Endoscopy-assisted ultrasonic surgical aspiration of axillary osmidrosis: a retrospective review of 896 consecutive patients from 1998 to 2004

Axillary osmidrosis is a distressing and troublesome problem that causes a serious handicap in personal and social life. Many different methods have been introduced to treat axillary osmidrosis, however, they are often accompanied by marked complications. We analysed our experiences using endoscopy-assisted ultrasonic surgical aspiration in treating the axillary osmidrosis. From June 1998 to February 2004, a total of 896 patients (562 females, 334 males) were treated for axillary osmidrosis using endoscopy-assisted ultrasonic surgical aspiration. Our method was satisfactory in 815 patients (91%) and recurrence of odour occurred only in 29 (3.2%) patients. It also showed complications in 28 (3.1%) patients. Our method leaves a small inconspicuous scar and no contracture of the axillary skin after a short and comfortable recovery period and maintains normal axillary hair growth patterns. Axillary osmidrosis can be best treated by endoscopy-assisted ultrasonic surgical aspiration and this operation has many advantages with a high success rate, a low complication rate, and a rapid recovery period.

Comparison of bone morphogenetic protein receptors expression in the fetal and adult skin

Wounds on fetal skin can be repaired without leaving scars until the second trimester, but after this period, skin wounds leave scars as in adults. It's known that certain growth factors such as TGF-beta, and bFGF are present at a very low levels during wound repair in fetal skin. These low levels of growth factors minimize inflammatory response and fibroblast proliferation at the wound site, which in turn inhibit collagen synthesis, and thus, allows scarless wound healing. Recently bone morphogenetic proteins (BMPs), one of the TGF-beta superfamily members, have been studied in the wound healing process. According to several studies, BMPs are related to the differentiation and growth of epithelial and mesenchymal cells, but the precise functions of BMPs and of BMP receptors on skin wound healing have not been elucidated. In this study, we investigated the expression pattern of BMP receptors in fetal skin during the second trimester and in adult skin by immunohistochemical staining and RT-PCR. BMP receptors were detected on the suprabasal epithelial cells and in the hair follicles in adult skin, but were not defected in the fetal skin except for the hair follicles. This was confirmed by confirming mRNA levels of BMP receptors by RT-PCR in both adult and fetal skins. In conclusion, BMPs and BMP receptors seem to be related to fetal and adult wound healing, and low levels of BMPs and BMP receptors during the second trimester seem to contribute to scarless wound healing in the fetus, as is TGF-beta during the second trimester.

Sensate sole-to-sole reconstruction using the combined medial plantar and medialis pedis free flap

The coverage of soft-tissue defects of the sole needs special consideration because of the forces of weight bearing on the reconstruction. A variety of free tissue transfers have been advocated for soft-tissue replacement of the weight-bearing portions. However, there is no doubt that the ideal tissue for resurfacing the sole is the plantar tissue itself. The authors present a case of reconstructing the sole with the combined medial plantar and medialis pedis free flap that involves approximately 70% of the weight-bearing portion. This contralateral, combined fasciocutaneous free flap based on the posterior tibial-medial plantar vascular system is a good alternative in covering extensive sole injuries.

Quantitative and qualitative muscular changes after selective neurotomy

Disfigurement of body contour, caused by excessive muscular hypertrophy, can seldom be effectively and safely corrected by lipectomy, liposuction or combined partial myomectomy. This study was conducted to obtain basic knowledge for the development of a safe and effective method of treating patients with excessive and unwelcome muscle hypertrophy. Accordingly, we developed a new experimental rat model, consisting of the peroneal nerve and its target muscles - the anterolateral crural muscle group. After severance of 1/4, 1/2, and 1/1 of the peroneal nerve, functional parameters based on gross movement and electrophysiologic data were monitored. Changes in the external circumference and weight of the anterolateral crural muscle were documented and compared with control sides. Histologic and histomorphometric parameters of the muscle were also documented. Average takeoff latency in 1/4 and 1/2 neurotomy groups was increased to 130% and 154% of the control at 3 months, and 156% and 149% of control at 6months, respectively. Similarly, average peak-to-peak compound action potentials were 72% and 59% of the control at 3months and 57% and 50% of control at 6months. No definite gait disturbances were evident in the partial neurotomy groups. Maximal circumferences of the anterolateral crural muscle group were significantly reduced to 86%, 71% and 66% of the control in the 1/4, 1/2 and 1/1 neurotomy groups at 3 months (p < 0.001), and to 74%, 68% and 64% of the control at 6 months, respectively (p < 0.001). The corresponding weights were 76%, 62%, and 50% of the control sides at 3 months, and 70%, 56%, and 48% at 6 months in 1/4, 1/2 and 1/1 neurotomy groups. Histograms drawn showing the number of muscle fibers per mm2 in cross-sections, showed a total number of 239 +/- 52 in the control group; the size of muscle fibers was mainly medium to large. The more extensive the neurotomy, the greater the was the number of small angulated muscle fibers, up to a total of 1,564 +/- 211. Although more research work and clinical trials are required, we believe that selective neurotomy has the potential of being an effective tool for reducing muscle bulk, and avoiding apparent muscular dysfunction and complications.

Morphometric study of regeneration through vascularized nerve graft in a rabbit sciatic nerve model

Adequate vascularization is essential for a successful nerve graft. Theoretically, immediate vascularization will minimize fibroblast infiltration and support axonal regeneration. In this study, histomorphologic and morphometric studies were carried out to determine whether vascularized grafts are beneficial, in terms of axonal regeneration. In a rabbit model, 4-cm segments of sciatic nerve were obtained and placed as a nonvascularized graft on one side, and as a pedicled vascularized graft fed by the inferior gluteal vessel on the contralateral side. Histomorphologically, the distribution of myelinated nerve fibers and Schwann cells was evaluated after toluidine blue staining, at 2-, 3-, and 4-month intervals. The following results were obtained. 1) Myelinated nerve fibers were more abundant in the proximal, middle, and distal segments of the vascularized nerve group at 2 and 3 months. 2) The average nerve-fiber diameter was greater in the vascularized nerve graft group at 2, 3, and 4 months (2 to 10 microm). 3) Schwann cells were more abundant in the proximal, middle, and distal segments of the vascularized nerve graft group at all time points. Based on the above findings, the immediate restoration of circulation in the vascularized nerve graft can be accountable for the increased number of surviving Schwann cells, the rapid clearing of axons, and myelin-sheath changes that occur during Wallerian degeneration, thus enabling "morphologically" optimal regeneration.

A vascularized osteocutaneous fibular free flap for reconstruction of a complex injury of the foot

The foot plays a vital role in standing and gait. Its function results from harmonious interaction of bones, joints, and soft tissue. An imbalance or a defect in these structures can result in problems. The cuneiform bone of the foot consists of three bones: medial, intermediate, and lateral. Its structure plays an important role in maintaining the skeletal arch and it supports the body's weight. A defect or dislocation can disrupt the distribution of the weight-bearing complex of the foot and can lead to difficult gait.

Histologic change of arteriovenous malformations of the face and scalp after free flap transfer

In three patients with long-standing vascular malformations of the face and scalp, radial forearm free flaps were transferred after a near-total excision of the lesion. All patients had typical high-flow malformations with thrill and bruit. The onset and progression of the malformations were analyzed through clinical and histologic studies. After free flap transfer, the vascular malformations were followed up grossly and histologically for between 4 and 9 years. There was no recurrence of arteriovenous malformation after free flap transfer. The portion of the residual lesion adjacent to the transferred free flap disappeared, and the remaining discoloration also vanished grossly. Histologic comparison of immediate postoperative and 4-month postoperative specimens from the margin and residual lesion using Victoria blue staining showed that the typical preoperative findings for arteriovenous malformation-an intermingling of thick-walled vessels with abundant elastic fibers and thin-walled vessels without elastic fibers-had undergone change, resulting in the disappearance of the thick-walled vessels and leaving only homogeneous, thin-walled vasculature. The highly vascularized free flap, which does not contain abnormal fistulas, impacted the histologic change of the arteriovenous malformation by blocking the vicious cycle of ischemia and anatomic replacement of disfigured skin and subcutaneous tissues.

Skin flap prefabrication using acellular dermal matrix and cultured keratinocytes in a porcine model

In an effort to minimize the amount of autogenous tissue that is sacrificed in using a random skin flap, the authors, in a porcine model, implanted 3.0 x 7.0-cm (median thickness, 1 mm) sheets of commercially available nonmeshed acellular dermal matrix (AlloDerm) subcutaneously. After a vascularization period of 2 weeks, the implants were elevated and used as turnover dermal flaps to cover adjacent 3.0 x 3.0-cm full-thickness skin defects. Sheets of autogenous cultured keratinocytes were used for epithelium. The AlloDerm-cultured keratinocyte complex flaps healed without any complications. Measurements for percent contraction of the wound to determine the suitability of AlloDerm as a dermal flap showed that the wounds had contracted an average of 18 +/- 3.6% at 24 weeks. Histological evaluation revealed multilayered keratinocytes and indurations between the cultured keratinocytes and AlloDerm. Fibroblast infiltration and the presence of luminal spaces surrounded by capillary endothelium characteristic of neovascularization of the matrix were also noted. This preliminary study may form the basis for developing other types of prefabricated flaps using AlloDerm and cultured keratinocytes.

Orbital floor and infraorbital rim reconstruction after total maxillectomy using a vascularized calvarial bone flap

A number of techniques have been introduced to support the orbital floor after maxillectomy without orbital exenteration. These methods include skin graft or muscular sling, but they have resulted in severe complications, such as enophthalmos, global ptosis, diplopia, and facial deformity. Currently, advanced microvascular reconstruction using bone and soft tissue is performed by many surgeons. This usually results in the filling of the postmaxillectomy defect, but the lack of support for the orbital rim and floor by the bone flap may still cause the complications mentioned above. Vascularized calvarial bone flap was chosen in this study for reconstruction of the orbital floor and infraorbital rim to function as a buttress, to reconstruct recipient sites of poor vascular bed after radiation therapy, and to withstand further postoperative radiation. By providing a solid floor and rim, these complications can be prevented with satisfactory function and aesthetically acceptable results. From September of 1995 to July of 1998, we performed vascularized bone flap for the reconstruction of the orbital floor and infraorbital rim in four cases after total maxillectomy involving the orbital floor. With a follow-up period from 19 to 35 months (mean, 27 months), we obtained significant improvement of functional and aesthetically acceptable results without global ptosis, enophthalmos, diplopia, or severe facial contour deformity.

Simultaneous reconstruction of the Achilles tendon and soft-tissue defect using only a latissimus dorsi muscle free flap

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenging problem. These patients need not only soft tissue but also dynamic and functional reconstruction. Four cases of major defects of the Achilles tendon and overlying soft tissue after trauma are presented. In each case, the tendon and the overlying soft tissues were reconstructed using only a latissimus dorsi muscle free flap and overlying split-thickness skin graft. In conventional methods, evolved in the reconstruction of the Achilles tendon and soft tissue, the size of the defect was a limit. However, this technique can be used to reconstruct an extensive defect, including distal calf muscle to the plantar metatarsal area. In one case, the flap was harvested in a myocutaneous unit, and the skin portion was deepithelialized for the coverage and enough padding on the bony exposure area in reverse position. The purpose of the present study was to reevaluate the potential of denervated muscle flap for a force-bearing conduit as an alternative reconstructive method of the Achilles tendon. The denervated latissimus dorsi muscle in this study eventually experienced the process of atrophy and fibrosis but maintained its original length. Although there remained some atrophic muscle fibers, a fibrosis of the muscle fibers formed a tendon-like fibrous band, and so the action of the posterior calf muscle could be transmitted through the tendon-like fibrotic change of the denervated latissimus dorsi muscle. The advantages of this technique are that (1) it is a single procedure, (2) it is adaptable to a wide range of defect sizes, (3) it allows faster wound healing supported by well-vascularized tissues, (4) it produces satisfactory function of the ankle joint and a padding effect, and (5) it produces good contour of the posterior calf to the sole and an acceptable donor-site morbidity.

Pulp reconstruction of fingers with very small sensate medial plantar free flap

The essence in dealing with the pulp deficit accompanying fingertip injuries lies in functional restitution of the inherent skin texture and characteristics unique to that area and sufficient preservation of digital length, along with successful restoration of fine tactile sensation indispensable to delicate and skillful maneuvers. Among various techniques used to meet such demands, the very small sensate medial plantar free flap can be considered an excellent method in view of the skin texture that allows firm grasping, durability to friction rub, a cushion effect, and adequate sensation. Six cases of finger pulp reconstruction with the very small sensate medial plantar free flap are presented. At follow-up examination (an average follow-up of 24.3 months), the patients were evaluated clinically and neurologically. The operative procedures, advantages, and results in clinical cases are presented. Satisfactory results were obtained with sufficient preservation of digital length and good sensory recovery. No functional deficit was found at the donor site.

Flap prefabrication: effectiveness of different vascular carriers

A new experimental model of a vascular carrier to prefabricate a "secondary" island flap, the popliteal musculovascular pedicle, was developed in the rat. Using quantitative skin-surface fluorometry 30 minutes after sodium fluorescein injection and a flap survival area in the prefabricated 8 x 2.5-cm abdominal composite island flap, we compared the revascularization ability of our muscular carrier to nonrevascularized controls: the skeletonized arteriovenous pedicle and the fasciovascular pedicle. The free composite graft with no vascular carrier exhibited near-total necrosis. The skeletonized vascular pedicle demonstrated 15.2% +/- 7.8% perfusion of normal skin on dye fluorescence index measurements and 50% flap survival. The fasciovascular pedicle exhibited better revascularization, with a dye fluorescence index of 36.2 +/- 15.5 (p < 0.01) and 90% +/- 10% flap survival (p < 0.001). India ink injection study and histological examination of our model provided visual evidence of revascularization from the musculovascular pedicle, along with preservation of the carrier's muscular architecture. The musculovascular pedicle is a reliable carrier for making new, vascularized composite flaps.

The revascularization interface in flap prefabrication: a quantitative and morphologic study of the relationship between carrier size and surviving area

To make a quantitative assessment of the relationship between size of vascular carrier and surviving area in a prefabricated flap, vascular carriers composed of the superficial epigastric arteriovenous bundles and a surrounding fascial patch with varying sizes were transferred under a 7- x 7-cm bipedicled abdominal skin flap in a rat model. Seven days later, the abdominal flaps were raised as composite island flaps connected only by the superficial epigastric vascular pedicle, transferred, and then sutured back into place. Immediately after replacement, the degree of revascularization was assessed using quantitative skin fluorometry, after intravenous injection of sodium fluorescein. At 7 days after elevation as an island flap, the area of skin flap surviving was recorded and plotted on a map depicting the original flap surface. High levels of fluorescence appeared on the flap surface where the carrier was tacked underneath. The prefabricated island flaps survived with a circular shape up to approximately 4 times the radius of the vascular carrier. When the distance was converted into area, theoretically, an area 13 times the area of the vascular carrier survived, regardless of its size in this experimental model. Histologic examination revealed connections of fine capillaries between the carrier and flap.

Rhomboid design for tubed inguinal flap in fingertip reconstruction

The authors present a rhomboid design for the tubed inguinal flap mainly nourished by the superficial circumflex iliac vessels and the superficial inferior epigastric vessels. The length and width of the flap are mathematically determined based on the perimeter and length of the fingertip soft-tissue defect, respectively. The rhomboid tubed inguinal flap was used in the treatment of 21 patients with a variety of fingertip injuries. The thumb was involved in 12 patients and other digits in 9 patients. A complication, flap necrosis, occurred in one obese female patient and osteomyelitis of an amputated phalangeal bone developed in another. In all other patients, the rhomboid tubed inguinal flap healed uneventfully and provided satisfying results with minimal donor site morbidity. As a secondary procedure in thumb injuries, four neurovascular island flaps and one wrap around flap from the great toe were done for improved sensation. The precisely tailored rhomboid flap, with a safe and abundant vascular pedicle, allows for effective reconstruction of the fingertip with easy primary closure and minimal morbidity of the donor site.

The effect of basic fibroblast growth factor on the neovascularisation process: skin flap survival and staged flap transfers

Forty-two male Sprague-Dawley rats were utilised to determine whether the angiogenic property of basic fibroblast growth factor (bFGF) could be applied to improve the survival of the ischaemic portion of a random skin flap and to accelerate the process of staged flap transfer. In the ischaemic flap model, bFGF enhanced the development of vascular connections between the bed and the flap and prevented marginally perfused areas from undergoing necrosis. No effect was observed in the staged reconstruction model using the same dosage of bFGF. A speculative explanation is given for the differential effect of BFGF in these two models. The application of angiogenic factors may improve the survival of the random portion of skin flaps. Further investigations are needed to determine whether exogenously applied angiogenic factors can have a beneficial effect in staged flap reconstructions.

The fasciovascular pedicle for revascularization of other tissues

A fasciovascular pedicle based on the epigastric vessels was developed in a rat model to determine if it could be used as a "universal carrier" to revascularize a new composite flap. The effects of time course, carrier size, and flap ischemia on the revascularization process were studied. A 2.5 x 4-cm or 1 x 4-cm fascial patch pedicled on the vessels was transferred under bipedicled 2.5 x 4-, 6-, or 8-cm abdominal panniculocutaneous flaps. At different time intervals, the flap was raised as an island flap connected only by it vascular bundle and then sutured back in place. The skin perfusion by dermofluorometry and flap survival were both markedly increased on day 5 (p less than 0.001). The wide carrier had a 93% survival area, whereas the narrow carrier had only 71%. The wide carrier induced relatively faster and better revascularization (p less than 0.05). Moderate ischemia promoted revascularization (p less than 0.01). An india ink injection study and histological examination provided visual evidence of revascularization. This fasciovascular pedicle is a promising model for prefabrication of complex new composite flaps and for studying the process of revascularization between the layers. Based on these findings and further investigations, a thin, prefabricated abdominal free flap was successfully transferred for facial resurfacing in humans.

"Insert sutures first, tie later": new microvascular anastomosis techniques

Two reliable techniques for the microvascular anastomosis of difficult-to-handle, thin-walled smaller vessels--"insert sutures first, tie later" and "loops on hanger"--are described.

Effects of neurite-promoting factors on rat sciatic nerve regeneration

Neurite promoting factors (NPF), fibroblast growth factor, and laminin were instilled inside autologous venous nerve conduits (AVNC) interposed across a 1 cm gap in the rat sciatic nerve. Axonal regeneration was measured electrophysiologically and histologically and was compared to control AVNC and autologous nerve grafts (ANG) in 45 rats. By 1 month, the AVNC group with NPF recovered an average nerve conduction velocity twice that of the ANG group (24 m/sec vs. 12 m/sec). The gastrocnemius muscle action potential of NPF grafts was twice that of the control AVNC and was similar to the ANG (1.63 mV vs. 0.87 mV). In subsequent months, the advantage of NPF disappeared; these grafts were grossly reduced to fibrous bands. Histological examination of these grafts at 5 months revealed a florid intraluminal fibrovascular proliferation, which appeared to be "choking off" the regenerating axons. It is suggested that more refined mixtures of NPF should be instilled inside AVNC so that the improved axonal regeneration is maintained while the late inhibitory fibrosis is avoided.

Replantation and revascularization of hands: clinical analysis and functional results of 261 cases

During the past 4 years we performed 261 replantations and revascularizations on amputated digits and hands in 153 patients. The overall survival rate was 82%. Clean-cut proximal level amputations and hypothermically preserved amputation parts had the highest survival rate. A higher survival rate and more satisfactory results with accelerated return of sensory function correlated with repair of both digital arteries and two veins rather than only one. All patients experienced intolerance to cold, but this was more troublesome in patients with digital replantation in whom only a single artery was repaired. Digital sensibility and joint motion after replantation were better in these patients who had sharp amputations and on whom repairs were carried out in zone III. Return of intrinsic muscle function after hand replantation was poor; however, patient satisfaction with the procedures remained high.