Posterior Auricle Bilobed Cartilage-skin Flap for Reconstructing the Earlobe: A Case Report.

Because the auricle plays an important role in facial aesthetics, all earlobe operations must seek to limit postoperative ear deformity. This report describes the single-stage posterior-auricle bilobed cartilage-skin flap technique for reconstructing the earlobe. A 31-year-old man incurred a left earlobe deficiency due to a human bite. Earlobe reconstruction was conducted 102 days later. A bilobed flap was designed on the posterior-auricular skin. Both flaps were pedicled in the caudal posterior-auricular area. The first incision raised the upper lobe, which consisted of posterior-auricle skin and conchal cartilage. The skin was sutured to the auricle base so that it formed the anterior earlobe. The cartilage was then cut to separate and processed to the natural curve. The second incision elevated the second flap from the caudal posterior-auricular area. This was sutured to the first flap so that it formed the posterior earlobe. The donor sites were closed with simple sutures. The reconstructed earlobe had no obvious contracture after surgery. Most donor-site scarring was hidden behind the auricle. At 9 months postoperative, the patient was satisfied with the result. Our technique allows us to harvest cartilage from the same operative field, perform a single-stage reconstruction, and recreate a relatively large earlobe with good size and shape. The posterior auricle bilobed cartilage-skin flap technique is useful for earlobe reconstruction.

Cheek Reconstruction with a Nasolabial External-Rotation Flap.

It remains difficult to reconstruct large preauricular defects in a single step with good cosmetic outcomes. We describe here the nasolabial external-rotation (NER) flap, which was combined with a cervical-rotation flap to reconstruct a large skin defect on the preauricular area that included the malar prominence. The patient in case 1 was a 91-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Three weeks after excision, the 6.5 × 5.5 cm defect was covered with a 5 × 3 cm NER flap, which had a cephalad base and was rotated so its caudal tip covered the malar prominence. The resulting nasolabial defect and the remaining defect occupied the entire buccomandibular area, which was then covered with a 13 × 10 cm cervical-rotation flap. Revision surgery has not been needed for 8.5 months and the cosmetic outcomes are good. The patient in case 2 was a 90-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Four weeks after excision, the 4.7 × 4 cm defect was covered with an 8 × 3 cm NER flap. The buccomandibular defect was covered with a 9.5 × 5 cm cervical-rotation flap. The flaps survived completely. The NER flap is unique because the flap is moved from the midface to the lateral face. It can reconstruct the malar prominence with thick skin tissue, and it is particularly suitable for older patients. Combining it with a cervical-rotation flap allows for natural subunit reconstruction in a relatively minimally invasive manner with good aesthetic outcomes.

Geometric Wire-frame Fixation of Skin Grafting for Lip Reconstruction.

Postoperative fixation is required for skin grafts on mobile sites. External wire-frame fixation technique has demonstrated a beneficial role for grafts in specific areas such as lips, eyelids, and fingers. Although this technique is sufficient in most cases, patients with psychosis fail to maintain the lip in resting position, which led us to consider using a more rigid fixation method, known as "Geometric wire-frame fixation." Surgical technique included fixing a perimeter frame around skin graft similar to the conventional external wire-frame fixation. In addition, a geometric frame was prepared to divide the area of the graft geometrically. Then, it was placed on gauze to compress the grafted skin, and connected to the perimeter frame. In case 1, a 33-year-old man with a history of schizophrenia and presenting with flame burn injury sustained while attempting suicide was admitted. The scar on the lips was excised, and an external wire-frame fixation was performed. However, postoperative vigorous mouth movements caused incomplete survival of the skin graft. Geometric wire-frame fixation was performed in the next operation, and the graft fully survived. The patient in case 2 was a 62-year-old man who developed a facial scar contracture after chemical injury by sulfuric acid. We performed geometric wire-frame fixation with contracture release of the upper lip, and the skin graft was fully taken. The geometric wire-frame fixation method allows for rigid fixation of the skin graft and can be considered as a valuable option, especially for lip reconstruction in poorly compliant patients who are unable to maintain proper resting lips.

Calcium Phosphate Cement "Space Fill-in" Augmentation in Autologous Cranioplasty for Large Cranial Defect: Additional Technical Consideration and Its Long-term Follow-up.

In the skull tumor surgery that requires a large cranial reconstruction, economical one-time surgery is challenging. Calcium phosphate paste (CPC) alone is not applied in the large defect. Other plastic fill-in materials have each drawback. Ready-made implants are costly. The authors present additional technique of CPC cranioplasty combined with mainstay autologous grafts for a large cranial defect. The combination of split rib grafts was augmented by CPC. Tenons were placed for the stability of grafts. Our newly additional technique is that CPC is filled in the small adjacent spaces of autografts, not applied as the simple on-lay graft. We introduced this method to a 57-year-old gentleman with left parietal expansile skull tumor. The aesthetics of the patient has been satisfactory, and there were no complaints about pain in the graft site. In the follow-up period of 8 years, both autologous grafts and CPC were well maintained without marked resorption. This patient could work as a farmer in this period. Our methods fulfilled the requirements of aesthetics and in-situ plasticity for a larger cranial defect.

Ten-Year Outcomes After Catcher's Mask Cranioplasty for Large Cranial Bone Defects in Children: A Report of Two Cases.

Cranioplasty is complicated in children with severe, extensive head trauma because allografting is not advisable in pediatric patients and the amount of available autologous materials is limited. To overcome these problems, Takumi reported a novel procedure called "catcher's mask cranioplasty" in 2008, in which split-rib grafts are placed perpendicularly over each other while calvarial grafts are placed in the hairless forehead region. Despite the small amount of grafts used, this method can yield esthetically satisfactory results and provides excellent structural integrity. Here, we report 2 cases of catcher's mask cranioplasty and their long-term outcomes. After more than 10 years, the transplanted bone grafts have not resorbed and have maintained their esthetically pleasing contours. In conclusion, catcher's mask cranioplasty is an effective option for traumatic cranial defects in children.

A Comparative Finite Element Analysis of Two Surgical Methods for Cryptotia.

Cryptotia is an auricular muscle abnormality that causes the superior and posterior auricular area to be buried under the temporal skin. Surgical treatment approaches can be divided into skin grafts and local flaps. Complex cases also require cartilage/muscle modification. In this study, we treated one case each with the Square flap method and the Cat's Ear flap method. The aim was to help surgeons select the most appropriate surgical procedure on a case-by-case basis. METHODS: Two typical cryptotia cases were treated with the Square or Cat's Ear flap method. Finite element analysis was performed with ADINA v8.9 software, a PC (Windows 7, CPU: Core i7, Memory: 8 GB), and a hyperelastic skin model (skin diameter 20 cm; thickness 2 mm). The model scales were about 500 nodes and 500 elements (tetrahedron). RESULTS: The Square flap method involved advancing the square flap between the two triangular flaps. Switching then generated dog-ears that created a big valley. In the Cat's Ear flap method, the two triangular flaps were rotated in the same direction, whereas a square flap was advanced slightly on the opposite side. This created a large dog-ear. CONCLUSIONS: This study suggested that the Cat's Ear flap method may be particularly useful for cryptotia patients whose posterior auricular groove is shallow when the buried helix is pulled out. The Square flap method may be suitable for other cases because it effectively extrudes the buried helix with comparatively small excision.

Pedicle Galeo-pericranial Flap Augmentation in Salvage Frontotemporal Cranioplasty: Additional 'Neurosurgeon-friendly' Reconstruction Technique of Aesthetic Neurosurgery in Superficial Temporal Artery Branch Compromised Host.

This technical note aims to demonstrate the usefulness, indications and its limitations of augmentation technique by bipedicle galeo-pericranial rotation flap and by monopedicle galeo-pericranial flap, both in STA (superficial temporal artery) branch compromised hosts in salvage frontotemporal cranioplasty. Although these flaps are not always idealistically vascularized owing to accidental injuries to the STA branches during previous surgeries, they are properly augmenting after salvage frontotemporal craniotomy when infection is not active. The procedure is indicated for salvage frontotemporal craniotomy when vasculature is needed at the surgical site, such as beneath the skin incision line in a thin injured scalp, onto the titanium plates or beneath the fragile fibrous scar. We do not apply this technique by neurosurgeons alone where infection is active or if the host is irradiated. This technique is recommended as a reconstructive aesthetic neurosurgical procedure. It is a 'neurosurgeon-friendly' simple procedure, as it does not require any special tools or complicated techniques.

Use of an Inverted and Segmented Galea-Calvarial Flap for the Simultaneous Reconstruction of the Frontal Sinus and Forehead: A New Supplementary Method of Reconstructive Cranial Surgery.

We report on a new technical method of using an inverted and segmented galea-calvarial flap for simultaneous reconstruction of the frontal sinus and forehead. A 73-year-old man presented with the production of pus at the forehead, in which the frontal sinus had been involved 6 years postoperatively. The patient underwent surgery with our new simultaneous technique. During the 7 years of follow-up after this reconstructive surgery, no recurrence of surgical wound problems was noted.

Photoinduced bending of rod-like millimetre-size crystals of a rhodium dithionite complex with n-pentyl moieties.

Rod-like millimetre-size crystals of a newly prepared rhodium dithionite complex with n-pentyl moieties bend upon photoirradiation and return to the initial shape upon heating; the roles of the flexible n-pentyl moieties as well as the photoreactive dithionite unit (µ-O2SSO2) are disclosed by single crystal X-ray diffraction.

Biomechanics and computer simulation of the Z-plasty.

INTRODUCTION: We compared the results of our computer simulation studies of Z-plasties of different design to those of earlier studies, such as laboratory studies in dogs. MATERIAL AND METHODS: The contours of single Z-plasties of different designs on flat surfaces were transferred to finite element analytical software (ADINA version 8.7). RESULTS: The lengthening effect was almost proportional to the size of the Z-plasty, but was always less than what was predicted by geometric calculation. The percent gain in length decreased with the number of Z-plasties. CONCLUSION: We used ADINA software analyze the lengthening effects of Z-plasties of different patterns. Our results support those of earlier experiments and should help increase our understanding of Z-plasties of various patterns.

Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction.

We use evidence-based algorithms to treat abnormal scarring, including keloids and hypertrophic scars (HSs). This involves a multimodal approach that employs traditional methods such as surgical removal, postoperative radiotherapy, corticosteroid injection, laser, and silicone gel sheets. As a result, the rate of abnormal scarring recurrence has decreased dramatically over the past 10 years. However, several problems remain to be solved. First, despite the optimization of a radiotherapy protocol, over 10% of cases who are treated with surgery and postoperative radiotherapy still recur in our facility. Second, the treatment options for cases with huge keloids are very limited. To address these problems, we performed basic research on the mechanisms that drive the formation of keloids and HSs. Extrapolation of these research observations to the clinic has led to the development of two treatment strategies that have reduced the rate of abnormal scar recurrence further and provided a means to remove large scars. Our finite element analysis of the mechanical force distribution around keloids revealed high skin tension at the keloid edges and lower tension in the keloid center. Moreover, when a sophisticated servo-controlled device was used to stretch wounded murine dorsal skin, it was observed that the stretched samples exhibited upregulated epidermal proliferation and angiogenesis, which are also observed in keloids and HSs. Real-time RT-PCR also revealed that growth factors and neuropeptides are more strongly expressed in cyclically stretched skin than in statically stretched skin. These findings support the well-established notion that mechanical forces on the skin strongly influence the cellular behavior that leads to scarring. These observations led us to focus on the importance of reducing skin tension when keloids/HSs are surgically removed to prevent their recurrence. Clinical trials revealed that subcutaneous/fascial tensile reduction sutures, which apply minimal tension on the dermis, are more effective in reducing recurrence than the three-layered sutures used by plastic surgeons. Moreover, we have found that by using skin flaps (e.g., perforator flaps and propeller flaps), which release tension on the wound, in combination with postoperative radiotherapy, huge keloids can be successfully treated.

Merkel cell carcinoma on the upper lip of a 100-year-old woman.

Merkel cell carcinoma (MCC) is a rare skin tumor that usually occurs on the head, neck, or extremities of elderly patients; it has a high incidence of local recurrence, regional lymph node metastasis, and subsequent distant metastasis. We report a MCC that developed rapidly on the left corner of the upper lip of a 100-year-old woman. An incisional skin biopsy was performed to confirm MCC. Computed tomography showed no metastasis. The tumor was widely excised with a margin of 1 cm. Immediate reconstruction with a reverse Estlander flap from the lower lip was performed under general anesthesia. Additional surgery was also performed under general anesthesia 2 weeks later to widen the patient's lips. The surgical results were satisfactory. The patient died of senile deterioration a year after hospitalization for long-term medical treatment, without any recurrence or metastasis of MCC. Despite the patient's age, we considered it necessary to resect the tumor widely because of its rapid growth. The tumor margin was 1 cm. No radiotherapy was performed, but we believe that surgery alone was effective in allowing this patient to live an additional year without recurrence or metastasis. To the best of our knowledge, this patient is the oldest person with MCC yet described.

One-stage reconstruction using a vascularized calvarial flap for intractable scalp ulcers in relation with cranial implants without removing the whole prosthesis.

When alloplastic cranial implants present some complications, the classical strategy has been to remove them. Removal of the custom-made artificial skull, however, requires a second cranioplasty. We describe two representative cases of intractable scalp ulcer over the cranial prosthesis treated by vascularized calvarial flap without totally removing the implant. One patient had a previous ceramic implantation and the other a large titanium mesh, whose precedent local skin flap methods to treat the scalp ulcer were not successful. After the implant beneath the scalp ulcer was partially removed, a vascularized calvarial flap was raised. The calvarial graft of the flap was utilized to repair the implant defect and the galeal part of the flap was utilized to patch the ulcer from the reverse side. The clinical outcome is excellent. Our experience clearly demonstrated that the vascularized calvarial flap contributes to maintain a sufficient blood supply for the calvarial graft, reduces the risk of infection and provides a new tissue bed for the healing of a skin ulcer over a cranial implant for this difficult-to-treat cranial reconstruction.

Advantage of Catcher's mask cranioplasty for post-surgical infectious skin trouble.

INTRODUCTION: We report the case of a patient with repeated intractable cranioplasty infections who was successfully treated by partially removing the graft after Catcher's mask cranioplasty. MATERIALS AND METHODS: Aside from the cost of cranial artificial implants, our simple method saves the cost of subsequent removal and implantation surgeries in the process of cranioplasty trouble shooting.

Expansile neurenteric cyst arising in the frontal lobe associated with status epilepticus: report of a case and discussion of epileptogenesis.

The case of a 32-year-old Japanese man with an expansile supratentorial neurenteric cyst is described. The initial MRI revealed a left frontal extraaxial mass lesion 20 mm in diameter that showed marked expansion to 32 mm and change in its signal intensity 13 months later. Fifteen months after his visit, the patient fell into status epilepticus and underwent surgery. The cyst wall was excised, and the cyst content was totally removed. The cytology of the cystic content and pathological findings of the cyst wall were compatible with the diagnosis of neurenteric cyst. Our literature search revealed that in 86% of the patients with this lesion, the lesion was involved in the occurrence of epilepsy during the perioperative period. When a neurenteric cyst is diagnosed, shunt surgery should be avoided to prevent migrating spread of neurenteric cells.

The relationship between keloid growth pattern and stretching tension: visual analysis using the finite element method.

BACKGROUND: Keloids grow and spread horizontally, like malignant tumors, for reasons that remain unknown. Yet, stretching tension is clearly associated with keloid generation, as keloids tend to occur on high tension sites such as the anterior chest and scapular region. Thus, we analyzed the relationship between keloid growth patterns and stretching tension using a visualized finite element study. MATERIALS AND METHODS: Keloids, normal skin, and fat structures were reproduced using DISCUS software. The contours were transferred to ADINA analytical software to rebuild and mesh volumes. RESULTS: (1) High tension was observed at the edges, and not in the entire region, of stretched keloids. (2) Keloid centers were regions of low tension, which helps to explain the healing that generally occurs in the central regions of keloids. (3) Expansion of a keloid occurred in the direction in which it was pulled. (4) The "crab's claw"-shaped invasion occurred in response to increased stretching tension. (5) Skin stiffness in the circumference of a keloid was associated with greatly increased tension. (6) Fat hardness and thickness did not influence the amount of tension. (7) Adhesion with subcutaneous hard tissue greatly increased the tension in the keloid. CONCLUSION: These stretching results have advanced understanding of keloid formation under various conditions. Our results suggest that stretching tension is an important condition associated with keloid growth.

Catcher's mask cranioplasty for extensive cranial defects in children with an open head trauma: a novel application of partial cranioplasty.

OBJECTIVE: In children who have suffered a severe, extensive head trauma, cranioplasty is complicated because allografting is not advisable in pediatric patients and the amount of available autologous materials is limited. To overcome these problems, we employed a combination of autologous rib grafts and calvarial grafts for partial cranioplasty. MATERIALS AND METHODS: We named this partial cranioplasty technique 'catcher's mask cranioplasty'. Rib grafts were placed mimicking a baseball catcher's mask to obtain maximum strong coverage of the defect. Calvarial grafts were used to achieve a smooth forehead contour. Islands of osteoanagenesis were also used. CONCLUSIONS: These autografts were of sufficient strength, esthetically satisfactory, and no patient developed sinking skin flap syndrome. Catcher's mask cranioplasty is a useful technique to successfully reconstruct the skull in pediatric patients with extensive cranial defects and an insufficient amount of autologous graft material.

Finite element analysis of effect of softness of cushion pads on stress concentration due to an oblique load on pressure sores.

The concentration of mechanical stress in soft tissue can cause or worsen pressure sores. We have previously reported the results of analysis of stress concentration in soft tissue using a finite element model. In the present study, we hypothesized that even if a cushion pad was thin, it would effectively reduce horizontal loads that can increase stress concentration in soft tissue. To our knowledge, there have been no previous reports describing stress distribution in soft tissue attached to a thin cushion pad with a horizontal load. In the present study, we performed mechanical analysis of a model of a human seated on a thin cushion pad with a range of hardness values (i.e., Young's module). Two-dimensional finite element models were used to perform this analysis. Loads were applied at the upper edge of the model as oblique compulsory displacement. In all of the cushion pad models, the peak value of effective stress was less than that of the control model without a cushion pad. Also, the peak value of effective stress decreased as Young's module of the cushion pad decreased. These results suggest that use of a thin cushion pad is an effective way to prevent the development of pressure sores.

A case report on a full-thickness chest wall reconstruction with polypropylene mesh and stainless steel mesh concurrently using a transverse rectus abdominis myocutaneous flap.

A full-thickness chest wall resection requires subsequent chest wall reconstruction. A chest wall resection and reconstruction was performed using a transverse rectus abdominis myocutaneous (TRAM) flap, together with polypropylene mesh (Marlex mesh) and stainless steel mesh (SSM). A 71-year-old man was diagnosed as having recurrent lung cancer in the chest wall, and underwent surgical resection. Marlex mesh was sutured to the posterior wall of the surgical defect. A portion of the SSM was adjusted to the size of the defect and cut out. Its edges were folded to make the portion into a plate. This SSM plate was placed anteriorly to the Marlex mesh and sutured to the ribs. The Marlex mesh was folded back on the SSM plate by 2 cm and fixed. After the above procedures, a left-sided TRAM flap was raised through a subcutaneous tunnel up to the defect and sutured to the region. The patient was discharged from hospital 19 days postoperatively. The wound was fine and he had no flail chest or dyspnea, and carcinomatous pain resolved.