Hemihypoglossal nerve transfer for acute facial paralysis.

OBJECT: The authors have developed a technique for the treatment of facial paralysis that utilizes anastomosis of the split hypoglossal and facial nerve. Here, they document improvements in the procedure and experimental evidence supporting the approach. METHODS: They analyzed outcomes in 36 patients who underwent the procedure, all of whom had suffered from facial paralysis following the removal of large vestibular schwannomas. The average period of paralysis was 6.2 months. The authors used 5 different variations of a procedure for selecting the split nerve, including evaluation of the split nerve using recordings of evoked potentials in the tongue. RESULTS: Successful facial reanimation was achieved in 16 of 17 patients using the cephalad side of the split hypoglossal nerve and in 15 of 15 patients using the caudal side. The single unsuccessful case using the cephalad side of the split nerve resulted from severe infection of the cheek. Procedures using the ansa cervicalis branch yielded poor success rates (2 of 4 cases). Some tongue atrophy was observed in all variants of the procedure, with 17 cases of minimal atrophy and 14 cases of moderate atrophy. No procedure led to severe atrophy causing functional deficits of the tongue. CONCLUSIONS: The split hypoglossal-facial nerve anastomosis procedure consistently leads to good facial reanimation, and the use of either half of the split hypoglossal nerve results in facial reanimation and moderate tongue atrophy.

Cephalic index of Japanese children with normal brain development.

The cephalic index is a method of assessing skull morphology in craniosynostosis. There are known racial differences; however, there are few reports on this index in Japan. In this study, we investigated the cephalic indices of Japanese children with normal brain development using axial slice computed tomography. Children presented to our institution because of head injuries but received no particular diagnosis. One hundred four children with normal brain development (62 males and 42 females) were divided into 7 age categories, namely, 4 categories for those younger than 1 year and 3 categories for those between 1 and 3 years. The cephalic index was calculated according to the following equation: (cephalic width/cephalic length) × 100. The cephalic indices by age groups were as follows: 86.7, 0 to 3 months (n = 21); 87.5, 4 to 6 months (n = 9); 89.2, 7 to 9 months (n = 16); 86.3, 10 to 12 months (n = 9); 85.9, 1 year (n = 25); 86.3, 2 years (n = 15); and 83.7, 3 years (n = 9). In this study, the cephalic indices of Japanese children with normal brain development tended to be more brachycephalic than those of white children, as reported by Haas and Waitzman. Thus, we formulated the classification of current cephalic indices of children with normal brain development in Japan.

Consideration of median cleft lip with frenulum labii superior.

Median cleft lip is usually divided into true and false when being discussed. Owing to recent developments of diagnostic imaging methods that have improved the accuracy, the presence of an intermediate type of median cleft lip, which cannot simply be divided into true and false, has been suggested. However, the simple method of classification is still clinically valuable. We have previously reported in this Journal a case of median cleft lip with 2 upper labial frenums. In the present study, based on our experience with false median cleft lip, we set forth a hypothesis that 2 upper labial frenums can be found in true median cleft lip, whereas no upper labial frenum is found in false median cleft lip. A review of the results of previous Japanese cases (7 true and 4 false cases) supported our hypothesis. We also reviewed one of our cases of right cleft lip accompanied by holoprosencephaly and discuss the case from the developmental perspective. The shape of the upper labial frenum may be a factor that can be used for clinically classifying intermediate median cleft lip into either true or false in cases that are otherwise difficult to classify.

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.

Hemi-orbicularis oculi switch flap for upper eyelid defects.

BACKGROUND: The technique chosen to reconstruct anterior lamellar defects of the upper eyelid requires careful consideration. We modified pre-existing techniques used to reconstruct anterior lamellar defects after tumour resection and have called this procedure a hemi-orbicularis oculi switch flap. METHODS: This musculocutaneous flap is elevated with underlying orbicularis and its base abuts the anterior lamellar defect. The flap, which is half the height of the defect, is elevated and inset to cover the defect. Then, taking into consideration the extensibility of upper eyelid skin, the remainder of the defect and the donor site are closed directly. RESULTS: Five patients with basal cell carcinoma, haemangioma, and xanthoma of the upper eyelid were treated by this method. All flaps survived and complications were minimal. Aesthetically and functionally good results were obtained by this method. CONCLUSIONS: We have developed a surgical method for the reconstruction of anterior lamellar defects of the upper eyelid. The proposed method is technically simple and safe and provides consistent results for a potentially wide variety of upper eyelid tumours.

Recovery course of full-thickness skin defects with exposed bone: an evaluation by a quantitative examination of new blood vessels.

BACKGROUND: Full-thickness skin defects with exposed bone are often hard to heal. The lack or delayed re-vascularization is considered one of the major causes, and the periosteum is also suggested to have an important role in tissue regeneration. MATERIALS AND METHODS: Full-thickness skin defect wounds with exposed bone were made in the parietal region of Wister rats. The periosteum of the exposed parietal bone was removed in the periosteum-lacking group, but maintained in the control group (periosteum-intact group). The wound was covered by an artificial dermis made of collagen. The wound healing process was histologically compared. Double immunostaining of alpha-smooth muscle actin (SMA) and von Willebrand factor (vWF) was used for re-vascularization examination, and the blood vessel density in the artificial dermis was quantified. RESULTS: The density of the blood vessels in the uninjured parietal tissue was approximately 80 vessels/mm(2). To reach this density, 7 and 21 days were required for the control (periosteum-intact) and the periosteum-lacking groups, respectively. This coincided with complete revascularization, fibroblast migration and the reentry of blood vessels to the upper layer of the wound were observed. CONCLUSION: The described results support the importance of the periosteum in the full-thickness skin defect healing process.

Bilateral modified V-Y advancement flaps for closing meningomyelocele defects.

Various reports describe surgical techniques for closing a meningomyelocele defect. We have used a combination flap consisting of a vertical bipedicled flap and V-Y advancement flap and used this technique in the successful repair of 11 meningomyelocele defects. The vertical bipedicled flap enhances the blood supply to the V-Y advancement flap with no sacrifice of muscle tissue. This flap can easily be moved to the midline, and the donor area can be primarily sutured with no complications. Our method has several advantages compared with previously reported methods: 1) no skin grafts are needed; 2) no muscle tissue is killed; 3) it is simple and easy, leading to less blood loss and minimal operative time; and 4) it is safe and produces reliable results while eliminating wound dehiscence and skin necrosis.

Mandibular fractures treated with maxillomandibular fixation screws (MMFS method).

The purpose of the treatment of mandibular fractures is to restore proper dental occlusion and stable temporomandibular joint movement, as well as the reduction of the displaced fracture. Consideration must be given to the selection of the most appropriate surgical and rehabilitation methods in such patients. Typical surgical methods for the treatment of mandibular fractures include the arch bar method or plating at the location of the fracture combined with fixing the mandible to the maxilla using the arch bar method. However arch bars and circumdental wires, which require teeth for fixation, damage teeth and periodontal tissue, and tend to be uncomfortable for patients during the fixation period. Moreover, daily maintenance of oral hygiene is difficult for patients with an arch bar. Surgeons are also exposed to the risk of blood-transmitted diseases through skin punctures by wires when affixing these devices. For these reasons, we chose to study the potential of the MMFS method, which is thought to lessen all of the following problems: tissue damage, operating time, patient discomfort, and possible exposure to percutaneous infectious disease due to puncture of gloves and skin by the wires. We demonstrated the utility of the MMFS method in the present study.

A New Surgical Technique for Polysyndactyly of the Toes without Skin Graft.

Reconstruction for polysyndactyly of the toes aims at cosmetic improvement. A previous method that uses a skin graft has inherent disadvantages of mismatched pigmentation between the graft and the surrounding skin and scar formation at the donor site. The authors' new improved surgical technique for the treatment of polysyndactyly of the toes does not require a skin graft and therefore avoids these problems. The authors designed a subcutaneous flap from the distal portion of a rectangular flap of skin from the dorsal side of the interdigital webbing and moved the former flap to the sidewall of the base of a toe. Both flaps are the same size; therefore, an interdigital space had to be of sufficient size to accommodate both of them. To ensure an adequate blood supply to the flap, careful handling of the subcutaneous flap is essential for success. This procedure can apply to polysyndactyly of the fourth, fifth, and sixth toes when the fourth and fifth toes adhere over the distal side of the distal interphalangeal joint and when the skin on the dorsal side of the fifth toe, regarded as the excessive one, is at lease twice the size of the dorsal rectangular flap. Ten patients with polysyndactyly of the toe were treated with this method. Aesthetically good results were obtained.

Treatment of unilateral lambdoid synostosis with cranial distraction.

The accurate diagnosis and treatment of posterior plagiocephaly have been a source of controversy. The unilateral lambdoid synostosis that is characterized by flattening of ipsilateral occipital bone is a rare type of craniosynostosis. An 8-month-old infant with unilateral lambdoid synostosis is reported. The patient exhibited right occipital flattening, mastoid bulge, and right frontal bone prominence, with the right auricle displaced anteroinferiorly on gross examination. A Towne projection radiograph of the skull and three-dimensional computed tomography scans revealed that the right lambdoid suture was prematurely fused. Correction of the cranial shape was performed using distraction osteogenesis combined with a barrel stave osteotomy. Significant improvement in the skull was observed 1 year after surgery.

Collateral sprouting occurs following end-to-side neurorrhaphy.

Recent evidence supports the use of end-to-side neurorrhaphy for the treatment of certain peripheral nerve disorders. However, the mechanism by which nerves regenerate following this procedure is still unclear. To address this question, the authors designed a new end-to-side coaptation model in rats in which the donor nerves were uninjured. The regenerated axons at the coaptation site were observed directly using fluorescent dye as the neural tracer. The sciatic nerve from adult Wistar rats was transplanted between the left and right median nerves. Fifteen rats were divided into three groups. In group I, the donor (right median) nerve was sutured end to side to the divided grafted nerve using a noninjury technique. In group II, the aponeurosis of the spinal muscles was harvested and the sciatic and right median nerves were coapted end to side noninjuriously by wrapping them in the excised aponeurosis. In group III, a perineurial window was created and a partial neurectomy was carried out at the suture site, after which the sciatic and right median nerves were sutured end to side. Sixty days after the operation, nerve regeneration was evaluated by recording action potentials in the grafted nerve, by performing electromyography in the flexor muscles in the forearm, and by histological examination. The grafted nerves were fixed and sectioned, the number of regenerated nerve fibers was counted, and axonal diameters were measured. Fluorescent dye crystal was used, in conjunction with confocal microscopy, to observe the regenerated axons at the co-aptation site. The results showed that nerve regeneration had occurred in the animals, as determined electrophysiologically and histologically. Both the right and left flexor muscles of the forearm contracted simultaneously as a result of indirect electric stimulation of the grafted nerve, which suggests that the regenerated nerve was physiologically connected with the donor nerve. Nerve fiber counts did not show any differences among groups (p > 0.05), but axonal diameters were significantly greater in group III than in the other two groups. Fluorescent dye staining revealed the presence of regenerated nerve fibers beyond the coaptation site. In group III, the regenerating nerves were observed within the whole section of the coaptation site and collateral sprouting was found to occur even at a site distal to the suture. From these results, the authors conclude that in end-to-side neurorrhaphy, nerve regeneration occurs by collateral sprouting from the donor nerve.

Huge lymphangioma of the tongue: a case report.

Lymphangioma of the tongue is relatively rare and may cause facial structural deformity. Using a combination of a V-shaped and central resection, we successfully treated a 6-year-old girl who had massive lymphangioma of the tongue. Postoperatively, her tongue was located completely within her mouth with good cosmetic results. Sensory and motor nerves to the tongue appeared to be intact. Her speech was also improved.

Surgical treatment of aplasia cutis congenita of the scalp associated with bilateral coronal synostosis.

Aplasia cutis congenita is a rare condition characterized by the congenital absence of skin. The authors report a case of aplasia cutis congenita of the scalp associated with bilateral coronal synostosis. Simultaneous fronto-orbital advancement and skull reconstruction for large defect at the fontanelle were performed in the initial operation. A tissue expander made it possible to resect most of the hairless scar and totally cover the reconstructed defect and skull. During the second stage, the residual hairless scar was completely covered with hair-bearing scalp by tissue expansion and the residual skull defects were successfully reconstructed with split calvarial bone grafting.

Versatility of scanning laser Doppler imaging to detect cutaneous perforators.

Several perforator-based flaps have been developed recently and, although preoperative evaluation of perforator vessels is important, the conventional method using the Doppler flowmeter is still being used. The authors tried to identify perforator vessels in the abdominal region using scanning laser Doppler imaging and then compared the results with those obtained using an ultrasonic Doppler flowmeter in 10 healthy volunteers. The scanning laser Doppler detected several perforator vessels (range, 2-5 vessels; mean, 3.1 vessels) within a 7.5 x 7.5-cm area in the abdominal region. These results suggest that scanning laser Doppler imaging is a useful tool in the identification of perforator vessels.