHODS

CNNs with different algorithms and architectures were prepared. The four architectures were SegNet, LinkNet, U-Net and U-Net with the VGG16 Encoder Pre-Trained on ImageNet (Unet_VGG16). Each CNN learned the supervised data of sacral pressure ulcers (PUs).

RESULTS

Among the four architectures, the best results were obtained with U-Net. U-Net demonstrated the second-highest accuracy in terms of the area under the curve (0.997) and a high specificity (0.943) and sensitivity (0.993), with the highest values obtained with Unet_VGG16. U-Net was also considered to be the most practical architecture and superior to the others in that the segmentation speed was faster than that of Unet_VGG16.

CONCLUSION

The U-Net CNN constructed using appropriately supervised data was capable of segmentation with high accuracy. These findings suggest that eHealth wound assessment using CNNs will be of practical use in the future.

An International Collaborative Standardizing Patient-Centered Outcome Measures in Pediatric Facial Palsy

Importance

Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population.

Objective

To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives.

Design, Setting, and Participants

A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016.

Main Outcomes and Measures

The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention.

Results

The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy-reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy.

Conclusions and Relevance

This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy.

Level of Evidence

NA.

Risk Factors for Macroscopic Haemoglobinuria After Sclerotherapy Using Ethanolamine Oleate for Venous Malformations

OBJECTIVES

Sclerotherapy is an essential component of the treatment for venous malformations, and ethanolamine oleate (EO) is known as a useful sclerosing agent. However, macroscopic haemoglobinuria (MH) and subsequent renal impairment are severe complications after sclerotherapy using EO. The present study aimed to clarify the MH risk factors for better peri-operative management of venous malformations.

METHODS

Data collected during 130 procedures involving 94 patients who were undergoing sclerotherapy using EO for venous malformation were retrospectively analysed. Pre-operative and operative variables, including sex, age, pre-operative body mass index, location, depth, type of lesion, size, number of procedures, type of drainage vein, ratio of sclerosant to air, and injected total dose of 5% EO per body weight (BW), were examined. Univariable analysis and multivariable logistic regression were performed to determine the possible risk factors for MH.

RESULTS

Following sclerotherapy, MH occurred in 27.7% of patients, but no patient developed post-operative renal impairment because of aggressive hydration and haptoglobin administration. On univariable analysis, diffuse lesion, lesion size ≥50 cm², and total injected dose of 5% EO ≥ 0.18 mL/kg were found to be the MH risk factors. Multivariable logistic regression analysis identified a total injected dose of 5% EO ≥ 0.18 mL/kg as the significant independent factor contributing to MH risk.

CONCLUSIONS

Macroscopic haemoglobinuria is a reversible complication if immediate and appropriate interventions with aggressive hydration and haptoglobin administration are performed; therefore, it should be closely monitored following sclerotherapy, especially when using 5% EO ≥ 0.18 mL/kg.

A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Influence of Weight Loss on Volumetric Change in Contralateral Breast During 2-Stage Breast Reconstruction

Objective: During 2-stage breast reconstruction in patients with unilateral breast cancer, we sometimes experience cases in which the contralateral breast volume changes greatly. However, few studies have examined volumetric changes in the contralateral breast during 2-stage breast reconstruction. Methods: Changes in contralateral breast volume between the first and second operations were examined in patients who underwent 2-stage unilateral breast reconstruction between February 2013 and August 2016 (123 patients aged 49.1 ± 8.6 years). Influences of age, postoperative treatment, and body weight on volumetric changes in the contralateral breast were statistically analyzed. Results: A positive correlation was observed between changes in body weight and contralateral breast volume (correlation coefficient = 0.218, P = .015). Weight loss was particularly important: all patients who lost more than 3 kg showed decreased contralateral breast volume (P = .010). Age and postoperative treatment had no significant effect on the change in contralateral breast volume. Conclusion: Change in body weight, and massive weight loss in particular, is an important factor for volumetric changes in the contralateral breast during 2-stage unilateral breast reconstruction.

Risk Factors for Complications in Expander-Based Breast Reconstruction: Multivariate Analysis in Asian Patients

Background:

There have been many studies examining risk factors for complications in expander-based breast reconstruction after mastectomy, and some patient factors have been identified as risk factors. However, most of the previous studies were based on Caucasian patients.

Methods:

Asian patients who had a tissue expander placed for immediate breast reconstruction between January 2006 and December 2015 (363 patients and 371 expanders) were analyzed retrospectively. Univariate and multivariate analyses were performed to elucidate risk factors for complications.

Results:

The rate of skin necrosis was significantly higher in nipple-sparing mastectomy than in other types of mastectomies (12 patients among 107 patients, P = 0.001). The weight of the resected specimen was significantly higher in the group with complications than in the group without complications (444 g compared with 363 g, P = 0.027). Other factors (age, body mass index, smoking, expander type, preoperative chemotherapy, axillary dissection) had no significant effect on complications. Multivariate analysis with a logistic regression showed that a large breast (over 500 g) was the only significant risk factor for complications, with an odds ratio of 3.20 and a 95% confidence interval of 1.33–7.54 (P = 0.010).

Conclusion:

In this series of Asian patients, breast size, rather than body mass index, is the most important predictor for complications in expander-based breast reconstruction.

Efficient isolation and culture of endothelial cells from venous malformation using the Rho-associated protein kinase inhibitor Y27632

BACKGROUND

The investigation of primary cells from a pathological lesion can elucidate the pathogenesis of diseases, but, for vascular malformations in humans, such basic research is still stagnant, because the isolation and culture of vascular endothelial cells (ECs) is very difficult. To obtain a sufficient amount of ECs from venous malformation (VM) this study took advantage of a Rho-associated protein kinase inhibitor, Y27632, which had been used for the efficient procurement of primary keratinocytes.

METHODS

ECs were isolated and cultured from VM lesions, combining enzymatic digestion, cell sorting, and Y27632. The proliferative effect of Y27632 on ECs was examined by proliferation assay. The characteristics of the ECs cultured with Y27632 by EC marker expression and tube formation assay were also examined.

RESULTS

Y27632 enhanced the proliferation of ECs and elongated the senescence of the cells. The expression of specific markers of ECs such as von Willebrand factor, endothelin-1, and VE-cadherin, was confirmed in the cells cultured with Y27632. In a tube formation assay, the cells cultured with Y27632 showed higher tube formation ability compared to the cells cultured without Y27632, indicating that Y27632 promoted the angiogenic capability of ECs.

CONCLUSIONS

The protocol using Y27632 offers a new EC culture methodology and provides a new option for the biological investigation of vascular malformations. This new method will contribute to other types of vascular biology research as well.

Toxic Shock Syndrome Caused by Methicillin-Resistant Staphylococcus aureus (MRSA) After Expander-Based Breast Reconstruction

OBJECTIVE

Toxic shock syndrome is a rare but life-threatening complication after plastic surgery procedures.

METHODS

We experienced 2 cases of toxic shock syndrome after expander-based breast reconstruction caused by methicillin-resistant Staphylococcus aureus.

RESULTS

The first patient took a severe clinical course due to the delayed diagnosis and treatment, and the second patient recovered rapidly after the early diagnosis and treatment based on our experience of the first case. Fever, rash, and gastrointestinal symptoms (diarrhea and/or vomiting) were characteristic and important for the early diagnosis of toxic shock syndrome.

CONCLUSIONS

Considering the increased prevalence of methicillin-resistant Staphylococcus aureus, we should suspect methicillin-resistant Staphylococcus aureus in cases of toxic shock syndrome that occur postoperatively, and the empiric administration of vancomycin should be initiated in such cases.

Examination of tissue oxygen saturation (StO2) changes associated with vascular pedicle occlusion in a rat Island flap model using near-Infrared spectroscopy

PURPOSE

The purpose of this study was to perform continuous StO(2) monitoring of rat island flaps during pedicle vessel occlusion using near-infrared spectroscopy (NIRS) in order to collect experimental data for StO(2) flap monitoring under optimized conditions.

MATERIALS AND METHODS

Twenty rats were used in this study. The 3 × 3 cm(2) epigastric skin island flaps were elevated on either side. The animals were randomly assigned to two groups; an arterial occlusion group (n = 10) and a venous occlusion group (n = 10). The StO(2) values of the flaps were observed for over 30 min for the pedicle artery or venous occlusion, followed by an additional 30 min release.

RESULTS

The baseline StO(2) value was 78.4% ± 3.2% in the arterial occlusion group, compared to 78.5% ± 5.8% in the venous occlusion group, with no significant differences (P > 0.05). The StO(2) values decreased immediately after arterial occlusion, whereas a temporal StO(2) increase was initially observed after venous occlusion, followed by a StO(2) decrease. The StO(2) values decreased 27.3% ± 7.1% after arterial occlusion and 28.4% ± 19.1% after venous occlusion at 30 min after pedicle vessel clamping (P > 0.05). The StO(2) values were 0.4% ± 5.8% lower than baseline 30 min after arterial release (P > 0.05), while 18.9% ± 11.3% lower than baseline 30 min after venous release (P < 0.01).

CONCLUSION

NIRS can be used to indicate StO(2) changes in flaps with the pedicle vessel occlusion and differentiate between pedicle artery and vein occlusion. Further investigations are needed to obtain definitive evidence associated with predicting the degree of flap viability and determine the practical use of this technique.

Reinnervation of segmented latissimus dorsi muscle with the distal stump of the thoracodorsal nerve: A preliminary experimental study in rats

To date, nerve stumps have been dissected at the proximal side of the donor muscle for reinnervation of the muscle in free neurovascular muscle transfer. Herein, we examined the use of the distal thoracodorsal nerve, dissected from the muscle belly at the distal side of the latissimus dorsi muscle, for the reinnervation of muscle. The rat right latissimus dorsi muscle was employed as the model for our study. Twenty Wistar rats were used in this study. A rectangular muscle segment was dissected with the distal stump of dominant thoracodorsal nerve. After rotation of muscle, the distal nerve stump was sutured to a severed proximal recipient thoracodorsal nerve (n = 5). The degree of reinnervation through the distal nerve stump was compared with control groups that received proximal-to-proximal nerve sutures (n = 5), nerves that were not severed (n = 5), and severed nerves that were not sutured (n = 5) using electrophysiological, histological, and muscular volume assessments. Reinnervation of the distal nerve stump was confirmed by the contraction of the muscle following electrical stimulation and electromyography. Crossing of axons into motor endplates was confirmed by histology. Results of these assays were similar to that of the proximal nerve suture group. The volume of muscle in the distal nerve suture group was not significant different from that of the proximal nerve suture group (P = 0.63). It was demonstrated that the distal stump of the thoracodorsal nerve can be used to innervate segmented latissimus dorsi muscle. This novel procedure for the reinnervation of transplanted muscle deserves further investigations.

Silicone sheet containing all-trans retinoic acid and hydroquinone for the treatment of epidermal melanosis

BACKGROUND

Although bleaching treatment using all-trans retinoic acid (RA) and hydroquinone (HQ) improves epidermal melanosis, the application of two medications and the irritant dermatitis induced by RA inconvenience patients. To overcome these problems, we developed a silicone sheet containing RA and HQ.

OBJECTIVE

To compare the efficacy of a silicone sheet containing RA and HQ with that of conventional bleaching treatment.

METHOD

Silicone sheets containing 1% RA and 5% HQ were applied at night during the bleaching phase of 4 weeks, followed by application of sheets containing 5% HQ during the healing phase of 4 weeks. Hemifacial epidermal melanosis, for which the sheets were applied, was compared with a contralateral face which was treated conventionally using RA and HQ. Twenty-four Japanese women who were enrolled in this study and followed up for more than 6 months were analyzed.

RESULTS

RA/HQ sheets improved epidermal melanosis, as did the conventional bleaching method, but irritant dermatitis occurred less in patients treated using silicone sheets.

CONCLUSION

RA/HQ sheets, which are easily applied to face skin, can improve epidermal melanosis to the same extent as conventional bleaching.

Recycle of temporal muscle in combination with free muscle transfer in the treatment of facial paralysis

We experienced three patients with long-standing unilateral complete facial paralysis who previously underwent temporalis muscle transfer to the cheek for smile reconstruction. All patients complained of insufficient and uncomfortable buccal motion synchronised with masticatory movements and incomplete eyelid closure with ptotic eyebrow. To attain a near-natural smile and reliable eyelid closure, temporalis muscle was displaced from the cheek to the eyelid, and a neurovascular free latissimus dorsi muscle was transferred for the replacement of cheek motion. As a result, cheek motion synchronised with the contralateral cheek upon smiling and sufficient eyelid closure were obtained in all cases. Smile reconstruction using the temporal muscle is an easy and a versatile way in general. However, spontaneous smile is not achieved and peculiar movement of the cheek while eating is conspicuous in some cases. Replacement with neurovascular free latissimus dorsi muscle and recycling previously used temporalis muscle for eyelid closure are considered to be valuable for such cases.

Differential expression of wound fibrotic factors between facial and trunk dermal fibroblasts

Clinically, wounds on the face tend to heal with less scarring than those on the trunk, but the causes of this difference have not been clarified. Fibroblasts obtained from different parts of the body are known to show different properties. To investigate whether the characteristic properties of facial and trunk wound healing are caused by differences in local fibroblasts, we comparatively analyzed the functional properties of superficial and deep dermal fibroblasts obtained from the facial and trunk skin of seven individuals, with an emphasis on tendency for fibrosis. Proliferation kinetics and mRNA and protein expression of 11 fibrosis-associated factors were investigated. The proliferation kinetics of facial and trunk fibroblasts were identical, but the expression and production levels of profibrotic factors, such as extracellular matrix, transforming growth factor-β1, and connective tissue growth factor mRNA, were lower in facial fibroblasts when compared with trunk fibroblasts, while the expression of antifibrotic factors, such as collagenase, basic fibroblast growth factor, and hepatocyte growth factor, showed no clear trends. The differences in functional properties of facial and trunk dermal fibroblasts were consistent with the clinical tendencies of healing of facial and trunk wounds. Thus, the differences between facial and trunk scarring are at least partly related to the intrinsic nature of the local dermal fibroblasts.

Fifteen-year survey of one-stage latissimus dorsi muscle transfer for treatment of longstanding facial paralysis

BACKGROUND

Neurovascular free muscle transfer is one of the main reconstructive options for established or long-standing facial paralysis. The two-stage gracilis muscle transfer combined with the cross-face nerve graft (two-stage method) has been supplanted by one-stage reconstruction using the latissimus dorsi muscle (LD) at our institution. This study retrospectively evaluated the results of one-stage LD transfer.

METHODS

Between September 1993 and December 2008, 344 patients (133 males, 211 females; age range, 5-75 years) with unilateral facial paralysis underwent 351 one-stage LD transfers. Patients were evaluated with a custom grading scale. Differences in grading scale score were compared according to age, past surgical history and the duration from operation to neuromuscular recovery.

RESULTS

Contraction of the transferred muscle was recognised in 305 (87.0%) transfers. The duration until neuromuscular recovery ranged from 3 to 16 months (average ± standard deviation: 6.48 ± 1.92 months). The grading scale was significantly lower in middle-age group than in younger and elder groups (P < 0.01). Duration until neuromuscular recovery was significantly different when comparing the younger group and the oldest group. There was no difference in grading scale score or in duration until neuromuscular recovery when comparing the patients with a past surgical history and those without. The grading scale negatively correlated with the duration until neuromuscular recovery.

CONCLUSIONS

The results are consistent and statistical analysis revealed the versatility of the one-stage LD transfer. Although we believe the two-stage method is still a good option for facial reanimation, the one-stage method is advantageous regarding the shorter period of recovery and little donor-site morbidity.

Detrimental influences of intraluminally-administered sclerotic agents on surrounding tissues and peripheral nerves: an experimental study

The minimally-invasive nature of sclerotherapy makes it one of the first treatment options for venous malformations, although treatment-related complications, such as peripheral nerve paralysis, have been reported in some clinical cases. However, no studies of the aetiology of the detrimental effects of intraluminally-administered sclerotic agents on the surrounding tissues, including the peripheral nerves, have yet been published. This study therefore investigated the influences of intraluminally-administered sclerotic agents on the tissues surrounding the injection site using a newly-developed rat femoral vein model. Using this model, the effects of absolute ethanol, 5% ethanolamine oleate, and 1% polidocanol were compared histologically with those of normal saline controls. Fluorescein isothiocyanate-conjugated agents were administered and the leakage of sclerotic agents through the venous wall was evaluated by fluorescence microscopy. Damage to the adjacent femoral nerve was quantitatively evaluated by counting the numbers of axons in cross-sections. All the sclerotic agents caused vascular wall injuries and leakage into the surrounding tissues. The number of axons in the femoral nerve was significantly reduced following administration of absolute ethanol or 5% ethanolamine oleate, compared with normal saline. The results of this study suggest that sclerotic agents commonly leak out the vascular lumen, and some agents can cause adjacent nerve injury. It is important to be aware of this type of complication of sclerotherapy for venous malformations when selecting appropriate therapeutic interventions.

Features of wound healing shown by fibroblasts obtained from the superficial and deep dermis

Dermal fibroblasts (DF) obtained from the superficial dermal layer and those from the deep dermal layer have different cellular functions. These differences are often associated with excessive scarring; they also influence early wound healing. We therefore investigated the differences between superficial and deep dermal fibroblasts with special emphasis on their contractile properties, and ability to produce connective tissue. We investigated their proliferation kinetics, ability to contract collagen lattices, and chronological mRNA expression of eight genes associated with wound healing. To estimate the changes in the differences between them during the early phase of wound healing, we investigated mRNA expression in bFGF supplemented medium because bFGF is a representative cytokine that is familiar to clinicians. Superficial DF proliferate faster than deep DF in culture, whereas deep DF are better at contracting collagen lattices than superficial ones. In realtime analysis of polymerase chain reaction, the expression of type I and III collagen, fibronectin, TGF β1 and β3, and connective tissue growth factor were higher in deep DF than in superficial DF, while the expression of TGF β2 was higher in superficial DF. After bFGF supplementation, the relative dominance of mRNA expression between superficial and deep DF remained constant except for the expression of collagenase. According to our analysis, deep DF are superior to superficial DF at promoting wound healing (particularly contraction and production of connective tissue). The intradermal distribution of DF is appropriate for efficient wound healing.

Extravascular injection of sclerotic agents does not affect vessels in the rat: experimental implications for percutaneous sclerotherapy of arteriovenous malformations

OBJECTIVES

Sclerotherapy is useful for the treatment of arteriovenous vascular malformations. However, intravascular administration of sclerotic agents into small arteriovenous niduses is often difficult. Extravascular administration of sclerotic agents causes reduction of vascular flow on Doppler echo during clinical sclerotherapy. Therefore, we aimed to investigate whether the extravascular injection of sclerotic agents affects tiny vessels.

DESIGN

Animal study.

MATERIALS

The effect of extravascular injection of sclerotic agents on vessels was investigated using rat femoral and superficial inferior epigastric vessels.

METHODS

After surgical exposure of vessels, absolute ethanol, 5% ethanolamine oleate and 3% polidocanol were injected into perivascular surrounding tissues, and their effect on vessels was evaluated after 14 days using histology and coloured silicone rubber injection.

RESULTS

The integrity of the vascular lumen, endothelial cells and vascular patency were not affected by injection of sclerotic agents.

CONCLUSIONS

Attenuation of vascular flow of an arteriovenous shunt after extravascular injection of sclerotic agents is transient and/or trivial and does not cause disruption of vessels. Therefore, sclerotic agents should be delivered to obtain sufficient destruction of arteriovenous malformation lesions and blood flow.

Secondary reconstruction of vaginal stenosis with bilateral pudendal thigh flaps

We report the cases of two patients who had pronounced stenosis of the lower part of the vagina after vaginal reconstruction for congenital vaginal aplasia and hypoplasia. Bilateral pudendal thigh flaps were used for secondary reconstruction, and gave satisfactory results with no signs of recurrence or severe scarring at the donor site.

Clinical evaluation and morbidity of 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984–2003

We evaluated 192 patients who had 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984-2003. The main postoperative complications were thrombosis, leaks, and stenosis. In this series, the rate of thrombosis was 7/201 (3.5%), that of leaks was 17/201 (8.5%), and that of stenosis was 25/201 (13.0%). When we assessed the relation between pre-existing conditions, surgical techniques, and these complications, we found only one significant difference: a history of alcohol misuse was associated with a reduction in the incidence of thrombosis. The surgical techniques did not affect the development of leaks or stenosis, which means that a complicated surgical technique is unnecessary.

Distally‐based sural flap for reconstruction of the lower leg and foot

A distally-based sural flap was used in four patients with soft-tissue defects in the lower leg and foot. All flaps survived completely without venous congestion. To make safe use of this flap it is important to include both the sural nerve and the lesser saphenous vein in the flap. It also seems to be important to include the surrounding fatty tissues in the pedicle and to avoid compression at the point of its angulation. This flap has the advantages that it is quick and easy to raise, and the reconstruction can be done in a single operation. It is unnecessary to sacrifice the major arteries in the leg, although the sural nerve must be sacrificed. In general this type of reconstruction of the lower leg and foot is beneficial in cases similar to those presented here.

Reconstruction of maxillectomy defects with free flaps - comparison of immediate and delayed reconstruction: A retrospective analysis of 51 cases

To establish a standard reconstructive material we compared outcomes after immediate and delayed reconstruction. Of the 21 patients who had immediate reconstruction, six patients had upper horizontal plane reconstruction. All bone grafts survived without infection or absorption. Of the 30 patients who had delayed reconstruction, 22 patients had upper horizontal plane reconstruction, with vascularised bone in 14 patients, non-vascularised bone or cartilage in five patients, and hydroxyapatite bone block in three. Postoperative infections developed in three of four patients for whom costal cartilage was used, and in all three patients for whom hydroxyapatite blocks were used. Non-vascularised bone or cartilage grafts are preferable for immediate reconstruction because of their technical simplicity. Vascularised bone grafts or osteocutaneous flaps are preferable for delayed reconstruction, however, as in most cases the operating field is contaminated by bacterial.

Salvage reconstruction of the oesophagus: a retrospective study of 15 cases

Salvage reconstruction of the oesophagus is still considered a challenging procedure for all head and neck surgeons. The risk of postoperative infection and delayed wound healing is high because of thick scar formation and persistent inflammation. Furthermore, recipient vessels for free tissue transfer or vascular supercharge are not always available. Alimentary tract reconstruction with skin or musculocutaneous flap may be necessary, but this method is susceptible to fistula formation.[Nakatsuka T, Harii K, Asato H, et al. Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience. Scand J Plast Reconstr Surg Hand Surg 1998; 32: 307-10] In the past 10 years, we have experienced 15 cases of salvage reconstruction of the oesophagus after prior cancer treatment or aorto-oesophageal fistula; the cervical oesophagus was reconstructed in five cases and the cervico-thoracic oesophagus in 10. In four cases of cervical oesophagus and six of cervico-thoracic oesophagus we performed free jejunal transfer including two long segment transfers with double vascular pedicle. The cervico-thoracic oesophagus was also reconstructed with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge in four cases. In one case, cervical oesophageal defect was reconstructed with a latissimus dorsi musculocutaneous flap. We also used a deltopectoral flap to cover the skin defect in three cases. In three cases, a second salvage operation was necessary because of flap necrosis that was caused by unreliable recipient vessels resulting from scar formation and persistent inflammation. Successful restoration of the oesophagus and oral alimentation was achieved in 11 cases. From this study, we concluded that free jejunal transfer is a useful procedure for salvage reconstruction of the oesophagus, particularly for cervical oesophagus or short oesophageal defects. Nonetheless, surgeons should know the indications and limitations of this procedure thoroughly and always be ready to choose other reconstructive options if necessary.

Transzygomatic coronoidectomy as a treatment for pseudoankylosis of the mandible after transtemporal surgery

Pseudoankylosis of the mandible after a transtemporal operation is rare. In patients with severely limited mouth opening, a transzygomatic approach is the approach of choice. We report a case of pseudoankylosis of the mandible that was successfully treated by transzygomatic coronoidectomy.

Topical negative pressure therapy for para-ileostomal ulceration in a patient with Behçet's disease

BehCet's disease is a chronic, relapsing, inflammatory disorder. This case report describes how use of an improvised topical negative pressure (TNP) device in a patient with a non-healing para-ileostomal ulcer with Behçet's disease.

Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.

Secondary reconstruction of the eye socket in a free flap transferred after complete excision of the orbit

Reconstruction of the eye socket in a free flap transferred after complete excision for malignancy is difficult. Between 1980 and 2005 we secondarily reconstructed five eye sockets in free flaps after resection of cancer, cirsoid haemangioma, and the consequences of irradiation for retinoblastoma. Free flaps were used during the primary operations to cover the defects. The eye socket was then reconstructed during the secondary operations with a conventional skin graft in two cases, and with a skin graft using the modified Antia's method in three cases. All free flaps survived and all eye sockets accepted ocular prostheses. Three patients in particular, whose eye sockets were reconstructed using the modified Antia's method, had excellent results. Here we describe operations and problems related to secondary reconstruction of eye sockets in previously transferred free flaps after complete excision, and describe some typical cases.

Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer

BACKGROUND

Few authors have reported the subsequent treatment for patients in whom free tissue transfers in the head and neck have failed as a result of vascular thrombosis.

METHODS

Between 1993 and May of 2005, 502 free flaps were transferred after head and neck cancer ablation in the authors' hospital, 19 of which resulted in total necrosis caused by vascular thrombosis. The authors categorized these 19 cases into four groups and analyzed the salvage treatment.

RESULTS

For failed free jejunal transfer, early initiation of oral intake was obtained when another free jejunum was transferred. For failed free soft-tissue transfer for intraoral defects, reconstruction with common free (first choice) or pedicled flaps was used: a voluminous musculocutaneous flap for extensive defects, forearm flap or pedicled pectoralis major flap for intermediate defects, and direct closure for small defects of the oral floor. For failed secondary soft-tissue transfer to improve a certain function, salvage flap transfer was not chosen in the acute setting. For failed secondary maxillary reconstruction, simple reconstruction using the rectus abdominis musculocutaneous flap combined with costal cartilage achieved stable results. The overall success rate of the repeated free flap was 89 percent (eight of nine patients).

CONCLUSIONS

When a free flap is judged unsalvageable, surgeons should determine subsequent treatments, considering the success rate as one of the most important factors. The authors believe that simple reconstruction using a common free flap is the first choice in most cases. When regional or general conditions do not permit further free flap transfer or when defects are comparatively small, reconstruction with a pedicled flap or direct closure of the defect may be considered.

Reconstruction with Rectus Abdominis Myocutaneous Flap for Total Glossectomy with Laryngectomy

From October 1999 to July 2005, defects after total glossectomy with laryngectomy (TGL) for cancer of the tongue or middle pharynx were reconstructed with rectus abdominis myocutaneous (RAMC) flaps in nine patients. The skin flaps were designed larger in width than the original defect to create a funnel-shaped oropharynx and prevent stricture. Six patients had uneventful postoperative courses and began to eat perorally 8 to 15 days postoperatively. One patient suffered flap necrosis due to arterial thrombosis and two patients had leakage. Eventually, eight patients could eat soft foods or gruel, except one patient who had ingested food through a gastrostomy preoperatively. When TGL was performed without mandibulectomy, the blood supply for the remnant mucosa of the backside of the mandible is generally not good, for which the reconstruction with the overlapping deepithelialized flap and muscle is useful for prevention of the fistula formation. We considered that the RAMC flap is a good option for reconstruction after TGL.

Free jejunal transfer for patients with a history of esophagectomy and gastric pull-up

Some patients who undergo pharyngolaryngoesophagectomy with free jejunal transfer reconstruction have a history of esophagectomy and gastric pull-up. We retrospectively reviewed a series of 12 patients to examine the characteristic problems in free jejunal transfer for patients with a history of esophagectomy and gastric pull-up. There was no postoperative thrombosis. No anastomotic leakage or fistula was found. Five of 12 patients presented postoperatively with dysphagia. Two of the 5 patients showed stricture at the distal anastomosis. Three of the 5 patients showed no stricture. However, their reconstructed tracts were tortuous around the distal anastomosis, which could be a cause of dysphagia. Even in patients with a history of esophagectomy and gastric pull-up, free jejunal transfer can be performed safely, although the functional outcome of swallowing is not always satisfactory.

Extensive actinomycosis of the face requiring radical resection and facial nerve reconstruction

We present a case of extensive actinomycosis of the face, which appeared after dental surgery. Since antibiotic therapy was ineffective, the lesion was radically resected, and the skin, soft tissue and facial nerve were reconstructed using a free rectus abdominis musculocutaneous flap and simultaneously harvested intercostal nerves. Successful reanimation of the face was achieved 14 months postoperatively.

Efficacy of a skin-protection powder for use as a dressing for intractable ulcers

OBJECTIVE

Stomahesive skin-protection powder has been reported to be useful as a skin-care and skin-barrier product for the management of stomas. This study aimed to evaluate its efficacy, in terms of wound healing, moisture retention and pain management, as an alternative to conventional dressing materials. Both clinical and animal studies were undertaken.

METHOD

The efficacy of the Stomahesive powder was tested by measuring the thickness of granulation tissue formed in a total skin defect in a db/db mouse model. We then compared the healing process using either the skin-protection powder or a conventional film dressing material. In the clinical study 17 patients with various intractable ulcers were treated with Stomahesive powder, and healing was evaluated.

RESULTS

In the mouse model, granulation tissue in the wounds treated with the powder was 2.86 times thicker than that of the wounds treated with the film dressing. In the clinical study, 16 out of 17 wounds healed completely.

CONCLUSION

The Stomahesive powder could be an effective treatment modality for contact ulceration, superficial ulcers with complex contours and morphology, and superficial ulcers contaminated by liquid faeces or vaginal discharge that have not responded to conventional dressings.

DECLARATION OF INTEREST

None.