Molecular characterization of a novel putative pathogen, Streptococcus nakanoensis sp. nov., isolated from sputum culture.

Reports of novel species of α-hemolytic Streptococcus have increased recently. However, limited information exists regarding the pathogenicity of these species, with the exception of Streptococcus pneumoniae and Streptococcus pseudopneumoniae. In this study, a quinolone-resistant α-Streptococcus strain, MTG105, was isolated from the sputum of a patient with pneumonia. This strain was first identified as S. pneumoniae at the hospital laboratory; however, it exhibited unique genetic features upon further analysis. Digital DNA-DNA hybridization and average nucleotide identity based on BLAST values from whole-genome sequencing revealed MTG105 to be a novel species closely related to S. pseudopneumoniae. Although MTG105 carried two copies of the pneumolysin gene, similar to S. pseudopneumoniae, this isolate exhibited susceptibility to optochin under both aerobic and 5% CO2 conditions. Notably, no biochemical features could be used to definitively identify this species. In an infection assay using organotypic lung tissue models, MTG105 induced epithelial damage comparable to that of S. pneumoniae and S. pseudopneumoniae, possibly suggesting its potential as a pathogenic α-Streptococcus. The natural transformation abilities of Streptococcus species facilitate their exchange of genes within the same genus, resulting in the existence of species with increasingly more diverse genome structures. Therefore, the identification of this species highlights the importance of monitoring the emergence of novel species exhibiting virulence and/or multidrug resistance. This isolate was proposed as a novel species, designated Streptococcus nakanoensis sp. nov. The type strain was MTG 105T (= JCM 35953T = CCUG 76894T). IMPORTANCE: The genus Streptococcus encompasses a wide range of bacteria with more than 60 species. Recently, there has been a notable increase in reports of novel species of α-Streptococcus based on genomic analysis data. However, limited information exists regarding the pathogenicity of these species. In this study, a quinolone-resistant α-hemolytic Streptococcus strain, MTG105, was isolated from a patient with pneumonia. Genetic analysis revealed that this species was a novel species closely related to S. pseudopneumoniae. In an infection assay using organotypic lung tissue models, MTG105 induced epithelial damage comparable to that caused by S. pneumoniae and S. pseudopneumoniae, strongly suggesting its potential as a pathogenic α-Streptococcus. The natural transformation abilities of Streptococcus species facilitate gene exchange within the same genus, leading to the emergence of species with increasingly diverse genome structures. Therefore, the identification of this species underscores the importance of monitoring the emergence of novel species exhibiting virulence and/or multidrug resistance.

[Necessity of Meningioma Capsulectomy].

The need for resection of the meningioma capsule has long been debated and remains controversial. Even the definition of a capsule does not seem to have been established. We described the histopathological findings of the so-called capsule and the necessity for resection, considering tumor cell invasion and recurrence, based on a literature review.

Distinguishing Cerebral Infarction With Neck Pain and Hemiparesis From Cervical Spinal Epidural Hematoma Without MRI: A Case Report.

In patients presenting neck pain and hemiparesis, differentiation between cerebral infarction and cervical spinal epidural hematoma is vital yet challenging, particularly when magnetic resonance imaging (MRI) is not feasible. A 59-year-old woman presented with a sudden onset of left-sided hemiparesis and neck pain. MRI was contraindicated because the patient underwent embolization in childhood. Head computed tomography (CT) revealed no evidence of hemorrhage or early ischemic signs. Cervical CT revealed no evidence of hematoma within the spinal canal. Myelography and CT myelography revealed no significant cervical spine abnormalities. The diagnosis was cerebral infarction. Cervical spine MRI is the gold standard examination for diagnosing cervical spinal epidural hematoma, but cervical spine CT, myelography, and CT myelography may be useful when MRI is contraindicated.

High levels of plasma neurofilament light chain correlated with brainstem and peripheral nerve damage.

BACKGROUND AND OBJECTIVES: Blood neurofilament light chain (NfL) is a minimally invasive, but highly sensitive biomarker of neurological diseases. However, diseases and neurological damage associated with increased NfL remain unclear. Therefore, the present study investigated factors associated with increased plasma NfL levels in various neurological diseases, focal lesions and pathological processes. METHODS: This was a retrospective cohort study on 410 participants with various neurological diseases and 17 healthy and cognitively unimpaired controls (HCU). Plasma samples were analyzed to measure NfL using ECL immunoassay. The focal lesions were classified as the cerebrum, cerebellum, brainstem, meninges, spinal cord, peripheral nerves, neuromuscular junction, and muscles based on medical records. A multiple regression analysis and receiver operating characteristic curve (ROC) analysis were performed to investigate whether plasma NfL levels predict specific diseases and focal lesions. RESULTS: Plasma NfL levels discriminated between the HCU and all disease groups (area under the curve (AUC), 0.97), with a cut-off value of 63.4 pg/mL. A multiple regression analysis of focal lesions adjusted by pathogenic processes showed that brainstem and peripheral nerve involvement was associated with higher plasma NfL levels. A cut-off value of 53.8 pg/mL of NfL discriminated between the HCU and neurological disease group except for brainstem or peripheral disorders (AUC 0.962), while a cut-off value of 208.0 pg/mL distinguished this group from brainstem or peripheral nervous system disorders (AUC 0.716). DISCUSSION: These results demonstrate that plasma NfL has a potential to be a highly sensitive biomarker for neurological diseases and focal lesions.

A case of chronic progressive autoimmune GFAP astrocytopathy with extensive meningoencephalomyelitis and contrast enhancement on MRI.

•We herein present a case of chronic progressive autoimmune GFAP astrocytopathy.•Symmetrical high-intensity signals on FLAIR were observed in the white matter of the temporal and occipital lobes, lateral cerebral ventricle walls, hippocampus, amygdala, and occipital cortex, with extensive Gd enhancement in radial perivascular lesions and the ependyma in the choroid plexus.•Improvements were achieved by 4 courses of IVMP and one of IVIg.

Usefulness of the Glove Finger Pad for Ultrasonography in Nasal Fracture Reduction.

The treatment of nasal bone fractures involves closed reduction, in which the reduction position is generally evaluated indirectly by visual examination and palpation. While more direct evaluation methods using ultrasonography can improve treatment outcomes, ultrasonography of the nasal bones requires acoustic coupling materials to hold the entire ultrasonography probe in close contact with the nose. We report the use of the Glove Finger Pad, a homemade acoustic coupling material made from a medical glove. The Glove Finger Pad is easy to prepare and use and produces good images. We believe that the Glove Finger Pad will further enhance the usefulness of ultrasonography for the treatment of nasal fractures.

[Intracranial Anatomy and Surgical Techniques for Extended Orbital Exenteration for Sinonasal Malignancy with Orbital Apex Extension].

Gross total tumor resection for sinonasal malignancy with orbital apex extension requires orbital exenteration and bony skull base resection around the orbital apex with sufficient margins. With a detailed discussion of the anatomy, we describe our surgical procedure for extended orbital exenteration with orbital apex resection for sinonasal malignancy.

Clinical Evaluation of Cerebrospinal Fluid p217tau and Neurofilament Light Chain Levels in Patients with Alzheimer's Disease or Other Neurological Diseases.

BACKGROUND: The cerebrospinal fluid (CSF) levels of tau phosphorylated at threonine 217 (p217tau) or 181 (p181tau), and neurofilament light chain (NfL) are definite biomarkers of tauopathy and neurodegeneration in Alzheimer's disease (AD). OBJECTIVE: To validate their utility in excluding other neurological diseases and age-related changes in clinical settings. METHODS: We developed monoclonal antibodies against p217tau and NfL, established novel ELISAs, and analyzed 170 CSF samples from patients with AD or other neurological diseases. RESULTS: In AD, p217tau is a more specific and abundant CSF component than p181tau. However, CSF NfL levels increase age-dependently and to a greater extent in central and peripheral nervous diseases than in AD. CONCLUSIONS: CSF p217tau correlates better with AD neurodegeneration than other tau-related biomarkers and the major phosphorylated tau species. The clinical usage of NfL as a neurodegeneration biomarker in AD requires exclusion of various central and peripheral neurological diseases.

Multiscope Technique Combining an Endoscope and Exoscope for Neck Clipping of Cerebral Aneurysms.

OBJECTIVE: In aneurysm clipping, the use of an endoscope improves the visualization of the anatomic structures around the aneurysm, allowing for improved dissection and clipping techniques. Furthermore, it makes the surgery less invasive. The disadvantage of using the endoscope and microscope together is that the surgeon must move the line of sight significantly between viewing the operative field through the eyepiece of the microscope and viewing the endoscope monitor. This disadvantage makes it difficult for the surgeon to safely insert the endoscope in the optimal position. This study presents a new method for observing the surgical field with a picture-in-picture system using both an endoscope and an exoscope that can overcome the disadvantage of multiscope surgery. METHODS: The endoscope was used when the anatomic structures around the aneurysm could not be observed with the exoscope only. An image from the endoscopic monitor was inserted into the exoscopic monitor. The surgeon inserted the endoscope in the optimal position while viewing the endoscope monitor and ensured that the structures in the path of the endoscope were not damaged while they viewed the exoscope monitor. RESULTS: Three patients underwent aneurysm clipping. The use of an endoscope made the procedure less invasive, and the surgeon was able to safely insert the endoscope in the optimal position. Only slight movement of the line of sight was required to view the 2 monitors. CONCLUSIONS: The endoscope and exoscope multiscope picture-in-picture system can facilitate safer aneurysm clipping compared with combined microscopic and endoscopic surgery.

A Three-Dimensional Anterior and Middle Cranial Fossa Model for Skull Base Surgical Training with Two Layers of the Colored Dura Mater.

BACKGROUND: Adequate epidural procedures and anatomical knowledge are essential for the technical success of skull base surgery. We evaluated the usefulness of our three-dimensional (3D) model of the anterior and middle cranial fossa as a learning tool in improving knowledge of anatomy and surgical approaches, including skull base drilling and dura matter peeling techniques. METHODS: Using a 3D printer, a bone model of the anterior and middle cranial fossa was created based on multi-detector row computed tomography data, incorporating artificial cranial nerves, blood vessels, and dura mater. The artificial dura mater was painted using different colors, with 2 pieces glued together to allow for the simulation of peeling the temporal dura propria from the lateral wall of the cavernous sinus. Two experts in skull base surgery and 1 trainee surgeon operated on this model and 12 expert skull base surgeons watched the operation video to evaluate this model subtlety on a scale of 1 to 5. RESULTS: A total of 15 neurosurgeons, 14 of whom were skull base surgery expert, evaluated, scoring 4 or higher on most of the items. The experience of dural dissection and 3D positioning of important structures, including cranial nerves and blood vessels, was similar to that in actual surgery. CONCLUSIONS: This model was designed to facilitate teaching anatomical knowledge and essential epidural procedure-related skills. It was shown to be useful for teaching essential elements of skull-base surgery.

Tumor doubling time as preoperative predictor of malignancy and recurrence in newly diagnosed meningioma.

Most meningiomas are benign, and the indications for surgery are determined by size and symptoms, but some are malignant and have a high recurrence rate. Currently, no preoperative prognostic factors have been established. The purpose of this study was to investigate whether tumor doubling time (Td) is useful in predicting tumor prognosis. Patients who underwent surgery for newly diagnosed meningioma at our hospital between 2007 and 2021 with preoperative magnetic resonance (MR) imaging evaluation over a period of 6 months were included in this study. We calculated the Td from the preoperative MR images and examined the correlation between Td and WHO grade, MIB-1 SI, and other conditions. A total of 269 newly diagnosed meningiomas were operated on during the study period, of which 62 met inclusion criteria. The median Td was 1082 days (54-8579 days), and MIB-1 SI was 2.45% (0.7-14.6%). Td and MIB-1 SI had a negative correlation (r = - 0.319, p = 0.0122). MIB-1 SI was higher in patients with Td < 3 years than in those with Td ≥ 3 (p = 0.005), and the incidence of high WHO grade (grade2) was higher in patients with Td < 1 year than in patients with Td ≥ 1 (p = 0.014). Meningiomas with Td < 3 years had significantly higher MIB-1 SI, and tumors with Td < 1 year had a higher likelihood of malignancy. Therefore, early treatment should be considered in patients with short Td meningioma even if asymptomatic, and further consideration could be given to radical resection at the time of surgery.

Histopathological Investigation of Meningioma Capsule with Respect to Tumor Cell Invasion.

No previous study has histopathologically investigated whether a meningioma capsule presents with tumor cells. We investigated which types of tumor capsules (TCs) included tumor cells to help intraoperatively determine those TCs that do not need to be removed and have a low recurrence risk. We investigated 22 specimens of 14 newly diagnosed meningiomas from February 2011 to June 2021. The capsules were classified into three types: TC, capsule-like thickened arachnoid membrane (CAM), and extended membrane (EM). Capsule properties were scored by hardness (soft = 1, medium = 2, hard = 3) and transparency (high = 1, medium = 2, low = 3). The hardness, transparency, and score sums were compared between capsules with and without tumor invasion in the CAM and EM types. The mean follow-up duration was 40.6 months, and there was only one recurrence in a remote location from the residual capsule. Nine capsules were classified as TC, seven as CAM, and six as EM. The tumor cells invaded 88.9% of TCs, 42.9% of CAMs, and 50% of EMs. The hardness, transparency, and score sums for CAMs with tumor invasion were lower than those for CAMs without tumor invasion, although not significant (P = 0.114, P = 0.114, P = 0.057, respectively). A thickened TC or soft and highly transparent CAM indicated a high risk for tumor cell invasion; thus, such cases require a careful and long-term follow-up. Hard and low transparent residual CAMs may have had a low risk for tumor invasion; therefore, leaving such capsules that tightly adhere to the eloquent cortex can be theoretically justified to avoid damaging the brain surface.

Correlation of Intraoperative 5-ALA-Induced Fluorescence Intensity and Preoperative 11C-Methionine PET Uptake in Glioma Surgery.

BACKGROUND: 5-Aminolevulinic acid (5-ALA) is widely employed to assist fluorescence-guided surgery for malignant brain tumors. Positron emission tomography with 11C-methionine (MET-PET) represents the activity of brain tumors with precise boundaries but is not readily available. We hypothesized that quantitative 5-ALA-induced fluorescence intensity might correlate with MET-PET uptake in gliomas. METHODS: Adult patients with supratentorial astrocytic gliomas who underwent preoperative MET-PET and surgical tumor resection using 5-ALA were enrolled in this prospective study. The regional tumor uptake of MET-PET was expressed as the ratio of standardized uptake volume max to that of the normal contralateral frontal lobe. A spectrometric fluorescence detection system measured tumor specimens' ex vivo fluorescence intensity at 635 nm. Ki-67 index and IDH mutation status were assessed by histopathological analysis. Use of an antiepileptic drug (AED) and contrast enhancement pattern on MRI were also investigated. RESULTS: Thirty-two patients, mostly with Glioblastoma IDH wild type (46.9%) and anaplastic astrocytoma IDH mutant (21.9%), were analyzed. When the fluorescence intensity was ranked into four groups, the strongest fluorescence group exhibited the highest mean MET-PET uptake and Ki-67 index values. When rearranged into fluorescence Visible or Non-visible groups, the Visible group had significantly higher MET-PET uptake and Ki-67 index compared to the Non-visible group. Contrast enhancement on MRI and IDH wild type tumors were more frequent among the Visible group. AED use did not correlate with 5-ALA-induced fluorescence intensity. CONCLUSIONS: In astrocytic glioma surgery, visible 5-ALA-induced fluorescence correlated with high MET-PET uptake, along with a high Ki-67 index.

Early postoperative complications and their measures after skull base reconstruction: A study from the standpoint of plastic and reconstructive surgeons.

OBJECTIVE: In skull base surgery, postoperative complications may be lethal and it is important to know how to deal with these. There are several reports on complications after skull base reconstruction, but it is difficult to understand which are important for plastic surgeons in charge of reconstruction. The objective of this study is to clarify the early postoperative survival-related complications after skull base reconstruction of which plastic surgeons should participate in treatment. METHODS: One hundred and seventy-seven patients who underwent skull base reconstruction at our department over the last 12 years were retrospectively surveyed. The cases of early complications in which plastic surgeons were actively involved in treatment were investigated and the preventive measures actually taken at our facility are examined in addition to treatment methods after development. RESULTS: Plastic surgical complications were wound infection in seven patients, impaired blood flow in transplanted tissue in two patients, cerebrospinal fluid leakage in five patients, and intracranial compression in three patients. Total number of postoperative complications were seventeen and the total complication rate was 9.6%. Complication rates tended to be higher in anterior-middle skull base cases than in anterior or middle alone cases and higher with free tissue transfer than with locoregional flap. Multivariate analysis revealed that operation time was a significantly higher risk factor (p=0.012) and preoperative chemotherapy was a significantly lower risk factor (p=0.033) for the development of complications. It was also found that the hospitalization length was significantly longer when complications occurred (p<0.0001). Wound infection was treated with removal of the cause, sufficient drainage, and irrigation. Regarding preventive measures, it is necessary to pay attention especially to intracranial contamination with epithelial components. Rapid surgical measures were necessary when blood flow of the transplanted tissue was impaired. For pedicle flaps, conservation of the feeding vessel is needed, and for free flaps, reliable vascular anastomosis is needed as preventive measures. Plastic surgeons play a role in reducing the risk of cerebrospinal fluid leakage through covering the repaired dura mater with tissue with favorable blood flow, especially in reoperation after development of leakage. Skull base reconstruction with soft tissue may cause intracranial compression, and sometimes, it is not resolved by conservative treatment and reoperation is selected. CONCLUSION: Plastic surgical postoperative complications were clarified, and treatment methods and preventive measures for them were examined. Careful consideration of blood flow, placement, and volume of the transplanted flap is important to prevent complications.

The different concepts of surgical managements between anterior and lateral skull base reconstructions based on surgical purposes.

OBJECTIVE: Anterior and middle cranial fossa defects require different strategies, depending on their anatomical location. The aim of this study was to elucidate the surgical managements for the defects based on surgical purposes and to clarify the conceptional differences relating to anterior and lateral skull base reconstructions. METHODS: This study included patients who had undergone reconstructive surgery for anterior or middle cranial fossa defects in our institution between July 2008 and June 2019. It consisted of 66 patients who had been subject to anterior skull base reconstructions, and 84 patients who had experienced lateral skull base reconstructions. The medical records were examined retrospectively, and the surgical purposes and procedures performed were reviewed. The surgical purposes were divided into four groups: Separation, Restoration, Augmentation, and Coverage. RESULTS: Regarding anterior skull base reconstructions, the Separation group included 65 patients, who represented 98% of this category. There were 26 cases in the Separation-only group, 20 of which were reconstructed with locoregional flaps, and 6 of which with free tissue transfers. A Combination group, which consisted of Separation and Other purposes, consisted of 40 cases. Within this group, 5 cases were reconstructed with locoregional flaps, and 35 with free tissue transfers. Regarding lateral skull base reconstructions, the Separation group included 34 patients, who represented 40% of this category. The rate of the Other purposes represented the majority. In the Separation-only group of 24 patients, 16 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In the Combination group of 10 patients, 2 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In groups other than the Separation group, 27 cases were reconstructed with locoregional flaps and 23 cases with free tissue transfers. CONCLUSION: In most anterior cranial fossa defect cases, the surgical purpose is separation. In middle cranial fossa defect cases, there are many cases in which the surgical purpose is not separation. In the Separation groups, relating to both anterior and lateral skull base reconstructions, the use of locoregional flaps was an effective measure. Free tissue transfers were required in many cases of the Combination group. Outside of the Separation group associated with lateral skull base reconstructions, the use of locoregional flaps and free tissue transfers were almost equal in proportion, and the selection of reconstructive procedures tended to change from locoregional flaps to large free flaps with increase in the numbers of surgical purposes.

Novel detection of the CAMTA1-WWTR1 fusion gene in extra-adrenal myelolipoma-like lesion: a case report.

A mediastinal mass was incidentally detected by chest X-ray in a 44-year-old man. Computed tomography findings revealed that the mass was a possible malignancy in the right and middle mediastinum and was removed by surgical resection. Macroscopically, the resected specimen was a well-demarcated yellowish, brownish, and whitish mass. Microscopically, a solid lesion with cords of epithelioid cells in the extra-adrenal myelolipoma-like lesion was observed. Immunohistochemically, the solid lesion was positive for typical vascular markers and CAMTA1, the expression of which is highly specific for epithelioid hemangioendothelioma (EHE). The endothelial cells and bone marrow elements of myelolipoma-like lesion were also positive for CAMTA1. Fluorescence in situ hybridization examination detected the CAMTA1-WWTR1 fusion gene not only in the solid lesion but also in the endothelial cells and bone marrow elements of myelolipoma-like lesion. To our knowledge, this is the first report suggesting common genetic abnormality, CAMTA1-WWTR1 fusion, in cases of EHE and extra-adrenal myelolipoma.

Molecular characterisation of carbapenem- and tigecycline-resistant Klebsiella pneumoniae strains isolated from blood and bile samples.

INTRODUCTION: The number of carbapenem-resistant Klebsiella pneumoniae (CRKP) strains are increasing, further raising healthcare concerns worldwide. In this study, we isolated three CRKP strains from bile and blood samples of an elderly patient (90s) with acute cholangitis and characterised the features and antimicrobial resistance mechanism of CRKP isolates. METHODS: Three CRKP isolates were characterised by Pulsed-field gel electrophoresis (PFGE), whole genome sequencing using the NovaSeq 6000, and antimicrobial susceptibility testing. Transcriptional levels of resistance-associated genes were measured by real-time RT-qPCR. RESULTS: PFGE analysis revealed highly similar patterns for these isolates. Furthermore, they showed resistance to not only carbapenem but also tigecycline. Genomic analysis of the blood isolate identified the exogenous resistance genes blaCTX-M14, tet(A), tet(D), opxAB, and qnrS1 but not any carbapenemase-encoding genes. In addition, nonsense mutations were found in both the outer membrane protein K36 (ompK36) and transcriptional regulator ramR, suggesting that this isolate developed multidrug resistance by acquiring both exogenous resistance genes and nonsense mutations. The extended-spectrum ß-lactamase-producing carbapenem-susceptible K. pneumoniae isolate exhibited the same susceptibility pattern, except to ß-lactams, as prior CRKP isolates. CONCLUSIONS: Antimicrobial susceptibility to carbapenem and tigecycline should be continuously monitored, because it might change from susceptible to resistant during another antimicrobial treatment, even if an isolate initially shows susceptibility, and the patient has not been exposed to these agents.

Polygamous breeding system identified in the distylous genus Psychotria: P. manillensis in the Ryukyu archipelago, Japan.

Distyly is a genetic polymorphism composed of long-and short-styled flowers in a population. The evolutionary breakdown of distyly has been reported in many taxa, and mainly involves a shift toward monomorphism or dioecism. However, a shift toward monoecism has not been reported in distylous species. Psychotria (Rubiaceae), one of the world largest genera, consists of distylous species and their derivatives. In our preliminary study, however, we identified some monoecious individuals in a population of Psychotria manillensis. To understand the breeding system and reproductive biology of P. manillensis, we investigated floral traits, open fruit set, and flower visitors, and performed hand pollination and bagging experiments in five populations of Okinawa and Iriomote islands, Ryukyu Islands, Japan. The populations of P. manillensis were composed mainly of monoecious individuals (54%), followed by female (30%), male (14%), and hermaphroditic (2%) individuals at the time of flower collection. Of the collected flowers, 93% were functionally unisexual (male or female), whereas only 6.5% were perfect (hermaphroditic). However, some individuals changed sex mainly towards increasing femaleness during the flowering period. Moreover, 35% of the studied plants changed their sexual expression over the years. P. manillensis showed self-compatibility and no agamospermy. The fruit set under open pollination varied among populations and years (1.8-21.9%), but it was significantly higher than that of auto-selfing (0.68-1.56%). Wasps and flies were the main flower visitors and probably the main pollinators of the species. In conclusion, P. manillensis was revealed to be polygamous, involving monoecious, female, male, and hermaphroditic individuals. This is the first report of the polygamous breeding system not only in the genus Psychotria, but also in all heterostylous taxa.

A Concept of "Boundary Determination" by the Combination of a Local Flap and Free Tissue Transfer Useful for the Prevention of Postoperative Complications After Complex and Widespread Skull Base Reconstruction.

ABSTRACT: The transplanted tissue is sutured to the stumps of the bones in skull base reconstruction. Concerning reconstruction by free tissue transfer, it is difficult that the tissue is accurately sutured/fixed to a complex three-dimensional structure. The authors devised a technique in which free tissue transfer is combined with a local flap. A pericranial flap is sutured/fixed onto the irregular border between the cranial and nasal cavities. A free tissue graft is transplanted cranial or caudal to the determined border. Clinical presentation 1 is a patient with carcinoma of the frontal sinus (T4bN0M0). Resection of the frontal bone/nasal bone/medial and superior walls of the orbit, frontal lobectomy was performed. Clinical presentation 2 is a patient with carcinoma of the maxillary sinus (T4aN0M0). Extended total maxillectomy, simultaneous resection of the facial skin/temporal muscle were performed. There were no serious postoperative complications related to compression or occlusion of the cerebral parenchyma or paranasal sinus.