Vascular Anatomy for the Prevention of Sublingual Hematomas: Life-Threatening Complication of Genioplasty.

After genioplasty, the occurrence of bleeding is rare; however, rapid enlargement or displacement of the tongue secondary to lingual or sublingual hematoma can lead to life-threatening airway obstruction, necessitating prompt recognition, and immediate management. Therefore, the investigators aimed to evaluate the underlying etiologies of sublingual hematoma and relevant anatomy to facilitate early recognition of the initial presentation of these hematomas and appropriate management. The authors conducted a literature review on cases of delayed sublingual hematoma after genioplasty. The authors also report a case of delayed hematoma after performing genioplasty. The anatomical structures involved with the development of rare and serious hematomas therein are the sublingual and submental arteries, which are located in the sublingual area, rendering them susceptible to injury during genioplasty. The results of this study suggest that submental artery ligation should be performed for proper management of airway obstruction, if symptoms of sublingual bleeding are observed during the surgical procedure. If there is continuous bleeding despite the submental artery ligation, sublingual artery ligation should be performed.

Methodology in Conventional Head and Neck Reconstruction Following Robotic Cancer Surgery: A Bridgehead Robotic Head and Neck Reconstruction.

PURPOSE: Robotic head and neck surgery is widespread nowadays. However, in the reconstruction field, the use of robotic operations is not. This article aimed to examine methodologies for conventional head and neck reconstruction after robotic tumor surgery in an effort to obtain further options for future reconstruction manipulations. MATERIALS AND METHODS: A retrospective review of all patients who received head and neck robot surgery and conventional reconstructive surgery between October 2016 and September 2021. RESULTS: In total, 53 cases were performed. 67.9% of the tumors were greater than 4 cm. Regarding defect size, 47.2% of the lesions were greater than 8 cm. In terms of TNM stage, stage 3 disease was recorded in 26.4% and stage 4 in 52.8%. To make a deep and narrow field wider, we changed the patient's posture in pre-op field, additional dissection was done. We used radial forearm flap mostly (62.2%). CONCLUSION: Conventional head and neck reconstruction after robotic ENT cancer surgery is possible. One key step is to secure additional space in the deep and narrow space left after robotic surgery. For this, we opted for a radial forearm flap mostly. This can be performed as a bridgehead to perform robotic head and neck reconstruction.

Perforating patterns of cutaneous perforator vessels in anterolateral thigh flaps for head and neck reconstruction and clinical outcomes.

BACKGROUND: Anterolateral thigh (ALT) flaps are versatile soft tissue flaps that have become the standard soft-tissue flaps used for head and neck reconstruction. They provide a long vascular pedicle, constant vessel diameter, abundant soft tissue coverage, and minimal donor site morbidity. The ALT flap was initially designed on the basis of a septocutaneous (SC) perforator. However, more recent research has shown that a substantial number of ALT flaps are now based on musculocutaneous (MC) perforators, and the ratio between MC and SC perforators varies among studies. In this study, we analyzed the perforating pattern of ALT flaps along with their clinical outcomes during head and neck reconstruction in the Korean population. METHODS: From October 2016 to July 2020, 68 patients who had undergone an ALT flap procedure for head and neck reconstruction were enrolled retrospectively. The perforating pattern of the cutaneous perforator vessel (MC perforator/SC perforator/oblique branch), pedicle length, and flap size were analyzed intraoperatively. Patient demographics and flap necrosis rates were also calculated. RESULTS: The highest number of cutaneous perforator vessels supplying the ALT flap were the MC perforators (87%). The proportion of MC perforators was significantly higher than that of the SC perforators and oblique branches. Flap necrosis occurred in seven cases (11.86%); sex, hypertension, diabetes mellitus, coronary artery disease, perforator course, and history of radiotherapy did not significantly affect flap necrosis. CONCLUSION: The ALT free flap procedure remains popular for reconstruction of the head and neck. In this study, we observed that the majority of cutaneous vessels supplying the flaps were MC perforators (87%). When using the MC perforator during flap elevation, careful dissection of the perforator is required to achieve successful ALT flaps because intramuscular dissection is difficult. Perforator pattern and history of radiotherapy did not affect flap necrosis.

High-Resolution 3D Printing for Electronics.

The ability to form arbitrary 3D structures provides the next level of complexity and a greater degree of freedom in the design of electronic devices. Since recent progress in electronics has expanded their applicability in various fields in which structural conformability and dynamic configuration are required, high-resolution 3D printing technologies can offer significant potential for freeform electronics. Here, the recent progress in novel 3D printing methods for freeform electronics is reviewed, with providing a comprehensive study on 3D-printable functional materials and processes for various device components. The latest advances in 3D-printed electronics are also reviewed to explain representative device components, including interconnects, batteries, antennas, and sensors. Furthermore, the key challenges and prospects for next-generation printed electronics are considered, and the future directions are explored based on research that has emerged recently.

A New Technique of Open Septal Reduction Using Polydioxanone Plates for Nasoseptal Fracture: Three-Dimensional Volumetric Analysis.

BACKGROUND: In this study, we designed a new technique for open septal reduction using a polydioxanone (PDS) plate and compared it with closed reduction (CR). METHODS: This study included 19 consecutive patients with nasoseptal fracture: 10 receiving open reduction with a PDS plate (PDS group) and 9 undergoing CR group. Open septal reduction was performed after CR for nasal bone fracture. A mucoperichondrial flap was unilaterally elevated, and the deviated septal cartilage was reduced. The PDS plate was inserted horizontally above the vomerine suture. Surgical outcome was analyzed with three-dimensional volumetry and with a quality-of-life scale for nasal obstruction (Nasal Obstruction Symptom Evaluation scale). RESULTS: Complications included 1 case of septal perforation in the CR group and 1 case of PDS exposure and septal hematoma in the PDS group. In the three-dimensional volumetric analysis of the PDS group, the median value of the nasal cavity change significantly differed between 1.14 mL (interquartile range; 0.46-2.4) at the preoperative computed tomography scan and 0.33 mL (interquartile range; -0.22 to 1.29) at the postoperative computed tomography scan (∗∗P = 0.0039). The Nasal Obstruction Symptom Evaluation scale revealed significant improvement in nasal obstruction postsurgically (median value, 42.5-7.5; ∗P = 0.0139) in the PDS group. CONCLUSIONS: Polydioxanone plates potentially present a new concept of open septal reduction in terms of septal reinforcement compared with the subtractive approach of open septal reduction.

Endoscopic Transorbital Approach to Mesial Temporal Lobe for Intra-Axial Lesions: Cadaveric Study and Case Series (SevEN-008).

BACKGROUND: Endoscopic transorbital approach (ETOA) has been proposed as a minimally invasive technique for the treatment of skull base lesions located around mesial temporal lobe (MTL), mostly extra-axial pathology. OBJECTIVE: To explore the feasibility of ETOA in accessing intraparenchymal MTL with cadaveric specimens and describe our initial clinical experience of ETOA for intra-axial lesions in MTL. METHODS: Anatomic dissections were performed in 4 adult cadaveric heads using a 0° endoscope. First, a stepwise anatomical investigation of ETOA to intraparenchymal MTL was explored. Then, ETOA was applied clinically for 7 patients with intra-axial lesions in MTL, predominantly high-grade gliomas (HGGs) and low-grade gliomas (LGGs). RESULTS: The extradural stage of ETOA entailed a superior eyelid incision followed by orbital retraction, drilling of orbital roof, greater and lesser wing of sphenoid bone, and cutting of the meningo-orbital band. For the intradural stage, the brain tissue medial to the occipito-temporal gyrus was aspirated until the temporal horn was opened. The structures of MTL could be aspirated selectively in a subpial manner without injury to the neurovascular structures of the ambient and sylvian cisterns, and the lateral neocortex. After cadaveric validation, ETOA was successfully performed for 4 patients with HGGs and 3 patients with LGGs. Gross total resection was achieved in 6 patients (85.7%) without significant surgical morbidities including visual field deficits. CONCLUSION: ETOA provides a logical line of access for intra-axial lesions in MTL. The safe and natural surgical trajectory of ETOA can spare brain retraction, neurovascular injury, and disruption of the lateral neocortex.

Clinical applications of the endoscopic transorbital approach for various lesions.

BACKGROUND: The endoscopic transorbital approach (ETOA) was recently added to the neurosurgical armamentarium. Although this approach could result in less injury to normal brain tissue, shorter operation times, and smaller scars, its clinical applications have not been fully investigated. We, therefore, sought to share our unique experiences of exploring the application of this approach in various diseases. METHODS: From June 2017 to March 2019, we conducted ETOAs via the superior eyelid crease in 22 patients for the treatment of lesions confined to the middle fossa with and without slight extension to the posterior fossa. These lesions included 5 gliomas, 11 meningiomas, 3 schwannomas, 1 lymphoma, 1 cavernous hemangioma in the orbital wall, and 1 hemangiopericytoma mimicking schwannoma. Perioperative radiologic findings and clinical outcomes were recorded. RESULTS: Gross total resection was accomplished in three (60%) patients with gliomas, nine (81.8%) with meningiomas, two (66.7%) with schwannomas, and one (33.3%) with another lesion. The mean bleeding count was 1051.4 ± 961.1 cc, and major complications were observed in only two (9.1%) cases (one major cerebral artery infarction and one reoperation due to a large amount of bleeding). A cerebrospinal fluid leak was reported in two (9.1%) patients, and transient eye movement palsy was noted in four (18.2%) patients without permanent disability. CONCLUSIONS: The endoscopic transorbital approach could be considered to be feasible for various lesions with different characteristics. After carefully considering the lesion anatomy, consistency, and vascular relationships, using this approach, we could achieve a satisfactory extent of resection without severe complications.

In vitro characterization of osteoblast cells on polyelectrolyte multilayers containing detonation nanodiamonds.

Nanoparticle-enhanced coatings of bone implants are a promising method to facilitate sustainable wound healing, leading to an increase in patient well-being. This article describes the in vitro characterization of osteoblast cells interacting with polyelectrolyte multilayers, which contain detonation nanodiamonds (NDs), as a novel class of carbon-based coating material, which presents a unique combination of photoluminescence and drug-binding properties. The cationic polyelectrolyte, namely polydiallyldimethylammonium chloride (PDDA), has been used to immobilize NDs on silica glass. The height of ND-PDDA multilayers varies from a minimum of 10 nm for one bilayer to a maximum of 90 nm for five bilayers of NDs and PDDA. Human fetal osteoblasts (hFOBs) cultured on ND-PDDA multilayers show a large number of focal adhesions, which were studied via quantitative fluorescence imaging analysis. The influence of the surface roughness on the filopodia formation was assessed via scanning electron microscopy and atomic force microscopy. The nano-rough surface of five bilayers constrained the filopodia formation. The hFOBs grown on NDs tend to show not only a similar cell morphology compared to cells cultured on extracellular matrix protein-coated silica glass substrates, but also increased cell viability by about 40%. The high biocompatibility of the ND-PDDA multilayers, indicated via high cell proliferation and sound cell adhesion, shows their potential for biomedical applications such as drug-eluting coatings and biomaterials in general.

Comparative Analysis of Endoscopic Transorbital Approach and Extended Mini-Pterional Approach for Sphenoid Wing Meningiomas with Osseous Involvement: Preliminary Surgical Results.

OBJECTIVE: Sphenoid wing meningiomas (SWMs) can be treated with complete surgical resection and the recently introduced endoscopic transorbital approach (ETOA) offers a minimally invasive alternative. In this study, the surgical outcome of ETOA and the extended mini-pterional approach (eMPTA) for SWMs with osseous involvement is compared. METHODS: From October 2015 to May 2019, 24 patients underwent surgery for SWMs with osseous involvement. Among them, tumor resection was performed by ETOA for 11 patients (45.8%) and eMPTA for 13 patients (54.2%). The tumor characteristics, surgical outcome and morbidity, and approach-related aesthetic outcome were analyzed and compared retrospectively between ETOA and eMPTA based on SWM classification. RESULTS: The location of SWMs was mostly the middle sphenoid ridge (group III) (45.8%), followed by the greater sphenoid wing (group IV) (29.2%). Simpson resection grades I/II were achieved in 9 of 11 patients (81.8%) with ETOA and 11 of 13 patients (84.6%) with eMPTA. There were no differences in tumor characteristics between the 2 approaches. Surgery time, surgical bleeding, and hospital length of stay were significantly shorter with ETOA. Three patients had transient surgical morbidities such as diplopia (n = 1), ptosis (n = 1), and cerebrospinal fluid leak (n = 1) after ETOA. No differences could be seen in surgical morbidities between ETOA and eMPTA. CONCLUSIONS: ETOA can provide direct access to the sphenoid bone and resectability with a more rapid and minimally invasive exposure than does eMPTA. Maximal subtotal resection with extensive sphenoid bone decompression for tumors with cavernous sinus infiltration is the key to a good clinical outcome, regardless of the surgical approach.

Stem cell behaviors on periodic arrays of nanopillars analyzed by high-resolution scanning electron microscope images.

The biocompatible polyurethane acrylate (PUA) nanopillars were fabricated by soft lithography using three different sizes of nanobeads (350, 500, and 1000 nm), and the human adipose-derived stem cells (hASCs) were cultured on the nanopillars. The hASCs and their various behaviors, such as cytoplasmic projections, migration, and morphology, were observed by high resolution images using a scanning electron microscope (SEM). With the accurate analysis by SEM for the controlled sizes of nanopillars, the deflections are observed at pillars fabricated with 350- and 500-nm nanobeads. These high-resolution images could offer crucial information to elucidate the complicated correlations between nanopillars and the cells, such as morphology and cytoplasmic projections.

Endoscopic transorbital and endonasal approach for trigeminal schwannomas: a retrospective multicenter analysis (KOSEN-005).

OBJECTIVE: Trigeminal schwannomas are rare neoplasms with an incidence of less than 1% that require a comprehensive surgical strategy. These tumors can occur anywhere along the path of the trigeminal nerve, capable of extending intradurally into the middle and posterior fossae, and extracranially into the orbital, pterygopalatine, and infratemporal fossa. Recent advancements in endoscopic surgery have suggested a more minimally invasive and direct route for tumors in and around Meckel's cave, including the endoscopic endonasal approach (EEA) and endoscopic transorbital superior eyelid approach (ETOA). The authors assess the feasibility and outcomes of EEA and ETOA for trigeminal schwannomas. METHODS: A retrospective multicenter analysis was performed on 25 patients who underwent endoscopic surgical treatment for trigeminal schwannomas between September 2011 and February 2019. Thirteen patients (52%) underwent EEA and 12 (48%) had ETOA, one of whom underwent a combined approach with retrosigmoid craniotomy. The extent of resection, clinical outcome, and surgical morbidity were analyzed to evaluate the feasibility and selection of surgical approach between EEA and ETOA based on predominant location of trigeminal schwannomas. RESULTS: According to predominant tumor location, 9 patients (36%) had middle fossa tumors (Samii type A), 8 patients (32%) had dumbbell-shaped tumors located in the middle and posterior cranial fossae (Samii type C), and another 8 patients (32%) had extracranial tumors (Samii type D). Gross-total resection (GTR, n = 12) and near-total resection (NTR, n = 7) were achieved in 19 patients (76%). The GTR/NTR rates were 81.8% for ETOA and 69.2% for EEA. The GTR/NTR rates of ETOA and EEA according to the classifications were 100% and 50% for tumors confined to the middle cranial fossa, 75% and 33% for dumbbell-shaped tumors located in the middle and posterior cranial fossae, and 50% and 100% for extracranial tumors. There were no postoperative CSF leaks. The most common preoperative symptom was trigeminal sensory dysfunction, which improved in 15 of 21 patients (71.4%). Three patients experienced new postoperative complications such as vasospasm (n = 1), wound infection (n = 1), and medial gaze palsy (n = 1). CONCLUSIONS: ETOA provides adequate access and resectability for trigeminal schwannomas limited in the middle fossa or dumbbell-shaped tumors located in the middle and posterior fossae, as does EEA for extracranial tumors. Tumors predominantly involving the posterior fossa still remain a challenge in endoscopic surgery.

Effect of botulinum toxin A on vasoconstriction and sympathetic neurotransmitters in a murine random pattern skin flap model.

Blood supply is the most important factor determining the survival of a skin flap. Botulinum toxin-A (Botox-A) is used as pharmacologic agent not only for aesthetic purposes, but also for its vasomotor actions. This study was conducted to establish whether local application of Botox-A increased survival of random pattern skin flaps in rats by changing the expression of neurotransmitters. Forty adult Sprague-Dawley rats with a caudally-based random pattern skin flap were divided into two groups: Botox-A group and saline group. Surviving flap area and cutaneous blood flow in the flap were evaluated on postoperative days 3 and 7. After injection of Botox-A, changes in vessels were analyzed using immunohistochemical staining. Levels of norepinephrine, neuropeptide-Y, nitric oxide, and endothelial nitric oxide synthase were analyzed quantitatively by high performance liquid chromatography, Western blot, and colorimetric assay. The survived area in the Botox-A group was significantly higher than that in the control group on postoperative days 3 and 7. Blood flow in the Botox-A group was significantly high in the proximal and middle areas immediately after the operation. The number of CD31-positive vessels in the Botox-A group was significant greater than that in the control group. Norepinephrine level in the Botox-A group decreased significantly immediately after flap elevation and at postoperative day 3. There were no significant differences in neuropeptide-Y level between the two groups. Nitric oxide level did not change significantly in either group despite the increase in endothelial nitric oxide synthase immediately after flap elevation and at 3 days postoperatively. In conclusion, Botox-A increased vascular blood flow and viable flap area in rats by reducing norepinephrine level. In contrast, neuropeptide-Y, another vasoconstrictor, was not affected by Botox-A. Nitric oxide, a vasodilator, was also not affected by Botox-A, despite the significant increase in endothelial nitric oxide synthase expression in the flaps.

Cranioplasty Enhanced by Three-Dimensional Printing: Custom-Made Three-Dimensional-Printed Titanium Implants for Skull Defects.

The authors studied to demonstrate the efficacy of custom-made three-dimensional (3D)-printed titanium implants for reconstructing skull defects. From 2013 to 2015, 21 patients (8-62 years old, mean = 28.6-year old; 11 females and 10 males) with skull defects were treated. Total disease duration ranged from 6 to 168 months (mean = 33.6 months). The size of skull defects ranged from 84 × 104 to 154 × 193 mm. Custom-made implants were manufactured by Medyssey Co, Ltd (Jecheon, South Korea) using 3D computed tomography data, Mimics software, and an electron beam melting machine. The team reviewed several different designs and simulated surgery using a 3D skull model. During the operation, the implant was fit to the defect without dead space. Operation times ranged from 85 to 180 minutes (mean = 115.7 minutes). Operative sites healed without any complications except for 1 patient who had red swelling with exudation at the skin defect, which was a skin infection and defect at the center of the scalp flap reoccurring since the initial head injury. This patient underwent reoperation for skin defect revision and replacement of the implant. Twenty-one patients were followed for 6 to 24 months (mean = 14.1 months). The patients were satisfied and had no recurrent wound problems. Head computed tomography after operation showed good fixation of titanium implants and satisfactory skull-shape symmetry. For the reconstruction of skull defects, the use of autologous bone grafts has been the treatment of choice. However, bone use depends on availability, defect size, and donor morbidity. As 3D printing techniques are further advanced, it is becoming possible to manufacture custom-made 3D titanium implants for skull reconstruction.