Treatment of Epiphora in Patients with Conjunctivochalasis Using Conjunctival Fixation to the Sclera

PURPOSE: To report the effects and complications of conjunctival fixation to the sclera in conjunctivochalasis patients with inferior punctal occlusion. METHODS: The authors of the present study evaluated the degree of conjunctivochalasis and performed Fluorescein Dye Disappearance Test (FDT) in 15 eyes of 8 patients diagnosed with conjunctivochalasis with inferior punctal occlusion. Under topical anesthesia, the inferior bulbar conjunctiva was attached to the sclera with 3 8-0 vicryl stitches 8 mm posterior from the limbus. After surgery, the relief of symptoms, postoperative complications and improvement of conjunctivochalasis were observed. RESULTS: One week after the surgery, all 15 eyes achieved a subjective improvement of symptoms and the degree of conjunctivochalasis and FDT showed statistical difference after surgery (p = 0.000, 0.000, respectively). A complication occurred in 1 eye which was a retinal hemorrhage due to scleral puncture. CONCLUSIONS: Conjunctival fixation to the sclera could improve epiphora in conjunctivochalasis patients with inferior punctal occlusion. However, this procedure should be performed with caution.

Apoptosis of Human Islet Cells by Cytokines

FasL, perforin, TNFalpha, IL-1 and NO have been considered as effector molecule(s) leading to beta-cell death in autoimmune diabetes. However, the real culprit(s) of beta-cell destruction have long been elusive despite intense investigation. Previously we have suggested IFNgamma/TNFalpha synergism as the final effector molecules in autoimmune diabetes of NOD mice. A combination of IFNgamma and TNFalpha but neither cytokine alone, induced classical caspase-dependent apoptosis in murine insulinoma and pancreatic islet cells. IFNgamma treatment conferred susceptibility to TNFalpha-induced apoptosis on otherwise resistant murine insulinoma cells by STAT1 activation followed by IRF-1 induction. Here we report that IFNgamma/TNFalpha synergism induces apoptosis of human pancreatic islet cells. We also observed STAT1 activation followed by IRF-1 induction by IFNgamma treatment in human islet cells. Taken together, we suggest that IFNgamma/TNFalpha synergism could be involved in human islet cell death in type 1 diabetes, similar to murine type 1 diabetes.

Effective glycemic control achieved by transplanting non-viral cationic liposome-mediated VEGF-transfected islets in streptozotocin-induced diabetic mice

Hypoxic damage is one of the major causes of islet graft failure and VEGF is known to play a crucial role in revascularization. To address the effectiveness of a cationic lipid reagent as a VEGF gene carrier, and the beneficial effect of VEGF-transfected islets on glycemic control, we used effectene lipid reagent in a transfection experiment using mouse islets. Transfection efficiencies were highest for 4 microgram/microliter cDNA and 25 microliter effectene and cell viabilities were also satisfactory under this condition, and the overproduction of VEGF mRNA and protein were confirmed from conditioned cells. A minimal number of VEGF-transfected islets (100 IEQ/animal) were transplanted into streptozotocin (STZ)-induced diabetic mice. Hyperglycemia was not controlled in the islet transplantation (IT)-alone group (0/8) (non- diabetic glucose mice number/total recipient mice number) or in the IT-pJDK control vector group (0/8). However, hyperglycemia was completely abrogated in the IT-pJDK-VEGF transduced group (8/8), and viable islets and increased VEGF-transfected grafts vascularization were observed in renal capsules.

The Effect of Topical PGE4 (Prostaglandin E1) Analogue on Angiogenesis in the Hairless Mouse

An important aspect of plastic surgery is skin flap survival. Among the prostaglandins, PGE4 is used clinically to improve peripheral circulatory disturbances due to its action of augmenting blood flow by vascular smooth muscle relaxation and its strong inhibitory action of platelet aggregation. Clinically, many investigators found that the effect of PGE4 was prolonged for a long period even after short-term application. So a new hypothesis emerges that the prolonged effect of PGE4 may be due to neovascularization and not due to vasodilatation alone. This study was designed to clarify the mechanism of the prolonged effect of topical PGE4 with regard to angiogenesis. A total of 9 male hairless mice were treated with a topical application of PGE4 onitment (PGE4 powder mixed in hydrogen base) on the experimental side and only a hydrogen base on the contralateral control side of the back skin, respectively, for 7 days, once a day. Then they were divided into 3 groups. In group 1, specimens were obtained on the 7th day post-treatment using 3 mm size punch biopsy from both sides. In group 2, specimens were obtained on post-treatment 14th day. In group 3, specimens were obtained on post-treatment 28th day. The number of blood vessels were compared between the experimental side and control side with respect to neovascularization after PGE4 application using an image-analysis program under hemtoxyline-eosin stain. Treatment on the experimental side did not affect its contralateral mate, since there was no evidence of a systemic effect. From our experimental data, we could conclude that PGE4 may induce angiogenesis by topical application without systemic effect.

Geometrical design of bilobed flap for nasal reconstruction(5 cases)

The nose has number of characteristics that make it unique when planning or reconstruction of surgical defects. The topography of nose is complex with multiple adjacent convex and concave surfaces that must be preserved. The free margins of the alar rims are mobile and easily distorted in case of inadequate planning. The skin over the lower one third of the nose id liss mobile and, therefore, cannot be easily recruited for closure of small defects. In addition, the texture and color of this skin are so unique that neither distant nor nearby skin can always provide a good match. Finally, the function of the nose must always be considered by preserving or replacing the bony and cartilaginous framework, mucosal linig, and never compromising a patent airway. The bilobed flap is particularly suited for reconstruction of small sized or medium sized nasal defects up to 1.5 cm in diameter. By definition, it is a double transposition flap and it is designed to move more skin over a longer distance than would be possible with a single transposition flap in the same location. On the lower one third of the nose where the skin is the least mobile, the bilobed flap allows the surgical site to be covered with nearby skin matched for color and texture and then allows for repair of that secondary defect with another well-matched flap whose donor site can finally be closed primarily. This flap also results in little or no distortion of the nose since the flap efficiently recruits skin from distant and more lax sites. While the standard design often results in tissue protrusions or pincushioning effect, improvements in the design are outlined herein to achieve the best results for defects of the nose.

Long term outcome of columellar lengthening in bilateral cleft lip nose deformity using several methods

A typical bilateral cleft lip nose shows a short columella, depressed nasal tip, bilateral dislocation and flaring of alar cartilage, wide alar base and almost no nasolabial angle in profile. Among them, the most conspicuous residual stigmata of the repaired bilateral cleft lip nose deformity is apparently a short columella. The optimal columellar lengthening procedure should be selected according to the particular nasolabial deformity and the age of patient. However, whatever methods are used, it is extremely difficult to produce the natural columellar contour. Among the numerous techniques employed for columellar lengthening. Cronin's method and forked flaps have been widely used. The operation for lengthening the columella can be classified into three groups on the basis of source of material:lip,nose, or ear. Cronin's method is an advancement of skin medially and forward from the floor of the nose and alae on two bipedicle flaps, based medially on the columella and laterally on the alae. But, Cronin's method is rarely sufficient in achieving good nasal projection. Forked flap is a method using vertical scar flaps. It is effective in ways, but the method disturbs the well formed arhitectures of the Cupid's bow and philtral width attained at the primary lip repair, and creates new upper lip scar with adverse effect on upper lip tightness. Columellar composite graft from the helical rim has been used quite effectively, but the curvature and consistency of the conventionally used ear cartilage graft are often inadequate. The author peformed and reviewed the results of the above various techniques of columellar lengthening and found that the various techniques had its own unique disadvantages. So, the author developed a new composite graft that the chondrocutaneous composite graft is harvested from the concha rather than the rim and is folded into a file-folder design. This method allows symmetrical and straight columellar formation with firm and stable support. The author performed this chondrocutaneous composite graft of a file-folder design in our series of 19 patients and the postoperative results were satisfactory in a follow-up period of 12months. This study included 46 cases of bilateral cleft lip nose deformity for the past 10 years from February of 1987 to September of 1997. They consist of 3 cases of Cronin's method, 3 cases of primary forked flap, 17 cases of forked flap, 4 cases of bilateral reverse W-plasty and 19 cases of composite graft of file folder design by author's method. The follow-up period was variable from 1 month to 13 years (mean:13 months) and the results of long term follow-up more than 2 years are shown.

Lymphangioma circumscriptum on buccal mucosa: a case report

Lymphangioma circumscriptum is a benign disorder of lymphatic channels. The pathologic findings consist of a collection of deep, sequestered subcutaneous lymphatic cisterns which are encircled by smooth muscle. The lymphatic cisterns are communicating with superficial clusters of vesicles through dilated lymphatic channels. The etiology of this lesion is unclear ; however, lymphatic obstruction has been suggested as a possible cause. It is characterized clinically by grouped vesicles, some of which may be filled with serosanguinous fluid. It is an unpleasant, but benign condition conventionally managed by wide local excision, which provides symptom control and often prevents recurrence. Neither long term complication nor association with squamous cell carcinoma has been previously documented. Some cases were reported following mastectomy and radiation therapy or radiation therapy for squamous cell carcinoma of the cervix. We present a 17-year-old patient with lymphangioma circumscriptum developed on buccal mucosa, which developed 3 months after innervated serratus anterior muscle free flap for functional reconstruction of cheek. We suppose that it was caused not only by lymphatic blockage resulted from wide operation but also by chronic masticating local irritation. In review of literatures, we didn't have found any report of lymphangioma circumscriptum developed on buccal mucosa.

Lymphangioma circumscriptum on buccal mucosa: a case report

Lymphangioma circumscriptum is a benign disorder of lymphatic channels. The pathologic findings consist of a collection of deep, sequestered subcutaneous lymphatic cisterns which are encircled by smooth muscle. The lymphatic cisterns are communicating with superficial clusters of vesicles through dilated lymphatic channels. The etiology of this lesion is unclear ; however, lymphatic obstruction has been suggested as a possible cause. It is characterized clinically by grouped vesicles, some of which may be filled with serosanguinous fluid. It is an unpleasant, but benign condition conventionally managed by wide local excision, which provides symptom control and often prevents recurrence. Neither long term complication nor association with squamous cell carcinoma has been previously documented. Some cases were reported following mastectomy and radiation therapy or radiation therapy for squamous cell carcinoma of the cervix. We present a 17-year-old patient with lymphangioma circumscriptum developed on buccal mucosa, which developed 3 months after innervated serratus anterior muscle free flap for functional reconstruction of cheek. We suppose that it was caused not only by lymphatic blockage resulted from wide operation but also by chronic masticating local irritation. In review of literatures, we didn't have found any report of lymphangioma circumscriptum developed on buccal mucosa.

Secondary Lumbar Spinal Stenosis; Clinical and Radiological Features, and Surgical Outcomes (Five-years Follow Up)

One hunderd and ten patients who had undergone surgery for lumbar spinal stenosis between March, 1988 and March, 1991 were evaluated in terms of radiological findings, classification, clinical features, coexisting disease and postoperative results. The overall mean age was 60 years, and patients with lateral stenosis were, an average, 11years younger than those with central canal stenosis. There was a high incidence of coexisting disease but its effect on symptoms and disease progression was statistically not significant. Characteristic radiological features were disc height decrease, facet joint hypertrophy, facet joint arthrosis, diffuse bulging disc, and ligamentum flavum hypertrophy, but no significant difference between the sexes was seen Nor were there differences between the symptoms of patients with lateral and central stenosis, though claudication was found mainly in patients with multiple level stenosis. The relief of symptoms by decompressive surgery more significantly successful in lateral than in central stenosis, and the surgical success rate was 74%.

Far Lateral Extraforaminal Disc Herniation after Percutaneous Laser Lumbar Discectomy

The authors report a case of far lateral disc herniation at L4-5 found one year after percutaneous laser lumbar discectomy. The patient was found to be suffering from new-onset right lumbar radiculopathy 6 months after his first operation, and post operative lumbar MRI confirmed a far lateral extraforaminal disc herniation at L4-5, with compression of the nerve. This corresponded to the nucleotomy site of the probe. The patient underwent surgery employng the combined paraspinal intertransverse and interlaminar approach, and his symptoms were relieved. This case emphasizes the importance of removing nuclear material, and shows that remaining material can herniate through a percutaneous discectomy window.

Combined Interlaminar and Paraspinal Intertransverse

A technique combining usual interlaminar approach and paraspinal intertransverse approach for exposing far-lateral disc herniations without disrupting the facet is described. This approach is useful because disc fragments can be removed from both intraspinal and paraspinal route with easy retraction and under short skin incision. This approach prevents reherniation by complete removing of residual nucleus pulposus. At the end of procedure the foramen can be explored in order to verify that foramen is opened. This approach is usuful especially in operating the double herniations and extruded far lateral disc herniations.

Clinical and Biomechanical Analysis of Transarticular Screw Fixation for Atlantoaxial Instability

Transarticular screw fixation augmented with interspinous wiring technique for atlantoaxial instability was analyzed to provide immediate multidirectional rigid fixation and increase likelihood of fusion of C1-2 for atlantoaxial instability in several biomechanical studies. Transarticular screw fixation eliminates anterior, posterior translation at C1-2 and reduce flexion and extension movement. 13 patients with atlantoaxial instability were operated with posterior atlantoaxial facet screws fixation augmented with an interspinous C1-2 strut graft and posterior wire fixation technique. One patient died postoperatively from cardiac problem. All surviving patients restored C1-2 alignment and stability without complication due to instrumentation and osseous unions have developed even 2 cases of screw breakage developed. This technique was analyzed to be superior to wiring or clamp fixation biomechanically and leads to success without external orthosis in several series. But precaution is needed to avoid the vertebral artery injury.