Free tissue transfer is the standard reconstructive approach for complex head and neck defects; however, major recipient-site complications remain clinically significant. Reported risk factors for these complications have been inconsistent, partly because of heterogeneity in defect characteristics, reconstructive techniques, and perioperative management across institutions. This study aimed to identify independent predictors of major recipient-site complications and total flap or jejunal necrosis in patients with continuous intraoral-cervical composite defects managed in a standardized single-center setting. We retrospectively analyzed 183 consecutive patients who had undergone free tissue transfer within a standardized reconstructive program. The same 2 senior plastic surgeons primarily planned the reconstructions and performed the key steps, including flap design, vascular anastomosis, and flap inset. Techniques were standardized within each reconstructive category, with 3-dimensional planning when indicated and protocolized postoperative flap monitoring. Recipient-site complications were graded using the Clavien-Dindo (C-D) classification, and cumulative smoking exposure was quantified using the Brinkman index (BI; cigarettes/day×years). Severe (C-D ≥III) complications occurred in 20.8% of patients, and total necrosis occurred in 3.3%. Seventeen patients (9.3%) had grade IIIb complications, 13 of whom underwent reoperation requiring wound closure, revision reconstruction, or thoracic duct ligation. BI and bilateral neck dissection were independent predictors of severe complications, whereas BI was the only factor significantly associated with total necrosis. Each 100-unit increase in BI increased the odds of severe complications and necrosis, and receiver operating characteristic analysis yielded an area under the curve of 0.858 (95% CI: 0.735-0.981) for total necrosis. The length of hospital stay was significantly prolonged in patients with C-D ≥III complications and in those with total necrosis. In all necrosis cases, circulatory compromise was recognized after postoperative day 3 despite protocolized monitoring. Even under standardized reconstructive and monitoring conditions, clinically significant complications remained relatively common, suggesting that cumulative smoking exposure may reflect patient-related vascular vulnerability in a setting designed to minimize technical variation.

OBJECTIVE:Early postoperative wound dehiscence is the most common complication of pressure ulcers (PUs). The authors previously investigated the risk factors for this complication and reported that the main cause of early wound dehiscence was surgical site infection. This study aimed to improve the surgical method to decrease early postoperative wound dehiscence. METHOD:Patients with PUs between 2005 and 2022 were retrospectively investigated. In the control group, the ulcer surface was stained with methylene blue and debrided using the conventional method (surgical debridement). For comparison purposes, three test groups were established. In group 1, the ulcer surface was covered with hydrofibre with ionic silver, and debridement was performed using the covered debridement method. In group 2, debridement was performed using the conventional method and postoperative incisional negative pressure wound therapy (iNPWT) on the skin flap. Group 3 underwent both the covered debridement method and iNPWT. Patient data on: sex; age; body mass index (BMI); history of diabetes; smoking history; PU site; detection of meticillin-resistant Staphylococcus aureus in wound bacterial culture; serum albumin level; operation time; and ulcer size, were collected. Significant differences from the control group were determined for each factor. RESULTS:A total of 60 patients underwent flap coverage (control group: 39 patients; group 1: six patients; group 2: eight patients; group 3: seven patients). There were no significant differences between the groups for each item except for albumin level and BMI. Rates of early wound dehiscence in the control group and groups 1, 2 and 3 were 15/39 (38.5%); 2/6 (33.3%; p=0.81); 2/8 (25%; p=0.47), and 0/7 (0.0%; p=0.049), respectively. CONCLUSION:A combination of methods may effectively reduce the incidence of early wound dehiscence.

A 75-year-old woman presented with scalp and cranial defects caused by implant exposure, infection,and cranial necrosis following multiple craniotomies. To reduce the risk of complications after cranioplasty, weplanned a two-stage cranial reconstruction. A wide bipedicled scalp flap with a long longitudinal axis above the cranium covered the scalp defect after debridement, and skin grafting was performed on the periosteum after flap harvesting during the first surgery. A custom-made titanium plate was implanted under the bipedicled flap during the second cranioplasty 4 months after the initial surgery. The patient had no complications during the two surgeries, and her clinical course was uneventful for 6 months after the last surgery. Although a two-stage approach, our technique is relatively safe for patients who have previously undergone multiple surgeries and decreases the risk of postoperative complications due to the shorter exposure time of the titanium plate during the second surgery. J. Med. Invest. 72 : 185-188, February, 2025.

Background Free flap reconstruction can be performed in patients with chronic limb-threatening ischemia (CLTI). However, early walking training may increase the risk of wound dehiscence and prolong hospitalization. Total contact cast (TCC) treatment effectively addresses diabetic plantar ulcers by immobilizing the foot and distributing weight away from the ulcer area. This study aimed to assess the effect of postoperative TCC use on early limb loading and hospital stay in patients with CLTI with free flaps. Methods Patients with CLTI who underwent free flap reconstruction between 2006 and 2023 were enrolled in this study. Postoperative time until weight-bearing initiation was compared between the TCC (n = 5) and non-TCC groups (n = 7). Results The time to the initiation of weight-bearing on the affected limb was 52.3 ± 33.2 days in the non-TCC group and 19.8 ± 3.56 days in the TCC group (p = 0.105). The wound dissection rates were 42.9% (3/7) in the non-TCC group and 20% (1/5) in the TCC group (p = 0.408). At discharge, 28.6% (2/7) of the non-TCC group and 20% (1/5) of the TCC group had ulcers (p = 0.735). The average flap size was 149 ± 69.1 cm2 in the non-TCC group and 95.6 ± 73.1 cm2 in the TCC group (p = 0.268). Conclusion Postoperative TCC use after free flap foot reconstruction may lead to early weight-bearing of the affected limb. Further studies with larger numbers of cases are needed.

Objectives: Voriconazole is a broad-spectrum antifungal agent known to be associated with cutaneous squamous cell carcinoma (cSCC) in White organ transplant recipients; however, such cases are rarely reported in Asian populations. This study aimed to examine the epidemiology and treatment outcomes of Japanese patients without a history of organ transplantation who developed invasive cSCC during voriconazole therapy. Methods: This retrospective observational study analyzed data from six Japanese male patients who were treated at our hospital between the years 2013 and 2023. All patients had Fitzpatrick skin type IV and were undergoing long-term voriconazole therapy for pulmonary aspergillosis. The diagnosis of invasive cSCC was confirmed via skin biopsy. Clinical, pathological, and treatment data were collected and analyzed descriptively. Results: Fifteen facial lesions were identified (nine at initial presentation and six during follow-up). The median duration of voriconazole treatment before cSCC diagnosis was 66.5 months. Tumors had a median diameter of 17 mm, with an estimated growth rate of 6 mm per month. Most lesions demonstrated deep invasion (Clark level IV or V), and some exhibited perineural or perivascular infiltration. All lesions were surgically excised, except for one that was treated with radiotherapy. No regional recurrence or distant metastasis was observed during a median follow-up period of 9 months. Conclusions: Prolonged voriconazole therapy may increase the risk of aggressive cSCC in Japanese patients, even in the absence of prior transplantation. Early identification of phototoxic skin changes and prompt intervention are crucial to prevent deep tissue invasion and improve clinical outcomes.

Background: The objective of this study was to present 3 cases of bilateral cleft lip and palate in which early application of premaxilla-guiding nasoalveolar molding (PG-NAM) achieved proper premaxillary alignment, columella, and upper lip lengthening by 2 months of age. Methods: Patients with bilateral cleft lip and palate were referred shortly after birth for intraoral scanning, which enables the creation of a 3-dimensional–printed jaw model. Using the jaw model, the Hotz plate was designed as a feeding plate. One week after birth, a nasal stent was applied to the Hotz plate. Once the stent was in place, 2 elastic lip tapes were used to prevent premaxillary collapse. Results: In all 3 cases, premaxillary alignment was completed within 1 through 2 months of appliance placement, and nasal septal curvature was observed after posterior premaxillary movement; however, at the time of palatoplasty, the nasal septum was straightened in all cases. Conclusions: These findings suggest ultraearly application of PG-NAM achieves appropriate premaxillary alignment, columella, and upper lip lengthening by 2 months of age, allowing for smooth surgical interventions.

Diabetic foot ulcers are a leading cause of lower extremity amputations, significantly affecting the quality of life. Excessive plantar surface pressure and shear stress are key factors in ulcer development and aggravation. This study aimed to determine the association of these forces with the progression of diabetic peripheral neuropathy to help in foot-ulcer treatment and prevention. Participants were categorized into four groups: individuals with no diabetes (NS), people with diabetes without peripheral neuropathy or foot-ulcer history (DM), those with diabetes with peripheral neuropathy but no foot-ulcer history (DPN), and people with diabetes with active or past foot ulcers (DFU). Plantar pressure and shear stress were measured during walking. The study included 47 participants. The DFU group demonstrated significantly higher pressure peak value and plantar pressure time integral value at the fifth metatarsal head compared to the DPN and DM groups. The DPN group exhibited significantly higher shear-stress time integral and shear stress time compared to the NS group. In the DPN group, an increase in shear stress was observed. In the DFU group, an increase in plantar pressure and a tendency for an increase in shear stress were noted. Further research is needed to understand how these changes trigger the onset of foot ulcers.

Objectives: Remote medical care is becoming popular worldwide, but not as much has yet been done in plastic surgery. We provided online treatment related to plastic surgery using a 5G system. This study aimed to investigate the usefulness and future of online telemedicine in plastic surgery. Methods: A plastic surgeon alternated between face-to-face and telemedicine. The interval between consultations was 1 week. Specifically, local doctors and staff provided medical care to patients at the suburban hospital, and the plastic surgeon remotely observed patients and provided instructions and guidance on procedures to the local doctors and staff. In this study, we evaluated the patients who were treated under telemedicine with respect to their age, use, and effectiveness. The study encompassed the period from August 2021 to October 2022. Results: Thirty-five patients were treated via online telemedicine (mean age, 73.0 years). Twenty-one (60%) of the postoperative procedures were related to surgeries performed by a plastic surgeon. Consultation for simple wound care was performed in 8 (22.9%) patients. Guidance on pocket incision surgery for pressure ulcers was given to one patient. As for the quality of communication, images were clear, no delays were encountered, and no cases interfered with medical care. Conclusions: Our system was primarily useful as a postoperative management tool. The high image quality and low-latency communication allowed for real-time instruction during complex postoperative procedures and surgical techniques. Even in hospitals with infrequent visits from plastic surgeon, telemedicine has the potential to make surgery safer and more proactive.

Background:Keloids most commonly develop in the regions where the skin is constantly stretched. Although some keloid-derived fibroblasts exhibit higher single calcium spikes than normal dermal fibroblasts during short-time cyclical stretching, the calcium signal responses to long-time stretching remain unclear. Methods:This study compared the intracellular Ca2+ dynamics induced by cyclical stretching stimuli between the control group (normal dermal fibroblasts) and the keloid group (keloid-derived fibroblasts). Each group was cyclically exposed to a two-dimensional stretch (10% strain). A confocal laser microscope was used to examine intracellular Ca2+ for 30 min fluorescently. The fluorescence intensity ratio (Fluo-8H/calcein red-orange) was used to evaluate intracellular Ca2+ concentration every 0.5 s. A calcium spike was a transient ratio increase of ≥ 20%. Receiver operating characteristic analysis was performed to determine the cutoff value of a normal calcium spike. Results:No significant difference was observed between the keloid and control groups in the calcium signal response-positive rates (26.9% vs. 25.0%; p = 0.9). However, the calcium spike amplitudes were significantly higher in the keloid group than in the control group (1.66 vs. 1.41; p = 0.02). The cutoff value was 2.12, and 9.6% of keloid-derived fibroblasts exhibited multiple hypercalcium spikes. Discussion:We are conducting further research based on the hypothesis that this keloid-specific subpopulation triggers the pathogenesis of keloid formation, that is, collagen overproduction, accelerated angiogenesis, and chronic inflammation.

A 10-year-old Japanese female was referred to our hospital for a rapidly growing and easily bleeding nodule on her right temple. A physical examination revealed a red ulcerated nodule on her right temple. Our clinical diagnosis was pyogenic granuloma (PG), and cryotherapy was performed several times. However, this did not remove the tumor;therefore, we excised it under local anesthesia. A histopathological examination of the removed tumor showed vascular proliferations arranged in discrete lobules in the dermis. Based on these findings, we confirmed the diagnosis of PG. About 4 months after the surgery, small nodules gradually developed around the surgical scar. The patient returned to our hospital 1 year after the surgery. A physical examination showed multiple, small, red papules scattered around the surgical scar. Based on the clinical findings of this case, we made a diagnosis of the recurrence of PG with satellitosis (RPGS). The lesions disappeared after 6 months of topical steroid and liquid nitrogen therapy. RPGS is a rare phenomenon, but its diagnosis and management can be problematic. It is important for physicians to recognize this phenomenon and inform patients of the possibility of recurrence and the development of satellite lesions after PG is resected. J. Med. Invest. 72 : 440-442, August, 2025.

Functional outcomes associated with prognostic factors and innervated muscle transplantation after wide soft tissue sarcoma resection remain unclear. We retrospectively examined the functional outcomes of reconstructive flap surgery for soft tissue sarcoma. Twenty patients underwent innervated muscle transplantation with pedicled or free flaps for functional reconstruction of resected muscles. Thirteen latissimus dorsi muscles and one vastus lateralis muscle combined with an anterolateral thigh flap were transferred as free flaps using the epi-perineural suture technique. Six latissimus dorsi muscles were transferred as pedicled flaps with neural continuity. Postoperative functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scores for the upper and lower extremities of 22 and 24 patients, respectively. The mean MSTS score for all patients was 82.3 at 12 months postoperatively. The mean scores for patients who underwent reconstruction with pedicled and free flaps were 89.2 and 77.1, respectively. The MSTS scores for the lower extremity, tumor size ≥5 cm, and free flap reconstruction were significantly lower than those for the upper extremity, tumor size <5 cm, and pedicled flap reconstruction (P = 0.02, 0.37, and 0.008, respectively). The postoperative MSTS score for innervated muscle transplantation was 76.7 at 12 months and was significantly higher (83.7) at 24 months (P = 0.003). Functional outcomes were significantly associated with tumor location, tumor size, and reconstructive flap type based on the MSTS scores. Innervated muscle transplantation improved functional outcomes at 24 months postoperatively via sufficient recovery of the innervated muscle, not the compensatory recovery of the remaining muscle.

Free jejunal transfer is one of the most useful procedures for reconstructing circumferential defects following total pharyngolaryngoesophagectomy (TPLE). When an extended resection of the surrounding soft tissue is performed in addition to the TPLE, the defect may require another flap in addition to the jejunal flap to reconstruct the soft tissue defect. In such multiple defects, the choice of reconstruction method remains unanswered and unsolved. Herein, our objective was to clarify the utility of our newly developed technique of simultaneous reconstruction of two defects in the neck using a combination of free jejunal and mesenteric flaps. An 81-year-old man had defects in the upper esophagus, total larynx/pharynx, and posterior tracheal wall caused by the resection of invasive upper esophagus cancer anterior to the membranous part of the trachea. A chimera flap composed of a 15 cm free jejunal and mesenteric flap along with 15 cm of surplus mesentery was harvested; the jejunum was inserted into the esophageal defect and the mesentery was placed on the tracheal defect. The patient exhibited a favorable postoperative course at 8 months with no recurrence or stenosis in the reconstructed respiratory or gastrointestinal tract. This method offers a straightforward vessel anastomosis, making it a good and reasonable option for reconstructing partial tracheal defects along with TPLE.

Lower eyelid reconstruction using skin flaps sometimes results in undesirable deformities due to postoperative flap drooping. We aimed to examine the effectiveness of a novel procedure for reconstructing the skin-tarsoligamentous sling of the lower eyelid. We included 37 patients who underwent anterior lamellar reconstruction with a cheek rotation flap for full- thickness lower eyelid defect. They were divided into two groups: Group A included 19 patients who underwent tarsoligamentous sling reconstruction with a fascia lata strip and buccal mucosa grafting, and Group B comprised 18 patients who underwent skin-tarsoligamentous sling reconstruction using an additional combination of a periosteal flap and de-epithelialized triangular flap at the lateral canthal region, representing our novel approach. To evaluate the severity of postoperative deformities, we used the drooping index, the ratio of drooping compared to the healthy side, along with the angular difference in canthal tilt, obtained between the reconstructed and healthy sides, using photographs taken >= 6 months post-reconstruction. Group B demonstrated superior outcomes, with mean drooping indices of 1.13 compared to 1.33 in Group A (P = 0.031) and mean angular differences in canthal tilt of -0.73 degrees compared to -2.45 degrees in Group A (P = 0.021). Patient satisfaction was significantly higher in Group B than in Group A (P = 0.042). Furthermore, patients with drooping index < 1.2 and an angular difference in canthal tilt >=-1.0 degrees exhibited higher satisfaction scores. Our novel approach to lower eyelid reconstruction using a skin-tarsoligamentous sling yielded improved aesthetic outcomes, fewer complications, and higher patient satisfaction. (c) 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

AIMS:The most common postoperative complication when treating a pressure ulcer with a flap or primary closure is early wound dehiscence. In this study, we aimed to investigate the cause of early wound dehiscence and its associated risk factors. Early wound dehiscence was defined as the wound dehiscence within the post operation period where no weight or tension is applied to the wound.METHODS:We conducted a retrospective study of 40 patients with pressure ulcers (69 sites). We calculated the significant difference in the incidence of wound dehiscence between the groups for the following 15 factors : age, obesity, emaciation, diabetes mellitus, smoking, ulcer site, musculocutaneous flap, methicillin-resistant Staphylococcus aureus, presence of two or more types of bacteria, albumin level, C-reactive protein level, white blood cell count, hemoglobin level, operative time, and ulcer size.RESULTS:Bacteria were detected in all wounds with early dehiscence, which was found in 28 (40.6%) of the 69 cases. C-reactive protein level, albumin level, musculocutaneous flap, and operative time were found to be risk factors for early wound dehiscence using the χ2-test and t-test. (P?=?0.011, 0.045, 0.018, and 0.003, respectively).CONCLUSION:The cause of dehiscence was considered to be surgical site infection. C-reactive protein level, albumin level, musculocutaneous flap, and operative time may be risk factors of the occurrence of early wound dehiscence. J. Med. Invest. 70 : 101-104, February, 2023.

Aims This study analyzed the gait patterns of diabetic peripheral neuropathy (DPN) patients and changes in the center of mass sway to prevent the formation and recurrence of foot ulcers. Methods Forty-two subjects were divided into the diabetes mellitus (DM), DPN, and diabetic foot ulcer (DFU) groups. We measured the range of motion (ROM) of the lower limb joints in the resting position and the center of mass sway in the standing position. Joint angles, ROM during walking, and distance factors were evaluated. Results In the DFU group, ROM limitation during walking was detected at the knee joint, and functional and ROM limitations were found at the ankle joint. The step length ratio and step width in the DFU group were significantly lower and higher than those in the DM group, respectively. The sway distances in the DFU group were greater than those in the DM and DPN groups. Conclusions Functional joint limitations and gait changes due to the decreased ability to maintain the center of gravity were observed in the DFU group. As DPN progressed, the patients’ gait became small, wide, and shuffled. Thus, supporting joint movement during walking may help reduce the incidence and recurrence of foot ulcers.

Microvascular anastomotic coupler system is used in vascular surgical procedures. By using this device, vascular anastomosis can be performed faster and more easily. It is often used for venous anastomosis during microsurgical reconstruction. We performed distal bypass surgery on two patients with critical limb ischemia with spliced vein grafts using the microvascular anastomotic coupler system. The blood vessel diameters were 2 and 2.5 mm, respectively. Both grafts showed obstruction at 3 and 1 months, respectively, after surgery. The microvascular anastomotic coupler system may not be suitable for small-diameter spliced vein grafts.

Background: The spread of coronavirus disease 2019 (COVID-19), which began in 2020, has had a major impact on healthcare systems. The spread of COVID-19 has been reported to have affected the readiness to treat patients with burns worldwide. However, the existing reports have evaluated burn care status within a limited time period during the pandemic, and no report clarifies the change in the impact of infection status on burn care from the beginning of the pandemic to the present. Methods: Japanese Society for Burn Injuries-accredited burn care facilities were surveyed using questionnaires on April 9-23, 2020; June 23-July 6, 2020; July 9-21, 2021; and January 21-31, 2022. Differences between groups were evaluated using Friedman's test or Bonferroni's multiple comparison test, as appropriate. Results: From the 103 facilities included in the study, we received 85, 55, 56, and 58 re- sponses in the first, second, third, and fourth surveys, respectively. We could continuously observe 34 facilities. The rate of acceptance of patients with severe burns improved sig- nificantly over time (P < 0.05). However, in the second and third surveys, there was an increase in the number of respondents who did not accept patients with burns irrespective of COVID-19 status. Conclusions: The number of facilities treating patients with burns who have COVID-19 is increasing; however, COVID-19 care may negatively impact routine burn care. It is neces- sary to continuously examine medical resource allocation through methods such as in- formation sharing by academic societies. (c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

BACKGROUND:The incidence of keloids is higher in the case of darker skin. It is more common in the parts exposed to stretching (thorax, abdomen, and joints). Cyclical stretching reportedly induced each Ca2+ spike through differential mechanosensitive channels in human synovial and dermal fibroblasts. Therefore, the authors hypothesized that cyclical stretching also induces a specific Ca2+ spike in keloid-derived fibroblasts.METHODS:This in vitro study compared the intracellular calcium dynamics induced by cyclical stretching between control (human dermal fibroblasts) and keloid (human keloid-derived fibroblasts) groups. Each group was exposed to two-dimensional stretch using an originally developed stretch microdevice. Intracellular Ca2+ was observed for 5 minutes, including 30 seconds of baseline, under a fluorescent confocal laser microscope. The intracellular Ca2+ concentration was evaluated every 0.5 second using the fluorescence intensity ratio. A positive cellular response was defined as a rise of the ratio by greater than or equal to 20%. The normal response cutoff value was determined by receiver operating characteristic analysis.RESULTS:The keloid groups were significantly more responsive than the control groups (15.7% versus 8.2%; P = 0.029). In the cellular response-positive cells, the keloid groups reached significantly higher intracellular Ca2+ concentration peaks than the control groups (2.20 versus 1.26; P = 0.0022). The cutoff value was 1.77, and 10.4% of the keloid-derived fibroblasts exhibited a hyper-Ca2+ spike above the normal range.CONCLUSIONS:Keloid-derived fibroblasts with a hyper-Ca2+ spike might constitute a keloid-specific subpopulation. Hereafter, the authors will study whether the normalization of excessive intracellular Ca2+ concentration leads to keloid treatment in vivo.CLINICAL RELEVANCE STATEMENT:This study result provided a clue to the onset mechanism of keloids, which the authors hope will lead to the development of new therapy in the future.