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Eyelid malignancies are often resected in the entire layer, typically requiring anterior and posterior lamellae reconstruction. Posterior lamella reconstruction has been reported using grafts from the nasal septum, palatal mucosa, and auricular cartilage, which have advantages and disadvantages. The authors performed anterior and posterior lamellar reconstruction using a local skin flap and stripe-shaped anti-helical cartilage with the perichondrium in 3 total defect cases after basal cell carcinoma resection of the lower eyelid. The auricular cartilage was excised in strips with the surrounding perichondrium attached and simultaneously reconstructed, with the auricular cartilage as the tarsal and the perichondrium as the conjunctival substitute. In all 3 cases, good results were obtained without eyelid ectropion or corneal irritation 1 year postoperatively. No auricular deformities were observed. However, partial lower eyelid ptosis was observed in 2 cases. In future cases, correctively over-fixating the lower eyelid morphology is necessary., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

A challenging aspect of Le Fort I osteotomy is bleeding control. Osteotomy techniques, devices, drugs, and anesthetic management have been reported to reduce bleeding; however, there are no reports on the use of hemostatic agents. We aimed to evaluate the hemostatic efficacy of a new topical absorbent hemostatic agent, Surgicel Powder, consisting of oxidized regenerated cellulose (ORC). We reviewed the records of 40 patients who underwent Le Fort I surgery for jaw deformities, with or without cleft lip and palate. Twenty of the 40 patients did not have cleft lips or cleft palates (CLCP); the remaining 20 had CLCP. In each group, an absorbent hemostatic agent was used in 10 patients but not in the other 10. Total blood loss and operative time for each group were evaluated. In the jaw deformity without CLCP group, the amount of bleeding with or without ORC was 112.0±33.8 and 158.6±75.3 mL, respectively, with a significant difference between groups ( P <0.05). Operative time with or without ORC was 206.4±31.3 and 238.3±42.5 minutes, respectively, with a significant difference observed between groups ( P <0.05). In the jaw deformity with CLCP group, the amount of bleeding with or without ORC was 199.7±64.6 and 476.8±104.8 mL, respectively, with a significant difference between groups ( P <0.05). Operative time with or without ORC was 213.7±27.6 and 220.8±41.5 minutes, respectively, with no significant difference between groups ( P =0.329). In conclusion, oxidized regenerated cellulose powder may be a beneficial hemostatic agent for reducing blood loss during Le Fort I osteotomy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

In defect reconstruction after maxillary tumor resection, filling the dead space created by resection and reconstruction of surrounding areas are crucial for good cosmetic outcomes. Although various procedures have been described in the literature, most are complex and require advanced surgical skills. Therefore, in this study, the authors aimed to identify a simple procedure for successful reconstruction with minimal bone fixation. Three patients who underwent total maxillectomy and reconstruction using the rib-attached free latissimus dorsi flap at Keio University Hospital between 2012 and 2014 were included and followed up with for a minimum of 5 years. After total maxillectomy, the authors used a free latissimus dorsi flap with a portion of the rib to fill the dead space and reconstructed the orbit, nasal cavity, and oral cavity.The authors performed a rigid reconstruction of the zygomatic ridge using only 2-point plate fixations of the ribs at the outer orbit and anterior nasal spine. Patients were followed up for ≥5 years, and the flap successfully survived in all cases. There was an issue with rib fixation in 1 case; however, all patients were highly satisfied with the procedure's cosmetic results., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: In orthognathic surgery, it is well known that maxillary osteotomies and displacements sometimes affect auditory function. Thus, this study examined the relationship between the direction of maxillary displacement and postoperative otalgia., Methods: Twenty consecutive patients underwent Le Fort I maxillary osteotomy using advancement, impaction, setback, or a combination of these procedures. The direction of movement and incidence of otalgia were investigated. Patients provided informed consent preoperatively, and postoperative reassurance was prudent., Results: Pure-tone average evaluation based on horizontal or vertical movements did not show significant differences, although vertical movements resulted in fewer changes in the hearing threshold. Specifically, no significant changes were observed in the hearing thresholds of patients after surgery. No significant difference was also observed between horizontal and vertical movements in the tympanometry results. Negative changes were found in the results of the Eustachian tube dysfunction test in vertical movements, which returned to preoperative values in the final test., Conclusions: The risk of minor changes in hearing function is probable during the first week after orthognathic surgery; however, these negative changes either completely disappear or remain negligible., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

The effects of operative intervention on vertical nasal growth in patients with unilateral cleft lips (CLs) are well described. However, the factors influencing nasal symmetry have not been sufficiently evaluated. Therefore, this study aimed to study the factors that cause difficulties in obtaining nasal symmetry postoperatively in patients with CLs. We conducted a retrospective analysis using data from patients with CLs who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on the patients' sex, cleft type, number and time of revision surgery, palatal fistula incidence, and history of the pharyngeal flap and orthognathic surgery. Nasal symmetry was analyzed as the symmetrical ratio after the final touch-up surgery, and multivariate analysis was conducted using binary logistic regression to determine the factors affecting nasal symmetry. This study included 89 patients with unilateral CL. Multivariate analysis revealed that complete cleft lip and palate ( P < 0.05, odds ratio = 4.37) and repeated revision surgery ( P < 0.05, odds ratio = 9.28) were significant predictors of the final nasal symmetry. Our study showed that cleft type and the number of revision surgeries were identified as important factors for obtaining nasal symmetry after final touch-up rhinoplasty. Revision surgery may be necessary to relieve patients' psychological stress due to nasal deformity, suggesting that this dilemma needs to be overcome., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Although patients with cleft lip and palate often present with poor maxillary growth because of intrinsic and iatrogenic factors, the surgical influence of lip revision surgery, palatal fistula repair, and pharyngeal flap procedures remains uncertain in contrast to that of primary cleft lip repair and palatoplasty. Therefore, this study aimed to reveal factors inhibiting maxillary growth and inducing later orthognathic surgery. A retrospective analysis was conducted on the data of patients with cleft lip and palate who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on patient sex, cleft type, number and timing of lip revision surgery, the incidence of palatal fistulae, history of pharyngeal flap procedures, and timing of a repeat bone graft, and reviewed whether these patients underwent orthognathic surgery later in life. Multivariate analysis was conducted using binary logistic regression to extract factors affecting later orthognathic surgery. A total of 52 patients were included in this study. Results showed that revision surgery conducted more than twice was the highest statistically significant predictor of later orthognathic surgery in patients with a cleft lip and palate ( P <0.05, odds ratio=43.3), followed by palatal fistula occurrence after cleft palate repair ( P <0.05, odds ratio=22.3). Therefore, primary surgical procedure is most important for these patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Cryptotia is a relatively common auricular congenital anomaly in Asia. Nonsurgical molding is easy in infancy. However, surgical correction is often necessary after infancy. The authors report a case of cryptotia in which intraoperative tissue expansion and superior auricular muscle transfer were performed through a small incision at the hairline with good results. The patient is a 7-year-old girl. Three years after the operation, successful results were obtained. This method is advantageous as the procedure is simple, risk of relapse can be reduced by also treating the auricular muscle, and scarring is relatively inconspicuous. In addition, it is possible to switch to another technique when the improvement is poor., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Several stent expansion criteria derived from the intravascular ultrasound (IVUS) evaluation have been proposed to predict future clinical outcomes, but optimal stent expansion criteria as a guide during percutaneous coronary intervention (PCI) are still controversial. There are no studies evaluating the utility of stent expansion criteria along with the clinical and procedural factors in predicting target lesion revascularization (TLR) after contemporary IVUS-guided PCI., Methods: OPTIVUS-Complex PCI study (Optimal Intravascular Ultrasound Guided Complex Percutaneous Coronary Intervention) multivessel cohort was a prospective multicenter study enrolling 961 patients undergoing multivessel PCI including left anterior descending coronary artery using IVUS with an intention to meet the prespecified criteria for optimal stent expansion. We compared several stent expansion criteria (minimum stent area [MSA], MSA/distal or average reference lumen area, MSA/distal or average reference vessel area, OPTIVUS criteria, IVUS-XPL [Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions] criteria, ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in "All-Comers" Coronary Lesions] criteria, and modified MUSIC [Multicenter Ultrasound Stenting in Coronaries Study] criteria) as well as clinical, angiographic, and procedural characteristics between lesions with and without TLR., Results: Among 1957 lesions, the cumulative 1-year incidence of lesion-based TLR was 1.6% (30 lesions). Hemodialysis, treatment of proximal left anterior descending coronary artery lesions, calcified lesions, small proximal reference lumen area, and small MSA had univariate associations with TLR, while all of the stent expansion criteria except for MSA were not associated with TLR. The independent risk factors of TLR were calcified lesions (hazard ratio, 2.34 [95% CI, 1.03-5.32]; P =0.04) and small proximal reference lumen area (Tertile 1: hazard ratio, 7.01 [95% CI, 1.45-33.93]; P =0.02; and Tertile 2: hazard ratio, 5.40 [95% CI, 1.17-24.90]; P =0.03)., Conclusions: In contemporary IVUS-guided PCI practice, the 1-year incidence of TLR was very low. MSA, but not other stent expansion criteria, had univariate association with TLR. Independent risk factors of TLR were calcified lesions and small proximal reference lumen area, although the findings should be interpreted with caution due to small number of TLR events, limited lesion complexity, and short duration of follow-up., Competing Interests: Disclosures Dr Morimoto reports lecturer’s fees from AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Japan Lifeline, Kowa, Toray, and Tsumura; article fees from Bristol-Myers Squibb and Kowa; advisory board for Novartis and Teijin. Dr Tanabe reports honoraria from Abbott Medical, Boston Scientific, Japan Lifeline, Medtronic, Orbusneich, and Terumo. Dr Kimura reports research grant from Abbott Medical and Boston Scientific; honoraria from Abbott Medical, Boston Scientific, Daiichi Sankyo, Sanofi, and Terumo; participation on advisory board from Abbott Medical, Boston Scientific, and Sanofi. The other authors report no conflicts.

Monobloc advancement by distraction osteogenesis is the treatment of choice in patients with syndromic craniosynostosis. This procedure is usually performed at 18 to 24 months/5 to 10 years of age. Herein, we present the case of a male patient with Crouzon syndrome who underwent monobloc advancement at the age of 62 years. Although the patient lived a normal life (employed, married, and being a father of a daughter), he visited our hospital for surgical improvement in facial esthetics. The patient underwent monobloc advancement by distraction osteogenesis. He was satisfied with the postoperative esthetic improvement and did not experience any major complications. This case highlights the fact that patients with syndromic craniosynostosis desire esthetic improvement and suggests that multidisciplinary treatment involving both the neuro and plastic surgeons is important in such cases., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Bioabsorbable systems have been commonly used in pediatric patients for primary cranioplasty and other related surgeries. However, subcutaneous swelling, a unique complication related to bioabsorbable osteosynthesis, is a concern. Differences in the incidence of subcutaneous swelling, depending on the bioabsorbable material used to construct the plate, are still unknown., Methods: The authors retrospectively reviewed all incidences of subcutaneous swelling related to resorbable systems used during primary cranioplasty for patients with craniosynostosis at their hospital between 2014 and 2018 during a 12-month follow-up period. Furthermore, the authors reviewed all published English-language articles (since 1995) on subcutaneous swelling in bioabsorbable systems used for craniosynostosis., Results: The most common resorbable systems used in the literature were divided into 2 groups: mixtures of poly D-lactic acid and polyglycolic acid, and mixtures of poly D- and L-lactic acid. In patients for whom poly D-lactic acid and polyglycolic acid were used, the incidence of subcutaneous swelling during resorption was 0% to 4.2% between 3 and 9 months of follow-up. In patients for whom poly D- and L-lactic acid was used, subcutaneous swelling during resorption occurred in 5% to 16.7% of these patients between 6 and 12 months of follow-up. All cases resolved spontaneously after complete absorption of the plate., Conclusions: It was difficult to determine which system had the lowest incidence of subcutaneous swelling. The thickness of each resorbable system and the thickness of the infants' scalps were different in each study. However, subcutaneous swelling occurred in every resorbable system. Therefore, preoperative counseling and careful follow-up are necessary., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Abstract: Bilambdoid and sagittal synostosis (BLSS), a rare form of multisutural craniosynostosis, is sometimes known as the Mercedes-Benz syndrome due to the appearance of the fused sagittal and bilateral lambdoid sutures. Although previous studies have described some of its clinical features, the pathology of this disease is not yet fully understood. Moreover, it has been pointed out that BLSS is more common among individuals of Hispanic ethnicity, but its incidence in Asia remains unclear. In the present study, BLSS cases in Japan were analyzed to determine the characteristics of the condition in Japan. Three hospitals in Tokyo participated in the present study. Patients with BLSS who underwent cranial remodeling were included. Data on patient demographics, clinical symptoms, status of the cranial sutures, morphological subclassification, surgical procedures, developmental status, and genetic mutations were analyzed. In total, 22 patients met the enrollment criteria and were included, indicating a higher incidence of BLSS in Japan than in other nations reported in previous studies. In terms of morphological subclassification, there were 15 brachycephalic, 4 dolichocephalic, and 3 normocephalic. For the initial cranial procedure, 7 patients underwent a single-stage cranioplasty, 13 underwent a posterior distraction, and 2 underwent lateral expansion. Patients with a normocephalic cranial morphology tended to undergo surgery at an older age than patients with the other two types. Appropriate timing for surgery is important for healthy development; hence, surgeons should remember that BLSS can lead to "balanced dysmorphism" that may have led to a delay in diagnosis due to its normal-looking morphology., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Purpose: Recently, midfacial hypoplasia for syndromic craniosynostosi has been corrected by Le Fort III distraction osteogenesis. During conventional Le Fort III osteotomy, osteotomy is performed via bicoronal incision. In contrast, the authors have developed a technique for performing Le Fort III osteotomy using internal devices but without bicoronal incision., Patients and Methods: The authors performed the Le Fort III distraction technique in 22 patients. Of these, 17 patients underwent an approach using conventional coronal incision; the others underwent an approach without coronal incision. This new approach was performed using a McCord incision, a brow incision, and gingivo-buccal sulcus incisions. We then performed osteotomy and attached the internal device., Results: The age of patients ranged from 6 to 21 years (mean: 14.1 ± 5.0 years) and 6 to 38 years (mean: 19.6 ± 11.5 years) in the groups with or without coronal incision, respectively. Mean operative time was 410 ± 196 minutes in the group with coronal incision and 357 ± 121 minutes in the group without coronal incision. Mean blood loss (per unit of body weight) was 51.3 ± 38.5 and 33.9 ± 9.9 ml/kg) in the groups with or without coronal incision, respectively. There were no complications, except in the case of a 38-year-old patient, the oldest patient, who lost vision in the left eye after surgery., Conclusion: A direct facial approach for Le Fort III distraction was useful because of its reduced operative time and blood loss. However, down fracture following incomplete osteotomy or inadequate dissection of the orbit may cause blindness. Consequently, this technique requires careful attention.

Sagittal craniosynostosis is the most common of all craniosynostoses. Patients with sagittal craniosynostosis exhibit a typical cranial appearance, including scaphocephaly, and an elongated head, with a fused and ridged sagittal suture. Moreover, some recent reports described atypical sagittal craniosynostosis accompanied by autism, speech delay, and hyperactivity. This condition, known as delayed-onset craniosynostosis, is rarely reported, given that it is difficult to determine if the condition is congenital or has a delayed-onset.This report describes the clinical course and treatment of 2 brothers with atypical sagittal synostosis. The shapes of their heads were not indicative of scaphocephaly and the younger brother exhibited delayed-onset sagittal synostosis. Their father and paternal grandmother exhibited similar cranial morphologies. Therefore, we hypothesized the involvement of a familial factor in the etiology of atypical sagittal synostosis in these patients.

Purpose: Posterior calvarial vault expansion using distraction osteogenesis is performed for syndromic craniosynostosis as the first choice. This procedure allows far greater intracranial volume than fronto-orbital advancement (FOA). This study aimed to determine the most suitable timing of posterior distraction or FOA to sufficiently increase the intracranial volume and remodel the skull shape., Patients and Methods: From 2014 to 2017, the authors performed posterior distraction in 13 patients with syndromic craniosynostosis. Data on premature suture fusion, age at first visit, age at surgery, skull thickness, and complications were collected., Results: Five patients underwent posterior distraction at approximately 12 months of age and had no complications, including cerebrospinal fluid leakage or gull wing deformity. However, during the waiting period for the operation, the skull deformity continues to extend upward (turribrachycephaly). To prevent progress of the skull deformity, the authors performed the operation at approximately 6 months of age in 7 patients. However, in 3 of 7 patients whose lambdoid sutures were opening, gull wing deformity occurred. From these results, in a patient with severe Beare-Stevenson syndrome, the authors performed FOA first at 5 months of age, followed by posterior distraction at 12 months of age, and achieved favorable results., Conclusions: Treatment patterns are patient specific and should be tailored to premature suture fusion, specific skull deformity, and required intracranial volume of each patient.

Hydroxyapatite and poly-L-lactide plates are often used for maxillofacial surgery. These plates take 3 to 4 years to resorb completely, leading to the possibility of a foreign-body reaction. A 20-year-old woman who developed a foreign-body reaction to the plates was reported. Based on review of the relevant literature, foreign-body reactions have often been reported with this plate. Long-term follow-up is warranted to evaluate patients using this plate in maxillofacial surgery.

Purpose: To evaluate the utility and efficacy of bioabsorbable hydroxyapatite and collagen complex (HA/Col) for cranioplasty repair of cranial bone defects in children., Methods: Two patients (a 6-year-old male and 11-year-old female) with Treacher Collins syndrome received zygoma and orbital floor reconstruction using a full thickness of parietal bone. The bone grafts were taken from each patient's parietal cranium. The right parietal cranial defect was repaired with autologous bone dust, and the left side was repaired with HA/Col in each patient. Computed tomography scans were taken immediately after and at 12 months following surgery. The osteosynthesis areas and thicknesses were measured using computer-aided engineering., Results: Both patients experienced no complications, including infection. In the 6- and 11-year-old patients, the extent of osteosynthesis for HA/Col was 92.2% and 89.4%, respectively; and for the autologous bone dust was 78.5% and 53.2%, respectively. Because of the small sample size, a significant difference could not be calculated; however, the percentage of osteosynthesis for HA/Col was higher than for the autologous bone dust., Conclusion: This study showed that HA/Col can be effectively used in cranial defects and can be considered an alternative graft material for cranial reconstruction.

Background: The management of fronto-orbital fibrous dysplasia involves total excision of the dysplastic bone and bone reconstruction using implants. Custom-made implants are used to achieve good contouring. However, the remnant defect after excising the lesion often does not match the implant., Methods: To design the craniotomy line, a template was prepared by preoperative computed surgical simulation. The template was overlaid on the preoperative cranium, such that its inner surface fits exactly with the cranial surface. After excising the lesion by performing osteotomy, the implant was placed in the defect and fixed. Both template and implant were made of hydroxyapatite., Results: The authors treated 4 patients, with fibrous dysplasia involving the fronto-facial region by using the template. Intraoperative trimming of the implant or bone defect was not required in 2 patients, while the third patient required mild trimming. They did not have any complications and obtained good contouring., Conclusion: The hydroxyapatite templates reduced the surgical time by determining the precise craniotomy line preoperatively, thus avoiding needless trimming of the implant and bone defect. Therefore, they can enhance the efficacy of treatment for fronto-orbital fibrous dysplasia lesion.

Aim: The aim of this study was to evaluate the clinical outcomes of single-port surgery for colon cancer in octogenarians., Materials and Methods: A retrospective cohort study was performed on patients who underwent single-port surgery for colon cancer from 2010 to 2014 at a single institution. Patients were categorized into the following 3 groups according to age: ≤69 years (n=196), 70 to 79 years (n=143), and ≥80 years (n=86). Short-term and long-term outcomes were assessed among 3 groups., Results: The rate of overall postoperative complications in the octogenarian group did not differ significantly, compared with the other groups (20.9% in the octogenarians group vs. 14.3% in the ≤69 y group and 15.4% in the 70 to 79 y group, P=0.363). The 3-year relapse-free survival rates were similar among groups (83.9% in the octogenarians group vs. 87.8% in the ≤69 y group and 87.5% in the 70 to 79 y group, P=0.754). The 5-year overall survival rates were 79.8% in the octogenarians group, 89.9% in the ≤69 years group, and 81.7% in the 70 to 79 years group (P=0.063)., Conclusion: Single-port surgery is safe, feasible, and can provide satisfactory oncological outcomes in octogenarians with colon cancer.

Postoperative radiation can cause ulcer formation, leading to the denudation of skin over alloplastic materials. The influence of backscatter radiation from fixation devices has not been investigated. The aim of this study is to evaluate backscatter dose variations for different cranial bone fixation devices in an experimental model designed to simulate postoperative radiotherapy. The authors assessed the radiation backscatter doses associated with resorbable (PLLA-PGA) and titanium plates. The samples were irradiated with 6 and 10 MV photon beams from a linear accelerator. Measurements were obtained using an ionization chamber and radiochromic films cut from the same batch. As a result, the backscatter radiation of water and PLLA-PGA proportionally decreased as the depth increased. However, the backscatter radiation of the titanium plate increased just above the plate. This depth lies in the region of the scalp. Each material showed a dose of radioactivity that was higher at 10 MV than that at 6 MV. These devices showed a significant difference, which suggested that these materials amplified the dose compared with water at 6 MV. In conclusion, it is supposed that PLLA-PGA should be used to fix the cranium to decrease the potential for radiation ulcers.

Transcranial vertical orbital translocation is useful for correcting vertical orbital dysplasia. However, the technique is limited by the degree of uncertainty regarding the amount of vertical movement required after the osteotomy. As for landmark movement, Z osteotomy is performed as part of a box osteotomy. This technique is useful in that it is easy to know how far the orbit should be moved, and stabilization can be obtained.

Osteomas are slow-growing, benign bony tumors. Most are asymptomatic. Paranasal sinus osteoma in the pediatric population is rare; hence, there are few reports of symptomatic osteomas. The authors report the case of a giant ethmoid sinus osteoma in an 11-year-old girl who presented with diplopia and proptosis. Total excision and reconstruction of the medial orbital wall were performed via a coronal approach. The postoperative period was uneventful, the child's vision improved, and a good cosmetic result was obtained.

Synthetic hydroxyapatite (HAP) implants are common in craniofacial surgery; the major problem with HAP implants is fixation instability. An ultrasound-assisted pinned resorbable fixation system has recently been introduced. The authors hypothesized that this resorbable system could be used to fix HAP implants. The authors evaluated the optimal HAP porosity and resorbable pin using the pull-out test and microscopic analysis. Hydroxyapatite blocks were synthesized with 0% (dense type), 35% (fine pore type), and 50% (large pore type) porosity. Bioabsorbable pins of 4 sizes were tested: diameters of 1.6 or 2.1 mm and lengths of 4 or 7 mm. Among the 1.6 mm diameter pins, the 7-mm length pins showed higher pull-out strength (large pore, 6.5 ± 1.2 kgf; fine pore, 4.1 ± 0.7 kgf; dense, 2.4 ± 0.4 kgf) than the 4-mm length pins (large pore, 2.1 ± 1.0 kgf; fine pore, 1.3 ± 0.4 kgf; dense, 1.5 ± 0.9 kgf) with all 3 HAP types (P < 0.01). Among 2.1-mm diameter pins, all were removed from the large and fine pore HAP types without any resistance. Only three of seven 2.1 × 7 mm pins inserted into the dense type HAP showed pull-out strength (3.9 ± 2.1 kgf). Among all conditions, the 7-mm length, 1.6-mm diameter pin in large pore type HAP showed the highest pull-out strength. Microscopically, the large pore type HAP showed the liquefying pin flowing into the large pore adjacent to the pilot hole. By contrast, the fine pore and dense pore types of HAP did not allow flow, and the pins did not change in structure 3-dimensionally. The authors found that pull-out strength depends on HAP porosity, and pin length and diameter.

The purpose of this study was to evaluate the effectiveness of platelet-rich plasma (PRP) on the absorption of the bone graft in the alveolar cleft.Twenty-nine patients with alveolar clefts in unilateral cleft lip were examined; 6 were the control group and received iliac cancellous bone and marrow grafts without PRP, while the remaining 23 comprised the PRP group and received grafts with PRP. Quantitative evaluation of remaining bone was made by the computer-aided engineering with multidetector row computed tomography at 1 month and 1 year after surgery.Satisfactory bone bridging formation was observed in all patients. Two patients in control group and 1 patient in PRP group developed wound dehiscence with minor bone exposure. One year postoperatively, the canine was exposed and orthodontically guided into an ideal arch relation in all patients. The mean resorption ratio was 49.9 ± 17.2% and 44.9 ± 14.4% with no significant difference (P = 0.60).In conclusion, there is currently no evidence to suggest that autologous PRP is of value for effect on the bone resorption for alveolar bone graft.

Background: Simultaneous tumor resection and cranioplasty with hydroxyapatite osteosynthesis are sometimes necessary in patients of skull neoplasms or skull-invasive tumors. However, the disadvantage of simultaneous surgery is that mismatches often occur between the skull defect and the hydroxyapatite implant. To solve this problem, the authors developed a customized template for designing the craniotomy line., Methods: Before each operation, the craniotomy design was discussed with a neurosurgeon. Based on the discussion, 2 hydroxyapatite implants were customized for each patient on the basis of models prepared using computed tomography data. The first implant was an onlay template for the preoperative cranium, which was customized for designing the osteotomy line. The other implant was used for the skull defect. Using the template, the osteotomy line was drawn along the template edge, osteotomy was performed along this line, and the implant was placed in the skull defect., Results: This technique was performed in 3 patients. No implant or defect trimming was required in any patient, good cosmetic outcomes were noted in all patients, and no complications occurred., Conclusion: Use of predesigned hydroxyapatite templates for craniotomy during simultaneous skull tumor resection and cranioplasty has some clinical advantages: the precise craniotomy line can be designed, the implant and skull defect fit better and show effective osteoconduction, trimming of the implant or defect is minimized, and the operation time is shortened.

Background: Posterior cranial vault distraction osteogenesis is a common treatment for syndromal patients of brachycephaly and oxycephaly. Although posterior distraction can increase intracranial volume, the flattened head phenotype is difficult to correct. The authors examined a new posterior distraction technique termed double-door distraction for improvement of the flattened head phenotype., Methods: From 2010 to 2013, 6 patients with flattened posterior craniums were operated on using the double-door distraction technique. The calvarial segment was cut at the midline and divided into 2 pieces. Distractors were then fixed in parallel to join the calvarial pieces. The distraction was initiated at a rate of 1.0 mm/day and continued until proper cranial form was confirmed by radiography and appearance., Results: The average surgery time was 2 hours 47 minutes and the amount of distraction ranged from 15 to 22 mm. An improved head shape and expanded cranial vault was achieved in all patients without any complications., Conclusions: The double-door distraction technique is a useful technique not only for calvarial expansion, but also for correction of the flattened posterior cranium phenotype.

The causes of idiopathic exophthalmos were still unknown. We used computed tomography to compare the orbital structures of patients with idiopathic exophthalmos and those of a healthy Japanese population. A total of 18 orbits (ranged 17-52 years) in idiopathic exophthalmos and 334 normal orbits (ranged 17-59 years) were included. On computed tomography, the eyeball and orbit sizes, lateral wall thickness and length, perpendicular distance from the interzygomatic line to the medial orbital rim, and the nasal cavity width were measured. No significant differences in eyeball or orbit sizes were found between the idiopathic exophthalmos and control groups (P > 0.05). In contrast, the mean lateral wall thickness of the idiopathic exophthalmos group was significantly thicker than that of the control group (P < 0.01). The lateral wall length was shorter with significant difference (P < 0.05). The perpendicular distance and the width of the nasal cavity in the idiopathic exophthalmos group were longer with significant difference (P < 0.05). The cause of idiopathic exophthalmos is compression of orbital contents by the medial wall expansion. The force of expansion of medial wall also influences the zygoma according to Wolff law.

Background: Simulated craniomaxillofacial surgery is critical for planning the procedure, shortening operative time, and practicing the procedure. However, typical models are expensive, given their solid materials, and the surgical sensations do not accurately reflect the procedure performed using human bone. To solve these problems, a new solid salt model has been developed., Method: Stereolithography data was generated using computed tomography data, and a salt model was created using a 3D inkjet printer. By extracting specific data for elements such as the teeth and mandibular canal, these elements were highlighted in the solid model using different colored material. Also, we compared the maximum load and plastic deformation of the salt model, a stereolithographic resin model, and a pig limb., Result: The salt model had similar tenacity to bone, and the risk of damage to the teeth and inferior alveolar nerve was easily confirmed., Conclusion: The material cost of the salt model is extremely low, and the salt model may provide a more accurate sensation of cutting human bone. Thus, this model is useful for both simulated operation and practice for inexperienced surgeons.

"Collapsed nasal tip," one of the most characteristic features of cleft lip nose, resembles the effect of pushing the nose tip with a finger and is especially noticeable among Asians. The authors examined a rhinoplasty technique for improving collapsed nasal tip. Using an intercartilaginous incision, the distal nasal framework, including the alar cartilages, and the caudal septum were widely exposed. A septal extension graft was fixed to the caudal septum, and the alar cartilages were precisely sutured to the extension graft using markings transferred to the extension graft. This procedure was applied to 15 Asian rhinoplasties, with all patients having substantial improvement in the shape of their nasal tip. Comparing those with and without a history of rhinoplasty, effecting a projection of the nasal tip was more difficult in patients with a history of previous rhinoplasties. The advantages of this technique include inconspicuous scarring and versatility in the modification of the nasal tip. Rhinoplasty during the growth period should be planned with consideration of future augmentation rhinoplasties.

Some case reports described the usage of bone cement mixed with antibiotics. However, there are few studies that referred to experimental research of calcium phosphate cement with antibiotics. Thus, we mixed vancomycin and amikacin with bone cement in various concentrations and examined its characterization and antibacterial activity. As a result, 6.25 wt% over the concentration could not mix with cement. With an increase in the antibiotic content, the hardening time was prolonged and the compressive strength tended to decrease. In consistency, vancomycin mixed cement increased, whereas amikacin mixed cement decreased. The elution of antibiotics showed sustained release. In conclusion, the characteristics of the bone cement changed based on the amount of antibiotics added, and calcium phosphate cement is useful as a drug carrier.

Cranioplasty using custom-made hydroxyapatite (HAP) ceramic implants is a common procedure for the repair of skull defects. The advantages of using HAP are that it is nonmetallic, unlike titanium; biocompatible; and osteoconductive. Furthermore, it can be molded to any complex shape that may be needed. A disadvantage is that titanium screws and plates are in development for its fixation. We developed a technique for implant fixation using bioabsorbable screws and plates, and named this technique RIVET: resorbable immobilization for vacuolar en bloc technique.Before each operation, the implant was customized for the patient in question on the basis of models prepared using computed tomography data. The bioabsorbable plates were attached to the implant by drilling, tapping, and screwing, as shown in the video (http://links.lww.com/SCS/A43). The interior portion of the screw was then melted to flatten it against the internal surface of the implant, forming a rivet to join the plate and HAP implant.We used this technique for cranial reconstruction in 2 patients, with satisfying and functional results. We did not encounter any complications.In conclusion, the technique described here allows surgeons to fix implants and plates together more rigidly, giving a better result than possible with previous methods.

Objective: The aim of the study was to evaluate the volume of the maxillary sinus in patients with cleft alveolus., Study Design: This is a retrospective, descriptive study., Patients and Methods: The 3-dimensional computed tomographic data of 218 maxillary sinuses of 109 patients with cleft alveolus were compared with those of 100 sinuses of 50 healthy individuals., Results: No significant difference in the maxillary sinus volume was found between the patients with cleft alveolus and the noncleft individuals. In the patients with cleft palate and alveolus, the maxillary sinus volume was significantly larger on the right side, but no significant difference was found between the cleft and noncleft sides., Conclusions: The volume of the maxillary sinus in the patients with cleft alveolus is not different from that of the noncleft individuals. The information about the maxillary sinus is clinically important in executing such operations as endoscopic sinus surgery.

Exposing the alloplastic materials after skull reconstruction is very difficult because of the risk of infection and the choice of reconstruction procedures. Conventional procedures were divided into two-step or multi-step surgery.To perform one-stage surgery, a transverse rectus abdominis myocutaneous flap combined with vascularized costal cartilages has been used for head reconstruction after exposing the alloplastic materials in two patients. This is the first report using the flap for skull reconstruction.In this article, we describe the usefulness and the disadvantages of the transverse rectus abdominis myocutaneous flap combined with vascularized costal cartilages.

The etiology of the clinical entity commonly known as unilateral coronal synostosis is often described as the unilateral fusion of the coronal ring. However, recent theories have poorly explained the basis of the deformities associated with unilateral coronal synostosis. We retrospectively analyzed computed tomographic data sets from 18 patients who presented with unilateral coronal synostosis and arrived at our hospital between 1985 and 2010. Using three-dimensional reconstructions of the computed tomographic images, analyses of the cranial base and measurements of each cranial bone were performed. As a result, the ipsilateral and contralateral basion-clinoid-pterion angles did not differ significantly (P = 0.49) and were almost identical in each case. However, the ipsilateral basion-partis-petrosae angle was wider than the corresponding contralateral angle (P < 0.001). In addition, the ipsilateral nasion-clinoid-pterion angle and the sphenoid, zygomatic, and temporal bones on the ipsilateral side were significantly shorter than those on the contralateral side (P < 0.001). Based on a shortening ratio, the sphenoid bone was smaller (42.0% ± 10.9%) than the temporal (68.9% ± 7.58%) and zygomatic bones (71.1% ± 8.38%). This difference was significant (P < 0.001). In conclusion, restricted growth potential of the central portion of the ipsilateral sphenoid bone was identified. We propose that the coronal ring, which includes the frontoparietal and frontosphenoidal sutures, and the sphenosquamosal suture are involved in unilateral coronal synostosis. Using our findings and the theory of Delashaw et al, the deformity observed in unilateral coronal synostosis can be explained more adequately and/or completely.

Currently, simultaneous maxillomandibular distraction osteogenesis is a standard procedure for the correction of hemifacial microsomia. Many variations of the procedure have been reported. However, a common problem has been the extended duration of the procedure. In particular, the lengthy intermaxillary fixation period includes a prolonged distraction series that requires the restriction of oral food intake and creates significant stress for the patient, which has a profound effect on patient satisfaction. To avoid this stress, we have developed tandem osteotomy with distraction osteogenesis, termed the TODO procedure. The TODO procedure not only shortens the intermaxillary fixation period and the duration of therapy but also creates the ideal skeletal proportions, with horizontalization of the occlusal plane. The TODO procedure has the added benefit of producing a marked aesthetic improvement. The patient was extremely satisfied by the result and endured minimal stress.

Background: To achieve optimal outcomes in reduction malarplasty, the area of zygoma from which volume should be reduced must be accurately identified. This anatomical study aims to evaluate the location of the zygoma region that contributes most to the protrusion of the cheek., Methods: The morphology of the zygoma was studied on 121 Japanese adults (73 men and 48 women). The midpoint of the inferior orbital rim, zygomaticomaxillary junction, the junction between the frontal process and the zygomatic arch, and the lateral orbital rim were marked to be used as anatomical reference points. Then, a vertical plane intersecting the anterior and posterior edges of the zygoma was marked. The point of the zygoma most distant from the plane was defined as the summit of the zygoma. Three-dimensional measurement using graphic software was performed, and the positional relationships between the summit and the four reference points were evaluated., Results: In terms of horizontal position, the summit is located lateral to the lateral orbital rim and medial to the junction between the frontal process and the zygomatic arch. Regarding vertical position, the summit exists at higher positions in men than in women., Conclusions: The summit of the zygoma is located medial to the junction of the frontal process and zygomatic arch. Therefore, bone incision lines should be placed medial to the posterior edge of the frontal process in reduction malarplasty; effective correction of the protrusion cannot be achieved solely by detachment of the zygomatic arch. The summit is located higher for men than for women. Therefore, bone incision lines should be placed higher for men than for women.

Background: Ostial left anterior descending coronary artery (LAD) lesion has been regarded as a lesion subset unsuitable for coronary stenting. Long-term outcomes of sirolimus-eluting stent (SES) implantation for ostial LAD lesions have not been adequately evaluated., Methods and Results: Among 12 824 patients enrolled in the j-Cypher Registry, 3-year outcomes were compared between 481 patients with SES-treated ostial LAD lesions and 5369 patients with SES-treated nonostial proximal LAD lesions. Patients with ostial LAD lesions had similar incidences of target lesion revascularization (TLR) as those with nonostial proximal LAD lesions (9.4% versus 9.7%; P=0.98; adjusted hazard ratio [HR], 0.99; 95% CI, 0.7 to 1.36; P=0.94) and death/myocardial infarction (MI) (10.7% versus 11.4%; P=0.82; adjusted HR, 1.05; 95% CI, 0.76 to 1.4; P=0.77). Among the patients with ostial LAD lesions, those undergoing both main and side branch stenting (n=62) compared to main branch stenting alone (n=419) had a higher risk for TLR (adjusted HR, 4.65; 95% CI, 2.32 to 9.25; P<0.0001) but similar risk for death/MI (adjusted HR, 1.15; 95% CI, 0.49 to 2.41; P=0.73). In patients with main branch stenting alone, outcomes after crossover stenting across the circumflex coronary artery (n=225) were not different from those after ostial stenting (n=194) for TLR (adjusted HR, 0.77; 95% CI, 0.33 to 1.82; P=0.55) and for death/MI (adjusted HR, 1.54; 95% CI, 0.78 to 3.2; P=0.22)., Conclusions: In terms of both safety and efficacy, 3-year outcomes of percutaneous coronary intervention using SES for ostial LAD lesions were comparable to those for nonostial proximal LAD lesions. Crossover stenting with a 1-stent approach might be a reasonable option in treating ostial LAD lesions.

There are no procedures available to reconstruct the normal cranial shape irrespective of the type of cranial deformity with minimal patient stress and morbidity. To achieve dynamic total skull remodeling, we considered a new remodeling concept and developed a new procedure by combining morcellation craniotomy and distraction osteogenesis, termed the MoD procedure, and designed a distraction device, namely the angle variable distraction (AVD) system. Between 2000 and 2009, we treated 41 patients with craniosynostosis (28 and 13 cases of isolated and syndromic craniosynostosis, respectively) by using the MoD procedure with the AVD system. Compared with the conventional methods, the mean operative time was significantly shorter, and the mean transfusion volume was significantly less for the MoD procedure. In all the patients, good cranial shape and adequate cranial volume were achieved without serious complications. In conclusion, the MoD procedure with the AVD system is safe, effective, and reliable for dynamic total skull remodeling with minimal morbidity. It could be used to improve the previous surgical concepts for treating craniosynostosis.

This report describes a pitfall of reconstruction for severe enophthalmos after time has passed following traumatic injury. In severe cases, hypoglobus may be refractory to reconstructive surgery. The posterior wall of the maxillary sinus is sometimes implicated in severe enophthalmos. Thus, we considered that reconstruction of this posterior wall is critical for improvement in hypoglobus. In addition, a satisfactory contour and improvement in hypoglobus were maintained postoperatively.

This report addresses a pitfall of decompression for severe exophthalmos. In mild cases, removal of the orbital floor is an effective treatment, but in severe cases, the results of this approach are sometimes unsatisfactory, and only decompression is necessary. In these cases, orbital decompression in 3 areas including the medial wall, the lateral wall, and the orbital floor is usually performed. A 5.0-mm mean reduction in exophthalmos is observed, but more reduction is difficult to achieve.We considered the possibility that removal of the posterior wall of the maxillary sinus is critically important to achieving greater recovery. It is proposed that this technique is effective in creating about 10 mm of improvement for severe exophthalmos.

Purpose: Defects of the dura mater caused by surgical intervention are often reconstructed using artificial substitutes such as polytetrafluoroethylene membrane (Gore-Tex in commercial name). In cases where secondary infection develops after the initial operation, the artificial substitute used in the primary surgery needs to be removed, and the cranial defect should be covered with tissues abundant in blood supply. The present study discusses the necessity of secondary reconstruction of the dural defect in the recovery operation., Methods: A retrospective study was conducted on 12 patients in whom artificial substitute was exposed because of necrosis of the overlying tissues due to infection or radiation. In recovery operations, the artificial substitute was removed, and the conditions of the underlying defects were evaluated., Results: In all cases, capsule formation had developed to cover dural defects underneath the infected artificial substitutes. The capsules were transparent and watertight, presenting no leakage of cerebrospinal fluid. After coverage of the defect regions using free-flap transfer, no patient developed postoperative complications in follow-up periods of at least 6 months., Conclusions: Capsule formation occurs under artificial substitutes after replacement of the dura mater. Because the capsules retain the cerebrospinal fluid, replacement of the artificial materials is unnecessary in the secondary operation.

Background: Optimal treatment strategies for restenosis of sirolimus-eluting stents (SES) have not been adequately addressed yet., Methods and Results: During the 3-year follow-up of 12 824 patients enrolled in the j-Cypher registry, 1456 lesions in 1298 patients underwent target-lesion revascularization (TLR). Excluding 362 lesions undergoing TLR for stent thrombosis or TLR using treatment modalities other than SES or balloon angioplasty (BA), 1094 lesions with SES-associated restenosis in 990 patients treated with either SES (537 lesions) or BA (557 lesions) constituted the study population for the analysis of recurrent TLR and stent thrombosis after the first TLR. Excluding 24 patients with both SES- and BA-treated lesions, 966 patients constituted the analysis set for the mortality outcome. Cumulative incidence of recurrent TLR in the SES-treated restenosis lesions was significantly lower than that in the BA-treated restenosis lesions (23.8% versus 37.7% at 2 years after the first TLR; P<0.0001). Among 33 baseline variables evaluated, only hemodialysis was identified to be the independent risk factor for recurrent TLR by a multivariable logistic regression analysis. After adjusting for confounders, repeated SES implantation was associated with a strong treatment effect in preventing recurrent TLR over BA (odds ratio, 0.44; 95% confidence interval, 0.32 to 0.61; P<0.0001). The 2-year mortality and stent thrombosis rates between the SES- and the BA-treated groups were 10.4% versus 10.8% (P=0.4) and 0.6% versus 0.6%, respectively., Conclusions: Repeated implantation of SES for SES-associated restenosis is more effective in preventing recurrent TLR than treatment with BA, without evidence of safety concerns.