Long-term Outcomes of Non-syndromic and Syndromic Craniosynostosis: Analysis of Demographic, Morphologic, and Surgical Factors.

In this study, we analyzed the outcomes of patients (followed for 5-38 years, average 17.3 years) with craniosynostosis and evaluated their long-term prognosis. In all, 51 patients who underwent surgery for craniosynostosis between 1982 and 2015, including 12 syndromic and 39 non-syndromic cases, were included. The average age at the initial surgery was significantly lower in the syndromic group than that in the non-syndromic group (9.8 months old vs. 19.9 months, respectively). The surgical procedures did not significantly differ between the two groups, but repeat surgery was significantly more common in the syndromic group than in the non-syndromic group (4 children [30.8%] and 3 children [7.7%], respectively). The children requiring repeat surgery tended to be younger at the initial surgery than those who did not. Those patients who required repeat surgery did not have significantly different surgical procedures initially. The incidence of developmental retardation was 49.0% (43.5% in the non-syndromic group and 66.7% in the syndromic group), and only two children in the non-syndromic group displayed recovery. This study is the first to analyze the prognosis for patients who were followed for at least 5 years after cranioplasty. Repeat surgery was common, especially in syndromic patients. Severity of skull deformity and early initial surgery may be important factors determining the need for repeat surgery. Developmental retardation was also common, and improvement was rare even after surgery.

Minced Skin Grafting for Promoting Wound Healing and Improving Donor-Site Appearance after Split-Thickness Skin Grafting: A Prospective Half-Side Comparative Trial.

BACKGROUND: Minced skin grafting is a procedure that involves mincing of the harvested skin and grafting it back onto the wounds. The authors aimed to investigate whether minced skin grafting reduces the healing time and improves the sequential postoperative appearance of donor sites. METHODS: A single-center, two-treatment, half-side comparative study was performed. The split-thickness skin remaining after grafting was minced until pasty. The small pasty graft mass was uniformly spread on half of the entire donor site. Minced skin grafting was not performed on the other side. The data from 30 patients were used for analysis. RESULTS: The average time to complete healing of the donor sites in the minced skin grafting and control groups was 9.4 ± 2.5 and 12.4 ± 3.6 days, respectively. The difference in the healing time between the two groups was statistically significant (p < 0.001). Three blinded surgeons used a scale to grade photographs according to the degree of conspicuous donor sites in comparison with the normal skin around the donor sites. All observers reported that the differences in donor-site appearance between the minced skin grafting and control groups were statistically significant at postoperative months 1 and 2, and two observers reported that the differences in donor-site appearance were significant at months 4, 6, and 12. The differences in the number of patients with donor-site dyspigmentation between the minced skin grafting and control groups at 12 months were statistically significant (p < 0.05). CONCLUSION: This prospective half-side comparative trial demonstrates that minced skin grafting promotes wound healing and improves donor-site appearance after split-thickness skin grafting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A Perifascial Areolar Tissue Graft With Topical Administration of Basic Fibroblast Growth Factor for Treatment of Complex Wounds With Exposed Tendons and/or Bones.

The management of wounds with tendon and/or bone exposure is challenging because of the insufficient blood supply to the wound bed. We describe our experience with 19 patients using a perifascial areolar tissue (PAT) graft with topical administration of basic fibroblast growth factor (bFGF) in the treatment of complex wounds with exposed tendons and/or bones in the extremities. Using a PAT graft is minimally invasive and technically easy, and the donor site is relatively preserved. However, PAT grafts for the treatment of a complex wound with large areas of exposed tendons and/or bones have sometimes failed to survive because of insufficient vascularization of the wound bed. Therefore, topical administration of bFGF, which promotes angiogenesis, was added to the graft. All grafts showed good graft survival and successfully covered the tendons and bones. Topical administration of bFGF accelerated vascularization in the PAT graft and facilitated wound healing by increasing the blood supply to the wound bed and achieved success with the PAT graft. In conclusion, using a PAT graft with topical administration of bFGF is a suitable option for the treatment of complex wounds with a large proportion of exposed tendons and/or bones. With minimal damage to the tissues near the wound, the PAT graft can be a useful option for limb salvage and could become a valuable tool for reconstructive surgeons.

The Double Volar Flap Technique for Aesthetic Repair of Syndactyly and Polysyndactyly of Toe without Skin Grafting.

BACKGROUND: Aesthetic repair of syndactyly of the toes is desirable because patients may have psychological concerns about its appearance. There are 2 important factors for the aesthetic repair of syndactyly of the toe. One is to hide the operative scar from the visual site (dorsal site), whereas the other is to create an interdigital space close to the normal anatomical skin characteristics (2 general types of skin: glabrous and hairy). METHODS: In total, 12 patients (4 males and 8 females) with 15 syndactylous webs were operated on by using the double volar flap technique. The following 3 local flaps were designed with this technique: an M-shaped flap designed on the dorsal side of the interdigital region (flap A) and double volar flaps (flaps B and C) designed on the volar side of the interdigital region. Flap A was used for reconstruction of the web slope, whereas flaps B and C were used for reconstruction of the proximal sidewall of toes. RESULTS: The corrected toes showed a deep and natural interdigital commissure with no exposure of skin grafts or conspicuous scars on the dorsal visible side. The scars on the volar side were also inconspicuous. CONCLUSIONS: The double volar flap method for repair of syndactyly and polysyndactyly of the toes has the same advantages as those of the local flap method, in addition to an optimum aesthetic result through matching with the normal anatomical skin characteristic of the interdigital space and hiding of the operative scar from the visual site.

Correction of Late Posttraumatic Enophthalmos Using an Antral Balloon.

Enophthalmos is the posterior displacement of the ocular globe within the bony orbit. Correction of late posttraumatic enophthalmos is one of the most challenging surgical procedures. We have performed a corrective procedure for late enophthalmos using an antral balloon, with or without minimal bone grafting. All orbital contents were separated from the bone fragments, infraorbital nerve, and mucosa of the maxillary antrum. The remaining orbital floor was fractured by the surgeon's digital pressure from the maxillary antrum. The antral balloon was placed in the maxillary antrum and inflated under direct vision from inside the orbit. After a consolidation period, the patient underwent antral balloon removal. A total of 5 patients underwent repair of late enophthalmos using this antral balloon technique. The median time from initial injury was 14 months (range, 6-90 months). The median antral balloon placement duration was 76 days (range, 53-106 days). Satisfactory symmetries were achieved in 4 patients. Mild residual enophthalmos remained in 1 patient, who had an orbital framework deformity and was missing the entire orbital bony floor preoperatively and who required simultaneous bone grafting. The ideal indication for our technique was the need for orbital floor reconstruction, without an orbital framework deformity. This technique could avoid autogenous bone grafting or permanent alloplastic implantation, which may cause a foreign body reaction, chronic inflammation, and migration. We believe that our new technique is one of the least invasive corrective procedures for late posttraumatic enophthalmos.

One-piece bone flap osteotomy using thread wire saw for fronto-orbital advancement with distraction osteogenesis in craniosynostosis.

PURPOSE: The objectives of this study are to describe our new technique of one-piece bone flap osteotomy for fronto-orbital advancement with distraction osteogenesis in craniosynostosis using a thin, flexible, and safe thread wire saw (the T-saw) and to compare the results with those of classic osteotomy using an osteotome. METHODS: Initial osteotomy is performed between two pterion burr holes using a craniotome with a guarded footplate. The outer sphenoid wing and lateral orbital rim are separated using a reciprocating saw. Limited dura dissection from inner cortex between burr holes in the pterion and nasion is performed. The T-saw is inserted through the epidural space behind the superior orbital wall between the lateral orbital rim and nasion burr hole; the osteotomy is performed with gentle reciprocating strokes. Dura protection with a malleable retractor is not absolutely necessary. RESULTS: Five patients underwent one-piece fronto-orbital bone flap osteotomies using a T-saw in 2009-2014. The median age was 26 months (7-132 months), median operation time was 275 min (183-303 min), and median estimated blood loss was 65 mL (20-250 mL). These values did not differ from those of control cases. No complications, including incomplete osteotomy, occurred. CONCLUSIONS: The T-saw creates an osteotomy as a "one-stroke sketch," so incomplete osteotomy never occurs. The osteotomy can be performed safely without protecting the dura. Osteotomy with T-saw does not negate the advantages of fronto-orbital advancement with distraction osteogenesis, including shorter operative time, less intraoperative bleeding, and fewer complications.

Facial asymmetry with enlarged frontal sinus and hyperplasia of the cranial, nasal, and mandible bones.

The conditions of facial asymmetry are caused by congenital or acquired diseases, and several unclassifiable syndromes with unknown etiologies exist. In this report, a case of facial asymmetry with enlarged frontal sinus and hyperplasia of the frontal cranial bone and nasal bone is presented. Although the etiology of the facial malformation was clear, it was thought that the cause of the enlarged frontal sinus was related to the unidentified bony hyperplasia and facial asymmetry related to hemimandibular hyperplasia.

Incidence of lower eyelid complications after a transconjunctival approach: influence of repeated incisions.

Although many authors have described advantages of the transconjunctival approach, few reports describe risks of postoperative lower eyelid complications with repeated incisions. The objective of this study was to investigate whether the incidence of postoperative lower eyelid complication using the transconjunctival approach was different, depending on the time of incision. Patients who underwent orbital bony surgery at the Kanazawa Medical University Hospital between 1996 and 2012 were reviewed. Patients were divided into a group that underwent single transconjunctival incision and a group that underwent repeated incisions. Intraoperative and postoperative complications, including eyelid ectropion, entropion, and scleral show, were compared between the groups. A total of 154 transconjunctival incisions were made in 145 patients (mean age, 35.6 y; 99 men and 46 women), who were observed for a mean of 14 months (range, 6-97 mo). Two patients had eyelid lacerations with inferior lacrimal canaliculus injuries. Lower eyelid malposition requiring operative correction occurred in 3 of the 140 patients in group A (2.1%) and in 3 of the 14 patients in group B (21.4%) (P = 0.01). The total postoperative complication rate in patients with a single incision was 5.0% (n = 7), and that for repeated incisions (2-5 times) was 35.7% (n = 5) (P = 0.001). The total complication rate of transconjunctival incision was slightly high. Although repeated incision cases were significantly more frequent, the eyelid could be corrected without visible scarring although eyelid complications occurred.

Repair of orbital fracture: the antral balloon with implantable reservoir technique.

The antral balloon technique is a useful procedure for the treatment of orbital fracture. Its advantages include being able to apply it without any donor-site morbidity. However, the saline injection catheter, which is inserted nasally from the natural ostium, sometimes causes discomfort. We present our new antral balloon technique with an implantable reservoir dome. This technique did not cause patient discomfort because no saline injection catheter was inserted nasally. It contributed to long-term placement of the antral balloon. Of 30 patients, satisfactory symmetries were achieved in 27 patients and the others required subsequent calvarial bone grafting for correction because of residual enophthalmos.

Three-dimensional computed tomography venography as a guide for cranioplasty in parietal cephalocele.

We present cranioplasty for a patient who underwent encephalocele surgery during infancy. Preoperative 3-dimensional computed tomography venography showed the skull defect and abnormal running of the superior sagittal sinus in simultaneous images. Using computed tomography venography images as a guide, we could safely harvest full-thickness calvarial bone from the contralateral side of the superior sagittal sinus.

Intraoperative acquired pressure ulcer on lower lip: a complication of rhinoplasty.

Device-related pressure ulcers are not rare. However, few studies have reported pressure ulcers of the lower lip. We encountered 2 patients with an intraoperative pressure ulcer on the lower lip caused by an endotracheal tube during rhinoplasty. A 46-year-old man showed a deviated nose and nasal obstruction. Surgery was performed under general anesthesia with endotracheal intubation. The surgery time was 270 minutes. A 23-year-old man also showed a deviated nose and nasal obstruction. Surgery was performed under general anesthesia in the same fashion. The surgery time was 273 minutes. A preformed endotracheal tube was inserted and positioned over the mandible and secured with polyurethane film intraoperatively. Both patients had pressure ulcers on their lower lip. One showed a slightly visible scar. Care must be taken to avoid ulcers of the lower lip in rhinoplasty patients.

Troubleshooting distraction osteogenesis for craniosynostosis.

PURPOSE: We previously reported that distraction osteogenesis is less invasive and gives greater skull advancement compared to conventional cranioplasty [Akai et al: Pediatr Neurosurg 2006;42:288-292]. In this study, we analyzed the distraction osteogenesis process and tried to identify and solve various technical problems. PATIENTS AND RESULTS: We operated on 22 patients, 5 syndromic and 17 nonsyndromic. During treatment, we encountered several problems: (i) dural laceration during craniotomy (2 cases), solution: repair by suturing with fascia; (ii) skull fracture at sphenofrontal or coronal sutures (2 cases), solution: completed distraction; (iii) device dislocation during distraction (1 case), solution: the device was secured to the skull with stainless wire; (iv) wound issues around shaft and device (3 cases), solution: treated with antibiotic ointment. DISCUSSION: (1) Extra caution is needed to avoid dural damage at frontal bottom burr holes. (2) Completion of craniotomy should be confirmed by checking if the bone flap moves in sync with brain pulsation. The craniotomy line should be placed forward of coronal sutures. (3) For patients younger than 2 years, employ clamp-type devices. (4) Shafts should be cut short enough to prevent their tips from exerting pressure or puncturing the scalp from beneath. CONCLUSIONS: The distraction osteogenesis technique has complications that may not occur in conventional one-stage cranioplasty. In this study, neither age at operation nor distraction distance were significant causes of complications during distraction osteogenesis.

[In vitro susceptibilities to levofloxacin and various antibacterial agents of 12,919 clinical isolates obtained from 72 centers in 2007].

We have reported in this journal in vitro susceptibilities of clinical isolates to antibiotics every year since 1992. In this paper, we report the results of an analysis of in vitro susceptibilities of 12,919 clinical isolates from 72 centers in Japan to selected antibiotics in 2007 compared with the results from previous years. The common respiratory pathogens, Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae maintained a high susceptibility to fluoroquinolones (FQs). The resistance of S. pyogenes to macrolides has been increasing every year and this was especially clear this year. Most strains of Enterobacteriaceae except for Escherichia coli showed a high susceptibility to FQs. Almost 30% of E. coli strains were resistant to FQs and the resistance increased further this year. FQs resistance of methicillin-resistant Staphylococcus aureus (MRSA) was approximately 95% with the exception of 45% for sitafloxacin (STFX). FQs resistance of methicillin-susceptible S. aureus (MSSA) was low at about 10%. FQs resistance of methicillin-resistant coagulase negative Staphylococci (MRCNS) was higher than that of methicillin-susceptible coagulase negative Staphylococci (MSCNS), but it was lower than that of MRSA. However, FQs resistance of MSCNS was higher than that of MSSA. FQs resistance of Enterococcus faecalis was 22.5% to 29.6%, while that of Enterococcusfaecium was more than 85% except for STFX (58.3%). In clinical isolates of Pseudomonas aeruginosa derived from urinary tract infections, FQs resistance was 21-27%, which was higher than that of P. aeruginosa from respiratory tract infections at 13-21%, which was the same trend as in past years. Multidrug resistant strains accounted for 5.6% in the urinary tract and 1.8% in the respiratory tract. Acinetobacter spp. showed high susceptibility to FQs. The carbapenem resistant strains, which present a problem at present, accounted for 2.7%. Neisseria gonorrhoeae showed high resistance of 86-88% to FQs. The results of the present survey indicated that although methicillin-resistant Staphylococci, Enterococci, E. coli, P. aeruginosa, and N. gonorrhoeae showed resistance tendencies, and other species maintained high susceptibility rates more than 90% against FQs, which have been used clinically for over 15 years.