Modified Lengthening Temporalis Myoplasty Using an Intraoral Approach.

BACKGROUND: Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves inserting the whole temporal tendon directly into the nasolabial fold. However, the nasolabial fold incision remains one of the difficulties of this procedure, particularly in young or female patient. To avoid the need for this incision, the authors developed an intraoral approach to manipulate the temporal muscle tendon toward the nasolabial fold. in this study, we describe the details of this procedure. METHOD: The authors performed their intraoral approach procedure in 5 patients with established complete facial paralysis. instead of making an incision at the nasolabial fold to approach the coronoid process, the authors made the incision at the buccal mucosa. The results were evaluated both subjectively and objectively. RESULTS: The authors achieved facial reanimation without leaving any obvious scar on the face or neck and the effect of static reconstruction is obvious, even immediately after the surgery. All the patients obtained good facial movement within 4 months (2.5 months in average), and improved all evaluated parameters postoperatively. No infections or other major complications were reported following surgery; however, 1 patient developed a slight dimple that required revision. DISCUSSION: The authors could advance temporal tendon toward nasolabial fold firmly obtaining sufficient surgical field similar to that of nasolabial fold incision, and achieved fairly good results without an obvious scar on the face.Establishing LTM without nasolabial fold incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reanimation in all generation.

Cylinder syringe suction: a simple and efficient technique for the evacuation of subcutaneous hematoma.

BACKGROUND: Subcutaneous hematoma is commonly caused by trauma or surgery. Proper treatment of the condition is needed to avoid severe complications. The present paper introduces a simple technique of hematoma evacuation, called cylinder syringe suction (CSS). Experiments were also performed to determine the detailed mechanism underlying its effectiveness. METHODS: The CSS procedure was performed as follows. A cylindrical plastic cylinder syringe was used. Either a few stitches were removed or a very small incision was made on the site of the hematoma. The edge of the syringe was compressed to the skin, which was covered by a thin hydrocolloid dressing. Vacuum aspiration was enforced at the site of the wound or incision, and the hematoma was gradually aspirated.For the experiment, house rabbits were used. Hematoma evacuation was performed in 4 different ways, including needle aspiration alone (group 1), needle puncture followed by CSS (group 2), and creation of a small wound (5 mm) followed by needle aspiration (group 3) or CSS (group 4). The amount of evacuated hematoma and the suction pressure created by each of the 4 methods were compared. RESULTS: Group 4 showed the highest suction pressure and the greatest evacuated amount of hematoma. High suction pressure was also obtained in group 1; however, the amount of evacuated hematoma was small as the other 2 groups. CONCLUSION: The CSS technique becomes effective mainly by creating high suction pressure, and the opening of a small wound enables the viscous coagula to pass through the skin.

Expression of transforming growth factor-ß1, -ß2, and -ß3 in plagiocephalic fused and patent coronal suture.

BACKGROUND: Craniosynostosis is a relatively rare disease. Recently, several studies have investigated the etiology of craniosynostosis using animal models; however, the etiology remains unknown. In this study, we examined transforming growth factor (TGF) ßs immunostaining from coronal sutures in patients with plagiocephaly. MATERIALS: The examined materials were obtained from 3 patients who had undergone surgery for plagiocephaly. The sections were obtained from the normal patent side and the abnormal fused side of the coronal suture. The subjects included 2 girls and 1 boy with ages ranging from 1 to 4 years. Osteoblasts and connective tissue were observed with hematoxylin and eosin stain. Immunohistochemistry of the TGF-ß isoforms was performed to investigate the difference between the patent and fused sutures. RESULTS: No connective tissue was observed in the fused suture. The osteoblasts in the patent suture were activated, whereas the osteoblasts in the fused suture were inactivated. The osteoblasts were positive for TGF-ß1, -ß2, and -ß3. The periosteum tended to be positive for TGF-ß2 and negative for TGF-ß1 and -ß3. There was no distinct difference between the patent and fused sutures in this study. DISCUSSION: In this study, all sutures had fused completely, and therefore, we may have missed the period when there are differences in protein manifestation. The modulation of the growth factor profile at the suture site may have a potential therapeutic value.

Levator lengthening technique using cartilage or fascia graft for paralytic lagophthalmos in facial paralysis.

INTRODUCTION: Lid loading using gold weights has been commonly used to treat paralytic lagophthalmos (PL); however, the procedure has a relatively high complication rate and the availability of these plates varies among social circumstances. We used a levator lengthening (LL) technique, which originally elongated the levator aponeurosis by inserting a fascia graft between the edge of the levator aponeurosis and the tarsal plate. However, because this procedure tends to result in a wide residual lagophthalmos, we changed the graft material from fascia to conchal cartilage. In this study, we describe in detail our experience with LL using the cartilage graft. METHODS: LL was performed in 18 patients with PL. Fascia grafts were used in seven patients and cartilage grafts in 11. Static reconstructions of the lower eyelid and eyebrow were also performed in most patients. Efficacy was evaluated from patient reports of ocular symptoms and by measuring the palpebral fissure width at opening and closing for both eyes. RESULTS: All patients experienced improved ophthalmological symptoms, which were more apparent in cartilage cases. The average palpebral fissure at eyelid closure was 1.8 mm in cartilage cases and 4.0 mm in fascia cases. In cases where an eyebrow lift was concurrently performed, the residual lagophthalmos became wider in fascia grafting but remained acceptable in cartilage grafting. DISCUSSION: LL is a simple and useful procedure for treating PL with higher efficacy when a cartilage graft is used. However, the level of the upper eyelid can be easily adjusted by changing the fixation position of the cartilage. Additional experience is required to obtain more consistent outcomes.

End-to-Side Neurorrhaphy as Schwann Cells Provider to Acellular Nerve Allograft and Its Suitable Application.

Axonal regeneration relies on support from proliferating host Schwann cells (SCs), and previous studies on acellular nerve allografts (ANGs) suggest that axons can regenerate into ANGs within a limited distance. Numerous studies have demonstrated that the supplementation of ANGs with exogenous factors, such as cultured SCs, stem cells, and growth factors, promote nerve regeneration in ANGs. However, there are several problems associated with their utilization. In this study, we investigated whether end-to-side (ETS) neurorrhaphy, which is an axonal provider, could be useful as an SC provider to support axonal elongation in ANGs. We found that ETS neurorrhaphy effectively promoted SC migration into ANGs when an epineurium window combined with partial neurectomy was performed, and the effectiveness increased when it was applied bilaterally. When we transplanted ANGs containing migrated SCs via ETS neurorrhaphy (hybrid ANGs) to the nerve gap, hybrid ANGs increased the number of regenerated axons and facilitated rapid axonal elongation, particularly when ETS neurorrhaphy was applied to both edges of the graft. This approach may represent a novel application of ETS neurorrhaphy and lead to the development of hybrid ANGs, making ANGs more practical in a clinical setting.

Assessment of T-shape double fascia graft for lower lip deformity from facial paralysis: A questionnaire survey.

INTRODUCTION: There are two main methods to treat lower-lip deformity (LLD) in facial paralysis. The first method is surgical intervention on the side of the paralysis, and the second involves denervating the depressor muscles on the healthy side. It is sometimes difficult for patients to ethically accept the denervating healthy tissue; therefore, we performed the T-shape double fascia graft (TSDFG), which reportedly restores symmetry. In this study, we report our experience with TSDFG and evaluation of the outcomes including the patient questionnaires. METHODS: Two fascia strips from the thigh, 7 × 70 mm in size, were used; one was grafted horizontally at the lower lip to correct the static position, and the other was grafted obliquely at the lateral side by folding and crossing the horizontal fascia. A total of nine patients were treated by this procedure; three procedures were performed individually and six were performed in combination with another static or reanimation procedure. A questionnaire containing a five-point scoring system for facial appearance in multiple situations and other problems was sent to each patient at least 6 months after the surgery. RESULT: From the physicians' point of view, all patients achieved an improvement in symmetry of the lower lip, particularly when opening of the mouth; however, assessments from the patients demonstrated much less satisfaction. The main reason for the dissatisfaction was the slight bulkiness of the red lip. There was one comment that noted that with more treatment, the expectations were higher, and, as a result, the patient could not admit satisfaction at the end. DISCUSSION: TSDFG is a simple and effective procedure for LLD; however, slight modifications may be required. In addition, there were some gaps in the perception of the results between the physicians and patients, and we need to consider these when planning to treat LLD.

Effectiveness of platysma muscle flap in preventing Frey syndrome and depressive deformities after parotidectomy.

BACKGROUND: Frey syndrome (FS) or depressive deformity (DD) occurring after parotidectomy significantly reduces a patient's quality of life. However, there seems to be no effective treatment strategy against these complications. In this study, we report our experience of using platysma muscle flap (PMF) to prevent the development of FS and DD after parotidectomy, and evaluate its effect subjectively and objectively. METHODS: Superficial parotidectomy was performed for eight cases of parotid gland tumor, and a PMF was transferred to cover the site. The incidence of FS and DD were evaluated subjectively, using a questionnaire to the patients and board-certified reconstructive surgeons, and objectively, using Minor's starch-iodine test. RESULTS: In seven patients, the defect could be completely covered with PMF, and none of them developed FS or obvious DD. However, in one patient, the defect could be only partially covered, and the patient developed complications in the exact site that the flap did not cover. Overall scores from the questionnaire were high in relation to both cosmetic and functional perspectives from most of the patients and all the surgeons. No patients had major postoperative complications requiring revision. CONCLUSIONS: PMF can be useful to cover the defect and prevent complications after parotidectomy. PMF is relatively easy to perform with fewer complications; however, a complete coverage of the defect should be ensured to obtain optimal results.

Microvascular Reconstruction of Free Jejunal Graft in Larynx-preserving Esophagectomy for Cervical Esophageal Carcinoma.

BACKGROUND: Losing the ability to speak severely affects the quality of life, and patients who have undergone laryngectomy tend to become depressed, which may lead to social withdrawal. Recently, with advancements in chemoradiotherapy and with alternative perspectives on postoperative quality of life, larynx preservation has been pursued; however, the selection of candidates and the optimal reconstructive procedure remain controversial. In this study, we retrospectively reviewed our experience with free jejunal graft for larynx-preserving cervical esophagectomy (LPCE), focusing on microvascular reconstruction. METHODS: Seven patients underwent LPCE for cervical esophageal carcinoma, and defects were reconstructed by free jejunal transfer subsequently. We collected preoperative and postoperative data of the patients and assessed the importance of the procedure. RESULTS: We mostly used the transverse cervical artery as the recipient, and a longer operative time was required, particularly for the regrowth cases. The operative field for microvascular anastomosis was more limited and deeper than those in the laryngectomy cases. Two graft necrosis cases were confirmed at postoperative day 9 or 15, and vessels contralateral from the graft were chosen as recipients in both patients. CONCLUSIONS: Microvascular reconstruction for free jejunal graft in LPCE differed in several ways from the procedure combined with laryngectomy. Compression from the tracheal cartilage to the pedicle was suspected as the reason of the necrosis clinically and pathologically. Therefore, we should select recipient vessels from the ipsilateral side of the graft, and careful and extended monitoring of the flap should be considered to make this procedure successful.

Preoperative transcutaneous electrical nerve stimulation for localizing superficial nerve paths.

During surgery, peripheral nerves are often seen to follow unpredictable paths because of previous surgeries and/or compression caused by a tumor. Iatrogenic nerve injury is a serious complication that must be avoided, and preoperative evaluation of nerve paths is important for preventing it. In this study, transcutaneous electrical nerve stimulation (TENS) was used for an in-depth analysis of peripheral nerve paths. This study included 27 patients who underwent the TENS procedure to evaluate the peripheral nerve path (17 males and 10 females; mean age: 59.9 years, range: 18-83 years) of each patient preoperatively. An electrode pen coupled to an electrical nerve stimulator was used for superficial nerve mapping. The TENS procedure was performed on patients' major peripheral nerves that passed close to the surgical field of tumor resection or trauma surgery, and intraoperative damage to those nerves was apprehensive. The paths of the target nerve were detected in most patients preoperatively. The nerve paths of 26 patients were precisely under the markings drawn preoperatively. The nerve path of one patient substantially differed from the preoperative markings with numbness at the surgical region. During surgery, the nerve paths could be accurately mapped preoperatively using the TENS procedure as confirmed by direct visualization of the nerve. This stimulation device is easy to use and offers highly accurate mapping of nerves for surgical planning without major complications. The authors conclude that TENS is a useful tool for noninvasive nerve localization and makes tumor resection a safe and smooth procedure.

Experience and anatomical study of modified lengthening temporalis myoplasty for established facial paralysis.

Lengthening temporalis myoplasty, reported by Daniel Labbé in 1997, is a unique and definite facial reanimation procedure that involves moving the whole temporal muscle anteroinferiorly and inserting its tendon directly into the nasolabial fold. In the present article, we report our experience in the use of his modified method of the procedure, which preserves the zygomatic arch by transecting the coronoid process through the nasolabial fold incision. We also describe our cadaveric study that aimed to elucidate a secure approach for coronoid process transection. We performed this procedure in five patients with permanent facial paralysis. To improve facial symmetry, we also performed several additional static reconstructions such as T-shaped double-sleeve fascia grafts for lower lip deformities. We were successful in achieving considerable static improvement at rest, immediately after the surgery, and the recovery of facial movement was apparent approximately 3 months after the surgery. With regard to the cadaveric study, we noted that the entry to the buccal fat region, which is also the pathway of the temporal fascia, was a narrow space, and a short transection of the medial upper edge of the masseter fascia would make it easy to locate the coronoid process. Therefore, for a safe and secure access to the coronoid process from the nasolabial fold, we believe that we should first expose the cranial side and continue to dissect along the side and lower edge of the maxilla to locate the medial upper edge of the masseter fascia. By transecting along its edge, we could easily access the coronoid process, located immediately behind it, and widen the pathway of the temporal fascia. This modified method is less invasive and simpler compared to the original procedure, and understanding the detailed anatomy for dissection would help surgeons perform this procedure more confidently.

Intraoperative Use of Indocyanine Green Fluorescence Angiography during Distally Based Radial Artery Perforator Flap for Squamous Cell Carcinoma of the Thumb.

Distally based radial artery perforator flap (DBRAPF) is useful for hand defects; however, the location of the perforator varies among individuals. Preoperative evaluation has been a problematic issue when performing this flap. A 64-year-old man developed squamous cell carcinoma on an old burn scar at the dorsal thumb and was referred to our clinic for further treatment. After wide resection of the tumor, including the long and short extensors of the thumb, we reconstructed the defect with DBRAPF. At that time, near-infrared fluorescence angiography with indocyanine green (ICG) was used to identify the position of the perforator. After injecting ICG intravenously, we could observe its uptake at approximately 5 cm proximal to the styloid process. We designed a 10 × 6 cm island flap with that uptake as pivot point. During flap elevation, the perforator could be confirmed at the point of uptake; the flap was then transferred to the defect by rotating the pedicle at the identified point. The vascularity of the flap could also be checked intraoperatively through ICG angiography. The tip of the flap that showed weak ICG fluorescence indicated epidermal necrosis. Nevertheless, the entire flap was viable and enabled good functionality without tumor recurrence and metastasis after 5 years. Using ICG angiography, DBRAPF could be performed smoothly, easily, and safely.

The availability of perifascial areolar tissue graft for deep cutaneous ulcer coverage.

Soft tissue defects or skin ulcers associated with tendon or bone exposure located distally on the extremities are always difficult to treat. The introduction of the vacuum-assisted closure (VAC) and dermal templates has led to major changes in ulcer treatment strategies. However, it is necessary to find an alternative method to treat these defects when VAC is not available. Perifascial areolar tissue (PAT) is the loose connective tissue on the deep fascia that could be a candidate for repairing soft tissue defects or skin ulcers. Grafting PAT on the exposed bone or tendon, including a wide coverage of well-vascularized tissue surrounding the granulation tissue, can prepare the wound to be subsequently closed by a skin graft. In this study, the PAT was used in various situations and its optimal usage and outcomes were evaluated. A total of 13 PAT grafts were performed and were especially useful for covering narrow ulcers with narrow tendon exposure and filling fistula areas. In comparison to other cases, covering the exposed cortical bone ulcers seemed to be more difficult to perform. However, an option for these ulcers could be the exposure of bone marrow and usage of intraosseous blood flow. It was also possible for the simultaneous engraftment of PAT and skin in narrow areas and could be an alternative in cases of small concave ulcers or fistulae. The PAT graft is a simple and minimally invasive procedure that can be a good alternative when VAC is not available.

Massive myoepithelial carcinoma originating from the submandibular gland that was successfully treated with surgical excision, using a part of the lengthened skin as a local flap.

Myoepithelial carcinoma is rare and mostly originates from the major salivary glands. Sometimes, it is difficult to differentiate the benign from the malignant histologically, and its clinical behavior and histological features may vary. Here, we describe the case of a 55-year-old woman who presented with a massive myoepithelial carcinoma, which hung like a temple bell from her right side of the jaw, and she refused to go to the hospital for 3 years. Based on its size and location, we initially thought that, before surgical resection, neoadjuvant therapy would be necessary to reduce the tumor volume. However, after careful evaluation of the tumor characteristics (low-grade histology with outward expansion and little invasion of the adjacent tissues) and imaging findings, we decided that excision was possible. The tumor was encapsulated and had a clear border; it weighed 10.5 kg. By setting the incision line posterior to the equatorial plane and using the lengthened skin posterior to the tumor as a large local flap for the skin defect, we successfully reconstructed the skin defect without harvesting additional flap from other areas. No additional treatment was administered because a sufficient surgical margin was maintained, pathologically. She regained her daily life without recurrence or distant metastasis for 2 years. When treating a massive tumor, careful consideration of its characteristics and location is important, and in this case, we were able to use a simpler and less invasive treatment than we initially envisioned.