Extended reduction malarplasty for Asians with flat and wide face: Comparison with L-shaped osteotomy.

BACKGROUND: Reduction malarplasty is effective in correcting prominent zygomatic body and arch in Asian populations, but periorbital zygomatic bony protrusion may not be sufficiently improved. In this study, we present the extended reduction malarplasty procedures to correct it simultaneously and compare the outcome with that of conventional L-shaped osteotomy. METHODS: A retrospective review of consecutive patients who received reduction malarplasty between August 2021 and September 2023 at our hospital was conducted. Computed tomography images obtained before and after surgery were assessed to evaluate the facial skeletal changes, and to compare between the extended and conventional L-shaped malarplasty results. RESULTS: Twenty extended reduction malarplasty patients and 23 conventional reduction malarplasty patients were eligible for the study. Cephalometric analyses showed significant reduction in the zygomatic width in both groups, but the protrusion of the periorbital area was improved significantly greater in the extended reduction malarplasty group. In terms of facial angulation, the extended reduction malarplasty also provided more horizontal convexity in the periorbital area, whereas the angular change in the caudal part of zygoma was not significantly different. CONCLUSION: The extended reduction malarplasty enabled to reduce the protrusion of the periorbital area, as well as the prominent zygomatic body and arch, and provided more three-dimensionality and horizontal convexity with the midface contour. It is a viable option for harmonizing the facial profile for Asian patients with flat and wide face.

Does 20 Hz Transcranial Alternating Current Stimulation over the Human Primary Motor Cortex Modulate Beta Rebound Following Voluntary Movement?

Beta frequency oscillations originating from the primary motor cortex increase in amplitude following the initiation of voluntary movement, a process termed beta rebound. The strength of beta rebound has been reported to predict the recovery of motor function following stroke, suggesting therapeutic applications of beta rebound modulation. The present study examined the effect of 20 Hz transcranial alternating current stimulation (tACS) on the beta rebound induced by self-paced voluntary movement. Electroencephalograms (EEGs) and electromyograms (EMGs) were recorded from 16 healthy adults during voluntary movements performed before and after active or sham tACS. There was no significant change in average beta rebound after active tACS. However, the beta rebound amplitude was significantly enhanced in a subset of participants, and the magnitude of the increase across all participants was negatively correlated with the difference between individual peak beta frequency and tACS frequency. Thus, matching the stimulus frequency of tACS with individual beta frequency may facilitate therapeutic enhancement for motor rehabilitation.

Event-Related Brain Potentials N140 and P300 during Somatosensory Go/NoGo Tasks Are Modulated by Movement Preparation.

The Go/NoGo task requires attention and sensory processing to distinguish a motor action cue or 'Go stimulus' from a 'NoGo stimulus' requiring no action, as well as motor preparation for a rapid Go stimulus response. The neural activity mediating these response phases can be examined non-invasively by measuring specific event-related brain potentials (ERPs) using electroencephalography. However, it is critical to determine how different task conditions, such as the relationship between attention site and movement site, influence ERPs and task performance. In this study, we compared attention-associated ERP components N140 and P300, the performance metrics reaction time (RT) and accuracy (%Error) and movement-related cortical potentials (MRCPs) between Go/NoGo task trials in which attention target and movement site were the same (right index finger movement in response to right index finger stimulation) or different (right index finger movement in response to fifth finger stimulation). In other Count trials, participants kept a running count of target stimuli presented but did not initiate a motor response. The N140 amplitudes at electrode site Cz were significantly larger in Movement trials than in Count trials regardless of the stimulation site-movement site condition. In contrast, the P300 amplitude at Cz was significantly smaller in Movement trials than in Count trials. The temporal windows of N140 and P300 overlapped with the MRCP. This superposition may influence N140 and P300 through summation, possibly independent of changes in attentional allocation.

Real-Time Assessment of Free Flap Capillary Circulation Using Videocapillaroscopy.

BACKGROUND: Free tissue transfer is a common method of reconstruction for various surgical defects. Many clinical assessment methods, including flap color monitoring and capillary refill time measurements, are commonly used to assess the microcirculation of the flap, yet there is no objective tool available that can clear real-time visualization of the flap microcirculation. The purpose of this study was to use a novel videocapillaroscope to evaluate the circulation changes on free flap skin surfaces while purposely clamping pedicle vessels. METHODS: Ten patients who underwent free flap transfer for head and neck cancer from November of 2019 to June of 2020 were included in the study. Videocapillaroscopic observation was performed after flap elevation, and changes in the flap skin capillary circulation with artery-controlled and vein-controlled clamping were recorded. RESULTS: Average total surgery time was 517.91 minutes (SD, 73.3 minutes), average flap elevation time was 102.9 minutes (SD, 18.3 minutes). When the pedicle artery or vein was purposely clamped, the movement of red blood cells in blood vessels stopped; when clamps were removed after 60 seconds, the restoration of red blood cell movements was rapidly observed. When the pedicle artery was clamped, the number of visualizable blood vessels decreased and flap color became relatively white. When the pedicle vein was clamped, the number of visualizable blood vessels increased, and flap color tone had a tendency toward red. CONCLUSION: Novel videocapillaroscopy can be utilized for objective real-time flap monitoring by directly visualizing flap skin capillary microcirculation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Use of a Surgical Microscope for Subperichondrial-Subperiosteal Dissection in Preservation Rhinoplasty: Ergonomic Considerations.

Preservation of anatomical components in rhinoplasty has gained increasing popularity over recent years. Given that elevation of the soft tissue envelope in a continuous subperiochondrial-subperiosteal dissection preserves soft tissues, vessels, nerves, and lymphatics, this procedure may result in faster healing time and less swelling and scarring. However, the technique requires a learning phase and can be challenging to perform because it typically requires meticulous dissection under surgical loupes. The dissection may thus be time-consuming and a burden for surgeons, especially in secondary rhinoplasty cases. Further, the potential risk of musculoskeletal discomfort and injury to the surgeon should not be overlooked; consideration for surgical ergonomics is needed to prevent injuries and enhance surgical performance. To address these issues, we propose the use of a surgical microscope for subperiochondrial-subperiosteal dissection in preservation rhinoplasty. A microscope enables clear visualization of the surgical field and allows surgeons to make precise and delicate manipulation maneuvers. Moreover, it may also enable surgeons to maintain an ideal ergonomic posture and neutral positioning of their joints, thereby reducing physical strain. A surgical microscope may thus be a useful tool for subperiochondrial-subperiosteal dissection by providing clear visualization of the surgical field and improved surgical ergonomics for surgeons.

Reinforced Polyphenylene Ionomer Membranes Exhibiting High Fuel Cell Performance and Mechanical Durability.

We report on the preparation of reinforced membranes (SPP-QP-PE, where SPP stands for sulfonated polyphenylene), composed of an in-house proton-conductive polyphenylene ionomer (SPP-QP) and a flexible porous polyethylene (PE) mechanical support layer. By applying the push coating method, dense, uniform, transparent, and thin SPP-QP-PE membranes were obtainable. The use of SPP-QP with higher ion exchange capacity induced very high proton conductivity of SPP-QP-PE, leading to high fuel cell performance even at low humidified conditions (e.g., at 80 °C and 30% relative humidity), which had not been attainable with the existing reinforced aromatic ionomer membranes. The flexible porous PE substrate improved the mechanical toughness of the membranes; the elongation at break increased by a factor of 7.1 for SPP-QP-PE compared to that with the bare SPP-QP membrane, leading to mechanical durability at least 3850 wet-dry cycles under practical fuel cell operating conditions (the United States Department of Energy protocol). Overall, the reinforced aromatic ionomer membranes, SPP-QP-PE with balanced proton conductivity, mechanical toughness, and gas impermeability, functioned well in fuel cells with high performance and durability.

Multidirectional cranial distraction osteogenesis technique for treating bicoronal synostosis.

Fronto-orbital advancement by distraction osteogenesis is a useful means of surgically correcting bicoronal synostosis. However, the scope for morphological revision is limited. To address this issue, we developed a multidirectional cranial distraction osteogenesis (MCDO) technique that we quantitatively assessed in patients with bicoronal synostosis. In this case series, five patients with bicoronal synostosis were treated with MCDO at a mean age of 13.4 months (range 9-22 months). Distraction started 5 days after surgery and the activation period was 11.2 days (range 10-14 days). The distraction devices were removed 47.2 days (range 33-67 days) after completing distraction. Improved cranial shape was confirmed by CT data. Mean preoperative CI, APL, and ICV readings of 102.1%, 13.5 cm, and 1179.4 ml, respectively, had reached 94.0%, 14.9 cm, and 1323.9 ml, respectively, upon device removal. These values were well preserved at 1 year (90.4%, 15.8 cm, and 1461.3 ml, respectively). In conclusion, MCDO successfully enables both cranial expansion and correction of a flat forehead, constituting a valid treatment alternative for patients with bicoronal synostosis.

Development of Multidirectional Cranial Distraction Osteogenesis for the Treatment of Craniosynostosis.

BACKGROUND: Previously, the authors developed a new method of distraction osteogenesis for the treatment of craniosynostosis, multidirectional cranial distraction osteogenesis (MCDO). The purpose of this study is to review the authors' experience of MCDO for remodeling of the anterior cranium in the patients of craniosynostosis. METHODS: Forty-five patients with craniosynostosis underwent MCDO for anterior cranial remodeling from 2003 to 2017. The ages of the patients ranged from 8 to 72 months (mean: 23.9 months, median: 13 months). The involved sutures included the bicoronal suture in 14 patients, unicoronal suture in 4 patients, sagittal suture in 14 patients, metopic suture in 2 patient, and multiple sutures in 10 patients. RESULTS: An improvement of in cranial shape was achieved in 40 patients. In 1 patient, intraoperative massive bleeding forced us finishing the procedure before completing the planned osteotomy. Transient cerebrospinal fluid leakage occurred in 3 patients during the activation phase but recovered with conservative therapy. The mean blood transfusion was 25.5 mL/kg. The phase of activation ranged from 7 to 17 days (mean, 10.6 days) and the consolidation period ranged from 16 to 67 days (mean, 32.4 days). Loosening of traction pins occurred in 7 patients, resulting in undercorrection in 2 patients, and loosening of anchor pins occurred in 19 patients, resulting in acceleration of removal of the devices in 7 patients. CONCLUSIONS: Multidirectional cranial distraction osteogenesis was effective and has several advantages over the conventional procedures. Therefore, the authors conclude that MCDO will be a useful alternative for all phenotypes of craniosynostosis.

Multidirectional Cranial Distraction Osteogenesis with Simplified Modifications for Treating Sagittal Synostosis.

BACKGROUND: Multidirectional cranial distraction osteogenesis (MCDO) is a procedure of ours developed earlier for treating craniosynostosis. However, the numerous bone flaps led to prolonged operative time and occasional bone detachment from dura. We have since simplified the osteotomy design. In treating sagittal synostosis, required bone flaps have been reduced to 11 (from ~20). METHODS: In a 2-year period (2014-2015), 5 boys with sagittal synostosis underwent MCDO using our simplified and fixed-form osteotomy. Mean age at surgery was 9.4 months (range, 8-11 months). Pre- and postoperative cranial morphology was assessed by cephalic index and by mid-sagittal vector analysis. RESULTS: Improved cranial shape was confirmed by 3-dimensional CT scans and by mid-sagittal vector index. Mean preoperative cephalic index (68.7) progressively increased to means of 78.5 immediately after distraction device removal, 75.2 at postoperative month 6, and 75.1 at 1 year postoperatively. There were no major complications, although transient cerebrospinal fluid leakage and loosening of anchor pins occurred in 1 patient. CONCLUSIONS: Simplified MCDO has a number of advantages over conventional distraction procedures such as discretionary reshaping/expansion of cranium and predictable osteogenesis and is a valid treatment option for patients with sagittal synostosis.

Growth curves for intracranial volume in normal Asian children fortify management of craniosynostosis.

BACKGROUND: Although the charting of normal intracranial volume (ICV) is fundamental for managing craniosynostosis, Asian norms in this regard are unknown. The purpose of this study was to establish a growth curve for ICVs in a large series of normal Asian children, providing reference values to guide corrective surgery. METHODS: A total of 124 normal children (male, 63; female, 61) and 41 children diagnosed with craniosynostoses were analyzed. Patients aged 0-8 years presenting to the emergency room and subjected to computed tomography (CT) for head trauma served as the reference cohort. Axial CT head scan data were obtained from radiographic archives at Jichi Medical University. Imaging was done on a Siemens CT scanner (5-mm slice thickness), using a DICOM viewer to measure ICVs. RESULTS: ICVs were plotted against age, and best-fit logarithmic curves for normal subjects were generated, without and with gender stratification. Male and female growth curves were similar in shape but diverged past the age of 1 year (male > female). ICVs of patients with craniosynostoses were plotted to male and female growth curves by disease subset, revealing the following: sagittal synostosis, near normal (or marginally larger); metopic synostosis, below normal; other non-syndromic synostoses (unilateral, bilateral, and lambdoidal) and Crouzon syndrome, near normal; Apert syndrome, above normal; and Pfeiffer syndrome, variable. CONCLUSION: ICVs of early childhood were investigated in Asian subjects, creating growth curves that set criteria for timing, planning and goalsetting in surgical correction of craniosynostosis.

Clinical and Quantitative Isokinetic Comparison of Abdominal Morbidity and Dynamics following DIEP versus Muscle-Sparing Free TRAM Flap Breast Reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap, which is a modification of the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, is being more frequently used in an effort to reduce postoperative abdominal morbidity. However, there is no consensus as to which of these flaps is superior. The authors aimed to compare quantitative measurements of abdominal function obtained with an isokinetic dynamometer after DIEP and muscle-sparing free TRAM flap elevation. METHODS: Patients who underwent unilateral single-pedicled DIEP (n = 42) or muscle-sparing free TRAM flap (n = 36) breast reconstruction performed by a single surgeon were included in this study. Preoperative and postoperative trunk flexion parameters were measured prospectively using an isokinetic dynamometer in all patients. The occurrence of postoperative pain, stiffness, and bulging along with patient activity level were also investigated. RESULTS: At 3 months postoperatively, abdominal functions were decreased in both groups, with a larger decline in the muscle-sparing free TRAM flap group. However, at 6 months postoperatively, abdominal muscle function recovered to preoperative levels in both groups. These findings were consistent with the absence of a statistically significant difference in patient postoperative abdominal pain and stiffness, activity level, and the incidence of bulging between the two groups at 6 months postoperatively. CONCLUSION: From these results, we propose that the surgeon can select the muscle-sparing free TRAM flap, without hesitation or concern regarding abdominal morbidity, when a thick and reliable perforator does not exist and multiple thin perforators must be incorporated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Studying the blood pressures of antegrade and retrograde internal mammary vessels: Do they really work as recipient vessels?

BACKGROUND: The proximal ends of internal mammary (IM) vessels are now the most common recipient vessels for breast reconstruction. On the other hand, bilateral deep inferior epigastric artery perforator (DIEP) flaps are often needed according to the territory and the volume required for reconstruction. The usefulness of retrograde IM vessels as second recipients has recently been reported, but there are very few quantitative studies on the hydrodynamics of the retrograde IM vessels. Because the flow is dependent on the pressure differential, the blood pressures of the antegrade IM artery (AIMA), antegrade IM vein (AIMV), retrograde IM artery (RIMA), retrograde IM vein (RIMV), and recirculated intraflap vein (FV) were investigated to solve this question and to confirm the reliability and usefulness of the retrograde IM vessels. METHODS: Ten free flap breast reconstructions were included in this study. The IM vessels were exposed, and the pressures were measured. After recirculation, the FV pressures were measured when the flap was not ischemic or congestive. Systemic blood pressure was also recorded during the whole measurement period. RESULTS: The AIMA and RIMA pressures were 70.4 ± 8.2 mmHg and 54.0 ± 8.6 mmHg (p = 0.000003), respectively, while the systemic pressure was 65.1 ± 10.0 mmHg. The AIMV pressure was always smaller than the RIMV pressure; the mean AIMV pressure was 5.3 ± 1.6 mmHg. In addition, the FV pressure was greater (p = 0.03) than the RIMV pressure (17.7 ± 9.9 mmHg), while the RIMV pressure was 8.7 ± 2.0 mmHg. CONCLUSIONS: Both the RIMA and RIMV are useful and reliable as second recipients for bipedicled free flap transfers. This is a great benefit because it would provide two recipients in one surgical site and would be especially useful in thin patients or patients with previous abdominal scars requiring double pedicled DIEP flaps. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.

Reconstitution of Human Keloids in Mouse Skin.

BACKGROUND: Keloids are a dermal fibroproliferative scar of unknown etiology. There is no good animal model for the study of keloids, which hinders the development and assessment of treatments for keloids. METHODS: Human keratinocytes and dermal fibroblasts were isolated from 3 human skin tissues: normal skin, white scars, and keloids. A mixed-cell slurry containing keratinocytes and dermal fibroblasts was poured into a double chamber implanted on the back of NOD/Shi-scid/IL-2Rγnull mice. After 12 weeks, the recipient mice had developed reconstituted human skin tissues on their backs. These were harvested for histological studies. RESULTS: Macroscopically, the reconstituted skins derived from both normal skin and white scars were similar to normal skin and white scars in humans, respectively. Keloid-derived reconstituted skins exhibited keloid-like hypertrophic nodules. Histological findings and immunohistochemical staining confirmed that the reconstituted skin tissues were of human origin and the keloid-derived reconstituted skin had the typical features of human keloids such as a hypertrophic dermal nodule, collagen type composition, orientation of collagen fibers, and versican expression. CONCLUSION: The mouse model with humanized keloid tissue presented here should be a useful tool for future keloid research.

Use of Multidirectional Cranial Distraction Osteogenesis for Cranial Expansion in Syndromic Craniosynostosis.

Patients with syndromic craniosynostosis often require a large amount of cranial expansion to avoid intracranial hypertension, but the surgical procedure remains controversial. A patient of severe syndromic craniosynostosis with multiple bony defects and anomalous venous drainage at the occipital region was treated by multidirectional cranial distraction osteogenesis (MCDO) at the age of 8 months. Distraction started 5 days after surgery and ceased on postoperative day 16. The distraction devices were removed 27 days after completing distraction. After device removal, the increase of intracranial volume was 155 ml and the cephalic index was improved from 115.5 to 100.5. The resultant cranial shape was well maintained with minimal relapse at postoperative 9 months. In cases of syndromic craniosynostosis with multiple bony defects and/or anomalous venous drainage at the occipital region, expansion of the anterior cranium by MCDO is a viable alternative to conventional methods.

A Novel Technique That Protects the Lips during Orthognathic Surgery.

Serious lip injuries can occur during orthognathic surgery. Although an Angle Wider device, which is commonly used during orthognathic surgery, provides some lip protection, it leaves more than half of the lip exposed to surgical instruments. Here, we describe a novel technique to protect the entire upper and lower lips during orthognathic surgery using a minilaparotomy wound edge protector (Lap-Protector). We used this method in 60 patients who have undergone orthognathic surgeries such as sagittal split ramus osteotomy and Le Fort I osteotomy since 2009, and no lip injuries have occurred. Although this technique can be somewhat challenging at first and creates some difficulty in exposing the surgical field on the lateral side, we believe that using a wound edge protector minimizes the risk of lip injury during orthognathic surgery.

Distraction Osteogenesis Update: Introduction of Multidirectional Cranial Distraction Osteogenesis.

In this review, we discuss in detail our current procedure for treating craniosynostosis using multidirectional cranial distraction osteogenesis (MCDO). The MCDO method allows all phenotypes of skull deformity to be reshaped by distraction osteogenesis, except in patients who are 5 months of age or younger and patients with posterior cranial vault problems. We report the results of clinical data of 36 children with craniosynostosis who underwent MCDO between 2005 and 2014 in our institute. This method has the following benefits, such as a high flexibility of reshaping, shorter treatment period and less invasive secondary intervention. We also discuss the other distraction osteogenesis techniques that are used to treat craniosynostosis and compare them with MCDO. The preferred procedure for correction of craniosynostosis may depend on the patient's age, the extent of deformity, and the extent of correction achievable by surgery. We can arrange the combinations of various methods according to the advantage and disadvantage of each technique.

Vertically Set Sombrero-shaped Abdominal Flap for Asian Breast Reconstruction after Skin-sparing Mastectomy.

BACKGROUND: Immediate autologous breast reconstruction after skin-sparing mastectomy is an esthetically superior method, and a free abdominal flap is often used. However, in Asian patients, little redundant abdominal skin and thin subcutaneous tissue are common, necessitating the development of a more suitable flap design and setting. We devised a narrow flap, the sombrero-shaped flap (S-flap), set vertically, to reduce postoperative abdominal morbidity without sacrificing cosmetic results. METHODS: To assess this new flap design and setting, the recipient- and donor-site complications of consecutive patients treated by S-flap (n = 40) and conventional flap (C-flap) (n = 22) were retrospectively investigated. Postoperative abdominal pain, stiffness, and patient activity were also assessed in each group with our original grading scale. RESULTS: Compared with the C-flap group, the S-flap group had a significantly lower skin paddle vertical height (mean, 14.0 and 10.2 cm, respectively; P < 0.001), lower abdominal stiffness (P = 0.023), and higher rate of double-pedicled flap use (27.3% and 52.5%, respectively; P < 0.048). The rates of donor and recipient site complications, postoperative abdominal pain, and activity did not significantly differ between the groups. CONCLUSIONS: For immediate breast reconstruction after skin-sparing mastectomy in Asian patients, our newly designed S-flap and vertical flap setting achieved cosmetically good, consistent results with low abdominal morbidity, even though the abdominal flap was thin and narrow. The viability of the S-flap, including medial fan-shaped adipose flap, was reliable, even though the flap often required elevation with double pedicles.

Mandibular Reconstruction Based on the Concept of Double Arc Reconstruction.

The natural mandible has 2 arcs, the marginal arc and the occlusal arc. The marginal arc is situated along the lower margin of the mandible and affects the contour of the lower third of the face. The occlusal arc is situated along the dental arc and affects the stability of prosthodontics. The gap between these 2 arcs widens in the molar area. Our developed concept of "double arc reconstruction" involves making these 2 arcs for the reconstructed mandible. For the double-barrel fibula reconstruction, 2 bone segments are used to make both arcs. For reconstructions using the iliac crest, the double arc is made by inclination of the top of the bone graft toward the lingual side. Ten patients underwent double arc reconstruction: 2 underwent reconstruction with the double-barrel fibula, and 8 underwent reconstruction with the iliac crest. Four patients had a removable denture prosthesis, 1 had an osseointegrated dental implant, and 5 did not require further prosthodontic treatment. The shape of the reconstructed mandible after double arc reconstruction resembles the native mandible, and masticatory function is good with the use of a dental implant or removable denture prosthesis, or even without prosthodontics.

New finding that might explain why the skin wrinkles more on various parts of the face.

The mechanism of formation of facial wrinkles has not been fully clarified due to the existence of many distinct influential factors. To clarify the relationship between facial wrinkles and structures in the skin, especially sebaceous glands, image analysis was performed on the forehead and lateral canthus regions of cadaveric skin specimens; 58 male and female donated cadavers (age range at death 20s - 90 s) were included in the study. Specimens were obtained from forehead and lateral canthus region after measuring wrinkle depth. Then tissue slices were prepared to observe the sebaceous gland and its density was measured and analyzed in relation to wrinkle depth, retinacula cutis density, dermal thickness, and solar elastosis degree. A correlation was found between sebaceous gland density and wrinkle depth in forehead specimens with a lower retinacula cutis density. Wrinkles were shallower in specimens with a higher sebaceous gland density. However, no such correlation was found in lateral canthus wrinkles, presumably due to the lack of sebaceous glands in that region. In addition, specimens with a higher sebaceous gland density tended to have a thicker dermis and/or less solar elastosis. Sebaceous gland density seems to be one of the multiple factors that prevent wrinkle deepening, and that is why wrinkles are deeper in the lateral canthus area than in the forehead. Functional studies will elucidate the mechanism of wrinkle formation in the future.