Addition of a Buccinator Musculomucosal Flap Improves Surgical Outcomes of Conventional two-Flap Palatoplasty: A Comparative Study.

OBJECTIVE: The surgical outcomes of novel two-flap palatoplasty adding a buccinator musculomucosal flap were compared with those of conventional two-flap palatoplasty to clarify the effects of lengthening the nasal mucosa of the soft palate using a BMMF in cleft lip and palate or cleft palate cases. DESIGN: Retrospective, comparative study. SETTING: Tertiary, cleft team. PATIENTS: Non-syndromic patients undergoing primary cleft palate repair using two-flap palatoplasty with BMMF (BMMF group) or conventional two-flap palatoplasty (non-BMMF group). INTERVENTIONS: Palatoplasty between January 2012 and March 2020. MAIN OUTCOME MEASURES: Perceptual Japanese speech evaluation, rate of an indication for additional speech surgery (AS), rate of incidence of oronasal fistula (IF) including spontaneously closing fistula, and rate of occurrence of oronasal fistula (OF) present for more than 3 months. RESULTS: Of 92 analyzed patients, 70 received two-flap palatoplasty with BMMF and 22 received two-flap palatoplasty. In the BMMF and non-BMMF groups, the respective percentage of hypernasality (no, mild) was 91.4% and 77.2%, no nasal emission was 71.4% and 63.6%, velopharyngeal function (competent, borderline competent) was 83.7% and 77.4%, intelligibility (very good, good) was 93.7% and 86.4%, AS was 1.4% and 13.6%, IF was 7.1% and 36.4%, and OF was 1.4% and 9.1%. Significant improvements were observed for AS (p = 0.0412) and IF (p = 0.00195) in the BMMF group, with no recorded major adverse effects. CONCLUSION: Adding a BMMF on the nasal side of the soft palate to conventional two-flap palatoplasty significantly improved postoperative outcomes. This approach may therefore be a good option for cleft palate treatment.

Longitudinal Morphological Changes in the Mucosal Free Margin After Unilateral Cleft Lip Repair.

Weakness of the mucosal free margin is common in secondary cleft lip deformities. However, the incidence is rarely reported after a long-term follow-up. We evaluated the evolution of patient mucosal free margin after primary repair and until the end of growth.Blinded retrospective study (photography and chart reviews).Tertiary care hospital; private practice.Forty-eight patients with unilateral cleft lip with or without cleft palate who underwent primary nasolabial repair between 1996 and 2004 were followed up until their end of growth marked at 18 and 16 years of age for male and female patients, respectively.Primary nasolabial repair using a straight-line closure without a triangular flap on the vermilion was performed; if needed, a revision surgery was performed at 5 years of age (85%).The contour of the mucosal free margin was classified into nodular, smooth, and recessed types at 1, 5, and 10 years and at the end of growth.At 1 year of age, the nodular type was more common (58%). However, the recessed type was more common (75%) at the end of growth. The mucosal free margin continued to change after 10 years of age. At the end of growth, half of the patients with incomplete cleft experienced center weakness, and the others had cleft-side weaknesses.Patients with incomplete clefts showed favorable results at early ages. However, two-thirds of the patients with complete and incomplete clefts showed focal weakness at the end of growth.

Successful endovascular treatment with a stent graft for chronic deep vein thrombosis with multiple arteriovenous fistulas: a case report.

BACKGROUND: Deep vein thrombosis with arteriovenous fistulas is rare, with few therapeutic options available for chronic-phase deep vein thrombosis. Moreover, the effectiveness of endovascular treatment for chronic-phase deep vein thrombosis with arteriovenous fistulas has not been established. We describe herein a case of successful endovascular treatment for chronic deep vein thrombosis with multiple arteriovenous fistulas. CASE PRESENTATION: We describe the case of a 72-year-old Asian woman who had begun experiencing left leg swelling and intermittent claudication 2 years prior. Enhanced computed tomography revealed left common iliac vein occlusion with vein-to-vein collateral formation and several arteriovenous fistulas. Angiography and ultrasound showed the arteriovenous fistulas to run from the common and internal iliac arteries to the external iliac and superficial femoral veins. We opted against surgical repair for the arteriovenous fistulas due to their complex nature and complicated morphology. Since her condition was progressive, endovascular treatment with a stent graft was performed for the deep vein thrombosis, after which her symptoms gradually improved. Four months following the procedure, enhanced computed tomography confirmed remarkable reduction of the vein-to-vein collaterals and arteriovenous fistulas. CONCLUSIONS: In the present case, enhanced computed tomography with a stent graft was effective in improving symptoms. This strategy may therefore be a treatment option for intractable chronic deep vein thrombosis with arteriovenous fistulas.

Morphological Changes in Faces Depending on Posture.

Facial surgeries are usually performed with the patient in the supine position; however, it is crucial to predict postoperative results in the upright position. This study aimed to clarify the posture-related morphological changes in the facial soft tissue regarding age and sex, using physical measurements to obtain results in specific linear metric measurements of standard facial features. One hundred healthy volunteers were divided into four groups based on age and sex (25 young men, 25 young women, 25 old men, 25 old women). For all participants, 18 measuring points were marked on the skin along with 18 paired linear measurements, and the angle was measured using a digital sliding caliper and angle meter in both upright and supine positions. In all four groups, the intercanthal width (en-en), binocular width (ex-ex), length of the eye fissure (en-ex), length of the nasal bridge (n-prn), width of the nose (al-al), height of the lower face (sn-gn), vermilion height of the lower lip (sto-li), height of the lower lip (sto-sl), width of the philtrum (cphi-cphi), width of the mouth (ch-ch), and nasolabial angle (NLA) were significantly larger in the supine position than in the upright position. The increase was larger in the older age groups than in the younger age groups. Moreover, the increase was larger in old men than in old women. During facial surgery involving these areas, surgeons should consider the patient's age and sex and understand what facial figuration change would occur depending on posture and change their preoperative design or make minor adjustments during operation in the supine position to increase patient satisfaction.

The Palatal Fistula Closure Using Buccal Fat Graft After Palatoplasty for Cleft Palate: Two Case Reports.

Fistula recurrence is high after secondary follow-up operation to close the fistula after primary palatal surgery. Therefore, preventing fistula recurrence is important. Here, we describe the technique of closing palatal fistula after palatal surgery with a buccal fat graft in 2 cases. We elevate the mucosal flap around the palatal fistula, suture the nasal mucosa, transplant the buccal fat between the nasal and oral mucosa for the palatal fistula after palatal surgery, and suture the oral mucosa. Palatal fistula did not recur after surgery. This method is simple and useful for suturable fistula and does not require a local flap.

Vibrant soundbridge implantation prior to auricular reconstruction with unilateral microtia-atresia.

We presented the first successful application of VSB implantation prior to auriculoplasty, which can provide hearing improvement in safe conditions and open new strategies for earlier hearing rehabilitation in unilateral microtia-atresia children.

Hallucal thenar index: A new index to detect peripheral arterial disease using laser speckle flowgraphy.

OBJECTIVES: Laser speckle flowgraphy is a technology using reflected scattered light for visualization of blood distribution, which can be used to measure relative velocity of blood flow easily without contact with the skin within a short time. It was hypothesized that laser speckle flowgraphy may be able to identify foot ischemia. This study was performed to determine whether laser speckle flowgraphy could distinguish between subjects with and without peripheral arterial disease. MATERIALS AND METHODS: All subjects were classified based on clinical observations using the Rutherford classification: non-peripheral arterial disease, class 0; peripheral arterial disease group, class 2-5. Rutherford class 6 was one of the exclusion criteria. Laser speckle flowgraphy measured the beat strength of skin perfusion as an indicator of average dynamic cutaneous blood flow change synchronized with the heartbeat. The beat strength of skin perfusion indicates the strength of the heartbeat on the skin, and the heartbeat strength calculator in laser speckle flowgraphy uses the blood flow data to perform a Fourier transform to convert the temporal changes in blood flow to a power spectrum. A total of 33 subjects with peripheral arterial disease and 40 subjects without peripheral arterial disease at a single center were prospectively examined. Laser speckle flowgraphy was used to measure hallucal and thenar cutaneous blood flow, and the measurements were repeated three times. The hallucal and thenar index was defined as the ratio of beat strength of skin perfusion value on hallux/beat strength of skin perfusion value on ipsilateral thenar eminence. The Mann-Whitney U-test was used to compare the median values of hallucal and thenar index and ankle brachial index between the two groups. A receiver operating characteristic curve for hallucal and thenar index of beat strength of skin perfusion was plotted, and a cutoff point was set. The correlation between hallucal and thenar index of beat strength of skin perfusion and ankle brachial index was explored in all subjects, the hemodialysis group, and the non-hemodialysis (non-hemodialysis) group. RESULTS: The median value of the hallucal and thenar index of beat strength of skin perfusion was significantly different between subjects with and without peripheral arterial disease (0.27 vs. 0.87, respectively; P < 0.001). The median value of ankle brachial index was significantly different between subjects with and without peripheral arterial disease (0.8 vs. 1.1, respectively; P < 0.001). Based on the receiver operating characteristic of hallucal and thenar index, the cutoff was 0.4416 and the sensitivity, specificity, positive predictive value, and negative predictive value were 68.7%, 95%, 91.7%, and 77.6%, respectively. The correlation coefficients of all subjects, the hemodialysis group, and the non-hemodialysis group were 0.486, 0.102, and 0.743, respectively. CONCLUSIONS: Laser speckle flowgraphy is a noninvasive, rapid, and widely applicable method. Laser speckle flowgraphy using hallucal and thenar index would be helpful to determine the differences between subjects with and without peripheral arterial disease. The correlation between hallucal and thenar index of beat strength of skin perfusion and ankle brachial index indicated that this index was especially useful in the non-hemodialysis group.

Additional Relaxing Suturing Using Absorbable Symmetric Barbed Sutures to Help Close Scalp Defects.

Closing a scalp wound with skin defects is challenging because the scalp skin lacks extensibility and closing it tends to result in a remarkable, widespread, hairless scar. Absorbable symmetric barbed suture device (Stratafix Symmetric; Ethicon, USA) allows wound closure using a pulling motion alone and provides a strong and secure closure for the high-tension area. We used this device to close wide scalp defects easily without tension and with minimized sequential scalp alopecia. The aim of this study was to show our experiences with using this technique. From January 2017 to March 2019, our relaxing suture technique was performed in 7 pediatric patients with scalp alopecia due to various lesions that ranged 23.0 ± 6.5 mm. After resecting the lesions, the galea was sutured using the 3-0 absorbable symmetric barbed suture via a running subcutaneous suture technique. The widespread wound edges were approximated by pulling the suture device. Wound closure was completed with galeal suturing and a superficial suture. We evaluated the width of the postoperative hairless scar at the final follow-up. In all 7 patients, we could approximate the widespread wound edges by pulling alone. Subsequently, the wounds could be closed without tension or difficulty. The mean width of the postoperative hairless scar was 3.3 ± 0.8 mm (range: 1.9-4.3 mm), and no complication was detected during the follow-up period. Our new relaxing suture technique using an absorbable barbed suture with symmetric anchors is a supportive and additional way to help close scalp defects.

Gliding Tissue Reconstruction Using a Dorsal Digital Adipofascial Flap in Complex Extensor Injury.

BACKGROUND: Postoperative scar adhesions between tendons and phalanx bones cause persistent disability in complex injuries involving tendons and bones of the hand. Although gliding tissue reconstruction is effective in preventing peritendinous adhesion formation and a dorsal digital adipofascial flap is a reliable method to prevent scar adhesion between tendon and bone after extensor tendon repair, no comparative clinical reports exist. This study aimed to determine the usefulness of a gliding tissue reconstruction method by comparing postoperative range of motion between patients who underwent gliding tissue reconstruction and those who did not. METHODS: Medical records of patients with complex extensor tendon injury who underwent extensor repair between April 2005 and March 2018 were retrospectively analyzed. Ten patients underwent extensor repair with gliding tissue reconstruction using a dorsal digital adipofascial flap and 13 underwent only extensor repair. A triangular flap was separated after zig-zag incision to expose the injured extensor tendon into dermal and adipofascial flaps. The adipofascial flap, based on a dorsal branch of the digital artery, was placed on the injured bone as the tendon gliding surface. The same extensor tendon suture method and rehabilitation protocol were used in both groups. All patients were followed up for 6 to 12 months. RESULTS: The mean ± SD % total active movements were 84.1% ± 12.4% and 57.6% ± 13.0% in the groups with and without gliding tissue reconstruction, respectively. Significant differences were found between the 2 groups (P < 0.05). CONCLUSIONS: Patients with gliding tissue reconstruction had better functional recovery. This reconstruction is recommended to restore the extensor function in cases of complex extensor injury involving finger tendons and bones.

How to Manage Disfiguring Scars in Involuted Infantile Hemangioma.

Objective: No active treatment is required in the majority of cases of infantile hemangioma (IH), while they proliferate and involute without sequelae. However, ulceration, bleeding, or destruction/obstruction of important structures may occur in 10% of cases during the proliferating phase. These lesions lead to a disfigured appearance with redundant skin, fibrofatty residuum, protruding surface, drooping, and scarring. This study focused on prevention and management of disfiguring scars in involuted IH. Approach: A retrospective photography and chart review were performed for patients with IH who visited our hospital (Shinshu University Hospital). Results: The study population consisted of 107 patients with IH. The lesions were located on the head and neck (59.8%), trunk (27.1%), upper limb (7.5%), or lower limb (5.6%). Twenty-four patients (22.4%) underwent surgical excision of the disfigured lesion after involution. The percentage of surgical interventions was highest for lesions in the head and neck area (28.9%) compared with other regions. The fibrofatty tissue and redundant skin after involution of each lesion were partly resected and sutured. All suture lines were finally set on the wrinkle line or the anatomical borderline. Innovation: Although total excision of the lesion was impossible in some cases, a natural surface contour was obtained. The operative scar was not visible in the residual damaged skin after involution. Conclusion: Effective preventive therapies during the proliferating phase are required to avoid tissue damage due to hyperexpansion of the surrounding tissue and surface breakdown to present excellent cosmetic results in patients with IH.

A Foxtail-Shaped Vermilion Flap to Reconstruct the Medial Tubercle in Asymmetric Bilateral Cleft Lip With Contralateral Lesser Form Defect.

OBJECTIVE: There have been few reports addressing asymmetric bilateral cleft lip repair with contralateral lesser form defects. Two studies have described the thin medial tubercle as the most common remaining labial deformity. In this study, we aimed to evaluate the use of a foxtail-shaped vermilion flap to reconstruct the median tubercle in primary repair. DESIGN: A blinded retrospective study of photography and chart review. SETTING: Shinshu University Hospital, tertiary care. Private practice. PATIENTS: Forty-nine patients with asymmetric bilateral cleft lip with lesser form defects treated using a primary "unilateral" repair by the senior author (S.Y.) between 2007 and 2017. INTERVENTIONS: The foxtail-shaped vermilion flap was applied at the time of the primary nasolabial repair. This flap is similar to Noordhoff laterally based triangular vermilion flap but with modifications to the shape and length. The body of the flap is wider than the pedicle to add tissue to the center of the vermilion, and the length is sufficiently elongated to reach the lesser side. MAIN OUTCOME MEASURE: Lip shape was graded on a 4-point scale when patients were 1 year old. RESULTS: Twenty-two patients were treated with the foxtail-shaped vermilion flap (group A) and 27 patients with Noordhoff triangular vermilion flap (group B). Group A had a better lip shape than group B (P = .006). CONCLUSIONS: The foxtail-shaped vermilion flap is useful to reconstruct the median tubercle in asymmetric bilateral cleft lip repair with contralateral lesser form defects.

Oronasal Transfixion Suture to Prevent Uplifted Nasal Floor Deformity in Cleft Lip and Palate Patients: A 5-Year Follow-Up.

OBJECTIVE: In unilateral cleft lip and palate, the reconstructed nasal floor is sometimes uplifted regardless of the reconstructive method used. We used a 5-0 absorbable anchoring suture, the oronasal transfixion suture (ONT suture), to fasten the reconstructed nasal floor to the orbicularis oris muscle to prevent this deformity. This study was performed to evaluate the effects of the ONT suture. DESIGN: Blind retrospective study of photography and chart review. SETTING: Shinshu University Hospital, tertiary care, Nagano, Japan. Private practice. PATIENTS: Ninety-three consecutive patients with unilateral complete cleft lip and palate who had undergone primary nasolabial repair in our department and affiliated hospitals between 1999 and 2011 participated in this study. Finally, 45 patients were included. INTERVENTIONS: The ONT suture was put in place at the time of primary nasolabial repair. MAIN OUTCOME MEASURE: The height of the nasal floor was evaluated on submental view photographs at 5 years old. RESULTS: The ONT suture was applied in 21 patients. The height of the nasal floor on the cleft side was significantly closer to that on the noncleft side with the ONT suture than without the ONT suture ( P = .008). CONCLUSIONS: The ONT suture is effective to prevent uplifted nasal floor deformity on the cleft side// in unilateral complete cleft lip and palate at the time of primary nasolabial repair.

Two Cases of Radial Ray Deficiency With Absence of First Metacarpus and 2 Tiny Fingers.

We report 2 cases showing both radial ray deficiency and thumb duplication. The common features of these cases were absence of the first metacarpus and presence of 2 tiny fingers. The features of our cases may have been due to continuous abnormality of the mesenchymal cells before limb bud formation and apical ectodermal ridge at the established limb bud. In 1 case, we created a 5-finger hand using 2 tiny floating fingers. Two fingers as vascularized bones with growth potential were useful to make 1 thumb. Two tendon transfers at 2 years of age were effective to allow gripping and pinching of objects. At 6 years of age, the thumb was lengthened by an iliac bone graft and a reverse forearm flap. At 27 years of age, the patient showed grip power of 20 kg in the affected hand. The Quick-DASH (the Japanese Society for Surgery of the Hand version) score was 4.6. The patient was satisfied with the appearance and function of the hand, although size discrepancy between the thumbs remained.

Evaluation of muscle hyperactivity of the grimacing muscles by unilateral tight eyelid closure and stapedius muscle tone.

Muscle hyperactivity of grimacing muscles, including the orbicularis oculi and corrugator supercilii muscles that cause crow's feet and a glabellar frown line with ageing, cannot be accurately evaluated by surface observation. In 71 subjects, this study investigated the extent to which grimacing muscles are innervated by the bilateral motor cortices, whether the corticofacial projection to the grimacing muscles affects the facially innervated stapedius muscle tone by measuring static compliance of the tympanic membrane, and whether unilateral tight eyelid closure with contraction of the grimacing muscles changes static compliance. Unilateral tight eyelid closure and its subsequent change in the contralateral vertical medial eyebrow position revealed that motor neurons of the orbicularis oculi and corrugator supercilii muscles were innervated by the bilateral motor cortices with weak-to-strong contralateral dominance. The orbicularis oculi, corrugator supercilii, and stapedius muscles innervated by the bilateral motor cortices had increased muscle hyperactivity, which lowered the vertical medial eyebrow position and decreased the static compliance of the tympanic membrane more than those innervated by the unilateral motor cortex. Unilateral enhanced tight eyelid closure with contraction of the grimacing muscles in certain subjects ipsilaterally decreased the static compliance with increased contraction of the stapedius muscle, which probably occurs to immobilise the tympanic membrane and protect the inner ear from loud sound. Evaluation of unilateral tight eyelid closure and the subsequent change in the contralateral vertical medial eyebrow position as well as a measurement of the static compliance for the stapedius muscle tone has revealed muscle hyperactivity of grimacing muscles.

Dorsally extended digital island flap for repairing soft tissue injury of the fingertip.

BACKGROUND: The digital triangular island flap is one of the most useful types of flap for repairing soft-tissue loss at the fingertip, because it is sensate and has glabrous skin. However, this type of flap has several disadvantages, including limited length of advancement and limited flap size. METHODS: We have developed a new type of dorsally extended digital island flap to extend the reach of the digital triangular island flap. This dorsally extended portion, 15 mm in width and 20 mm in length, is based on the dorsal branch of the digital artery at the distal phalanx level. This island flap has a longer reach than the conventional digital island flap and can transfer larger amounts of soft tissue to the injured fingertip. Sixteen patients with fingertip amputation were treated using this flap. RESULTS: All of the flaps survived. The dorsally extended digital island flap could repair pulp tissue losses up to 30 mm in length in oblique volar injury. In transverse injury, a new fingertip could be produced with this flap in a single stage. We successfully covered the exposed bone without shortening the digital bone of the fingertip using our extended flap. No claw nail deformity occurred and no flexion contracture remained in any of the cases. CONCLUSION: Use of a dorsally extended digital island flap is recommended for repairing fingertip injury in cases with defect sizes ranging from 10 to 30 mm in length and also in both oblique volar and transverse injuries. This flap is more versatile for repair of fingertip injury than the conventional digital island flap.