A new surgical tape with a mesh designed to prevent skin tears and reduce pain during tape removal.

We devised a surgical tape that prevents skin tears while maintaining adhesive strength. Under the assumption that microscopic damage to the skin is reflected in pain felt on the skin, we statistically analyzed skin pain when the tape was peeled off to show the skin protection effect of the mesh on the new tape. This tape has a three-layer structure consisting of a tape substrate, adhesive, and mesh. When the tape is applied to the skin, a mesh is located between the adhesive and the skin. The adhesive contacts the skin through the mesh holes and fixes the substrate to the skin; it does not come into contact with the skin at the mesh body; therefore, the adhesive-skin contact area is reduced. In this experiment, we used surgical tape with and without mesh. At 8 hours after the application of each tape to the forearm of five adult males, it was removed. All tapes were peeled off while maintaining an angle of approximately 120° between the skin and tape substrate. For the tape with mesh, the tape substrate was peeled off in two ways: peeling off the substrate together with the mesh and peeling off the substrate, leaving the mesh on the skin. A perception and pain quantification analyzer (Pain Vision™) was used to quantify pain. The data were compared and examined statistically (Friedman's test and Wilcoxon's coded rank test). The least pain was experienced while peeling off the tape substrate, leaving the mesh on the skin. There was a significant difference in pain levels among the three tape removal methods. There was also a significant difference between the two peeling methods in the experimental group. The skin protection effect of the mesh reduced pain when the surgical tape was removed.

Carbon monoxide combined with artificial blood cells acts as an antioxidant for tissues thermally-damaged by dye laser irradiation.

Artificial red blood cells [i.e., hemoglobin vesicles (HbVs)] can be used as photosensitizers in pulsed-dye laser (PDL) treatment for port wine stains in animal models. Small HbVs are distributed in the vicinity of the endothelial cells of the blood vessels. In our previous in vivo experiments, both HbVs and red blood cells absorbed photons of the laser and generated heat, contributing to removal of very small blood vessels and large deeper subcutaneous blood vessels with PDL irradiation. Herein, we tested carbon monoxide-bound HbVs (CO-HbVs) that would produce heat energy while releasing CO in vessels after dye laser irradiation in a rabbit auricle model. We conducted this experiment to confirm secondary progression of thermal injury being reduced with the antioxidative property of CO. We histopathologically evaluated the damages to the large vessels and surrounding dermal tissue following PDL irradiation alone or subsequent to the intravenous injection of the qualified HbVs. The soft tissue damages were graded on a five-point scale and compared statistically. Intravenous CO-HbVs significantly reduced damage to the surrounding tissue after subsequent PDL irradiation; however, the degree of damage to the larger vessel wall resulted in a variety of changes, including a slight increase in our histopathological grades. This beneficial effect in dye laser treatment for port wine stains may be the result of the antioxidative property of CO against free radicals in the zone of stasis that may still be theoretically viable in burns. This effect of CO protecting tissues from thermal damage is consistent with previous reports of CO as a reducing agent. If the reducing agent can be delivered directly to the affected area immediately after the burn injury, even in a small amount, the complex inflammatory cascade may be reduced and unnecessary inflammation after laser treatment that lowers the patient's quality of life can be avoided.

Efficacy and Safety of Propranolol Gel for Infantile Hemangioma: A Randomized, Double-Blind Study.

We aimed to evaluate the efficacy and safety of propranolol gel at various concentrations with infantile hemangiomas after proliferative phases. We designed a single-center, randomized, double-blind, dose-dependent trial with placebo control and randomized patients to receive propranolol gel at 0, 1, or 5%, twice daily for 24 weeks. The primary efficacy endpoint was the percentage change in redness of the tumors. Safety endpoints were skin characteristics changes and systemic symptoms. We made two comparisons to evaluate the superiority of 1 and 5% propranolol gels against placebo for primary endpoint analysis and used the t-test to compare parents' satisfaction with these treatments. Initially, 19 patients were enrolled, but 8 were excluded from the analysis. We were underpowered to answer the question of efficacy. In the per-protocol set, we found similar results for the redness percentage change among the patients on placebo, 1 and 5% gel. However, the difference in redness before and after treatment suggested a slight decreasing trend of lesion's redness as the propranolol concentration increased. The difference in parents' satisfaction between the placebo and 5% propranolol gel groups was significant (p = 0.08). We observed no serious adverse events. We did not find an obvious dose-dependent effect for the propranolol gel treatment against infantile hemangiomas after the proliferative phase. However, external applications twice daily were less burdensome for parents and led to good compliances. It had a favorable safety profile in Japanese pediatric patients with infantile hemangiomas.

Artificial red blood cells increase large vessel wall damage and decrease surrounding dermal tissue damage in a rabbit auricle model after subsequent flashlamp-pumped pulsed-dye laser treatment.

Artificial red blood cells (i.e. hemoglobin [Hb] vesicles [Hb-Vs]) function effectively as photosensitizers in flashlamp-pumped pulsed-dye laser (PDL) treatment for port-wine stains in animal models. Hb-Vs deliver more Hb to the vicinity of the endothelial cells. Both Hb-Vs and red blood cells absorb the laser energy and generate heat, supporting the removal of very small blood vessels and deeper subcutaneous blood vessels with PDL irradiation in in vivo experiments. Here, we analyzed the photosensitizing effect of Hb-Vs in PDL irradiation on large blood vessels and surrounding soft tissues. We histopathologically analyzed markers of damage to the large vessels and surrounding dermal tissue in a rabbit auricle model following PDL irradiation alone or subsequent to the addition of intravenous Hb-V injection. Markers were graded on a five-point scale and statistically compared. The changes in laser light absorption and reflection in a human skin model caused by the administration of Hb-Vs were evaluated using Monte Carlo light-scattering programs. Histological markers of damage to blood vessels were significantly greater in Hb-V-injected arteries and veins measuring 1-3 mm in diameter as compared with the controls. However, Hb-V injection significantly reduced PDL-induced necrosis and hemorrhage in the surrounding tissues. During computer simulation, photon absorption increased within the vessel layer and decreased around the layer. Intravenous Hb-Vs increase the extent of damage in larger vessel walls but significantly reduce damage to the surrounding skin after subsequent PDL irradiation. These beneficial effects are the result of improving vessel selectivity by Hb-Vs in vessels. Hb-V administration prior to PDL irradiation therapy could mechanically improve the outcomes and safety profiles of port-wine stain treatment protocols.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence-based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Evaluation of pain incidence due to venous malformation based on data from 85 institutions in Japan.

BACKGROUND: Depending on the size and site of the venous malformation (VM), patients with VM often experience pain and swelling. VMs in the head and neck typically have lower pain rates due to complications than VMs in the limbs and trunk. We evaluated the heuristics on VM pain by statistically analyzing data of patients with VM from a multicenter database in Japan. METHODS: We collected data on age, sex, pain, lesion site, lesion depth, and lesion size for 2199 clinical cases with common VMs. We created categories for lesion depth and size and excluded multiple lesion cases that overlapped in these categories. Next, we constructed cross-tabulation tables to analyze the factors that contributed to pain. Finally, we evaluated the risk of pain in patients with VM by performing binomial logistic regression analysis based on age, sex, lesion site, lesion depth, and lesion size. RESULTS: For patients with limb and trunk VMs, the most frequent site of pain was the muscle, tendon, and bone, with an incidence of 79%, followed by the skin and subcutis, with an incidence of 43%. For patients with head and neck VMs, the most frequent site of pain was the muscle, tendon, and bone, with an incidence of 28%, followed by the skin and subcutis, with an incidence of 11% (P < .01). For pain incidence by lesion size, pain most frequently occurred in lesions >10 cm (67%), followed by lesions between 5 cm and 10 cm (56%) and lesions <5 cm (29%). CONCLUSIONS: Our study indicated a clear order of factors that contributed to pain: lesion site > lesion depth > lesion size. Age was also an important factor. Infants and children had low pain complication frequencies with limb and trunk VMs. As the patients aged, the pain frequency became higher, reaching 50% at almost 7 years of age.

The beneficial effect of traditional Japanese herbal (Kampo) medicine, Hochu-ekki-to (Bu-Zhong-Yi-Qi-Tang), for patients with chronic wounds refractory to conventional therapies: A prospective, randomized trial.

Hochu-ekki-to (HET) is a traditional Japanese herbal (Kampo) medicine for the treatment of severe weakness, loss of appetite, and indigestion in elderly patients and for the prevention of opportunistic infections. The impact of HET on patients with chronic wounds refractory to conventional therapies was investigated in a prospective, randomized trial, including 18 patients divided into medication (7.5 g oral HET per day, n = 9) and control (n = 9) groups. Wound healing during the 12-week study period was scored based on depth, exudate, size, inflammation/infection, granulation tissue, necrotic tissue, and pocket size. At 12 weeks, wound healing progressed in all nine patients in the medication group, whereas wound healing progressed in only three patients in the control group (significant difference, p < 0.01; relative risk: 3.00). In the medication group, the total score decreased significantly at 8 weeks and later. To the best of our knowledge, this study was the first to show that HET promoted the healing of chronic wounds resistant to conventional treatments. HET may be a choice as an adjunctive therapy for chronic wounds, particularly for patients with malnutrition. This trial was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000031620).

Intravenous injection of artificial red cells and subsequent dye laser irradiation causes deep vessel impairment in an animal model of port-wine stain.

Our previous study proposed using artificial blood cells (hemoglobin vesicles, Hb-Vs) as photosensitizers in dye laser treatment for port-wine stains (PWSs). Dye laser photons are absorbed by red blood cells (RBCs) and hemoglobin (Hb) mixture, which potentially produce more heat and photocoagulation and effectively destroy endothelial cells. Hb-Vs combination therapy will improve clinical outcomes of dye laser treatment for PWSs because very small vessels do not contain sufficient RBCs and they are poor absorbers/heaters of lasers. In the present study, we analyzed the relationship between vessel depth from the skin surface and vessel distraction through dye laser irradiation following intravenous Hb-Vs injection using a chicken wattle model. Hb-Vs were administered and chicken wattles underwent high-energy irradiation at energy higher than in the previous experiments. Hb-Vs location in the vessel lumen was identified to explain its photosensitizer effect using human Hb immunostaining of the irradiated wattles. Laser irradiation with Hb-Vs can effectively destroy deep vessels in animal models. Hb-Vs tend to flow in the marginal zone of both small and large vessels. Increasing laser power combined with Hb-Vs injection contributed for deep vessel impairment because of the synergetic effect of both methods. Newly added Hb tended to flow near the target endothelial cells of the laser treatment. In Hb-Vs and RBC mixture, heat transfer to endothelial cells from absorbers/heater may increase. Hb-Vs function as photosensitizers to destroy deep vessels within a restricted distance that the photon can reach.

Artificial Red Blood Cells as Potential Photosensitizers in Dye Laser Treatment Against Port-Wine Stains.

We suggest a novel method that uses artificial blood cells (hemoglobin vesicles, Hb-Vs) as photosensitizers in dye laser treatment (at 595-nm wavelength) for port-wine stains (i.e., capillary malformations presenting as red birthmarks) based on the results of animal experiments. As compared with human red blood cells, Hb-Vs have the same absorbance of 595 nm wavelength light and produce the same level of heat following dye laser irradiation. Small sized Hb-Vs (250 nm) distribute in the plasma phase in blood and tend to flow in the marginal zone of microvessels. Intravenous injections of Hb-Vs caused the dilatation of microvessels, and dye laser treatment with Hb-Vs destroyed the vessel wall effectively. Following the intravenous injection of Hb-Vs, the microvessels contained more Hb that absorbed laser photons and produced heat. This extra Hb tended to flow near the endothelial cells, which were the target of the laser treatment. These attributes of Hb-Vs will potentially contribute to enhancing the efficacy of dye laser treatment for port-wine stains. Hemoglobin is a type of porphyrin. Thus, our proposed treatment may have aspects of photodynamic therapy using porphyrin that leads to a cytotoxicity effect by active oxygen.

Photosensitizer Effects of Artificial Red Cells on Dye Laser Irradiation in an Animal Model Assuming Port-Wine Stain Treatment.

BACKGROUND: The complete removal of port-wine stains has remained challenging. Based on the principle of treating port-wine stains with a dye laser, intravenous injection of artificial red cells (hemoglobin vesicles) immediately before laser treatment might improve the clinical outcome of the therapy. The hemoglobin vesicle injection increases the hemoglobin concentration in microvessels. Photons of dye laser are absorbed by the mixture of red blood cells and this newly added hemoglobin, potentially producing more heat and photocoagulation and, ultimately, necrosis of the endothelial cells effectively. METHODS: To confirm the performance of hemoglobin vesicles as a photosensitizer, the authors compared the absorbance of hemoglobin vesicles and human blood against 595-nm wavelength and the temperature increases that occur following dye laser irradiation. Furthermore, the authors investigated the microvessel transformation induced by the hemoglobin vesicle intravenous injection. Finally, the authors investigated the effect of the hemoglobin vesicle on the vascular destruction of dye laser irradiation with chicken wattle. RESULTS: Results show that hemoglobin vesicles have the same absorbance as that of human blood. They produce the same level of heat as human blood after laser irradiation. The hemoglobin vesicle intravenous injection caused dilatation of microvessels in animal models. The dye laser with hemoglobin vesicle can destroy the vessel wall effectively in animal models. CONCLUSIONS: Hemoglobin vesicles can function as photosensitizers to destroy the vessel wall. A possible mechanism of pulsed dye laser-resistant port-wine stains is that overly small vessels do not contain sufficient red blood cells. They are therefore poor absorbers/heaters for these lasers. Hemoglobin vesicle combination therapy will improve clinical outcomes of dye laser treatment against such lesions only.

Hyperpigmentation after surgery for a deep dermal burn of the dorsum of the hand: partial-thickness debridement followed by medium split-thickness skin grafting vs full-thickness debridement followed by thick split-thickness skin grafting.

BACKGROUND: Early excision and skin grafting are commonly used to treat deep dermal burns (DDBs) of the dorsum of the hand. Partial-thickness debridement (PTD) is one of the most commonly used procedures for the excision of burned tissue of the dorsum of the hand. In contrast, full-thickness debridement (FTD) has also been reported. However, it is unclear whether PTD or FTD is better. METHODS: In this hospital-based retrospective study, we compared the outcomes of PTD followed by a medium split-thickness skin graft (STSG) with FTD followed by a thick STSG to treat a DDB of the dorsum of the hand in Japanese patients. To evaluate postoperative pigmentation of the skin graft, quantitative analyses were performed using the red, green, and blue (RGB) and the hue, saturation, and brightness (HSB) color spaces. We have organized the manuscript in a manner compliant with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. RESULTS: Data from 11 patients were analyzed. Six hands (five patients) received grafts in the PTD group and eight hands (six patients) received grafts in the FTD group. Graft take was significantly better in the FTD group (median 98 %, interquartile range 95-99) than in the PTD group (median 90 %, interquartile range 85-90) (P < 0.01). Quantitative skin color analyses in both the RGB and HSB color spaces showed that postoperative grafted skin was significantly darker than the adjacent control area in the PTD group, but not in the FTD group. CONCLUSIONS: There is a possibility that FTD followed by a thick STSG is an option that can reduce the risk of hyperpigmentation after surgery for DDB of the dorsum of the hand in Japanese patients. Further investigation is needed to clarify whether the FTD or the thick STSG or both are the factor for the control of hyperpigmentation.

Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage.

BACKGROUND: Reconstruction of the great toe defect is difficult. The most distal point of the rotation arc of a retrograde-flow medial plantar flap is the plantar side of the proximal phalanx. The purpose of this report was to present a new procedure that extends the rotation arc of this flap. Results of anatomic study and application in two patients were presented. METHODS: An anatomical study was conducted on 10 freshly frozen cadavers to determine the rotation arc of the medial plantar flap based distally on the lateral plantar vessels. To enable anterograde venous drainage, two accompanying veins of the vascular pedicle were separated and anastomosed to each other. This surgical procedure was implemented in two clinical cases with the great toe defect. The maximum size of the elevated flap was 4 × 7 cm. The status of venous congestion of the flap was determined using the blood glucose measurement index. RESULTS: We confirmed that the rotation arc of the medial plantar flap based distally on the lateral plantar vessels could reach the tip of the great toe, preserving all lateral plantar nerves and plantar metatarsal arteries. In the two cases, the congestion of the flap improved with anterograde venous drainage and the flaps survived completely. CONCLUSION: A pedicled medial plantar flap with anterograde venous drainage may be a useful alternative option for the reconstruction of relatively large great toe defects.

Static reconstruction of malar region in facial paralysis: a new alternative technique for plasty of symmetric mouth appearance.

Static suspension using fascia lata graft is used as a reconstructive procedure against drooping of the mouth corner for treating longstanding facial paralysis. Although it achieves symmetry at rest, movement of the mouth corner at mouth opening is restricted to some extent because it is fixed with fascia lata to the immovable temporal fascia, the parotid fascia, or bones. This was overcome by suspending the mouth corner to the mandibular coronoid process with fascia lata, which enabled a shift of the mouth corner with mouth opening and closure. The nine patients discussed in this study were operated on since 1994 for longstanding facial paralysis and followed-up for over 1.5 years. As in conventional static suspension, the fascia lata was harvested and split into two bands. Next, one semi-oval fascial loop was inserted around the paralysed part of the mouth and tied with another fascial band at the mouth corner, which was looped to the mandibular coronoid process. The suspended fascia lata graft was relaxed with anteroinferior movement of the coronoid process at mouth opening, enabling the mouth corner to shift inferiorly. The mouth corner returned to its original position at mouth closure, and the nasolabial fold deepened during mastication. No limitation in mouth opening was observed. Suspension of the mouth corner to the mandibular coronoid process provided a dynamic element, thereby restoring a near-normal shift. The procedure is considered as an alternative for reconstructing the malar region of patients with facial paralysis and in whom dynamic reconstruction is not indicated.

Descending branch of the perforating branch of the peroneal artery perforator-based island flap for reconstruction of the lateral malleolus with minimal invasion.

BACKGROUND: Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described. METHODS: The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases. RESULTS: The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications. CONCLUSIONS: A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Early diagnosis and risk factors for lymphedema following lymph node dissection for gynecologic cancer.

BACKGROUND: Although early diagnosis is important for selecting an effective surgical treatment for secondary lymphedema, an efficient screening test for detecting early-stage lymphedema has not yet been established. Serial changes of lymphatic function before and after lymph node dissection and risk factors for secondary lymphedema are important indicators. METHODS: A prospective cohort observational study was conducted with 100 consecutive gynecologic cancer patients who underwent pelvic lymph node dissection. Lymphatic function was assessed by noninvasive lymphography using indocyanine green fluorescence imaging on a routine schedule. Earliest findings after lymphadenectomy and risk factors for lower leg lymphedema were investigated. RESULTS: Atypical transient dermal backflow patterns were observed in an early postoperative period in 50 cases, all of which disappeared within 3 months. Of these patterns, the splash pattern was observed in 31 patients, of which five improved to normal following a natural course. In contrast, the stardust pattern was observed in 27 patients, and none had improved with conservative therapy. Postoperative radiotherapy was a significant risk factor for the stardust pattern. CONCLUSIONS: All patients who undergo lymphadenectomy for gynecologic malignancies should be examined for secondary lower extremity lymphedema by qualitative evaluation methods on a routine schedule to determine the earliest possible diagnosis. Because the splash pattern on indocyanine green lymphography is a reversible lymphatic disorder following a natural course, surgical treatments are not recommended. The decision regarding surgical treatment can be made after observing the stardust pattern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Association between plate location and plate removal following facial fracture repair.

BACKGROUND: Titanium-based plates used to repair facial fractures are sometimes removed despite their high biocompatibility. Local discomfort can lead to plate removal surgery. Local discomfort may differ according to patient characteristics, tissue properties and plate thickness; however, little is known about the relationship between these conditions and plate removal. METHODS: We performed a hospital-based, retrospective cohort study of patients who underwent internal fixation for facial or frontal bone fracture. To identify factors associated with plate removal, we used multivariate logistic regression models. RESULTS: Data from 138 patients were analysed. All plates were made of commercially pure titanium, and all screws were made of titanium, 6% aluminium and 4% vanadium alloy. Plate thickness was 1.2 mm or 0.6 mm. Among plate locations, the frontozygomatic suture showed the highest percentage of complications (84%, 86 of 102 patients). The majority consisted of palpability and visibility. In patients who underwent plate removal (n = 96), all plates and screws were removed successfully. All plate-related complications were resolved after plate removal. No complications were introduced by plate removal. Plates 1.2 mm in thickness on the frontozygomatic suture had a relative risk of complications 2.48 times (95% confidence interval, 1.13-5.43) that of plates 0.6 mm in thickness. By multivariate analysis, the presence of plates on the frontozygomatic suture was a significant and independent risk factor for removal. Patients with plates on the frontozygomatic suture had a risk of plate removal 3.95 times (95% confidence interval, 1.55-10.07; P < 0.01) that of patients without plates on the frontozygomatic suture. CONCLUSION: Plates on the frontozygomatic suture have a high rate of complications. Thick plates increase these risks. Patients with plates on the frontozygomatic suture are more likely to undergo plate removal surgery than patients without plates on the frontozygomatic suture.