Preserving the posterior cortex of the sternum during resection of a superficial anterior chest wall sarcoma

Following resection of a sternal tumor, respiratory dysfunction can occur and rigid reconstruction is necessary. An 82-year-old woman noted a mass in the anterior chest wall that was increasing in size. The tumor was located on the left aspect of the sternum at the level of the third rib. A radiation-induced malignant spindle cell tumor was diagnosed because of a history of irradiation for hilar lymph node carcinoma. The tumor was resected with the surrounding tissues of the second-to-fourth ribs and sternum. The posterior sternal cortex was preserved by cutting with a curved chisel under fluoroscopy. The chest wall defect was reconstructed with a 2-mm thick Gore-Tex® sheet and a local transpositional flap. Sternal resection with a chisel under fluoroscopy avoids damage to the internal thoracic artery. Preserving the posterior sternal cortex does not require rigid reconstruction. The procedure is minimally invasive

Use of the duplication range concept for understanding morphology and predicting prognosis in thumb polydactyly

This study systematically and comprehensively analysed 129 thumb polydactylies in 122 patients using a duplicating range concept based on the level of skin and skeletal bifurcation. Numerical levels were defined along the longitudinal axis of the ulnar thumb duplicate from distal to proximal: level 0 (thumb tip) to level 6 (carpometacarpal joint). The relationships between duplication range and morphological parameters were evaluated. Nail asymmetry was associated with skin bifurcation levels 0 to 2. Proximal phalangeal asymmetry and interphalangeal joint deviation, associated with skin bifurcation levels were assigned scores of 1 to 2.5 and 1 to 2, respectively. Metacarpophalangeal joint deviation had a bimodal distribution, at levels 1.5 and 4 of the longitudinal axes. Morphological similarity was found in patients with the same duplication range. The duplication range concept could potentially improve our understanding of morphology variation and predicting prognoses in thumb polydactyly

Fingerstall-type tissue oximetry reduced anxiety of nurses in postoperative nursing monitoring of free flaps

Background: Postoperative free flap monitoring is essential for immediately detecting obstruction of anastomosed vessels with successive recovery surgery for salvaging flaps. We performed postoperative nursing monitoring using handheld Doppler sonography, but nurses reported feeling anxious with this approach and demanded a clear-cut evaluation method. Therefore, we implemented monitoring with the fingerstall-type tissue oximeter Toccare, a noninvasive device that enables easy flap checking by simply touching the flap with a probe. Method: Handheld Doppler was used for nursing monitoring from April to October 2020, with anxiety associated with its use reported. We collected information via an anonymous questionnaire to determine the reason for the anxiety. Toccare was subsequently applied for postoperative free flap monitoring by nurses. The protocol involved measuring tissue oxygen saturation by touching the flap with a Toccare probe every 4 hours from 24 to 100 hours postoperatively. Seven months later, a second anonymous questionnaire was conducted, and results were compared. Result: Free deep inferior epigastric artery perforator flaps and anterolateral thigh flaps (n = 5 each) were included. The average tissue oxygen saturation values in the deep inferior epigastric artery perforator and anterolateral thigh flaps were 52.0% and 52.4%, respectively. According to the second questionnaire about Toccare, 7% felt anxious, 62% felt slightly anxious, and 31% did not feel anxious. Toccare was preferred by 89% of nurses who had used both methods. Conclusions: Flap monitoring using Toccare reduced nurses’ anxiety. A numerical evaluation method with easy handling and clear doctor call criteria is essential for low-anxiety nursing monitoring

A Case of Giant Congenital Melanocytic Nevus Treated with Combination Therapy of Autologous Mesh-skin Grafts and Cultured Epithelial Autografts

Surgical excision of a giant congenital melanocytic nevus (GCMN) results in a full-thickness skin defect that is usually difficult to reconstruct even with tissue expansion or skin grafting. Here, we report the first case of GCMN treated with a combination of cultured epithelial autografts (CEAs) and mesh-skin grafts to reconstruct a large skin defect after surgical excision. A 14-month-old girl had a GCMN occupying 20% of the total body surface area of her neck and back. A 5-stage, full-thickness excision was performed between the age of 14 and 25 months. In each intervention, the wound after excision was covered with 1:6 mesh-skin grafts and CEAs, except for the neck, where patch skin grafts and CEAs were used. The skin grafts and CEAs were engrafted without shedding and epithelialization was completed within 3-4 weeks. Eighteen months after the last surgery, a mesh-like scar remained, with no recurrence or severe contracture observed. The cosmetic appearances of the donor sites (the scalp and lower abdomen) were acceptable. The application of CEAs with mesh-skin grafts has been established for the treatment of severe burns. This combined method also provides a possible option for the treatment of GCMNs

Central Mandibular Reconstruction by Semiopen Wedge Osteotomy Double-barrel Fibula Flap for a Slim Aesthetic Appearance

Mandibular reconstruction involving the central segment after malignant tumor resection requires the achievement of both functional and aesthetic quality. Three-dimensional reproduction based on the concept of a double arc composed of a marginal arc and an occlusal arc is important. Most reports of fibula flaps applied three-segmented closed wedge fibula osteotomy (bilateral and central segments); however, the aesthetic outcome sometimes became too stout for female patients because of the large central segment. We performed four-segmented fibula osteotomy for a 78-year-old woman using a semiopen wedge technique characterized by a half-open wedge and half-closed wedge. This procedure obtained a slim mandibular contour and made double-barrel reconstruction easier to apply. We used titanium plates that were prebent according to the shape of a three-dimensional model constructed from CT data. Small bone cortex fragments made from a surplus fibula segment were inserted in a half-opened area. The build-up preparation for central mandibular reconstruction was all performed at the lower leg area before cutting the peroneal pedicle. This prefabricated double-barrel fibula free flap was transferred to the mandibular defect with arterial and venous anastomosis to the right superior thyroid artery, right external jugular vein, and right common facial vein. Although the patient was nearly 80 years of age, the bone segments, including free cortex tips, were fused with smooth remodeling. Semiopen wedge osteotomy can be a key to reproducing an aesthetically slim feminine chin with a functional height of mandibular bone maintained for stability of the dental prosthesis

Less-invasive Treatment for Group A Streptococcal Fasciitis with Rapid Antigen Detection Test and Collagen/Gelatin Sponge

Patients with severe group A Streptococcus (GAS) induced necrotizing soft tissue infection sometimes develop Streptococcal toxic shock syndrome, which is a life-threatening condition with an extremely high fatality rate. Obtaining survival is the most important goal; however, an early diagnosis for debridement surgery and quick granulation formation for skin grafting surgery can better preserve the extremity functions. The patient was a 47-year-old man with a history of atopic dermatitis who presented with GAS-induced necrotizing soft tissue infection in his left lower extremity. His vital signs indicated shock, and he was diagnosed with streptococcal toxic shock syndrome. Emergency surgery was performed with his body pressure maintained with noradrenaline. Intraoperatively, rapid antigen detection tests (RADTs) were negative in the medial thigh and positive in the lower leg, which helped in decision-making regarding the area of aggressive debridement surgery. The wound culture results matched the intraoperative rapid antigen detection test results. A collagen/gelatin sponge with the sustained release of basic fibroblast growth factor was used as an artificial dermis before skin grafting. Excellent granulation was obtained, and skin grafting surgery was performed on the 11th day after collagen/gelatin sponge placement. He was discharged home on the 42nd day with normal lower extremity functions. First, an intraoperative diagnosis using GAS-rapid antigen detection tests with an appropriate sampling method from small incisions avoided excessive surgical debridement. Second, collagen/gelatin sponge with the sustained release of basic fibroblast growth factor promoted quick granulation tissue formation for wound bed preparation. These efforts resulted in the successful less-invasive treatment of a patient with streptococcal toxic shock syndrome caused by GAS-induced necrotizing soft tissue infection

Reconstruction of the Midfoot Area with Vascularized Chimeric Osteocutaneous Scapula Flap: A Case Report

We report a case of reconstruction of a left midfoot defect with a chimeric partial scapula and skin flap in a 20-year-old man. After radical debridement, bone and soft tissue defects were reconstructed with a chimeric scapula and skin flap. The postoperative course was uneventful. The patient could walk well without support, and bone union was achieved 6 months after surgery. In 14 months of follow-up, no clinical complications (including new ulcer or stress fracture) were noted and full ambulation was achieved, with the patient returning to his previous work. We suggest that the chimeric scapula and skin flap may be a useful alternative option for midfoot reconstruction

Y-shaped Muscular Wrapping Technique Avoiding Re-infection of a Replaced Aortic Graft: A Cadaveric Study

Replacing an infected prosthetic thoracic aorta graft carries a high re-infection risk. We previously reported two clinical cases successfully treated with a new muscular wrapping technique: latissimus dorsi (LD) muscle flap with a distally based serratus anterior (SA) extension; however, a cadaveric study to prove the regular existence of the distal attachment area was lacking. We tried to establish an appropriate way of elevating the combined muscle flap safely. All of the cadavers were preserved using the Thiel embalming technique to retain flexibility. We checked for the existence of the distal attachment area between the LD and SA. Combined muscle flaps were elevated proximally while identifying the thoracodorsal artery, including the LD and SA branches. After the SA branch was ligated and cut, the SA muscle was manually peeled from the LD muscle with only the distal tight attachment area remaining. Contrast-enhanced computed tomography was performed using a multislice computed tomography system. Six human cadavers (three men, three women: 91 years old, on average) were examined. All six LD and SA combined muscle flaps showed a distal tight attachment area at the level from the seventh rib to the ninth rib. The tip of the SA muscle easily reached the sternum. Contrast-enhanced computed tomography failed to reconfirm the distal vascular flow from the LD to the reverse SA muscle, which we had visualized in a clinical case. We demonstrated the anatomical reliability of the new Y-shaped muscular flaps, which are suitable for preventing re-infection of aortic graft replacement

A Case of a Giant Congenital Melanocytic Nevus Treated by Curettage with the Application of Cultured Epidermal Autografts before 6 Months of Age

Curettage is common in the treatment of a giant congenital melanocytic nevus (GCMN) in infants and should generally be performed before 6 months of age. Post-curettage retarded epithelialization often interferes with the ability to perform multiple operations within a short interval, and thus, it is difficult to treat large lesions in the neonatal period. We herein report a case of a GCMN comprising 20% of the total body surface area, which required multi-stage curettage, in which a cultured epithelial autograft was used to promote epithelialization of the post-curettage wound. The patient was a 1-month-old boy with a GCMN in his head, neck, chest, back, buttock, left upper arm, and a few satellite lesions. A four-stage operation was performed between 3 and 6 months of age; the cultured epithelial autograft took well after each operation, and complete epithelialization was observed at postoperative days 20, 23, 27, and 12, respectively. Seven months after the last surgery, hypertrophic scar formation was only observed in a small area of the left upper arm without axillary contracture. The color of the treated area improved, except for slight partial re-pigmentation. A skin biopsy was obtained from the re-pigmented area. The results demonstrated that nevus cells remained in the basal layer of the epidermis, hair follicles, and deep layer of the remaining dermis, suggesting that the recurrent nevus cells in the regenerated epidermis migrated from hair follicles. We conclude that the combination of curettage and the application of a cultured epithelial autograft is a promising option for GCMN treatment

Three-dimensional visualization of thoracodorsal artery perforators using photoacoustic imaging

Introduction: Diagnostic imaging modalities to evaluate the three-dimensional distribution of thoracodorsal artery perforators (TDAPs) are lacking. In this study, TDAPs were visualized and characterized using photoacoustic imaging. Material and methods: In this study, 34 sites in the lateral chest wall of 18 individuals were analyzed. The region extending 5 cm ventral and 5 cm dorsal to the lateral edge of the latissimus dorsi (LD) and 5–15 cm from the posterior axillary fold was scanned using photoacoustic imaging. The largest perforator closest to the edge of the LD was characterized. The location of the stem portion and the orientation of the longest cutaneous branch of the perforator were described. The relationship between the maximal depth of delineation on photoacoustic images and the depth of the deep fascia was assessed. Results: On average, 2.6 perforators (range, 1–5 perforators) were visualized in the region of interest. The distribution of the TDAP stem portion was similar to that in previous studies. Cutaneous branches were preferentially oriented in a medial-caudal direction. The length of delineated cutaneous branches varied (range, 7–78 mm) depending on the thickness of the subcutaneous layer. Vessels under the LD were observed when the subcutaneous layer was thin. Conclusion: Photoacoustic imaging can successfully visualize TDAPs in three dimensions. Visualization of TDAPs varied by the thickness of the subcutaneous layer. A thin deep fascia of the LD might be a cause of deep laser penetration