Sliding Flap for the Wide Upper Eyelid Margin Defect After Cancer Removal.

BACKGROUND: Reconstruction of eyelid margin defects following resection of upper-eyelid skin malignancies is typically performed using a lower eyelid switch flap, including eyelash reconstruction. However, a subsequent procedure for flap separation, and prolonged swelling of the flap may occur as a complication. OBJECTIVE: The authors performed anterior lamellar reconstruction using a sliding flap with excess upper eyelid skin, a procedure that is a less invasive and simpler. MATERIALS AND METHODS: The authors performed anterior lamellar reconstruction using a sliding flap in 7 patients with full-thickness upper eyelid margin defect after skin cancer resection. The mean age of the patients was 76.0 years. The horizontal width of the defect in our cohort ranged from 11 to 25 mm and the vertical width ranged from 5 to 10 mm. RESULTS: All the flaps and mucosal grafts were well taken, and none of the patients complained of lack of eyelash reconstruction. However, eyelid margin irregularity, possibly due to flap or mucosal graft contraction, was observed in 2 patients, and 1 patient developed keratoconjunctivitis. CONCLUSIONS: The sliding flap technique is a minimally invasive and simple procedure for wide eyelid margin reconstruction. However, 2 patients developed eyelid margin irregularities and 1 patient developed keratoconjunctivitis. Those complications might have occurred owing to the condition of posterior lamellar reconstruction. Therefore, for the successful use of a sliding flap for anterior lamellar reconstruction, the form of the eyelid edge and the choice of posterior lamellar reconstruction are key considerations. In future, we plan to establish a better reconstructive technique by accumulating more evidence.

Use of Sponge-Foam Inserts in Compression Bandaging of Non-Healing Venous Leg Ulcers.

Objective: Venous leg ulcers (VLUs) caused by chronic venous insufficiency are difficult to treat. Outcomes after compression therapy and the current standard of care often used in conjunction with other options vary widely. We examined the effects of foam inserts on sub-bandage pressures in patients with VLUs and compared use of foam inserts in elastic and inelastic compression bandaging. Methods: Six patients (≥20 years old) with VLUs and skin perfusion pressure >40 mmHg were included. Each patient underwent weekly treatment regimens of debridement, dressing changes, and dual sponge-insert application followed by elastic (n=3) or inelastic (n=3) compression bandaging. The median resting sub-bandage pressures of the ulcer beds, wound sizes, and healing percentages were recorded. Wound beds were biopsied before and after treatment for histological assessment. Nine healthy volunteers served as controls during preliminary testing. Results: With proper sub-bandage pressures (>35 mmHg), the average healing time was 88.0±66 days, which was shorter than anticipated (i.e., ≥6 months). Combining large and local sponge-foam inserts increased sub-bandage pressures regardless of the compression bandage selected, with marked improvements seen in deeper wounds. Conclusion: Layering one or two sponge-foam inserts beneath compression bandages facilitates uniform and optimal wound-bed pressure, which accelerates the healing of VLUs.

ECM-based microfluidic gradient generator for tunable surface environment by interstitial flow.

We present an extracellular matrix (ECM)-based gradient generator that provides a culture surface with continuous chemical concentration gradients created by interstitial flow. The gelatin-based microchannels harboring gradient generators and in-channel micromixers were rapidly fabricated by sacrificial molding of a 3D-printed water-soluble sacrificial mold. When fluorescent dye solutions were introduced into the channel, the micromixers enhanced mixing of two solutions joined at the junction. Moreover, the concentration gradients generated in the channel diffused to the culture surface of the device through the interstitial space facilitated by the porous nature of the ECM. To check the functionality of the gradient generator for investigating cellular responses to chemical factors, we demonstrated that human umbilical vein endothelial cells cultured on the surface shrunk in response to the concentration gradient of histamine generated by interstitial flow from the microchannel. We believe that our device could be useful for the basic biological study of the cellular response to chemical stimuli and for the in vitro platform in drug testing.

ECM-based microchannel for culturing in vitro vascular tissues with simultaneous perfusion and stretch.

We present an extracellular matrix (ECM)-based stretchable microfluidic system for culturing in vitro three-dimensional (3D) vascular tissues, which mimics in vivo blood vessels. Human umbilical vein endothelial cells (HUVECs) can be cultured under perfusion and stretch simultaneously with real-time imaging by our proposed system. Our ECM (transglutaminase (TG) cross-linked gelatin)-based microchannel was fabricated by dissolving water-soluble sacrificial polyvinyl alcohol (PVA) molds printed with a 3D printer. Flows in the microchannel were analyzed under perfusion and stretch. We demonstrated simultaneous perfusion and stretch of TG gelatin-based microchannels culturing HUVECs. We suggest that our TG gelatin-based stretchable microfluidic system proves to be a useful tool for understanding the mechanisms of vascular tissue formation and mechanotransduction.

Oncoplastic Lower Eyelid Reconstruction Analysis.

BACKGROUND: Oncoplastic lower eyelid reconstruction is a challenging task due to the complicated structure of the eyelid and requirement of high operative accuracy. Poorly treated defects result in ectropion and ptosis which may lead to keratitis and corneal ulceration. Previous related studies do not include a detailed comparison of the common reconstructive methods of the lower eyelid in terms of results and complication rates. OBJECTIVE: The authors aim to demonstrate whether the choice of reconstruction affects the aesthetic and functional outcome of oncoplastic lower eyelid reconstruction. METHODS & MATERIALS: The authors performed a 10-year retrospective review of all oncoplastic lower eyelid reconstructions carried out in our hospital. Information on patient background, diagnosis and the choice of reconstructive method were evaluated. Postoperative photographs of each patient were then subjectively evaluated for color match, cosmesis, quality of shape, symmetry, and overall appearance. The authors hypothesized that the outcome is related to the main trajectory of the flap. Patients treated with local flaps of horizontal and vertical trajectories were then compared in terms of outcome and complication rates. RESULTS: Reconstructions based on a horizontal trajectory compared with a vertical trajectory resulted with lower rates of ectropion and ptosis occurrence. The results were statistically significant.

Quantitative Analysis of Change in Intracranial Volume After Posterior Cranial Vault Distraction and Frontal Orbital Advancement/Remodeling.

INTRODUCTION: Patients with craniosynostosis with shortened occipitofrontal diameter are mainly treated with posterior cranial vault distraction osteogenesis (PVDO) in our institution. If further intracranial volume (ICV) expansion is needed, additional treatment with frontal orbital advancement (FOA) is done. On the contrary, frontal orbital remodeling (FOR) is done for better aesthetic results. In this study, post-treatment ICV changes in patients with craniosynostosis treated with these methods have been investigated. METHODS: Patients who underwent FOA or FOR in addition to PVDO at Juntendo University Hospital between 2011 and 2017 were reviewed for patient characteristics and pre/postoperative ICV measurements using 3-dimensional computed tomography scans. RESULTS: Nine patients aged from 5 months to 6 years 8 months at the time of PVDO were included. For PVDO, the ICV change was 113 to 328 mL, and the enlargement ratio of ICV was 109% to 152%. Two patients were further operated with FOA while the remaining 7 with FOR. With FOA, ICV change was 73 to 138 mL, while enlargement ratio of ICV was 107% to 114%. With FOR, ICV change was 3 to 45 mL (mean 20 mL), while enlargement ratio of ICV was 100% to 103%. CONCLUSION: The PVDO is our first line of treatment for ICV expansion and posterior cranial fossa decompression in patients with severe craniosynostosis. The FOA is performed if extra ICV increase is necessary. This approach seems to enable larger ICV expansions compared with other conventional methods. The FOR should be reserved for patients in whom adequate ICV levels are achieved with PVDO yet additional frontal reshaping is necessary.

Successful Treatment of Infantile Hemangiomas With Propranolol in Low-Birth-Weight Infants.

BACKGROUND: Infantile hemangioma (IH) is a benign neoplasm that causes scarring and cosmetic problems after spontaneous regression. Therefore, aggressive treatments such as laser irradiation and corticosteroid have been used; however, recently, the effect of propranolol has been widely noticed. In this study, the authors applied propranolol to low-birth-weight infants with IHs and evaluated its effect. METHODS: Four low-birth-weight infants having IH were selected, with birth weights ranging from 582 to 814 g (average 703 g). The administration of propranolol was started within 4 days of hospitalization. The dosage of propranolol was increased from 0.5 to 2.0 mg/kg/day step by step. Vital signs and blood sugar level were checked prior to every administration of the drug. Continuous monitoring of electrocardiography and arterial oxygen saturation were performed during entire hospitalization.The outcomes were assessed by the patient's family and 2 board-certified plastic surgeons based on 5 parameters pertaining to clinical findings, using a scale of 1 to 10. Reduction rate of the hemangioma was calculated at the end of treatment and compared with the size prior to treatment. RESULTS: The authors could administrate propranolol without any severe side effects in all patients. Infantile hemangiomas gradually shrank soon after the authors started the treatment. Reduction ratios were 22.1% to 100% (average 48.72%), and the comprehensive evaluation of treatment was 7.5 to 10 (average 8.55) on a 10-point scale. CONCLUSIONS: With careful monitoring of their vital signs, propranolol could be a good treatment option even for IH in low-birth-weight infants whose birth weights were less than 1000 g.

Quantitative Analysis of Change in Intracranial Volume After Posterior Cranial Vault Distraction.

Posterior cranial vault distraction is considered to be more effective for increasing intracranial volume than fronto-orbital advancement or anterior cranial vault expansion, but the changes in intracranial volumes after posterior cranial vault distraction remain unclear. The changes in intracranial volume were investigated in patients of premature craniosynostosis treated by this technique. Seven patients, 3 boys and 4 girls aged from 5 months to 3 years 3 months (mean 23 months) at operation, with craniosynostosis underwent posterior cranial vault distraction at Juntendo University Hospital from 2011 to 2014. Patient characteristics, length of distraction, and pre- and postoperative computed tomography findings were reviewed. Total intracranial volume, including the supratentorial space and posterior cranial fossa, was measured using the workstation functions on three-dimensional computed tomography scans. Posterior distraction was performed without severe complications except in 2 patients requiring additional surgeries. The distraction length was 22.3 to 39 mm (mean 31 mm), the intracranial volume change was 144 to 281 mL (mean 192 mL), and the enlargement ratio of intracranial volume was 113% to 134% (mean 121%). The present quantitative analysis of intracranial volume change after posterior distraction showed greater increases in intracranial volume compared with previous reports. Furthermore, intracranial volumes in our patients became nearly normal and were maintained for the follow-up period (maximum 13 months). Posterior cranial vault distraction is very effective to increase cranial volume, so may be the first choice of treatment in patients of craniosynostosis.

Posterior Cranial Vault Distraction Osteogenesis with Barrel Stave Osteotomy in the Treatment of Craniosynostosis.

Twenty years have passed since distraction osteogenesis was introduced into the field of craniomaxillofacial surgery, with distraction osteogenesis gradually consolidating its position for midface advancement in syndromic craniosynostosis. On the other hand, no consensus has been reached regarding its adaptation to calvarial bone. We reported that distraction osteogenesis was useful in posterior cranial vault expansion, and subsequently, similar reports have been successively observed worldwide. In posterior cranial vault distraction, intracranial capacity could be greatly expanded due to its simultaneous expansion with the scalp, with little risk of relapse because new bone is regenerated in the distraction gap. The possibility was suggested that the standard of first carrying out fronto-orbital advancement (FOA) for brachycephaly observed in syndromic craniosynostosis will greatly change posterior cranial vault distraction.

Effect of Control-released Basic Fibroblast Growth Factor Incorporated in ß-Tricalcium Phosphate for Murine Cranial Model.

BACKGROUND: ß-Tricalcium phosphate (ß-TCP) is used clinically as a bone substitute, but complete osteoinduction is slow. Basic fibroblast growth factor (bFGF) is important in bone regeneration, but the biological effects are very limited because of the short half-life of the free form. Incorporation in gelatin allows slow release of growth factors during degradation. The present study evaluated whether control-released bFGF incorporated in ß-TCP can promote bone regeneration in a murine cranial defect model. METHODS: Bilateral cranial defects of 4 mm in diameter were made in 10-week-old male Sprague-Dawley rats treated as follows: group 1, 20 µl saline as control; group 2, ß-TCP disk in 20 µl saline; group 3, ß-TCP disk in 50 µg bFGF solution; and group 4, ß-TCP disk in 50 µg bFGF-containing gelatin hydrogel (n = 6 each). Histological and imaging analyses were performed at 1, 2, and 4 weeks after surgery. RESULTS: The computed tomography value was lower in groups 3 and 4, whereas the rate of osteogenesis was higher histologically in group 4 than in the other groups. The appearance of tartrate-resistant acid phosphate-positive cells and osteocalcin-positive cells and disappearance of osteopontin-positive cells occurred earlier in group 4 than in the other groups. CONCLUSIONS: These findings suggest that control-released bFGF incorporated in ß-TCP can accelerate bone regeneration in the murine cranial defect model and may be promising for the clinical treatment of cranial defects.

Familial nonsyndromic craniosynostosis with specific deformity of the cranium.

An otherwise healthy, developmentally normal 3-week-old male infant presented with complex multisuture craniosynostosis involving the metopic suture and bilateral coronal sutures with frontal prominence and hypotelorism. Frontal craniectomy and bilateral frontoorbital advancement remodeling were performed at the age of 5 months. The postoperative course was uneventful. The child's development was normal up to 8 months after the operation. His father and grandfather had similar specific deformities of the cranium, but no anomaly of the extremities was found, and conversation suggested that their intelligence was normal, excluding the possibility of syndromic craniosynostosis. A DNA analysis revealed large-scale copy number polymorphism of chromosome 4 in the patient and his family, which may include the phenotype of the cranium. Neither FGFR mutation nor absence of a TWIST1 mutation in the sequence from 291 to 1087, which includes DNA binding, Helix1, Loop, and Helix2, was identified. The patient apparently had a rare case of familial nonsyndromic craniosynostosis. The authors plan further genomic analysis of this family and long-term observation of the craniofacial deformity of this patient.

Expression of transforming growth factor-ß1, -ß2, and -ß3 in plagiocephalic fused and patent coronal suture.

BACKGROUND: Craniosynostosis is a relatively rare disease. Recently, several studies have investigated the etiology of craniosynostosis using animal models; however, the etiology remains unknown. In this study, we examined transforming growth factor (TGF) ßs immunostaining from coronal sutures in patients with plagiocephaly. MATERIALS: The examined materials were obtained from 3 patients who had undergone surgery for plagiocephaly. The sections were obtained from the normal patent side and the abnormal fused side of the coronal suture. The subjects included 2 girls and 1 boy with ages ranging from 1 to 4 years. Osteoblasts and connective tissue were observed with hematoxylin and eosin stain. Immunohistochemistry of the TGF-ß isoforms was performed to investigate the difference between the patent and fused sutures. RESULTS: No connective tissue was observed in the fused suture. The osteoblasts in the patent suture were activated, whereas the osteoblasts in the fused suture were inactivated. The osteoblasts were positive for TGF-ß1, -ß2, and -ß3. The periosteum tended to be positive for TGF-ß2 and negative for TGF-ß1 and -ß3. There was no distinct difference between the patent and fused sutures in this study. DISCUSSION: In this study, all sutures had fused completely, and therefore, we may have missed the period when there are differences in protein manifestation. The modulation of the growth factor profile at the suture site may have a potential therapeutic value.

Whole cranial vault expansion by continual occipital and fronto-orbital distraction in syndromic craniosynostosis.

BACKGROUND: In cases of surgery for syndromic craniosynostosis with posterior flattering, it is not possible to achieve sufficient expansion of the skull through fronto-orbital advancement alone. Although it is necessary to expand the occipital region, the surgery is risky and highly invasive. We applied the distraction osteogenesis technique for skull expansion and performed occipital expansion and fronto-orbital advancement in succession. METHODS: Three patients with syndromic craniosynostosis (2 with Crouzon syndrome, 1 with Pfeiffer syndrome) were treated in Juntendo University Hospital between 2002 and 2007. Using the distraction osteogenesis technique, we performed occipital advancement followed immediately by fronto-orbital advancement for 2 cases of Crouzon syndrome and performed fronto-orbital advancement followed by occipital advancement for a case of Pfeiffer syndrome. RESULTS: In all of the cases, we were able to perform bone extension of 25 mm or more and achieve sufficient skull expansion for both of the frontal and occipital regions. Within 1 year after the surgery, in all of the cases, favorable osteogenesis was observed in the distraction gap, and there were no bone defects. DISCUSSION: By using the distraction osteogenesis technique, the difficult procedure of occipital advancement can be performed relatively safely. In addition, as active expansion of the cranium is possible after the surgery, sufficient expansion of the cranium can be successfully performed to a degree that cannot be achieved through conventional methods. New bone is formed in the distraction gap, and there are no bone defects. The present method is extremely useful for skull formation in cases of syndromic craniosynostosis with posterior flattering.

Decreased serum levels of adiponectin in subjects with autism.

The neurobiological basis for autism remains poorly understood. We hypothesized that adipokines, such as adiponectin, may play a role in the pathophysiology of autism. In this study, we examined whether serum levels of adiponectin are altered in subjects with autism. We measured serum levels of adiponectin in male subjects with autism (n=31) and age-matched healthy male subjects (n=31). The serum levels of adiponectin in the subjects with autism were significantly lower than that of normal control subjects. The serum adiponectin levels in the subjects with autism were negatively correlated with their domain A scores in the Autism Diagnostic Interview-Revised, which reflects their impairments in social interaction. This study suggests that decreased levels of serum adiponectin might be implicated in the pathophysiology of autism.

A repositioning technique for nasal fracture using the little finger.

A nasal bone fracture is usually repositioned using either Walsham or Asch forceps. However, accurate repositioning is often difficult. We therefore performed a repositioning technique using the little finger in 10 patients with a new nasal fracture. The results were satisfactory in all of the patients. Although medical experts may consider our method to be primitive, we believe that our method is both safe and effective, because the operator can recognize both the fractured part and its actual condition using the little finger. With this method, the occurrence of unnecessary new fractures can be prevented, in addition to minimizing the degree of mucosal damage and the occurrence of nasal hemorrhage. Furthermore, we consider that this technique can also reduce the occurrence of postoperative deformities due to the reduced mucosal contracture with this treatment modality. Even if the use of an instrument is deemed necessary, such as in treating saddle-nose-type fractures, initially feeling the fracture with the little finger will still allow for a more precise fracture reduction. We therefore consider our method to be both safe and effective at the initial stage of diagnosis and for the treatment of patients presenting with nasal bone fractures.