Publications by authors named "Mutsumi Okazaki"

124 Publications

Potentially serious incidental findings on medical imaging in plastic surgery patients: A single-institution retrospective cohort study.

J Plast Reconstr Aesthet Surg 2021 Apr 17. Epub 2021 Apr 17.

Department of Plastic, Reconstructive and Aesthetic Surgery, the University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan.

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http://dx.doi.org/10.1016/j.bjps.2021.03.118DOI Listing
April 2021

Secondary Vulvar Reconstruction Using Bilateral Gluteal Fold Flaps after Radical Vulvectomy with Direct Closure.

Plast Reconstr Surg Glob Open 2021 Apr 20;9(4):e3550. Epub 2021 Apr 20.

Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.

Although primary vulvovaginal reconstruction after vulvectomy has high potential to improve patients' outcomes, flap reconstruction is not an established part of the current standard treatment for vulvar cancer. We report a patient with successful secondary vulvar reconstruction 3 years after radical vulvectomy with direct wound closure. A 69-year-old woman presented with chronic, burning vulvar pain 3 years after radical vulvectomy without reconstruction for stage IB vulvar cancer. Her urethral orifice had everted because of the direct wound closure, which resulted in severe pain on contact. We performed secondary vulvar reconstruction using bilateral 14 × 5 cm gluteal fold flaps. Postoperative pain management and overall aesthetic outcomes were satisfactory. Secondary vulvar reconstruction with gluteal fold flaps can avoid the sequelae resulting from inadequate direct wound closure after radical vulvectomy. Thus, we strongly advocate immediate vulvar reconstruction to prevent such situations.
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http://dx.doi.org/10.1097/GOX.0000000000003550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057754PMC
April 2021

Chimeric Latissimus Dorsi Flap in One-Stage Reconstruction of Depressor Muscle Dysfunction and Depression Deformity in the Perimandibular Area.

J Craniofac Surg 2021 Mar 25. Epub 2021 Mar 25.

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, Tokyo, Japan.

Background: Depression deformity and paralysis of depressor muscles (DMs) may occur following tumor resection in the perimandibular region. Obtaining satisfactory results is challenging. The authors report 3 cases of 1-stage reconstruction by transferring neurovascular chimeric latissimus dorsi (LD) musculo-adipose flaps, with satisfactory results.

Methods: Three patients with depression deformity and DMs dysfunction after tumor resection in the perimandibular region underwent chimeric LD flap transfer. The flap comprised 1 portion with adipose tissue for augmentation, and the other contained muscle bellies with 1 or 2 neural pedicle (s) for DM reanimation. In case 1, the neural pedicle was sutured to the contralateral marginal mandibular branch. In case 2, the neural pedicle was sutured to the ipsilateral marginal mandibular branch. In case 3, the neural pedicle was sutured to both branches of the facial nerve.

Results: All patients were satisfied with the deformity corrections. However, contractions of the transferred muscles varied. Case 1 showed insufficient contraction. Case 2 had excessive muscle contraction. In case 3, the muscle had double innervation, and well-balanced contraction was maintained for 3 years.

Conclusions: Neurovascular chimeric LD flaps are versatile and useful for secondary reconstruction after tumor resection for functional loss of mimetic muscles. The ipsilateral facial nerve may be an effective motor source.
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http://dx.doi.org/10.1097/SCS.0000000000007652DOI Listing
March 2021

Arteriovenous Malformation of the Head and Neck in a Hemodialysis Patient.

Plast Reconstr Surg Glob Open 2021 Mar 24;9(3):e3485. Epub 2021 Mar 24.

Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan.

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http://dx.doi.org/10.1097/GOX.0000000000003485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990015PMC
March 2021

Establishing a Lymphatic Venous Anastomotic Training Model in Pig Trotters.

J Reconstr Microsurg 2021 Mar 11. Epub 2021 Mar 11.

Department of Plastic and Reconstructive Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.

Background:  Lymphatic venous anastomosis (LVA) is a widely accepted surgical procedure for lymphedema. To obtain the best outcomes, surgeons should be well trained. A recent study introduced an LVA training model using pig trotters for their utility and structural similarity to human tissues. However, details regarding the utilization of anastomosis models, such as feasible points for training based on vessel anatomy, have not been clarified. Therefore, we assessed the anatomical details of lymphatic vessels and veins of trotters to establish a practical training model of LVA.

Methods:  Ten frozen trotters were used. After thawing at room temperature, indocyanine green fluorescent lymphography was used to visualize the lymphatic course. To dissect the lymphatic vessels and veins from the distal to the proximal end, whole skins were detached thoroughly from the plantar side. Data from the lymphatic vessels and veins were collected based on their courses, diameters, and layouts to clarify adjacent points feasible for LVA training.

Results:  Both lymphatic vessels and veins were classified into four major courses: dorsal, medial, lateral, and plantar. The majority were dorsal vessels, both lymphatic vessels and veins. The adjacent points were always found in the distal dorsum center and were especially concentrated between the metacarpophalangeal (MP) joint and central interphalangeal crease, followed by the medial and lateral sides.

Conclusion:  The most relevant point for LVA surgical training in the trotter was the dorsal center distal to the MP joint, where parallel vessels of similar sizes were found in all cases. This practical LVA surgical model would improve surgeon skills in not only anastomosis but also preoperative fluorescent lymphography.
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http://dx.doi.org/10.1055/s-0041-1726026DOI Listing
March 2021

One-Stage Simultaneous Augmentation of 2 Regions of 3 Facial Reanimations After Mid Skull Base Surgery by Using a Neurovascular Latissimus Dorsi Chimeric Flap.

J Craniofac Surg 2021 Mar-Apr 01;32(2):730-733

Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, Tokyo, Japan.

Abstract: We report a patient who underwent secondary reconstruction for facial paralysis involving 2 regions of augmentation and 3 facial reanimations using a neurovascular latissimus dorsi (LD) chimeric flap.A 53-year-old man underwent mid-skull base surgery for a chondrosarcoma at the temporomandibular joint and primary reconstruction using a free anterolateral thigh flap. At 28 months after surgery, he showed temporal and buccal depression and incomplete facial paralysis. We planned 1-stage reconstruction using a neurovascular LD chimeric flap, which was divided into dual compounds of the neurovascular muscle with soft tissue along the descending and transverse bifurcation of the thoracodorsal neurovascular bundle. We added adipose tissue to the muscle belly of the transverse branch using microperforators. We cut the transverse nerve 2.7 cm from the hilus and about 5 cm from the bifurcation, enabling the proximal stump of the transverse branch to be sutured to the ipsilateral buccal branch and function as a cross-face nerve graft. The transverse branch compound was placed on the temporal region and its neural pedicle was sutured to the zygomatic branch. The descending branch compound was placed in the buccal region and sutured to the contralateral buccal branch.At 58 months after surgery, good contour remained, and smiling was voluntary and natural. On needle electromyography, the zygomatic major muscle and the muscle transferred to the buccal region showed good contraction, and the muscle transferred to the temporal region provided tonus to the lower eyelid. The versatility of the neurovascular chimeric flap facilitated multiple augmentations and 3 reanimations.
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http://dx.doi.org/10.1097/SCS.0000000000007010DOI Listing
March 2021

Factors Associated With Late Admission to Facial Plastic Surgery Among Patients With Long-Standing Facial Paralysis.

Ann Plast Surg 2021 Feb 19. Epub 2021 Feb 19.

From the Department of Plastic, Reconstructive, and Aesthetic Surgery, the University of Tokyo Hospital, Tokyo, Japan.

Background: Facial plastic surgeons often encounter patients experiencing untreated long-standing facial paralysis who are unaware that their condition can be managed by facial reconstructive procedures. To promote timely admission of patients with facial paralysis for facial plastic surgery, factors associated with late admission should be elucidated.

Methods: A retrospective chart review was conducted on patients admitted to our facial paralysis clinic. Late admission was defined by an onset-to-admission interval longer than the median value. Multivariable logistic regression analysis was used to assess the odds ratio of late admission with age, sex, etiology, referring physician specialty, and the time of first admission.

Results: A total of 199 cases from October 2017 to March 2020 were included. Onset-to-admission interval longer than 21 months (median) was considered late admission. Etiologies involving benign tumors and congenital diseases were significantly associated with late admission (odds ratio [95% confidence interval], 3.9 [1.0-14.4] and 31.7 [4.7-212.6], respectively). Most benign tumor cases were referred from nonplastic surgeons.

Conclusions: Benign tumors and congenital diseases were significantly related to late admission of patients with long-standing facial paralysis. As the majority of benign cases were referred from nonplastic surgeons, spreading awareness on facial plastic surgery as a treatment option may be necessary in promoting timely admission.
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http://dx.doi.org/10.1097/SAP.0000000000002754DOI Listing
February 2021

Sacral defect reconstruction using a sensate superior gluteal artery perforator flap based on the superior cluneal nerves: A report of two cases.

Microsurgery 2021 Feb 2. Epub 2021 Feb 2.

Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.

The superior gluteal artery perforator (SGAP) flap is a widely used flap for sacral reconstruction. However, it is non-sensate flap and sensory loss is one of the most important risk factors for pressure ulcer development and recurrence; therefore, a sensate SGAP flap would be ideal for the reconstruction. Because the upper buttock is innervated by the superior cluneal nerves (SCNs) which originate from Th11 to L4, a sensate SGAP flap based on SCNs is anatomically possible. Herein, we present a novel sensate SGAP flap based on SCNs for reconstruction of sacral defects. Two patients with a sacral defect underwent reconstruction using a sensate SGAP flap (53 and 56 years old, both men). Diagnoses were sacral spindle cell sarcoma and sacral pressure ulcer. The defect sizes were 16 × 13 and 12 × 11 cm. The flap was designed based on the locations of SCNs which are commonly located at 6-8 cm lateral from the midline at the iliac crest. Flap sizes were 16 × 9 and 15 × 13 cm, respectively. The flaps survived completely in both cases. Flap sensation was observed immediately after surgery except in flap margins. However, sensory recovery occurred in these areas as well several months postoperatively. None of the patients developed postoperative pressure ulcers during the follow-up period of 37 and 13 months. This method may preserve flap sensation and therefore can contribute to reducing the risk of postoperative pressure ulcers and could be a useful option for sacral reconstruction.
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http://dx.doi.org/10.1002/micr.30714DOI Listing
February 2021

Foot Web Space Transfer for Congenital Syndactyly.

Plast Reconstr Surg Glob Open 2020 Dec 17;8(12):e3292. Epub 2020 Dec 17.

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

Syndactyly of the hand is commonly treated using local flaps with skin grafts; however, contractures and/or pigmentation pose a challenge, requiring repeated surgery. Here, we describe a case of a 1-year-old boy who underwent web transplantation for syndactyly. To the best of our knowledge, no "web for web" transplantations have been documented in pediatric literature. Because the patient had an "extra" web space, functional and aesthetic reconstruction was performed with careful preparation. The vascular pattern was assessed using high-resolution ultrasonography. The flap was harvested under a microscope, intravascular stenting was performed for secure anastomosis, and the adequacy of circulation in the flap was verified using the indocyanine green test. Each technique in the procedure used by us contributed to making the microsurgery safer. The present case suggests that "web for web" is a favorable treatment option for some cases, although these would be limited in number.
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http://dx.doi.org/10.1097/GOX.0000000000003292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787337PMC
December 2020

Superficial Circumflex Iliac Perforator-Osteocutaneous Flap for Reconstruction of Extensive Composite Defects in the Forefoot.

Plast Reconstr Surg Glob Open 2020 Aug 25;8(8):e3076. Epub 2020 Aug 25.

Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.

Although the great toe plays important roles in walking, loading, and maintaining balance when compared with other toes, there are few reports on great toe reconstruction, including the reconstruction of distal phalanx. This report aims to describe the use of a superficial circumflex iliac artery perforator (SCIP)-osteocutaneous flap for reconstructing a complex tissue defect of the great toe. A 62-year-old man presented with a crush injury to the forefoot. Because the great toe was severely crushed, the defect distal to the proximal phalanx of the great toe was reconstructed using a SCIP-osteocutaneous flap. The immediate postoperative course was uneventful; however, surgical revision was necessary. Signs of osseous union could be observed on radiographic images taken 2 months after the initial surgery. Twenty-four months after surgery, the patient could freely walk without resorption of the transferred bone. We demonstrated that SCIP-osteocutaneous flaps may be promising free flaps in complex tissue defect reconstruction of the great toe.
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http://dx.doi.org/10.1097/GOX.0000000000003076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489706PMC
August 2020

Reconstruction for Severe Extracorporeal Membrane Oxygenation-induced Ischemic Lower Limb Injury Complicated by Osteomyelitis.

Plast Reconstr Surg Glob Open 2020 Aug 25;8(8):e3074. Epub 2020 Aug 25.

Department of Plastic, Reconstructive and Aesthetic Surgery, The University of Tokyo Hospital, Tokyo, Japan.

Extracorporeal membrane oxygenation (ECMO) is a well-established mechanical circulatory support system used in patients with life-threatening cardiopulmonary conditions. However, severe complications associated with vascular access require consideration. We report a patient with fatal ventricular arrhythmia who was successfully resuscitated with ECMO but who developed severe lower limb ischemia, which resulted in compartment syndrome. Even with emergent fasciotomy, tissue necrosis developed in wide areas of the limb, with subsequent tibial osteomyelitis. After extensive debridement and tibial sequestrectomy, the soft tissue and bone defect were simultaneously reconstructed with free tissue transfer of the latissimus dorsi muscle and scapular tip composite flap. The limb was successfully salvaged with satisfactory functional outcomes without major complications. This report discusses limb reconstruction for ECMO-induced compartment syndrome and illustrates the importance of appropriate selection of reconstruction methods among various composite flaps.
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http://dx.doi.org/10.1097/GOX.0000000000003074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489680PMC
August 2020

Microvascular Hepatic Artery Anastomosis in Living Donor Liver Transplantation for Erythropoietic Protoporphyria.

Plast Reconstr Surg Glob Open 2020 Aug 17;8(8):e3066. Epub 2020 Aug 17.

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

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http://dx.doi.org/10.1097/GOX.0000000000003066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489609PMC
August 2020

Application of Artificial Intelligence for Real-Time Facial Asymmetry Analysis.

Plast Reconstr Surg 2020 08;146(2):243e-245e

Department of Plastic, Reconstructive, and Aesthetic Surgery, University of Tokyo Hospital, Tokyo, Japan.

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http://dx.doi.org/10.1097/PRS.0000000000007035DOI Listing
August 2020

Measurement of optical reflection and temperature changes after blood occlusion using a wearable device.

Sci Rep 2020 07 13;10(1):11491. Epub 2020 Jul 13.

Department of Electrical Engineering and Information Systems, Graduate School of Engineering, The University of Tokyo, Tokyo, Japan.

Early detection of compromised circulation is essential for postoperative monitoring of free flap. Hourly clinical check-ups such as inspection and palpation still result in a delay in detection. Conversely, optical reflection and temperature measurement are useful alternatives for detecting blood circulation. However, conventional methods that verify ischemia and congestion within a short period have not been reported. In this study, we measured short-term changes in optical reflection and temperature in a rat flap using a wearable flexible sensor probe previously developed in our laboratory. Five ischemia and five congestion groin flap models were measured using a sensor probe and reference devices. Curve fitting was performed on transition signals to evaluate changes in signals and their time constants. The optical reflection signal decreased after venous ligation and increased after arterial ligation. The parameters of the fitted curves indicate a significant difference between congestion and ischemia at p < 0.01 (probability value), which was detected within a few minutes after ligation. However, insufficient significance was observed in the temperature signal. Our method gives supporting information to verify ischemia and congestion, and has the potential to rapidly detect compromised circulation.
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http://dx.doi.org/10.1038/s41598-020-68152-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359365PMC
July 2020

Combined Use of an Innervated Radial Forearm Flap and Labia Minora Peripheral Skin Graft for Total Upper Lip Reconstruction.

J Craniofac Surg 2020 Sep;31(6):1678-1680

Department of Plastic, Reconstructive, and Aesthetic Surgery, University of Tokyo Hospital.

The repair of a total lip defect and reconstruction of the vermilion border of the lip is challenging. Here, the authors report the successful functional and esthetic reconstruction of an injured upper lip using a free radial forearm flap and labia minora peripheral skin graft. A 43-year-old woman accidentally fell, resulting in a full-thickness wound in her entire upper lip. One month after the injury, the upper lip was reconstructed with an innervated free radial forearm flap. Six months postoperatively, a Semmes-Weinstein monofilament pressure esthesiometer indicated good recovery of neurosensory function with a value of 2.83. Nine months after the injury, the vermilion border, white roll, and philtrum were reconstructed. The vermilion border was reconstructed using a labia minora peripheral skin graft. The philtrum was reproduced using pigmented skin harvested from the vicinity of the labia minora, and the white roll was reconstructed 3-dimensionally by turning the dermis beneath the skin. Satisfactory results were obtained. The combined use of an innervated free radial forearm flap and labia minora peripheral skin graft may be an option for repairing extensive upper lip defects.
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http://dx.doi.org/10.1097/SCS.0000000000006688DOI Listing
September 2020

Two-stage Reconstruction Using a Free Jejunum/Ileum Flap After Total Esophagectomy.

Ann Plast Surg 2020 12;85(6):638-644

From the Department of Plastic and Reconstructive Surgery, The University of Tokyo, Bunkyo-ku.

Background: Reconstruction after esophagectomy is conventionally performed with a gastric conduit. However, in cases where a gastric conduit is unavailable, reconstructive procedures vary in terms of flap type, operative timing, and conduit route. Single-stage surgery is associated with a long operation time and high surgical stress, resulting in perioperative mortality. Recent advances in reconstructive microsurgery have made free intestinal flap transfer safe and reliable. Therefore, to overcome the shortcomings with previous methods, we performed 2-stage surgery involving free jejunum/ileum transfer for reconstruction after esophagectomy.

Patients And Methods: From 2010 to 2018, 42 free jejunum/ileum flaps were transferred for reconstruction after esophagectomy in 41 patients. The diagnosis was esophageal cancer in 38 patients. All operations were performed in 2 stages. In most cases, total esophagectomy was performed in the first operation. The cervical stump of the esophagus was sutured to the cervical skin, creating an esophagostomy in the left neck. About 4 to 7 weeks after the first operation, the second operation was performed. The free jejunum/ileum flap was transferred through the subcutaneous route. Microvascular anastomosis was performed with the internal mammary artery and internal mammary vein, transverse cervical artery, internal and external jugular veins (internal jugular vein and EJV, respectively), and cephalic vein. The mean follow-up duration was 20 months.

Results: Free jejunum/ileum transfer was performed as the first operation in 4 cases and as the second operation in 38 cases. A free jejunal flap was used in 36 cases and free ileal flap was used in 6 cases. The recipient arteries were the internal mammary artery in 38 cases and transverse cervical artery in 4 cases. The recipient veins were the internal mammary vein in 15 cases, cephalic vein in 13 cases, EJV in 10 cases, and internal jugular vein in 10 cases. The flaps survived in all cases, except 1 case (41/42, 97.6%). The complications were anastomotic leakage of the flap in 9 cases, respiratory complications in 10 cases, and ileus in 2 cases. Perioperative mortality was not noted.

Conclusions: Two-stage surgery using free jejunum/ileum flap transfer is a safe and reliable option for esophageal reconstruction in cases where gastric pull-up is unavailable.
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http://dx.doi.org/10.1097/SAP.0000000000002421DOI Listing
December 2020

Endoscopic open rhinoplasty enables a cosmetic approach for a rare case of intraosseous cavernous hemangioma in the nasal bone.

Auris Nasus Larynx 2020 Dec 10;47(6):1064-1069. Epub 2020 Jan 10.

Department of Plastic Reconstructive and Aesthetic Surgery, University of Tokyo, Clinical Research Center A 2F, Hongo 7-3-1, Bunkyoku-City, Tokyo 113-8655, Japan.

A rare case of intraosseous cavernous hemangioma was identified in the nasal root. Using a combination of endoscopic surgery and open rhinoplasty, an osteotomy was performed and resection of the hemangioma was successfully achieved with transcolumellar and infracartilaginous incisions and 2 stab incisions. No adverse side effects were observed after the procedure, no tumor recurrence was observed at the 16-month-postoperative follow-up. The preserved periosteum contributed to the osteogenesis and thus, a need for a reconstructive surgery was indicated. The favorable outcomes associated with this approach justify and authenticate the use of endoscopy-assisted open rhinoplasty in the treatment of intraosseous cavernous hemangiomas without leaving ventral surgical scarring.
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http://dx.doi.org/10.1016/j.anl.2019.12.002DOI Listing
December 2020

Miniaturization of Indocyanine Green Fluorescence Imaging Device Using a Smartphone.

Plast Reconstr Surg 2020 01;145(1):230e-232e

Department of Plastic, Reconstructive, and Aesthetic Surgery, University of Tokyo Hospital, Tokyo, Japan.

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http://dx.doi.org/10.1097/PRS.0000000000006365DOI Listing
January 2020

Additional venous anastomosis in free profunda artery perforator flap transfer using the posterior accessory saphenous vein.

J Plast Reconstr Aesthet Surg 2019 Dec 24;72(12):1936-1941. Epub 2019 Sep 24.

Department of Plastic and Reconstructive Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1138655, Japan.

Background: The profunda artery perforator (PAP) flap has recently been widely used for head and neck as well as breast reconstruction. Although this flap has various advantages, its vascular pedicle is relatively smaller and shorter than that of other workhorse flaps such as the anterolateral thigh flap. The posterior accessory saphenous vein (pASV) is a branch of the great saphenous vein, which runs in the posteromedial aspect of the thigh and can be included in the PAP flap. Here, we present the anatomical characteristics of the pASV and feasibility of its use in PAP flap transfers.

Patients And Methods: An anatomical study of the pASV was conducted in nine lower extremities of five patients using ultrasonography. Several landmarks such as point A (the point where the pASV crosses the posterior border of the adductor longus muscle), point B (the point where the pASV merges with the great saphenous vein) and the inguinal crease, were marked. Distribution of the pASV was plotted, and several distances were measured. On the basis of the anatomical study, nine free PAP flap transfers were performed.

Results: In the anatomical study, the mean diameter of the pASV was 3.4 and 4.9 mm at points A and B, respectively. The mean available length of the pASV was 9.4 cm. In clinical cases, all flaps completely survived. No flap-related complication was observed. The pASV was included in the PAP flap in eight cases. The mean length of the harvested pASV was 8.6 cm, and the mean diameter was 3.3 mm. Indocyanine green angiography showed effective drainage using the pASV alone.

Conclusions: The use of the pASV can be an effective option, particularly for head and neck reconstruction, and its application in various types of reconstructive surgery can be widened.
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http://dx.doi.org/10.1016/j.bjps.2019.09.013DOI Listing
December 2019

Development of de novo epithelialization method for treatment of cutaneous ulcers.

J Dermatol Sci 2019 Jul 22;95(1):8-12. Epub 2019 Jun 22.

Department of Plastic and Aesthetic Surgery, The University of Tokyo Hospital, Japan.

Cutaneous ulcers are a common cause of morbidity. We have developed a de novo epithelialization method for treating cutaneous ulcers by means of reprogramming wound-resident mesenchymal cells in vivo into cells able to form a stratified epithelium: induced stratified epithelial progenitors (iSEPs). Administration of 4 transcription factors (DNP63A, GRHL2, TFAP2A, and cMYC) expressed via adeno-associated viral vectors enabled generation of epithelial cells and tissues, thereby acheiving de novo epithelialization from the surfaces of cutaneous ulcers in a mouse model. Generated epithelia, having barrier functions equivalent to the original epidermis, were maintained for more than 6 months. Our findings constitute a proof of concept for future development towards innovative therapies for cutaneous ulcers via de novo epithelialization.
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http://dx.doi.org/10.1016/j.jdermsci.2019.06.006DOI Listing
July 2019

Treating Pulsatile Exophthalmos in Child with Minimally Invasive Approach and Custom-made Titanium Mesh Plate.

Plast Reconstr Surg Glob Open 2019 Feb 11;7(2):e2070. Epub 2019 Feb 11.

Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.

Orbital roof fracture is a relatively rare trauma. In most cases, surgical intervention is not needed since the fracture is slight. However, invasive surgical procedures are inevitable once pulsatile exophthalmos occurs if vision impairment is to be avoided. We report our rare experience of orbital roof fracture in a child with pulsatile exophthalmos. Good reconstruction of the anterior cranial base was achieved using a custom-made titanium mesh and a minimally invasive approach. A 3-year-old girl who had been diagnosed with subdural hematoma, brain contusion, and fracture of the right orbital roof caused by facial bruising underwent emergent external decompression by coronal skin incision and a transcranial approach on the same day as the trauma. Cranioplasty using autologous frozen bone in the same approach was performed 103 days posttrauma, but this was followed by pulsatile exophthalmos. After recovering from critical stage, the girl was brought to our department for reconstruction of the anterior base. Risk of vision impairment was also one reason for reconstruction, but the neurosurgeon hesitated to approach the region using a coronal approach considering the possibility of infection in the frozen autologous bone. Through cross-team discussion, reconstruction using a subeyebrow incision was performed with a custom-made titanium mesh plate. Pulsatile exophthalmos completely disappeared. Pulsatile exophthalmos is a very rare but serious complication that carries a risk of vision impairment. By applying a custom-made titanium mesh plate, precise reconstruction was enabled with minimal invasiveness and low risk.
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http://dx.doi.org/10.1097/GOX.0000000000002070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416129PMC
February 2019

Reply: Microanatomy of Sensory Nerves in the Upper Eyelid: A Cadaveric Anatomical Study.

Plast Reconstr Surg 2019 02;143(2):437e-438e

Department of Clinical Anatomy, Tokyo Medical and Dental University, Tokyo, Japan.

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http://dx.doi.org/10.1097/PRS.0000000000005235DOI Listing
February 2019

Microanatomy of Sensory Nerves in the Upper Eyelid: A Cadaveric Anatomical Study.

Plast Reconstr Surg 2018 08;142(2):345-353

From the Department of Plastic and Reconstructive Surgery, the Institute of Education, and the Department of Clinical Anatomy, Tokyo Medical and Dental University; and the Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East.

Background: Plastic surgery requires detailed knowledge of upper eyelid anatomy, but few authors have sufficiently described the specifics of upper eyelid nerve anatomy. This study aimed to provide a thorough description of sensory nerve anatomy in the upper eyelid and to propose considerations for upper eyelid surgery.

Methods: Sixteen orbits were dissected from 16 fixed, adult human cadavers. Microscopically, the authors identified the main trunks of the infratrochlear, supratrochlear, and supraorbital nerves and all branches that projected toward the upper eyelid. The number, size, and distribution of nerve branches were recorded.

Results: The branches of the infratrochlear, supratrochlear, and supraorbital nerves covered a wide range in the upper eyelid. The mean numbers of branches per nerve were 1.6 ± 1.2, 3.2 ± 1.5, and 2.6 ± 1.4, respectively. The branches of the infratrochlear nerve were distributed throughout the medial area of the upper eyelid. Those of the supratrochlear nerve were distributed throughout the medial and central areas, and the palpebral branches of the supraorbital nerve were distributed throughout the central and lateral areas of the upper eyelid. The lateral branches of the supraorbital nerve and the cutaneous branches of the lacrimal nerve were distributed in the lateral region of the orbit.

Conclusions: The authors show that upper eyelid sensation is transmitted mainly by the supratrochlear and supraorbital nerves, and the authors provide a map of the distribution of upper eyelid sensory nerves. This precise anatomical knowledge about upper eyelid sensory nerves will facilitate pain control and help minimize nerve injuries during surgery.
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http://dx.doi.org/10.1097/PRS.0000000000004554DOI Listing
August 2018

Efficacy of Tensed and Straight Free Jejunum Transfer for the Reduction of Postoperative Dysphagia.

Plast Reconstr Surg Glob Open 2017 Dec 28;5(12):e1599. Epub 2017 Dec 28.

Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan; Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan; Division of Plastic and reconstructive surgery, Miyagi Cancer Center, Natori, Japan; Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan; Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, Tokyo, Japan; Department of Otorhinolaryngology and Head and Neck Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Biostatistics Division, Center for Research Administration and Support, National Cancer Center, Kashiwa, Japan; Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan; Department of Plastic and Reconstructive Surgery, Iwate Medical University, Morioka, Japan; and Juntendo University Graduate School of Medicine, Advanced Clinical Research of Cancer, Tokyo, Japan.

Background: Free jejunal transfer (FJT) is a standard method of reconstruction after total pharyngo-laryngo-cervical esophagectomy (TPLE) in patients with advanced head and neck cancer. However, it is related to various degrees of postoperative swallowing dysfunction. This study aimed to assess whether the tensed and straight FJT method results in a reduced rate of postoperative dysphagia compared with historical controls.

Methods: Patients who were undergoing FJT after TPLE for squamous cell carcinoma of the hypopharynx or cervical esophagus were enrolled. The primary endpoint was the rate of not developing dysphagia within 6 months of the surgery, and we compared this value with that obtained from historical data of patients who underwent FJT. The secondary endpoint was the rate of developing surgical complications.

Results: Although 128 patients were registered between August 2012 and July 2015, 7 were excluded based on the exclusion criteria. Of the remaining 121 patients, FJT with the craniocaudally tensed and straight method was performed in all patients. The rate of not developing dysphagia and its 95% confidence interval (CI) were 66.1% and 57.0-74.5%, respectively. The lower limit of the CI was higher than the prespecified threshold value of 50.0%. The rate of developing complications of total necrosis of the jejunum was 3.3%, cervical infection was 9.9%, and major anastomotic leakage was 4.1%.

Conclusions: Our findings revealed that the proportion of postoperative dysphagia decreased in patients who underwent tensed and straight FJT. This method may become the standard surgical method in reconstruction of defects after TPLE.
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http://dx.doi.org/10.1097/GOX.0000000000001599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889443PMC
December 2017

A new method for selecting auricle positions in skull base reconstruction for temporal bone cancer.

Laryngoscope 2018 11 25;128(11):2605-2610. Epub 2018 Mar 25.

Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, Tokyo, Japan.

Objective: In advanced temporal bone carcinoma cases, we attempted to preserve as much of the auricle as possible from a cosmetic and functional perspective. Difficulties are associated with selecting an adequate position for reconstructed auricles intraoperatively. We improved the surgical procedure to achieve a good postoperative auricle position.

Methods: Nine patients were included in this study. All patients underwent subtotal removal of the temporal bone and resection of the external auditory canal while preserving most of the external ear, and lateral skull base reconstruction was performed with anterolateral thigh flaps. We invented a new device, the auricle localizer, to select the correct position for the replaced external ear. The head skin incision line and two points of three-point pin fixation were used as criteria, and a Kirschner wire was shaped as a basic line to match these criteria. Another Kirschner wire was shaped by wrapping it around the inferior edge of the external ear as the positioning line, and these two lines were then combined. To evaluate the postoperative auricle position, the auricle inclination angle was measured using head frontal cephalogram imaging.

Results: The external ear on the affected side clearly drooped postoperatively in nonlocalizer cases, whereas this was not obvious in localizer cases. Auricle inclination angles 1 year after surgery significantly differed between these two cases (P = 0.018).

Conclusion: The surgical device, the auricle localizer, is useful for selecting intraoperative accurate auricle positions. The assessment index, the auricle inclination angle, is useful for quantitatively evaluating postoperative results.

Level Of Evidence: 4 Laryngoscope, 2605-2610, 2018.
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http://dx.doi.org/10.1002/lary.27170DOI Listing
November 2018

Desmoplastic transformation of a nodular melanoma arising from a speckled lentiginous nevus.

J Dermatol 2018 Aug 21;45(8):e230-e231. Epub 2018 Feb 21.

Department of Plastic and Reconstructive Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.

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http://dx.doi.org/10.1111/1346-8138.14266DOI Listing
August 2018

Simultaneous Surgical Treatment for Smile Dysfunction and Lagophthalmos Involving a Dual Latissimus Dorsi Flap.

Plast Reconstr Surg Glob Open 2017 Jul 25;5(7):e1370. Epub 2017 Jul 25.

Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, Tokyo, Japan.

Paralytic lagophthalmos and smile dysfunction are serious complications of facial paralysis and various reconstructive procedures have been developed to treat them. Among these procedures, there is no doubt that dynamic procedures are more effective than static ones. The 1-stage simultaneous surgical treatment of these 2 dysfunctions with a dynamic procedure involving a single muscle would be ideal, but no such methods have been reported. In this article, we present a 1-stage method for the simultaneous surgical treatment involving the use of a dual latissimus dorsi muscle flap. In this method, 2 muscle flaps based on the descending and transverse branches of the thoracodorsal vessels are transferred to the face. The descending and transverse branches of the thoracodorsal nerve are sutured to separate branches of the masseteric nerve. Using this method, complete eyelid closure during strong clenching and voluntary smiling during weak clenching without eyelid closure were achieved. Although our method does not result in spontaneous smiling, we believe that it is a good option for some patients with long-standing facial paralysis.
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http://dx.doi.org/10.1097/GOX.0000000000001370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548557PMC
July 2017

The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report.

Microsurgery 2017 Sep 2;37(6):694-698. Epub 2017 Aug 2.

Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, Tokyo, Japan.

Microsurgical procedure of free tissue transfer in critical limb ischemia patients with large ulceration has already been established. The nutrient flap concept was that transferred tissue functioned not only to cover the skin defect but also as a supplementary blood supply to the ischemic lower leg. This report showed the justification for this concept, which was rarely discussed. A 58-year-old male patient with progressive forefoot gangrene caused by arteriosclerosis obliterans was presented. The distal bypass procedure was performed as revascularization surgery, and a latissimus dorsi (LD) myocutaneous flap was transplanted to cover ulceration. The arterial pedicle of the flap was anastomosed to the vein graft in an end-to-end manner, and the venous pedicle was anastomosed to the posterior tibialis vein in an end-to-end manner. Bypass graft blood flow went straight to the LD flap only. The postoperative course was uneventful. The free flap and right foot survived successfully and the patient was ambulatory with no recurrence of ulceration wearing order-made shoes more than three years after transplantation. Vessel-selective angiography was performed two months after surgery. An angiographic catheter was inserted into the bypass graft, which ran straight through the flap nutrient artery. The results obtained showed that not only the transferred flap area, but also the remaining original foot soft tissue (including the sole and heel) was clearly visualized radiologically only through the flap nutrient vessel. This findings of the angiography appear to provide direct evidence for the nutrient flap concept.
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http://dx.doi.org/10.1002/micr.30215DOI Listing
September 2017

Objective assessment of reconstructed breast hardness using a durometer.

Breast Cancer 2018 Jan 23;25(1):81-85. Epub 2017 Jun 23.

Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Background: Whether a durometer was suitable for objectively measuring reconstructed breast hardness was evaluated.

Methods: Subjects were 81 women who underwent expander-implant reconstructions following breast cancer ablation. Capsular contracture was evaluated with Baker grading. Capsular thickness was measured with T1-weighted MRI at the upper areola area. The durometer was placed on the upper areola. Multiple logistic regression analysis was performed to compare variables.

Results: On Baker grading, 17 breasts were Baker grade I, 52 breasts were Baker grade II, 11 breasts were Baker grade III, and 1 breast was Baker grade IV. Mean capsular thickness on MRI was 1.1 (SD 0.4) mm with Baker grade I, 1.2 (SD 0.3) mm with Baker grade II, 1.4 (SD 0.4) mm with Baker grade III, and 1.9 mm with Baker grade IV. Mean durometer value was 0 with Baker grade I, 0.2 (SD 0.5) with Baker grade II, 2.0 (SD 1.7), with Baker grade III, and 8 with Baker grade IV. Baker grade IV was excluded from analysis because there was only one case. When Baker grade III was defined as positive for hardness, multiple logistic regression analysis showed that durometer value was associated with Baker grade III (p = 0.0005), but capsular thickness was not. On receiver operating characteristic curve analysis of the durometer value for Baker grade III, the optimal cutoff value was 0.5 (sensitivity 0.92, 1-specificity 0.17, area under the curve 0.92).

Conclusions: The durometer offers an objective index of hardness that might replace the subjective Baker grading. Further studies are needed to confirm the utility of this index.
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http://dx.doi.org/10.1007/s12282-017-0791-yDOI Listing
January 2018