Use of an Orbital Septum Flap for Correcting Severe Blepharoptosis.

BACKGROUND: Several surgical procedures are available for the treatment of severe blepharoptosis with poor levator function. However, the procedures have advantages and disadvantages. Particularly, complications such as lagophthalmos and lid lag are commonly observed after conventional interventions. Thus, the present study aimed to introduce a surgical technique that uses an orbital septum flap without the orbital oculi muscle for the correction of severe blepharoptosis. METHODS: The technique utilizes the orbital septum flap, which is connected with the frontalis muscle via the galea aponeurosis and frontal periosteum, to suspend the tarsal plate. In this case series, the technique was used for the correction of blepharoptosis in 16 eyes from 12 patients. RESULTS: The margin reflex distance in all patients improved at 6 months after surgery. Two patients presented with lagophthalmos and three with mild recurrence. However, revision surgery was not required, and none of patients presented with lid lag. CONCLUSIONS: For the correction of blepharoptosis, the use of the orbital septum flap without the orbital oculi muscle can be easily selected compared with other conventional methods that are more likely to cause overcorrection and closure disorders. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Application of the Internal Mammary Artery Perforator Adipofascial Flap.

BACKGROUND: Skin ulcers on the anterior chest wall are caused mainly by radiation therapy for breast cancer and anterior mediastinitis after thoracotomy, and they are often refractory. Some muscle flaps are commonly used for anterior chest wall reconstruction, but muscle flaps accompany high invasion. We used the internal mammary artery perforator (IMAP) adipofascial flap and IMAP skin flap for the anterior chest wall reconstruction. METHODS: We examined the IMAPs using a handheld Doppler device and contrast-enhanced computerized tomography preoperatively. Each flap was designed based on the location of the IMAP and the size of the flap was dependent on the coverage required by the size and location of the skin ulcer. The location of the IMAPs functioned as the pivot point of the flap and the flap was flipped or swung on the defect. RESULTS: We used IMAP adipofascial flap for 2 cases and IMAP skin flap for 1 case. In those 3 cases, we could elevate the flap with no complications even after the internal mammary artery had been harvested. There was no recurrence of the skin ulcer or wound infection after the operation. CONCLUSIONS: In this study, we reported 3 cases of skin ulcer on the anterior chest wall reconstructed with the IMAP adipofascial and skin flap. To our knowledge, this is the first report of the use of the IMAP flap as an adipofascial flap. The IMAP adipofascial flap accompanies less invasion than muscle flaps and the surgical procedure is relatively easy. The IMAP adopofascial flap is considered as one of the effective means for anterior chest wall reconstruction.

Complete Genome Sequences of Staphylococcus argenteus TWCC 58113, Which Bears Two Plasmids.

Staphylococcus argenteus TWCC 58113 was isolated from a specimen from a 12-year-old boy with purulent lymphadenitis. The S. argenteus TWCC 58113 genome was completely sequenced. The TWCC 58113 chromosome was 2,761,442 bp in size with a GC content of 32.44%. S. argenteus TWCC 58113 was found to harbor two plasmids.

Purulent lymphadenitis caused by Staphylococcus argenteus, representing the first Japanese case of Staphylococcus argenteus (multilocus sequence type 2250) infection in a 12-year-old boy.

Staphylococcus argenteus is a novel species separated from a strain of coagulase-positive, non-pigmented S. aureus. Although S. argenteus has been reported to occur globally, multilocus sequence type (ST) 2250 is mainly found in Northeastern Thailand. Because conventional biochemical testing misidentifies this pathogen as S. aureus, multilocus sequence typing (MLST) or nucA sequencing is recommended to distinguish between S. argenteus and S. auereus. The patient was a previously healthy 12-year-old boy who was admitted because of right inguinal lymphadenitis and cellulitis. Although intravenous cefazolin was administered, his lymphadenitis worsened and formed an abscess on day 6 of hospitalization. Incision and drainage were performed on day 7 of hospitalization. Cefazolin was changed to oral cefaclor, and the patient was successfully treated over a period of 5 weeks. No recurrence was observed throughout 12-months of follow-up. He had a history of right axillary lymph node abscess 2 months before this admission, which was successfully treated with incision, drainage, and antibiotic therapy. He has lived in Japan since birth and never traveled abroad. He had no opportunity to interact with foreigners. His immune function, especially neutrophil function, was tested and we did not find any dysfunction. First, methicillin-sensitive S. aureus was misidentified from the abscess culture. Subsequently, the causative agent was re-identified as S. argenteus ST2250 based on MLST. To our knowledge, this is the first case of S. argenteus ST2250 infection in Japan. This pathogen should be taken into consideration in the diagnosis if the patient has atypical non-pigmented S. aureus.

An internal distraction device for Le Fort distraction osteogenesis: the NAVID system.

Le Fort distraction osteogenesis is sometimes applied to improve the facial appearance in craniofacial dysostosis or cleft lip and palate. Distraction devices are generally classified into external and internal types. The movement of external distractors can be controlled easily but their large size and the need for a facial mask cause much psychological stress to the patient. Internal distractors are smaller and better tolerated, but they are not easily controllable and removal is difficult. We designed an internal distraction device to eliminate the problems of the currently available distractors -Nakajima's angle-variable internal distraction (NAVID) system - and aimed to assess its clinical applicability. Between 2000 and 2010, we treated 16 patients with the NAVID system: Le Fort I, III, III + I and IV distractions were performed in three, five, four and four patients, respectively. Distraction was started after a 1-week latency period. Then, the exposed rod was cut, and the distractors were left in place for 3 months or more as retention devices, and thereafter removed. All patients showed satisfactory occlusion and facial aesthetics. Open bite during the consolidation period was the main complication. In conclusion, the NAVID system is safe, effective and reliable for all types of Le Fort distraction osteogenesis.

Dynamic total skull remodeling by a combination of morcellation craniotomy with distraction osteogenesis: the MoD procedure.

There are no procedures available to reconstruct the normal cranial shape irrespective of the type of cranial deformity with minimal patient stress and morbidity. To achieve dynamic total skull remodeling, we considered a new remodeling concept and developed a new procedure by combining morcellation craniotomy and distraction osteogenesis, termed the MoD procedure, and designed a distraction device, namely the angle variable distraction (AVD) system. Between 2000 and 2009, we treated 41 patients with craniosynostosis (28 and 13 cases of isolated and syndromic craniosynostosis, respectively) by using the MoD procedure with the AVD system. Compared with the conventional methods, the mean operative time was significantly shorter, and the mean transfusion volume was significantly less for the MoD procedure. In all the patients, good cranial shape and adequate cranial volume were achieved without serious complications. In conclusion, the MoD procedure with the AVD system is safe, effective, and reliable for dynamic total skull remodeling with minimal morbidity. It could be used to improve the previous surgical concepts for treating craniosynostosis.

Distribution of adipose-derived stem cells in adipose tissues from human cadavers.

BACKGROUND: Adipose-derived stem cells (ASCs) possess multipotency in vivo and in vitro, and thus are thought to be very promising precursors for use in regenerative medicine. ASCs can be concentrated from adipose tissue by enzymatic digestion and transplanted to increase angiogenesis or for cosmesis. ASC transplants are now being performed in a clinical setting. Although data on ASCs are extensive, the distribution of ASCs in human fat tissue has not been fully clarified. Thus, it is important to identify the distribution of ASCs to obtain cell populations rich in ASCs for clinical use. METHODS: ASCs express CD34, a cell surface marker. As CD34 is also expressed by endothelial cells, we immunohistochemically stained 2-µm-thick serial paraffin sections of fat tissue obtained from various parts of formalin-fixed cadavers with anti-CD31 and anti-CD34 antibodies to distinguish ASCs from endothelial cells. RESULTS: CD34(+)/CD31(-) cells were mainly found in connective tissue tracts and perivascularly. Among fat tissues obtained from various sites, fat tissues in the thoracic back and lower abdomen were richest in CD34(+)/CD31(-) cells. CONCLUSION: The concentrations of CD34(+)/CD31(-) cells in adipose tissues differ between sites. The sites most highly enriched for ASCs were identified, and it is now possible to select the best sites for collection of ASCs for transplantation.

A novel approach to thoracic wall reconstruction based on a muscle perforator.

When reconstructing the thoracic wall, non-adaptation of the suture line is a critical concern, especially when artificial implants are used. Therefore, a reliable and safe flap is required. Based on an anatomical study of cadavers, we decided to dissect the pectoralis major musculo-cutaneous flap into two parts, on the surface and beneath the muscle fascia, while preserving the muscle perforators. We designated the skin portion as the V-Y advancement flap or rotation V-Y advancement flap and the muscle flap as the transposition flap. Both flaps had different suture lines. We applied this method to two patients requiring reconstruction of anterior thoracic defects with artificial implants. One patient did not have adverse effects, and the flaps took well. The shape of the breast did not change significantly. However, the other patient was a heavy smoker. Although the V-Y advancement flap took well, the cutaneous triangular tip made at the time of tumour resection became necrotic. However, the underlying pectoralis major muscles successfully covered the implants and did not show any signs of infection. In conclusion, reconstruction of the anterior thoracic wall to change the suture line with a V-Y advancement flap, based on the muscle perforator and pectoralis major muscle flap, is a useful and reliable method, especially when an artificial implant is used.

Rat dorsal paired island skin flaps: a precise model for flap survival evaluation.

Rectangular flaps on the rat or mouse dorsum are frequently used for flap survival elongation research. However, since rectangular flaps are purely random, the survival rate varies among individuals. A reliable animal flap model with low individual variation is desirable for flap survival research, especially in the angiogenic field. We investigated the survival rate of paired flaps in the rat dorsum containing 3 vascular territories in each flap, and determined their usefulness for flap elongation research. Two symmetrical adjoining rectangular flaps (11 x 3 cm each) were drawn on the rat dorsum. Two days after material injection, flaps were elevated with only the deep circumflex iliac vessels as the vascular pedicle. Flaps were immediately sutured back and the flap survival area was measured 7 days after the operation. The control group (n = 9) had saline solution injected in both flaps. The bone marrow group (n = 8) had bone marrow injected in the right flap, and saline solution injected in the left flap. In the control group, the survival rate of the paired flaps was not statistically different (right flap, 89.0+/-5.6%; left flap, 89.3+/-4.5%). In the bone marrow group, the survival rate between the bone marrow injected flap (89.9+/-3.7%), and the saline flap (84.8+/-4.3%) was statistically different. The rat dorsal paired island skin flap model shows low difference in flap survival rate and uses an internal control. This is a suitable model for flap survival elongation research.