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

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

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

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

Pyoderma gangrenosum after breast cancer resection: A less-invasive and early treatment using the skin around ulcers

Surgical invasion is a risk factor of pyoderma gangrenosum (PG). A total of 25% of postoperative PG cases were reported to occur after breast surgeries, including bilateral breast reduction and breast reconstruction following cancer resection. Immunosuppressive therapy and less-invasive wound therapy are necessary; however, the complete healing of ulcers takes 5.1 months on average. We herein report a case of skin grafting under a surgical concept of less-invasive and short-term treatment. An 82-year-old woman complained of a high fever and severe pain at her breast wounds after bilateral breast cancer resection. Although we performed emergency debridement surgery to remove the necrotic tissue, suspecting surgical site infection and inflammation, her high fever persisted. She was diagnosed with PG because of the physical findings of characteristic painful, sterile ulcerations, bullae and pustules, and the pathological abundance of neutrophils in the absence of infection and vasculitis. Oral administration of prednisolone 30 mg/day improved the symptoms, and we applied negative-pressure wound therapy (NPWT) from day 16 following debridement surgery. After the gradual reduction of oral steroid intake to 12.5 mg/day, we performed skin grafting surgery. To limit the surgical invasion, we used the surplus skin around the ulcers. Split-thickness mesh skin grafts were fixed by NPWT to avoid the use of tie-over sutures. We achieved short-term treatment of PG with a less-invasive surgical strategy using skin around the ulcers and NPWT

Squamous Cell Carcinoma of the Scalp after Artificial Hair Implantation

A 48-year-old man with a protruding tumor on the parietal region had undergone treatment of alopecia using artificial synthetic fibers 2 or 3 times a year for 10 years from 30 to 39 years old. Three months before the first consultation at our hospital, he noticed a small tumor that had gradually shown bleeding and discharge, with expansion of the affected area. A diagnosis of squamous cell carcinoma (SCC) was made based on a biopsy, and we resected the tumor with a 1-cm surgical margin from the reddened area around the protruding tumor (14 × 11 cm), including the periosteum membrane. No tight adhesion was found between the periosteum and skull, so we excised the outer table of the skull of the central part (diameter: 8 cm) for a pathological analysis. A pathological study showed moderately differentiated SCC with a negative surgical margin. The whole tumor was surrounded by scar tissue with buried artificial hair implants. The second surgery was performed on the 15th postoperative day. An anterolateral thigh flap was divided into 2 flaps to fit the circle-shaped wound. This is the second report of SCC developing after artificial hair implantation in the frontal-parietal scalp. The whole protruding tumor was surrounded by scar tissue with buried artificial hair implants. Proving the direct causal relationship between inflammation of scar tissue and SCC generation is difficult; however, our pathological findings support the possibility of the harmful effects of artificial hair implants

Clinical utility of silk-elastin sponge in patients with chronic and acute skin ulcers: study protocol of a multi-center clinical trial

INTRODUCTION: Not only chronic but also some acute wounds have a risk of infection and become unhealed wounds. Silk-elastin sponge has been developed to treat chronic wounds that are susceptible to infection. Preclinical and clinical studies suggested that silk-elastin sponge is safe for humans and can promote granulation tissue formation by reducing bacterial growth in chronic wounds. The central aim of this trial is to evaluate the clinical utility and safety of silk-elastin sponge for the treatment of chronic and acute skin ulcers. METHODS: This study is a prospective, multicenter, single-arm, uncontrolled clinical trial. In this study, 20 patients with chronic ulcers and five with an acute one will be included; patients with wound infection will be excluded. Silk-elastin sponges are applied and covered with a dressing for 14 days. PLANNED OUTCOMES: The primary endpoint is the frequency of patients with chronic wounds in whom the investigator confirms the formation of a healthy wound bed at 14 days after the initial application of the study device. In addition, safety for acute wounds and handiness of the study device will be assessed. TRIAL REGISTRATION NUMBER: jRCT2052210072

Fournier's Gangrene with Edwardsiella tarda: A Gas Production Case by Bacterial Synergism with Streptococcus anginosus

Edwardsiella tarda is an anaerobe associated with freshwater and marine life. Necrotizing soft tissue infection caused by E. tarda is rare, but its mortality rate is extremely high (61.1%). We experienced a survival case of Fournier's gangrene with E. tarda. A key clinical feature for the diagnosis was gas production; however, there have been no previous reports of such a phenomenon in relation to E. tarda. A 64-year-old man was admitted with a 3-day history of a high fever. His medical history, which included paraplegia from the Th6 level down, made the focus of inflammation at the perineum difficult to notice. Whole-body CT revealed subcutaneous gas from the posterior scrotum around the entire circumference of the anus. During emergency surgery, an incision at the posterior scrotum revealed extensive fascia necrosis, and E. tarda and Streptococcus anginosus were identified. We speculated the gas production in this case to be the product of a mixed infection of aerobes and anaerobes, which acted synergistically to induce bacterial growth. Timely surgical debridement and antibiotic therapy led to the patient's survival