Craniosynostosis Treatment Using Distraction Devices.

BACKGROUND: The authors report on surgical treatment for 20 patients with craniosynostosis in Japan in collaboration with neurosurgery department since 2007. They could safely expand the skull using distraction devices. METHODS: Total number of patients with craniosynostosis joint surgery was 20 (23 surgeries) at the time of this report. All patients were referred from the neurosurgery department. Neurosurgeons decided the patient selection and the surgical indications, and performed osteotomy, intraoperative measurement of intracranial pressure, and perioperative management. The plastic and reconstructive surgeons set in bone models and simulate bone cutting line preoperatively, and performed skin incisions with flap, set bone distractors or bone absorption plate fitted with flap closure during surgery. Postoperative systemic management was undertaken in the neurosurgery intensive care unit. In the plastic and reconstructive surgery department, postoperative wound care and bone lengthening, and removal of the bone distractors were done. RESULTS: All patients showed good bone forms, and there were no patients of serious complications such as meningitis. CONCLUSION: With these roles shared, safe surgery and perioperative management could be performed. Use of the craniosynostosis distraction devices is safe and excellent way, and the authors will continue to explore that direction further.

Statistical analysis of complications in laser treatment under general anesthesia performed for pediatric inpatients.

OBJECTIVE: We report relationship between complications and predictive factors of occurrence with multivariate analysis for cases of laser treatment under general anesthesia.Study Design: Pediatric patients (330 cases, aged 1 to 15 years old) who underwent laser treatment under inpatient general anesthesia against body surface hemangiomas or melanocytosis were examined for the complications. METHODS: Retrospective study from medical and anesthesia records, statistical assessment was carried out using multivariate analysis by univariate and logistic regression analysis, and p value less than 0.05 was considered to be significant difference. RESULTS: Complications were confirmed in 25%, mostly due to emergence agitation from anesthesia, and no severe complications were recognized. Multivariate analysis of factors causing complications revealed a significant difference in the limbs, the Q-switched Nd: YAG laser, and the anesthesia time of 60 minutes or longer. CONCLUSION: While the length of anesthesia time was reported as a factor of complication occurrence in the past, there has been no report on the extremity and the Q-switched Nd: YAG laser as significant complication factors.

Comparison of contraction among three dermal substitutes: Morphological differences in scaffolds.

Various kinds of synthetic dermal substitutes are produced and used in clinical application and contribute to wound bed preparation for subsequent skin grafting. Although their appearance and outcomes are different, the criteria for the selection of proper synthetic dermal substitutes is not well defined yet. In this study, we focused on the contraction of dermal substitutes and compared the morphological differences in scaffolds. A marked contraction was observed with Pelnac® compared to Integra® and Terudermis® in vitro. We also showed that the pore size of Pelnac® was smaller than that of Integra® and Terudermis®. The shape of the pore was oval in Pelnac®, whereas those in Integra® and Terudermis® were more circular. Differences in the morphological structure may have affected the contraction of the synthetic dermal substitutes.

Changes in the sebaceous gland in patients with male pattern hair loss (androgenic alopecia).

BACKGROUND: The sebaceous gland and the follicular bulge region have important role in biology of the hair. They initiate destruction of the hair follicle both in human and animal models in certain conditions. The morphometric feature of the sebaceous gland is not well understood so as the distribution of the bulge stem cells in pathological conditions of male pattern hair loss or androgenic alopecia (AGA). OBJECTIVES: The authors perform morphometric analysis of the sebaceous gland in AGA patients and also study distribution of the follicular stem cells in the bulge region in these populations. METHODS: Two hundred and fifty cases of glass slide specimen from Japanese patients with male pattern hair loss were reviewed. Among these, 23 cases of the longitudinal (vertical) sections of the scalp skin with diagnosis of AGA were found and analyzed for the morphometric characteristics. Each sebaceous gland area was measured using NIH imagej system and statistically analyzed. For the identification of the follicular bulge region, an immunohistochemistry using anticytokeratin 15 (C8/144B clone) was carried out in the cases of AGA. RESULTS: The sebaceous gland area of the AGA group was noticeably increased, while the size of each sebaceous gland remains unchanged. It has more lobules in the hair follicular unit in the AGA population. In the immunohistochemistry, the follicular stem cells are present in the bulge regions in cases of AGA. CONCLUSIONS: The overgrowth (multilobulation) of the sebaceous gland and relative preservation of the follicular stem cells suggest that the changes in the sebaceous gland could be an important factor in the pathology of AGA.

The treatment dilemma caused by lumps in surfers' chins.

This is an account of 2 male surfing enthusiasts who recently sought care at our hospital after developing tumorous masses on their chins. Although the lesions appeared grossly benign, establishing a definitive treatment plan was perplexing because of the insidious nature of the protuberances. The lesion in the first patient was managed surgically. The approach was modified for the second patient because of information learned from the first. While the technical aspects of care management were simple, once the histologic structure of the tumor was defined, establishing an accurate clinical diagnosis before surgery was troublesome. The histologic findings for the lesion removed from the first patient consisted of primarily parenchymal fibrosis without concomitant structural abnormalities in overlying epidermis, suggesting that repetitive blunt trauma to the chin area while paddling the surfboard was probably the factor responsible for the pathogenesis of tumor formation. These findings and our experience in managing the 2 patients have formed the basis of this report.

[A case of nasal dermal sinus-cyst (NDSC) with intracranial extension].

Nasal dermal sinus-cyst (NDSC) is a rare abnormality consisting of a dermal sinus opening at the nasal skin and dermoid cyst localized in the frontobasal area. A 2-year-old boy was admitted to our hospital due to swelling of the fronto-nasal regions with pus running from an orifice situated in the nasal skin. Bone-image CT and 3D-CT revealed bone defects within the frontal skull base. MRI demonstrated that a dermoid cyst centered in a bone defect was in contact with the dura of the frontobasal area, and a dermal sinus extending to the frontonasal skin could also be detected. Surgical resection was performed by frontobasal craniotomy. The dermal sinus was followed subcutaneously into the orifice of the nasal skin. A small skin incision was made and the sinus was then totally removed. The authors describe in detail this case of NDSC which extended to the intracranium, and review the literature regarding this abnormality.

Treatment of facial angiofibroma of tuberous sclerosis using cultured epithelial autografts.

Treatment of facial angiofibroma of tuberous sclerosis is problematic, because the skin lesions involve entire dermis. Five patients aged from 14 to 33 (mean: 23.6) years old with angiofibroma of tuberous sclerosis were treated with cultured epithelial autografts between 1995 and 2004. The entire area of the facial lesions was excised using a razor to remove large nodules, and then the remaining lesions were further abraded to a rather deep layer of the dermis to smooth the skin and remove small nodules. Then a cultured autologous epithelium was grafted onto the wound. In all patients, epithelization was complete within 10 (mean: 9) days after the surgery. All patients were followed up for more than 6 months and showed neither depigmentation due to scar formation nor hypertrophic scars. In some patients, some pebbly regrowth had occurred at 5 years postoperatively, but the appearance was quite acceptable.

Ambulatory anesthesia for children undergoing laser treatment.

PURPOSE: Since 1993, we have performed laser surgery for cutaneous lesions, such as simple hemangioma and nevus of Ota, in children under ambulatory anesthesia. Although we anticipate that the numbers of patients treated under ambulatory anesthesia will increase, few reports detail the procedures involved and their perioperative management. We describe this method of anesthesia and discuss its limitations, and future issues. METHODS: To date, we have performed laser treatment on 633 pediatric patients under ambulatory anesthesia. The mean age of the children was 3.6 +/- 1.9 years and their mean weight was 16.4 +/- 4.7 kg. The lesions treated included simple hemangioma, nevus of Ota, nevus pigmentosus, nevus spilus, and ectopic Mongolian spots. Anesthesia is induced with oxygen, nitrous oxide, and sevoflurane; then an intravenous cannula is inserted under spontaneous respiration. Anesthesia is maintained with assisted ventilation using a mask. Children are not intubated unless a mask cannot be used because the lesion is on the face or back. RESULTS: No serious peri- or postoperative complications were encountered and there were no serious adverse reactions to anesthesia. With the exception of one child who was admitted overnight for a low-grade fever, all were released from hospital within a few hours. CONCLUSION: Ambulatory anesthesia can be performed safely using oxygen, nitrous oxide, and sevoflurane for the laser treatment of cutaneous lesions in pediatric patients.

Correction of late post-traumatic enophthalmos using a tissue expander.

We described a new technique to correct late post-traumatic enophthalmos using volume augmentation with a tissue expander. A 47-year-old male requiring enucleation with an implant replacement following orbital fracture with the globe injury had been complaining of persistent enophthalmos and cosmetic defect. Computed tomography scan demonstrated significant enophthalmos resulting from a volume discrepancy between an orbita and the orbital contents. To prevent worsening of the prosthesis motility with correction of enophthalmos, projection of the prosthetic globe was postoperatively adjusted by gradual inflation of an expander placed behind the enucleation implant. As a result enophthalmos was appropriately corrected without any change of the prosthesis motility.

Giant pleomorphic adenoma of the parotid gland with malignant transformation.

A 72-year-old female is described who was admitted to the hospital with a giant mixed tumor of the left parotid gland that had grown to a weight of 6051 g within 20 years and ultimately underwent resection of the mass. Histopathological examination revealed adenocarcinoma cells with hyperchromatic nuclei and mitotic figures proliferated in pleomorphic adenoma. Many authors have reported giant tumors weighing more than a few kilograms of the parotid glands, and most were benign. The present tumor was the sixth largest among all the parotid tumors, including both benign and malignant, which were reported. Furthermore, our case was the largest one confirmed as malignant recorded in the world literature. The tumor was successfully resected with no marked facial nerve paralysis.

Postoperative evaluation of palatoplasty using the modified Kaplan method.

PURPOSE: Bilateral buccal mucosal flaps were used for a pushback operation of the nasal mucosa as well as the oral mucosa. METHODS: Two flaps from the buccal mucosal areas were inserted into the nasal mucosal raw surface at the hard and soft palatal border to achieve nasal mucosal pushback. Forty-four children with cleft palates were retrospectively studied to investigate the velopharyngeal function, articulation, and craniofacial morphology following primary palatoplasty using the modified Kaplan method. RESULTS: 72.7% showed good velopharyngeal function. Articulation disorders were found in 26 of the 44 subjects (59.1%). A craniofacial morphological analysis revealed no major changes in the SNA (sella-nasion point A angle) and SNB (sella-nasion point B angle) and no cases of a marked loss of maxillary mandibular balance. In addition, no significant differences were observed in the maxillary length and width. CONCLUSION: The results of these palatoplasties by the modified Kaplan method indicated that the use of bilateral buccal mucosal flaps for the pushback of the nasal mucosa was effective in preventing the contraction of the maxillary and mandibular corpal lengths.

Unusual case of thoracic outlet syndrome caused by a neurilemmoma in the pectoralis minor space.

A 34-year-old man presented with a 5-year history of paraesthesia of the right palm and the right middle and ring fingers. This paraesthesia was exacerbated by elevation of the right arm. A tumour was palpable in the subclavicular fossa. As magnetic resonance imaging (MRI) indicated a neurogenic tumour originating from the brachial plexus, a diagnosis of thoracic outlet syndrome caused by a neurilemmoma in the pectoralis minor space was made. Pathological examination showed the tumour to be a benign neurilemmoma. There have been only three previous case reports of neurilemmomas as causes of thoracic outlet syndrome worldwide, and this is the first report of a neurilemmoma originating from the lateral fascicles of the brachial plexus in the pectoralis minor space causing thoracic outlet syndrome.

Successful management of a small infant born with a large meningomyelocele using a temporary artificial dermis.

A boy with a large meningomyelocele was born at 29 weeks' gestation. An artificial dermis was applied to the meningomyelocele six hours after birth. Four months later he had grown well, and the meningocele was reconstructed with a bilateral latissimus dorsi musculocutaneous flap.

Selective thromboxane A2 synthase inhibition by OKY-046 prevents cardiopulmonary dysfunction after ovine smoke inhalation injury.

BACKGROUND: Because thromboxane A2 is implicated in the pathophysiology of acute lung injury, the aim of this study was to evaluate the effects of selective thromboxane A2 synthase inhibition on cardiopulmonary function in the experimental setting of severe smoke inhalation injury. METHODS: Sixteen adult sheep were operatively instrumented for chronic study. The injured intervention group was treated with the selective thromboxane A2 synthase inhibitor OKY-046, whereas the injured control group received only the vehicle (n = 8 each). RESULTS: The progressive increase in thromboxane B2 lung lymph concentrations in control animals was associated with increased transvascular fluid flux, augmented resistances in the pulmonary and systemic circulation, and a reciprocal decrease in cardiac output. In addition, end-systolic pressure-diameter relation and maximum +dp/dt were markedly depressed as compared with baseline (24 h: 14.3 +/- 0.9 vs. 8.9 +/- 0.5 mmHg/mm and 2,120 +/- 50 vs. 1,915 +/- 40 mmHg/s, respectively; each P < 0.05). Infusion of OKY-046 significantly inhibited pulmonary thromboxane B2 delivery, attenuated the early increase in pulmonary vascular resistance, and blocked the increase in systemic vascular resistance. In addition, OKY-046 blunted and delayed the decrease in cardiac output and maintained end-systolic pressure-diameter relation, +dp/dt, and lung lymph flow at baseline values. CONCLUSIONS: These findings suggest that selective thromboxane A2 synthase inhibition may represent a goal-directed therapeutic approach to alleviate cardiovascular and pulmonary dysfunction in the setting of smoke inhalation injury.

Fibula osteoseptocutaneous flap with a variant perforator and peroneal artery arising from the anterior tibial artery.

Since the report of the first cases of vascularized free fibula graft for treatment of open fracture of the tibia and fibula in 1975, there have been many other reports of the use of vascularized free osteocutaneous fibula flaps for reconstruction of the mandible or lower leg. Usually, these flaps have a single pedicle composed of the peroneal artery, to supply the fibula with septocutaneous or musculocutaneous branches arising from the peroneal artery to supply the lateral skin of the leg. Although some authors have reported variant perforators, there have been no reports of the peroneal artery arising from the anterior tibial artery and perforator arising from the posterior tibial artery. This is the first report of a variant of the peroneal artery and perforator using a vascularized free osteocutaneous fibula flap.

Successful correction of severe contracture of the palm using arterialized venous flaps.

Severe contracture of the palm causes great difficulty in the performance of the tasks required in daily life. Resurfacing with skin grafts may be sufficient for treating mild and small contractures; but severe and extensive contractures involving the joints, tendons, and neurovascular bundles should be covered with thin flaps. The authors present four cases of successful reconstruction of severe and extensive contractures of the palm using large arterialized venous flaps.

Sinking skin flap syndrome: a case of improved cerebral blood flow after cranioplasty.

Sinking skin flap syndrome is defined as a series of neurologic symptoms with the skin depression at the site of cranial defect, which develop several weeks to months after large external cerebral decompression.The case of a 28-year-old female with the sinking skin flap syndrome is reported together with the evaluation of cerebral blood flow using xenon computed tomography (CT). Although her general condition stabilized within 7 months after the injury, the skin of the bilateral temporal regions was markedly depressed due to large bone defects. She was confined to bed and showed reduced levels of consciousness. We decided to treat this case by performing cranioplasty with a hydroxyapatite ceramic implant. Not only were good cranial contour reconstructed after cranioplasty, but neurologic conditions were also improved after cranioplasty. Regarding the change in cerebral blood flow in the present case, as measured with xenon CT, the cerebral blood flow 3 days after the injury was 18.7 +/- 12.3 mL/100 mL/min and 26.5 +/- 11.6 mL/100 mL/min in the left and right hemispheres, respectively. After the bilateral cranioplasty, it had increased by approximately 2-fold to 36.4 +/- 23.2 mL/100 mL/min in the left hemisphere and approximately 1.5-fold to 43.8 +/- 23.3 mL/100 mL/min in the right hemisphere as compared with the levels obtained 3 days after the injury.Therefore, xenon CT appears to be useful in the monitoring of regional cerebral blood flow in patients with cranial bone defects that are directly affected by atmospheric pressure and in predicting functional prognosis. For the sinking skin flap syndrome cases, cranioplasty is not only useful for cerebral protection and improvement of appearance, but cranioplasty is also useful for improving neurologic symptoms.

Treatment of paralytic lagophthalmos by loading the lid with a gold plate and lateral canthopexy.

Various methods of managing patients with lagophthalmos secondary to paralysis of the facial nerve have been reported. While addition of a gold plate facilitates displacement of the upper eyelid downwards, coaptation of the lid margin is often incomplete because of coexisting ectropion of the lower lid. The outcome obtainable from loading the lid with a gold plate alone is often unsatisfactory. To manage the deformity by combining the loading of the lid with gold plate and lateral canthopexy is technically simple. Morbidity is minimal as it can be done under local anaesthesia. Adequacy of coaption of the palpebral margin could be assessed immediately. We have managed a total of seven (mainly elderly) such patients between 1999 and 2000 in our hospitals. The outcome was generally satisfactory and there were no complications.

Use of an arterialised venous skin flap in the replantation of an amputated thumb.

We report the replantation of an amputated thumb using a venous skin flap, harvested from the volar surface of the forearm, to make up the soft tissue defect, and to restore the vascular continuity to the thumb.