Cranial Reconstruction Using Antibiotic-Impregnated Calcium Phosphate Bone Cement With a Titanium Mesh Sheet.

BACKGROUND: The authors treated skin ulcer accompanied by cranial osteomyelitis using a combination of antibiotic-impregnated calcium phosphate bone cement (Biopex; Pentax, Tokyo, Japan) and a titanium mesh sheet (3D Mesh Plate; Bear Medic, Tokyo, Japan). METHOD: A 71-year-old male was treated with superficial temporal artery-middle cerebral artery bypass surgery for diffuse cerebral infarction and obstruction of the left internal carotid artery by a previous doctor. Skin necrosis and epidural abscess developed in the sutured region after surgery, and ulcer accompanied by temporal bone exposure remained. Thus, the patient transferred to our department. A bone defect formed by debridement and sequestrectomy was measured at 4.5 × 8 cm (30 cm). Methicillin-resistant Staphylococcus aureus was detected on wound culture test. Cranioplasty with a combination of calcium phosphate bone cement impregnated with teicoplanin, to which the causative bacteria showed high sensitivity, and a titanium mesh sheet and scalp reconstruction with a free rectus abdominis musculocutaneous flap were performed. RESULTS: As of 6 months after surgery, no infection has relapsed and no complication, such as resorption of the calcium phosphate bone cement and breakage of the titanium mesh sheet, was noted on postoperative computed tomography. CONCLUSION: The authors performed cranial reconstruction with a combination of teicoplanin-impregnated calcium phosphate bone cement and a titanium mesh sheet in a patient with Methicillin-resistant Staphylococcus aureus infection-induced skin ulcer accompanied by cranial osteomyelitis and achieved subsidence of infection. Drug-impregnated calcium phosphate bone cement has a problem with strength, but combination with a titanium mesh sheet as an auxiliary support material enables application to relatively extensive cranial full-thickness defects and it may be a useful treatment method.

Use of Parotid Gland Fascia in the Prevention of Frey Syndrome After Parotidectomy.

BACKGROUND: Superficial parotidectomy is standard surgical procedure for parotid gland tumor, and Frey syndrome and depressed deformity of the region are often seen as complications. In this study, we performed prevention of Frey syndrome by covering the residual parotid gland defect with the parotid gland fascia flap. METHOD: The subjects were 5 patients with parotid gland tumor. Tumor was localized in the inferior and superior poles of the parotid gland in 3 and 2 patients, respectively, and it was confirmed on preoperative diagnostic imaging that the tumor and parotid gland fascia were not present in close proximity. Through Lazy-S incision, main trunk of facial nerve was identified and conserved following the surgical procedure of normal superficial parotidectomy, and the superficial parotid gland containing tumor was elevated. A parotid gland fascia flap with a pedicle on the nasal side was prepared and the defect after superficial parotidectomy was covered with it. RESULTS: The facial nerve and resected parotid gland stump could be sufficiently covered with the parotid gland fascia flap in all patients. The mean duration of postoperative follow-up was 36 months (10 months-4 years and 5 months), and there were no complications such as tumor recurrence, Frey syndrome, salivary gland fistula, or severe concavity in the parotid region. CONCLUSION: Although application of the present procedure is limited to patients in whom the parotid gland fascia and tumor are not located in close proximity, it may be useful to prevent Frey syndrome because extension of incision is not necessary, the surrounding tissue is not sacrificed, the flap can be easily elevated, and the parotid gland stump can be sufficiently covered.

Primary Reconstruction After Maxillectomy Defects Using Ultra Flex Mesh Plate and Rectus Abdominis Myocutaneous Free Flap Including Aponeurosis of External Abdominal Oblique Muscle.

BACKGROUND: In primary reconstruction after maxillectomy for cancer, simple and less invasive surgical techniques considering functionality and aesthetics are necessary. The authors performed reconstruction for tissue defects after maxillectomy using an Ultra flex mesh plate and a free rectus abdominis myocutaneous flap including the aponeurosis of the external abdominal oblique muscle. METHOD: A 72-year-old male with a maxillary squamous cell carcinoma underwent subtotal maxillectomy. For maxillary defects, including those in the orbital floor and hard palate, the authors performed rigid reconstruction using an Ultra flex mesh plate produced after simulation surgery using a 3-dimensional solid model, and palatal and soft tissue reconstruction using a free rectus abdominis myocutaneous flap including the aponeurosis of the external abdominal oblique muscle. After screw fixation of the mesh plate at the surrounding normal bone, the skinpaddle of the rectus abdominis flap was transferred to the oral defect. The surface of the mesh plate was completely covered with the aponeurosis of the external abdominal oblique muscle, and the remaining rectus abdominis flap was inserted into the maxillary sinus. RESULTS: At present, 1 year after the operation, there is no recurrence, complications, such as infection, or titanium mesh breakage/exposure, and his facial shape is favorably maintained. CONCLUSION: Reconstruction using this method is simple and less invasive. Postoperative infection and plate exposure were prevented by the complete coverage of the mesh plate with the aponeurosis of the external abdominal oblique muscle and flap. Mesh plates, when properly used, are useful reconstruction materials, but are susceptible to infection compared with autologous tissue, requiring long-term follow-up.

Unit Advancement Flap for Lower Lip Reconstruction.

BACKGROUND: Lower lip reconstruction requires consideration of esthetic and functional outcome in selecting a surgical procedure, and reconstruction with local tissue is useful. The authors reconstructed full-thickness defects with a unit advancement flap. METHODS: Reconstruction was performed using this method in 4 patients with lower lip squamous cell carcinoma in whom tumor resection with preservation of the mouth angle was possible. The lower lip resection width was 30 to 45 mm, accounting for 50% to 68% of the entire width of the lower lip. The flap was prepared by lateral extension from above the mental unit and matched with the potential wrinkle line of the lower lip in order to design a unit morphology surrounded by the anterior margin of the depressor labii inferioris muscle. It was elevated as a full-thickness flap composed of the orbicularis oris muscle, skin, and mucosa of the residual lower lip from the bilateral sides, and advanced to the defect. Flap transfer was adjusted by small triangular resection of the skin on the lateral side of the mental unit. RESULTS: The postoperative scar was inconspicuous in all patients and there was no impairment of the mouth opening-closing or articulation functions. CONCLUSIONS: This was a relatively simple surgical procedure. A blood supply of the flap was stable, and continuity of the orbicularis oris muscle was reconstructed by transferred the residual lower lip advancement flap from the bilateral sides. The postoperative mouth opening-closing function was sufficient, and dentures could be placed from an early phase in elderly patients. The postoperative scar was consistent with the lip unit morphology, being esthetically superior. This procedure may be applicable for reconstruction of defects approximately 1/3 to 2/3 the width of the lower lip where the mouth angle is preserved.

Medial canthal reconstruction with multiple local flaps.

BACKGROUND: It is often difficult to reconstruct comparatively large defects in the medial canthal region. The authors have performed reconstruction with multiple local flaps in 4 medial canthal defects after resection of malignant skin tumors. METHOD: The defects exceeded the medial canthal region, extending to the upper eyelid and the lower eyelid. The medial canthal defect was covered by transposition of a glabellar flap, the upper eyelid defect was covered by an upper eyelid myocutaneous advancement flap, and the lower eyelid defect was covered by a cheek rotation flap. Then the donor site of the glabellar flap was covered by a Rintala flap. RESULTS: There was no recurrence in any of the cases, and good results were obtained. One case showed mild linear contracture, but the patient did not want corrective surgery. CONCLUSION: This method is somewhat complicated compared to reconstruction with a single flap, but it is a combination of standard local flaps and is a simple reconstructive procedure. By adding additional resection, the suture line is consistent with the border of the facial unit, so postoperative scarring is inconspicuous. This technique is aesthetically useful because of the continuity of colour and texture resulting from the use of adjacent flaps.

Navigation-Assisted Nasal Bone Osteotomy for Malunited Fracture.

BACKGROUND: Nasal bone osteotomy subjectively judges the position for osteotomy by visual inspection and by manual feel using the fingertip. Therefore, the outcome depends on the surgeon's experience and mastery of the procedure is technically challenging. METHODS: The authors applied a navigation system for the intraoperative evaluation of the osteotomy line and reduction position in 5 patients with malunited nasal bone fracture. The authors performed the operation with a temporal bone post developed for otologic surgery using Stealth Station S7 System (Medtronic, Minneapolis, MN). The suretrack is attached to the bone chisel. The authors performed the osteotomies while visualizing the tip of the chisel on the monitor.In addition, evaluation of the reduction position was performed by insertion of a 23G needle syringe with the suretrack to the nasal bone surface. RESULTS: The tip of the bone chisel was visible on the monitor, and the authors could perform osteotomies while confirming the position and direction of osteotomy. In addition, the reduction position could be visualized clearly on the monitor. CONCLUSION: Navigation systems can confirm the 3-dimensional spatial relationship around the fracture site in real time, requiring only comparatively simple preoperative preparation and intraoperative operation without radiation exposure. Therefore, the advantage is that even an inexperienced surgeon can perform an accurate evaluation. This would be useful as a guide for young doctors and medical students as it would be possible to perform safe and accurate osteotomy for old nasal bone fractures.

Cauliflower-Like Shaped Osteoma.

Skull osteoma is a benign tumor that slowly and continuously enlarges. It is frequently observed in routine medical practice and many patients show an arc shape. The authors encountered a patient with osteoma with a rare morphology that developed in the occipital region. The patient was a 66-year-old male who had been aware of the presence of a mass in the occipital region for about 50 years, but its uncomfortable feeling had recently increased, and it was resected. The excised tumor showed a pedunculated cauliflower-like shape continuous to the skull. The pathological diagnosis was osteoma. The cause of rare morphologies includes trauma and infection, but this patient had no such past medical history. Since the development site was the occipital region, it was assumed that chronic stimulation caused the rare morphology.

Basic Fibroblast Growth Factor Induces Angiogenic Properties of Fibrocytes to Stimulate Vascular Formation during Wound Healing.

The role of fibrocytes in wound angiogenesis remains unclear. We therefore demonstrated the specific changes in fibrocyte accumulation for angiogesis in basic fibroblast growth factor (bFGF)-treated wounds. bFGF-treated wounds exhibited marked formation of arterioles and inhibition of podoplanin+ lymph vessels that were lacking in vascular endothelial growth factor-A-treated wounds. Real-time PCR in bFGF-treated wounds manifested enhanced expression of CD34, CD31, and bFGF mRNA and reduced expression of podoplanin and collagen type I, III, and IV mRNA. Double immunofluorescence staining focusing on fibrocyte detection in bFGF-treated wounds showed increased formation of capillary-like structures composed of CD34+/procollagen I+ fibrocytes, with a lack of capillary-like structures formed by CD45+/procollagen I+ or CD11b+/procollagen I+ fibrocytes. However, vascular endothelial growth factor-A-treated wounds lacked capillary-like structures composed of CD34+/procollagen I+ fibrocytes, with increased numbers of CD34+/fetal liver kinase-1+ endothelial progenitor cells. Furthermore, fibroblast growth factor receptor 1 siRNA injection into wounds, followed by bFGF, inhibited the formation of capillary-like structures composed of CD34+/procollagen I+ fibrocytes, together with inhibited mRNA expression of CD34 and CD31 and enhanced mRNA expression of collagen type I, indicating the requirements of bFGF/fibroblast growth factor receptor 1 system for capillary structure formation. This study highlights the angiogenic properties of CD34+/procollagen I+ fibrocytes specifically induced by bFGF, providing new insight into the active contribution of fibrocytes for vascular formation during wound healing.