Fusuma Sliding Flap for Lip Reconstruction of Lower Lip Cancer.

Lower lip cancer is typically treated with surgical excision, and this frequently results in a large defect and severe aesthetic problems. Local flap reconstruction is suitable for restoring appearance and function, and it causes less surgical stress than a vascularized free flap. The Fusuma sliding flap is a local flap technique introduced by Kasai et al in 2008. Here, the authors report their use of this method for lip reconstruction in a 94-year-old Japanese female after the removal of a cancerous mass.

Frontal Bone Fracture Patterns Suggesting Involvement of Optic Canal Damage.

PURPOSE: Fracture of the frontal bone can be accompanied by damage to the optic canal. The present study uses finite element analysis to identify fracture patterns, suggesting the involvement of the optic canal. METHODS: Ten finite-element skull models were generated from computer tomography data of 10 persons. Then, dynamic analyses simulating collision of a 2-cm-radius brass ball to 6 regions on the frontal bone in the 10 models were performed. Fracture patterns presented by the frontal bone in the 60 experiments were observed, and all those involving the optic canal were selected. Commonalities of the selected fracture patterns were identified. RESULTS: Fracture of the optic canal was observed in 9 of the 60 patients. In all 9 patients, fracture existed on the anterior and posterior walls of the frontal sinus and on the superior orbital wall. CONCLUSION: When the anterior and posterior walls of the frontal sinus and the superior orbital wall are all broken, the optic canal is highly likely to be involved in the damage. When this pattern is observed in emergency examination, preventive decompression of the optic nerve should be considered to avoid potential occurrence of blindness.

Utilization of a sero-muscular patch for safe wound closure after free jejunum transfer for a skin-esophageal fistula.

This paper introduces our original technique of free jejunum transfer, in which a sero-muscular patch is used to cover the jejunum. Our results demonstrate its effectiveness for touch-up surgery after esophageal leakage.

Scoring of Deformed Costal Cartilages Reduces Postoperative Pain after Nuss Procedure for Pectus Excavatum.

OBJECTIVE: The present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients. METHODS: A total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (n = 24); those who received no such scoring were categorized as the Non-Scoring Group (n = 22). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups. RESULTS: The maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days). CONCLUSION: High stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced.

Revisiting Microsurgical Distal Bypass for Critical Limb Ischemia.

Background The purpose of this study was to investigate the efficacy of introducing microsurgical techniques to distal bypass surgery for critical limb ischemia. Methods Datasets of 83 consecutive microsurgical distal bypasses in a multicenter (SKY) study were compared with the results of the PREVENT III (PIII) study regarding the following: (1) patients' characteristics, (2) clinical severity according to the PIII risk score, (3) conduits and procedures for revascularization, (4) proximal and distal anastomosis sites, and (5) primary patency and amputation-free survival (AFS) rates at 1 year. Results The high-risk group in the SKY study was larger compared with that in the PIII study (37 vs. 9%, respectively; p < 0.0001). Although all patients underwent revascularization in the perimalleolar region (100 vs. 65.1%, respectively; p < 0.0001), the primary patency rate at 1 year was 71.8%, compared with 59.9% in the PIII study (p = 0.0227). The AFS rate at 1 year was not significantly different between the SKY and PIII studies (80.6 vs. 75.1%, respectively; p = 0.189); however, there was a significant difference between the high-risk subsets of each group: 74.1% in the SKY study and 45% in the PIII study (p < 0.0001). Conclusions Our data demonstrated that microsurgical distal bypass is an effective and durable procedure, especially for high-risk patients. We believe that microsurgical techniques should be considered for distal bypass to optimize the treatment of ischemic limbs with severe peripheral artery disease.

A Hypothesis for the Pathologic Mechanism of Idiopathic Exophthalmos Based on Computed Tomographic Evaluations.

The causes of idiopathic exophthalmos were still unknown. We used computed tomography to compare the orbital structures of patients with idiopathic exophthalmos and those of a healthy Japanese population. A total of 18 orbits (ranged 17-52 years) in idiopathic exophthalmos and 334 normal orbits (ranged 17-59 years) were included. On computed tomography, the eyeball and orbit sizes, lateral wall thickness and length, perpendicular distance from the interzygomatic line to the medial orbital rim, and the nasal cavity width were measured. No significant differences in eyeball or orbit sizes were found between the idiopathic exophthalmos and control groups (P > 0.05). In contrast, the mean lateral wall thickness of the idiopathic exophthalmos group was significantly thicker than that of the control group (P < 0.01). The lateral wall length was shorter with significant difference (P < 0.05). The perpendicular distance and the width of the nasal cavity in the idiopathic exophthalmos group were longer with significant difference (P < 0.05). The cause of idiopathic exophthalmos is compression of orbital contents by the medial wall expansion. The force of expansion of medial wall also influences the zygoma according to Wolff law.

An anatomic study of nipple position and areola size in Asian men.

BACKGROUND: In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men. OBJECTIVES: The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men. METHODS: Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI. RESULTS: Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI. CONCLUSIONS: Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.

Relationship between locations of rib defects and loss of respiratory function - a biomechanical study.

OBJECTIVE: The present study elucidates the relationship between the locations of rib defects and loss of respiratory function. METHODS: Ten sets of three-dimensional finite element models were produced from computed tomography data of 10 persons and categorized as normal type models. These models were modified by removing part of the ribs, and the resultant models were categorized as defect type models. Varying the location of the defects, six types of defect model were produced from each of the 10 normal models; the defects were made on the anterior-superior, anterior-inferior, lateral-superior, lateral-inferior, posterior-superior, and posterior-inferior regions of the thorax. To simulate respiration, contracture forces were applied to nonlinear springs modeling respiratory muscles for each of the normal and defect models. Difference in volume of the thoracic cavity between inspiration and expiration phases was viewed as the indicator of respiratory function and was defined as ΔV. The values of ΔV were compared between normal type models and their corresponding defect type models. RESULTS: Among the six types of defect, the degree of functional loss was greatest with those defects on the lateral-inferior part of the thorax, where ΔV of the affected side hemithorax drops to 38 to 45% of normal values, whereas ΔV was 62 to 88% with other defect models. CONCLUSION: Thoraces that have defects on their lateral-inferior regions present lower respiratory functioning than thoraces with other defect locations. Hence, in treating clinical cases where defects are expected to occur in this region, effort should be made to minimize the area of the defect.

Classification of congenital midline upper lip sinuses: a case report and review of the literature.

BACKGROUND: We recently encountered a case of a midline upper lip sinus, one of the rarest congenital lip sinuses. Several embryological hypotheses have been proposed regarding the etiology of this rare disease, but it remains obscure. METHODS: We reviewed all cases of upper lip sinus reported in the English language through 2011, and classified them into three types according to accompanying anomalies and the site of the fistula. RESULTS: Twenty-eight studies involving 31 cases were reviewed and classified. A type I sinus was a midline sinus without accompanying anomalies. There were 13 such cases, with a female predilection. Type II sinuses were midline sinuses with accompanying anomalies, and there were nine such cases. Type III sinuses were lateral sinuses with or without accompanying anomalies; there were nine cases. CONCLUSIONS: Our classification scheme is not only convenient for clinical application, but also reflects the embryological process responsible for congenital lip sinuses.

Presence of manubrium-sternum joint does not assure sufficient elevation of sternum in Nuss procedure for pectus excavatum patients.

BACKGROUND: The manubrium and body of the sternum are connected by the manubrium-sternum joint (MSJ). In performing the Nuss procedure for pectus excavatum patients, the body of the sternum is elevated as the operator flips correction bars upside down. Theoretically, the presence of the MSJ should allow elevation of the sternum body. However, does the MSJ secure sufficient elevation of the sternum? This study aims to elucidate this clinical question. METHODS: Seventy-four adult pectus excavatum patients with moderate to serious deformity (with Haller Index being equal to or greater than 5) were included in the study. The MSJ was open in all patients. For 29 patients, the sternum was elevated by only bar flipping (Non-Separation Group); for 45 patients, the sternum was horizontally separated after bar flipping (Separation Group). Whether or not additional elevation for Separation Group patients results from the division was observed, and the degree of the additional elevation was evaluated. Furthermore, 74 patients subjectively evaluated postoperative pain and gave scores with a Visual Analog Scale ranging from 0 (no pain) to 10 (intolerable pain). The VAS scores were compared between the two groups. RESULTS: In the Separation Group, the sternums of all patients achieved additional elevation from sternum separation. The pain scores were lower for the Separation Group than for the Non-Separation Group. CONCLUSION: Even when the MSJ is present, horizontal separation enhances the elevation of the sternum. Furthermore, horizontal separation of the sternum reduces postoperative pain.

Evaluation of maxillary sinus volume in cleft alveolus patients using 3-dimensional computed tomography.

OBJECTIVE: The aim of the study was to evaluate the volume of the maxillary sinus in patients with cleft alveolus. STUDY DESIGN: This is a retrospective, descriptive study. PATIENTS AND METHODS: The 3-dimensional computed tomographic data of 218 maxillary sinuses of 109 patients with cleft alveolus were compared with those of 100 sinuses of 50 healthy individuals. RESULTS: No significant difference in the maxillary sinus volume was found between the patients with cleft alveolus and the noncleft individuals. In the patients with cleft palate and alveolus, the maxillary sinus volume was significantly larger on the right side, but no significant difference was found between the cleft and noncleft sides. CONCLUSIONS: The volume of the maxillary sinus in the patients with cleft alveolus is not different from that of the noncleft individuals. The information about the maxillary sinus is clinically important in executing such operations as endoscopic sinus surgery.

Separation of the seventh costal-sternal junction-A new technique to improve outcomes for the Nuss procedure for pectus excavatum.

BACKGROUND: In the standard Nuss procedure for pectus excavatum, the costal arch is often elevated together with the sternum, resulting in unevenness of the lower part of the thorax. This complication is commonly called rib flaring. This paper presents a technique to avoid rib flaring and evaluates its effectiveness. MATERIALS AND METHODS: In our technique, a part of the seventh costal cartilage is removed, disconnecting the costal arch from the sternum. The effectiveness of this technique was evaluated in a retrospective clinical study of 63 pectus excavatum patients who were randomly collected and were divided into two groups. One group-defined as the Standard Group-includes 27 patients (29.8 ± 6.5SD y/o) on whom standard Nuss procedure was conducted; the other group-defined as the Separation Group-includes 36 patients (31.8 ± 6.1SD y/o) on whom the cartilage removal was conducted in addition to the standard Nuss procedure. The degree of postoperative costal-arch elevation was defined as ECA (Elevation of Costal Arch) and was compared between the two groups. RESULTS: ECA was significantly greater for the Standard Group (10.2 ± 3.3SD mm) than for the Separation Group (-1.1 ± 3.42SDmm). CONCLUSION: Postoperative protrusion of the costal arch is prevented by the separation of the seventh costal cartilage from the sternum. Our original technique is a useful option for the treatment of pectus excavatum.

Biomechanical Evaluation of Additional Surgical Maneuvers to Improve Symmetry in Performing Nuss Procedure for Asymmetric Pectus Excavatum.

Background: Severing part of the thorax prior to bar placement is effective to improve outcomes in performing the Nuss procedure for asymmetric pectus excavatum. This study aims to elucidate the patterns of severing to provide an ideal outcome. Methods: Three-dimensional biomechanical computer models were produced simulating the thoraxes of 10 actual patients with asymmetric pectus excavatum. Virtual surgical operation was performed on the 10 models in 4 patterns: group 1-no part of the thorax was severed (default group). Group 2-The sternum was severed (sternum-severing group). Group 3-The ribs on the affected side were severed (rib-severing group). Group 4-Both the sternum and ribs on the affected side were severed (sternum/rib-severing group). After performing this preparation, simulation of bar placement was performed. Comparing the pre- and postoperative shapes of the models, we examined whether symmetry improved for each group. Results: Symmetry of the chest wall improved for rib-severing group and sternum/rib-severing group. Asymmetry remained for default group and sternum-severing group. Conclusions: Performance of the Nuss procedure for asymmetric pectus excavatum does not greatly improve symmetry of the chest wall. Severing the ribs as an additional maneuver is effective to improve symmetry.

Hardness of Artificial Bone and Vulnerability of Reconstructed Skull-A Biomechanical Study.

Background: Various materials are used to reconstruct cranial defects. The present study focuses on what happens when reconstructed skulls are impacted in trauma situations. Using biomechanical analysis, the present study elucidates how the hardness of reconstruction material affects the vulnerability of reconstructed skulls. Methods: A 3-dimensional finite element model was produced simulating the skull of an intact adult male. A defect was made on the left hemi-frontal part of the skull model. The defect was restored with artificial bone with 3 different hardness models. These models were respectively defined as Hard Model (simulating reconstruction with titanium), Moderate Model (simulating reconstruction with a material equivalent to human bone), and Soft Model (simulating reconstruction with hydroxyl apatite). Virtual impacts were applied on these models in 9 patterns, and the conditions of subsequent fracture were evaluated using finite element analysis. For each of the 9 impact patterns, the conditions of subsequent fracture were compared among the 3 models. Results: In 8 of the 9 impact patterns, the condition of fracture was more widespread for Hard Model than for Moderate Model and Soft Model. Conclusions: Skulls reconstructed with a hard material can develop serious fracture if they are impacted again. Therefore, usage of hard materials should be avoided to prevent serious injuries from secondary trauma.

How Partial Skull Defect Affects Vulnerability of the Skull in Traumatic Situations: A Biomechanical Study.

Background: Part of the skull can be lost due to neurosurgical diseases or trauma. Skulls with partial defects can develop different fracture patterns from those of intact skulls. This study aims to clarify the differences. Methods: A 3-dimensional skull model was produced by referring to the computer-tomography data of a 23-year-old intact male volunteer. We defined the model as Intact Model. Another model was produced by removing part of the frontal bone, which was defined as Defect Model. Dynamic simulations of impacts were performed varying the site and direction of impact. Fracture patterns caused by the impacts were calculated using dynamic analysis software (LS-DYNA; Livermore Software Technology Corp.) and were compared between the intact model and defect model. Results: When Defect Model was impacted, fracture involved wider areas than when Intact Model was impacted. This finding was observed not only when Defect Model was impacted on its defect side but also when it was impacted on its intact side. Conclusions: When a skull carrying a defect on one side is impacted, serious fracture occurs even when the non-defect side is impacted, meaning that a skull with a defect is vulnerable to impacts on the non-defect side. This finding should be taken into consideration in deciding indications of skull defect reconstruction.

Reconstruction of the scalp with a calvarial defect.

PURPOSE: To review our clinical cases and devise a protocol for selecting the best operative methods to reconstruct the scalp with a calvarial defect. METHODS: We reviewed the original disease, the areas and depths of the scalp and calvarial defects, the methods of reconstruction, and complications in 20 patients. RESULTS: The defect was caused by secondary cranial infection following decompressive craniectomy for intracranial hemorrhage (ICH) in 11 patients; extensive removal of the scalp and calvaria for resection of a malignant tumor in 6 patients; and by secondary cranial infection following removal of a malignant tumor in 3 patients. Cranial infection was frequently associated with abscess formation around the fixation screws and plates, suggesting that artificial materials induced the infection. We reconstructed the defect using free flaps in 15 patients and using local flaps in 5 patients. CONCLUSIONS: When restoring the calvaria in the primary operation, the use of metal screws and plates should be minimized to prevent cranial infection and subsequent scalp and calvaria defects. Local flaps are appropriate for reconstructing relatively small defects (<20 cm(2)), whereas free flaps are better for reconstructing relatively large defects (>25 cm(2)).

Morphological analysis of the upper eyelid tarsus in Asians.

PURPOSE: The present study aims to evaluate morphologic variations of the upper tarsus in Asians. METHODS: Measurements of superior-inferior and medial-lateral lengths were performed on 54 embalmed cadavers. The superior-inferior length of the tarsus was measured at the central and lateral parts. On the basis of the measured values, shapes of the tarsi were evaluated and categorized. RESULTS: The tarsi were classified into 3 morphologic categories-the sickle, triangular, and trapezoid types. The upper margins of the sickle, triangular, and trapezoid type tarsi present round, triangular, and flat lines, respectively. Among the 54 examined specimens, 29 (55.6%), 16 (29.6%), and 9 (16.7%) belonged to the sickle, triangular, and trapezoid groups, respectively. CONCLUSIONS: The upper eyelid tarsi present morphologic variations with the Asian population. In performing surgical correction of blepharoptosis or surgical production of double-folds, this individual variation should be taken into consideration.

Capsule formation can make secondary reconstruction of the dura mater unnecessary after cranial infection.

PURPOSE: Defects of the dura mater caused by surgical intervention are often reconstructed using artificial substitutes such as polytetrafluoroethylene membrane (Gore-Tex in commercial name). In cases where secondary infection develops after the initial operation, the artificial substitute used in the primary surgery needs to be removed, and the cranial defect should be covered with tissues abundant in blood supply. The present study discusses the necessity of secondary reconstruction of the dural defect in the recovery operation. METHODS: A retrospective study was conducted on 12 patients in whom artificial substitute was exposed because of necrosis of the overlying tissues due to infection or radiation. In recovery operations, the artificial substitute was removed, and the conditions of the underlying defects were evaluated. RESULTS: In all cases, capsule formation had developed to cover dural defects underneath the infected artificial substitutes. The capsules were transparent and watertight, presenting no leakage of cerebrospinal fluid. After coverage of the defect regions using free-flap transfer, no patient developed postoperative complications in follow-up periods of at least 6 months. CONCLUSIONS: Capsule formation occurs under artificial substitutes after replacement of the dura mater. Because the capsules retain the cerebrospinal fluid, replacement of the artificial materials is unnecessary in the secondary operation.

Biomechanical analysis of the effect of intracranial pressure on the orbital distances in trigonocephaly.

OBJECTIVE: This biomechanical study aims to elucidate differences in how skulls with trigonocephaly, normal skulls, and postoperative trigonocephalic skulls respond to intracranial pressure and how this affects the orbital distances. MATERIALS AND METHODS: For 10 patients with trigonocephaly (8.2 ± 4.5 months), simulation models were produced based on the computed tomographic data of the skulls. These models were categorized as the Trigono group. For each model, a 15-mm Hg pressure was applied to the neurocranium to simulate the intracranial pressure. The interorbital distances expanded in response to the applied pressure. The amount of the change in the orbital distance was calculated using finite element analysis. The same processes were repeated for 10 models simulating normal skulls (the Control group) and postoperative trigonocephalic skulls (the Remodeled group). The changes in the orbital distance were compared among the three groups. RESULTS: The changes in the orbital distance were significantly smaller for the Trigono group than for the Control group. However, changes were significantly greater for the Remodeled group than for the Control group. CONCLUSION: The expansion of interorbital distances in response to the cranial pressure is restricted in skulls with trigonocephaly. This restriction is eliminated by performing remodeling of the skull. These findings explain why spontaneous correction of hypotelorism occurs postoperatively in trigonocephaly.