Histological evaluation of grafted hard palate mucosa in the reconstruction of the upper eyelid.

We have used a hard palate mucosal graft for reconstruction of the posterior lamella of the eyelid and in only one case was replacement required because of discomfort and pain. The stratum corneum of the hard palate mucosa may have been the cause.

The use of calcium phosphate cement paste for the correction of the depressed nose deformity.

The authors report the use of calcium phosphate cement paste as a material for correction of depression after nasal bone fracture, and evaluate its usefulness. Biopex R (Mitsubishi Material Corporation, Tokyo, Japan) was used in this study as calcium phosphate cement (CPC), which was developed in Japan. CPC injection was used in six patients (four women and two men) with depressed nose deformity after nasal bone fracture. The patients' ages ranged from 29 to 67 years (mean, 49 years), and the follow-up period ranged from 12 to 27 months. The amount of injected cement varied from 0.5 to 2.5 mL, approximately. There was no postoperative infection or allergic reaction in any patient. Clinical and X-ray photography findings showed that a reduction in volume of the injected cement occurred gradually as long as 7 to 8 months after surgery. After that period, the volume was mostly maintained. It seemed that the degree of reduction was approximately 10% to 15% of the original volume. Satisfactory results were obtained in all cases. The authors conclude that the use of CPC is an option for the correction of depressed nose deformity and that its application must be determined in each case, considering its advantages and disadvantages.

Auricular composite graft for skin defect of the philtrum dimple.

Our method of performing an auricular composite graft for a skin defect of the philtrum dimple in a patient whose lip is not damaged and has retained its original softness and elasticity is presented. After resecting the lesion, an auricular composite graft is harvested from the conchal region. The size of the graft is almost the same as the size of the resected lesion, although the cartilage is harvested in an elliptical shape, and its size is approximately 60% in area of the overriding skin of the graft. The graft is harvested from the site, which has a similar curvature to the defect. The cartilage is sutured tightly to the graft bed at a minimum of four points with 6-0 absorbable suture. The transversal axis of the harvested cartilage is sutured as vertically as possible so as to fit the direction of the wrinkle line of the upper lip. The skin is sutured to the defect margin using 5-0 nylon suture. The graft donor site is closed primarily. This method has been used for the closure of six comparatively large skin defects after resecting a skin lesion (pigmented nevus in three cases and hypertrophic scar in three cases) in the philtrum dimple in six patients. In all cases, the upper lip was not damaged and retained its original softness and elasticity. The "take" of the graft was complete in all patients, and the donor site healed without any problem. In all cases, postoperative shrinkage of the graft was not significant during the follow-up period, and the graft had a smooth surface. In addition, no patients suffered from a feeling of discomfort in moving the mouth, and an acceptable shape of the philtrum dimple was achieved in all cases. There were no deformational changes in the graft donor site. In conclusion, our method is valid in the patient whose lip is not damaged and has retained its original softness and elasticity and in whom a full-thickness skin graft is selected as the covering method for a skin defect of the philtrum dimple.

Influence of periosteum on donor healing after harvesting hard palate mucosa.

The authors report the influence of periosteum on healing of palatal defect based on more than 10 years of experience of harvesting hard palate mucosa. Between June of 1991 and May of 2001, the authors harvested 80 hard palate mucosae as graft material for skin and mucosa defects. All grafts were harvested from the center of the hard palate. Patients ranged in age from 10 to 82 years old. Of 80 mucosae, 54 were harvested with periosteum, and periosteum was not retained in the defect bed. The other 26 mucosae were harvested without periosteum, which was therefore retained in the defect bed. The healing time increased depending on the defect size in both groups of patients retaining and not retaining periosteum. There was a significant relationship between the defect size and healing time in both groups (Spearman's rank correlation test, p < 0.0001 in both groups). In the two groups, there was no significant relationship between patient age and healing time in the patients with defect smaller than 1.99 cm or larger than 2.00 cm2. There were no significant differences in the rate of patients with pain and bleeding between the groups retaining and not retaining periosteum. In the group not retaining the periosteum, all 54 patients showed a flat or atrophic smooth surface at more than 6 months after epithelization and had no discomfort. However, 17 patients showed flat or atrophic smooth surface in the group retaining the periosteum and the remaining 9 patients showed hypertrophy at more than 6 months after epithelization, with accompanying discomfort. The rate of the patients with hypertrophy in the group of patients retaining periosteum was significantly high as compared with that in the group of patients not retaining periosteum (p = 0.000013, Fisher's exact test). In 26 patients retaining periosteum, the age of the patients with hypertrophic surface was significantly younger than that of the patients with flat or atrophic surface (p = 0.0010, Welch's -test), and the defect size in the patient with hypertrophic surface was significantly smaller than that of the patients with flat or atrophic surface (p = 0.0028, Welch's t-test). In conclusion, our study demonstrated that the existence of periosteum in the palate donor bed does not contribute to reduced healing time or reduced pain. Rather, retaining the periosteum caused hypertrophy of the donor site, leading to discomfort, especially in young patients with a comparatively small defect.

Successful free osteocutaneous scapular flap transfer for mandibular reconstruction in a 93-year-old patient.

With the extension of the average life span and the development of surgical technique, anesthesia, and pre- and postoperative management, operations for elderly patients have become more widely accepted. In the field of plastic surgery, free-flap transfers using microvascular techniques have become a common surgical procedure in reconstruction of the head and neck region after surgical removal of a cancer. There have been several reports of free-flap transfer in patients older than 90 years, but the authors know of no reports of free osteocutaneous flap transfer for mandibular reconstruction, which is a very invasive free-flap surgery, for such patients. The mandible plays a significant role in various kinds of dynamic functions, such as mastication, deglutition, and articulation. Disorder of these functions causes a deterioration in the patient's quality of life. The authors have performed a mandibular reconstruction using an osteocutaneous scapular free flap after resection of a gingival cancer invading the mandibular bone in a 93-year-old Japanese woman. In our case, an osteocutaneous scapular free flap, which permits the patient rapid rehabilitation of the lower leg, is thought to be a good choice because it allows the patient to get out of bed as quickly as possible in the postoperative period to minimize additional complications.

Use of calcium phosphate cement for bone defect after harvesting radial forearm osteocutaneous flap.

To resolve esthetic and psychologic discomfort of patient due to the lack of radius after harvesting radial forearm osteocutaneous flap, we filled the bone defect and recreated its contour using calcium phosphate cement (CPC; Biopex; Mitsubishi Material Corporation, Tokyo, Japan). Injection of CPC was performed in 5 patients (3 women and 2 men). The patients' age ranged from 61 to 72 years (mean, 65 years), and the follow-up period ranged from 8 to 18 months. The size of the radius harvested varied from 10 x 35 mm to 10 x 50 mm. The width of the harvested bone was approximately 25% to 35% of the circumference of radius. Injected CPC volume varied from 3 to 4 mL, approximately. There was no postoperative infection or allergic reaction in any patient, and movement of hand was also with no problem. The X-P findings showed that the bone defect was filled with a uniform, high-density mass. The injected cement reduced in volume gradually during the fourth or fifth postoperative months, but the degree of reduction was mild in any case, which is probably less than 5% of the injected amount, allowing successful recreation of the contour of the radius. We conclude that the use of CPC for filling the defect of the bone donor site after harvesting radial osteocutaneous flap is valid method to keep a patient free from esthetic and psychologic discomfort due to the lack of the radius.

Hard palate mucosal grafts for defects of the nail bed.

The authors present 2 children in whom a hard palate mucosal graft was used for a defect of the nail bed after resecting subungual exostosis. After the tumor was resected with the overriding nail bed, hard palate mucosa without periosteum was grafted to the nail bed defect. In both patients the graft took completely, and within 2 weeks after the operation the patients were able to enjoy activities of daily life, including athletic movement, without any symptoms. Nail growth was uneventful and was complete in 4 or 5 months after the operation without any complications. The authors think that a hard palate mucosal graft is a valid choice for a defect of the nail bed, and the mucosa does not need to be harvested with periosteum. The grafting of hard palate mucosa without periosteum to a defect of the nail bed contributes to a shorter healing time, resulting in a reduction in the period of restriction of movement in activities of daily life, and this is a great advantage in children.

Preshaped hydroxyapatite tricalcium-phosphate implant using three-dimensional computed tomography in the reconstruction of bone deformities of craniomaxillofacial region.

We prepared solid life-sized models and templates of implants based on three-dimensional computed tomography data in six cases with a bone deformity of the craniomaxillofacial region. After simulation surgery using these models and templates, the preshaped hydroxyapatite-tricalcium phosphate (HAP-TCP) implants were prepared to fill in the facial bone defects, and implantation was performed. Consequently, implants fitted the individual bone defects, and satisfactory facial contouring was obtained in five cases. In one case with severe cutaneous scarring in the grafted site, it was necessary to reduce the volume of the preshaped HAP-TCP implant during surgery. In conclusion, the three-dimensional, solid, life-sized model and template are useful for preoperative detailed simulation, and the use of preshaped HAP-TCP implants based on the template probably contributes to successful reconstruction of complex facial bone deformities and to the reduction of surgical invasion, resulting in achievement of better results.