A case of congenital generalized lipodystrophy with lipoatrophic diabetes developing anti-insulin antibodies.
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Adult↗
Biomedical subjects
I Koshima
Publications and source records attributed to I Koshima.
Perforator flaps in lower extremity reconstruction.
Perforator flaps are defined as skin flap without fascia or muscle and they are nourished by one or more perforating vessels perforating the fascia, muscle, or intermuscular septum. As early as 1985 in Japan, we proposed this concept over that of the fasciocutaneous flap, which was believed to be nourished by fascial plexus. The pedicle perforators are classified as septocutaneous, muscular (intermuscular), periosteal, and intertendinous perforators. As useful perforator flaps in the lower extremity, posterior tibial perforator island flaps, saphenous island flaps, peroneal island flaps, malleolar island perforator flaps, deep inferior epigastric perforator free flap (DIEP flap), anterolateral thigh free flap (ALT flap), and latissimus dorsi muscle free perforator flap (thoracodorsal artery perforator flap, T-DAP or TAP flap) were described. These flaps have the advantage of minimal donor-site morbidity, relatively rapid dissection and flap elevation, and reliable skin territory.
Adult↗
One-stage facial contour augmentation with intraoral transfer of a paraumbilical perforator adiposal flap.
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Adolescent↗
Free vascularized nail graft under digital block.
Vascularized toenail grafts with long vascular pedicles have usually been transferred under general anesthesia. In this paper, a minimally invasive vascularized nail graft with a short pedicle and small cutaneous flap, which was successfully transferred under digital block of the finger and toe, is described.
Amputation, Traumatic↗
One-stage facial augmentation with an intraoral groin adipose flap transfer.
A free groin adipose flap using an intraoral approach was used to correct facial contour deformities instead of a groin dermis-fat flap. The major disadvantages of the latter flap are that multistage debulking procedures are required and there are wide postoperative donor scars because of the wide skin portion included in the flap. To overcome these weaknesses the authors developed a free groin, customized ("berry picked") adipose flap, which was transferred by an intraoral approach for reconstruction of congenital hemifacial (orbitozygomatic) hypoplasia. The advantages of this method include one-stage augmentation without secondary defatting, no skin grafting of the donor defect, a donor scar in a concealed area, and possible transfer through an intraoral approach that results in minimal invasive surgery with no scar at the graft site.
Adipose Tissue↗
Free medial plantar perforator flaps for the resurfacing of finger and foot defects.
In this article, three cases in which free medial plantar perforator flaps were successfully transferred for coverage of soft-tissue defects in the fingers and foot are described. This perforator flap has no fascial component and is nourished only by perforators of the medial plantar vessel and a cutaneous vein or with a small segment of the medial plantar vessel. The advantages of this flap are minimal donor-site morbidity, minimal damage to both the posterior tibial and medial plantar systems, no need for deep dissection, the ability to thin the flap by primary removal of excess fatty tissue, the use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, short time for flap elevation, possible application as a flow-through flap, and a concealed donor scar.
Adolescent↗
Free tensor fasciae latae perforator flap for the reconstruction of defects in the extremities.
In the three cases presented in this study, free tensor fasciae latae perforator flaps were used successfully for the coverage of defects in the extremities. This flap has no muscle component and is nourished by muscle perforators of the transverse branch of the lateral circumflex femoral system. The area of skin that can by nourished by these perforators is larger than 15 x 12 cm. The advantages of this flap include minimal donor-site morbidity, the preservation of motor function of the tensor fasciae latae muscle and fascia lata, the ability to thin the flap by removing excess fatty tissue, and a donor scar that can be concealed. In cases that involve transection of the perforator above the deep fascia, the operation can be completed in a very short period of time. This flap is especially suitable as a free flap for young women and children who have scars in the proximal region of the lateral thigh or groin region that were caused by split-thickness skin grafting or full-thickness skin grafting during previous operations.
Adult↗
A new classification of free combined or connected tissue transfers: introduction to the concept of bridge, siamese, chimeric, mosaic, and chain-circle flaps.
Recently, combined tissues or flaps have been used for the repair of extensively massive or wide defects resulting from radical wide resection. To further advance the development of combined tissue transfers, they should be reclassified. Based on our cases with free tissue transfers, we have created a new classification of combined flaps composed of "bridge", "chimeric", "siamese", "mosaic", and "chain-circle" flaps. The bridge flap is fabricated out together of separate flaps with short vascular pedicles. These form a compound flap supplied with a solitary vascular source. The chimeric flap is compounded from multiple different flaps but consists of only a single different tissue form. Each of the flaps is usually supplied by different branches from the same source vessel. It differs from the bridge flap in that the pedicle of each flap or tissue has some length for its movement for transfer. The siamese connected flap has 2 adjacent flaps that are simultaneously elevated, and a disparate vascular pedicle for each flap must be reestablished. This connected flap has double isolated pedicles. Themosaic connected flap consists of 2 adjacent flaps that are simultaneously elevated, and the pedicle of the distal flap is anastomosed to the pedicle branch of the proximal flap in the "bridge" fashion. The vascular pedicle of the proximal flap is anastomosed to a single vascular source. The chain-circle flap has 2 or more flaps like the bridge and chimeric flaps, and the distal end of the vascular source is anastomosed to the branch of the recipient vessel. Based on results with our patients, the lateral circumflex femoral system seems to be the most suitable candidate for the axial pedicle of these combined flaps, because the system has several branches of large and small caliber, and several tissue components, such as the vascularized ilium, rectus femoris muscle, gracilis muscle, lateral femoral cutaneous nerve, and fascia lata, are located nearby.
Connective Tissue↗
Combined submental flap with toe web for reconstruction of the lip with oral commissure.
We present a new method employing a combined submental island flap and dorsalis pedis flap with the first toe web for reconstruction of a large lip defect including the oral commissure. The advantages of this method are: there is an excellent colour match; an anatomical structure similar to that of the oral commissure produces excellent results; there is superb function of the oral commissure; a donor-scar deformity can be avoided, since both flaps come from concealed areas; and good lining by the thin dorsal skin of the foot and submental skin results in a single-stage operation. The disadvantages are that complicated microvascular anastomoses may be required and there is a possibility of venous congestion of the submental flap in cases with a hypoplastic venous system. The use of the anterior jugular vein within the flap may be a key to overcoming this problem.
Aged↗
Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities.
Over the last eight years, the authors analyzed obstructive lymphedema of a unilateral upper extremity in a total of 27 females, comparing the use of supramicrosurgical lymphaticovenule anastomoses and/or conservative treatment. The most common cause of edema was mastectomy, with or without subsequent radiation therapy for breast cancer. As an objective assessment of the extent of edema, the circumferences of the affected and opposite normal forearms were measured at 10 cm below the olecranon of the arm. Twelve of these patients received continual bandaging. In these patients, the average excess circumference of the affected arm was 6.4 cm over that of the normal forearm; the average duration of edema before treatment was 3.5 years; the average period for conservative treatment was 10.6 months; and the average decrease in circumference was 0.8 cm (11.7 percent of the preoperative excess). Twelve patients underwent surgery and postoperative continual bandaging. In these patients, the average excess circumference was 8.9 cm; the average duration of edema before surgery was 8.2 years; the average follow-up after surgery was 2.2 years; and the average decrease in circumference was 4.1 cm (47.3 percent of the preoperative excess). These results indicated that supermicrolymphaticovenular anastomoses with postoperative bandaging have a valuable place in the treatment of obstructive lymphedema.
Adult↗
New multilobe "accordion" flaps for three-dimensional reconstruction of wide, full-thickness defects in the oral floor.
When reconstructing a wide, full-thickness intraoral defect, the following principles are necessary for active food transport and improved swallowing and speech. First, the flap should touch the palate and obliterate the oral cavity. Second, jaw or flap excursion should not be hindered by tethering of the flap in the neck. And third, all surfaces of the tongue and oral floor, and the dead space of the floor should be reconstructed. To accomplish these goals, two new designs, similar to an accordion, using an anterolateral thigh flap and a deep inferior epigastric perforator flap have been developed. The outlines of multilobe flaps create an accordion-type structure of the tongue and oral floor complex. The advantages of the new designs using anterior thigh or deep inferior epigastric perforator flaps are follows: First, three-dimensional intraoral reconstitution allows maximal movement postoperatively of the reconstructed tongue. Second, the donor sites are so far from the tongue that simultaneous flap elevation is possible for tumor resectioning. Third, even in obese patients, totally or partially thin flaps are available. And fourth, in most patients the donor defects can be closed directly.
Adult↗
Fingertip reconstructions using partial-toe transfers.
Fifty-six partial toes were transferred to reconstruct fingertip deficits. The transfers from the big toe mainly consisted of 3 trimmed big toetips, 3 vascularized nail grafts, 3 onychocutaneous flaps, 19 thin osteo-onychocutaneous flaps, and 2 hemipulp flaps. The transfers from the second toe mainly consisted of 8 trimmed second toetips, 5 reduced second toes, and 9 whole distal phalanges. The average values of postoperative sensory recovery of the osteo-onychocutaneous flaps including the vascularized nail grafts were 3.1 (Semmes-Weinstein test) and 6.3 mm (moving two-point discrimination) at 2.6 years after the transfer; those of the thin osteo-onychocutaneous flaps were 3.1 and 7.2 mm at 2.0 years after surgery; those of the trimmed big toe tip transfers were 3.61 and 6.5 mm at 1.8 years after surgery; and those of the trimmed second toetip transfers were 3.37 and 6.3 mm at 2.6 years after transfer. Those of the distal phalanx of the second toe were 3.41 and 7.9 mm at 1.2 years after surgery, and those of the reduced second toe were 3.2 and 6.7 mm at 10.6 months after surgery.
Adult↗
Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities.
Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.
Adolescent↗
New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps.
Pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps have generally been used for bilateral breast losses. The major disadvantages of this method are the total or partial loss of the rectus abdominis muscles and various resulting postoperative complications, such as abdominal bulging and lumbar pain. With the recent development of perforator flaps and supermicrosurgery with anastomosis of 0.5-mm caliber vessels, these serious complications can be overcome with a paraumbilical perforator adiposal flap, without sacrificing the rectus abdominis muscle. The breasts of a 57-year-old woman who had undergone a bilateral subcutaneous mastectomy, including silicone prostheses, were repaired simultaneously with this new method using free paraumbilical perforator adiposal flaps. This new method of breast augmentation with a vascularized adiposal flap and without any muscle component is minimally invasive; its advantages are the preservation of the rectus abdominis muscles and the short time elevation for the adiposal flap.
Arteries↗
Ear helix flap for reconstruction of total loss of the upper eyelid.
We present a patient with a recurrent carcinoma of the right upper eyelid who underwent resection of the subtotal upper eyelid resulting in a full-thickness defect. The eyelid was reconstructed with advanced conjunctival lining and an ascending helix chondrocutaneous flap from the right auricle. This flap was nourished with a reverse flow of the frontal branch of the superficial temporal vessels. A superficial temporal vein of the flap was anastomosed to the zygomaticofacial branch of the superficial temporal vein at the lateral canthal region to ensure adequate drainage. The flap survived without any congestion. An ascending helix flap is the best candidate for total loss of the upper eyelid.
Aged↗
Denervation of Pacinian corpuscles: electron microscopic observations in the rat following nerve transection.
Nerve transection using rat sciatic nerves was employed to observe morphologic changes in the periodic denervation of Pacinian corpuscles. During periods of from 1 to 20 weeks after surgery, a total of 15 corpuscles were obtained under the operating microscope and processed for morphologic analysis using light and electron microscopes. Based on the morphologic findings, normal corpuscles were composed of an axon terminal and inner and outer core cells. Following nerve transection, the axon terminal immediately disappeared at 1 week, but the original inner and outer core cells were preserved, with macrophage migration occurring in the outer core. After 8 weeks, the circular regularity of the inner and outer core lamellae was occasionally broken. The lamellae had wavy courses and there were many empty spaces in the inner core. Even at 20 weeks after denervation, there was interruption in the continuity of the outer core cells; the membranous structure of the outer core and the lamellar structure of the inner core were well-preserved; the outer and inner core cells were still present. Simultaneously, a small number of collagen fibrils were observed between the inner and outer core cells from the earliest postoperative stage. These fibrils increased in number in later stages. The results suggest that, immediately after destruction of axon terminals, macrophages migrate into the interlamellar spaces where they engulf the debris of the degenerated axon terminals. The degeneration of the corpuscles seems to be similar to that of denervated nerve axons; therefore, the inner core cells, which are continuous with the Schwann cells, maintain their original condition for at least 20 weeks after corpuscle denervation. The outer core cells, which are continuous with the perineurial nerve cells, are assumed to be the main cells producing the collagen fibrils in the denervated Pacinian corpuscles.
Animals↗
Free vascularized appendix transfer for reconstruction of penile urethras with severe fibrosis.
Despite the development of newer techniques with a free radial forearm tube flaps for phallus reconstruction, severe urethral strictures are still seen in such cases after irradiation or repeated infection because of the paucity of healthy, well-vascularized tissue. For urethral reconstruction in cases with poorly vascularized tissue as well as for total penile creation, a new technique involving a free vascularized appendix transfer combined with a radial forearm osteocutaneous flap was successfully used in two cases. The appendix provides a normal tube structure composed of a muscular tubular layer lined with mucosal epithelium. It has no hair and has rich vascularization. This results in little stricture at the junction with the original urethra, no occurrence of urethral stones, and possible postoperative enlargement of the diameter with changes in catheters. This method will allow a patient with severe fibrosis around the urethra to undergo one-stage phallus reconstruction with minimal complications.
Adult↗
Flow-through thin latissimus dorsi perforator flap for repair of soft-tissue defects in the legs.
Flow-through thin latissimus dorsi perforator flaps were used in six cases with complicated defects of the legs. This flap has a small amount of latissimus dorsi muscle with a considerable amount of fatty tissue removed to make a thin flap. In addition, the flap has several branches of the subscapular vessel, which are interposed to the recipient vessels of the legs. The advantages of this thin flap are: (1) flow-through vascular reconstruction can preserve the main vessels of the damaged legs; (2) the double arterial inflows and venous drainage systems of the flap ensure safe vascularization of the flap; (3) a flow-through venous drainage system from the distal extremities can also be established to prevent congestion of the affected legs; (4) this flap is versatile (it can be either thin or large); and (5) even in emergent ischemic legs, simultaneous elevation of the flap is possible with preparation of the legs. This flow-through flap is indicated for: (1) cases with a large skin defect and obstruction of the main vessels in the leg; (2) cases with a possibility of tumor recurrence in the legs; and (3) young women or girls with a large defect in the legs, rather than the rectus abdominis musculocutaneous flap.
Adult↗