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Elsahy-Waters syndrome (EWS; OMIM#211380) is a rare autosomal recessive disorder that is caused by loss-of-function variants in CDH11, which encodes cadherin 11. EWS is characterized by brachycephaly, midface hypoplasia, characteristic craniofacial morphology, cervical fusion, cutaneous syndactyly in 2-3 digits, genitourinary anomalies, and intellectual disability. To the best of our knowledge, there have been only six patients of molecularly confirmed EWS. We report the first patient of EWS in East Asia in a Japanese man with a novel splice site homozygous variant of CDH11. We reviewed the clinical and molecular findings in previously reported individuals and the present patient. In addition to the previously reported clinical features of EWS, the present patient had unreported findings of atlantoaxial instability due to posterior displacement of dens, thoracic fusion, thoracic butterfly vertebra, sacralization of the lumbar vertebra (L5), and multiple perineural cysts. The spinal findings in this patient could represent a new spectrum of skeletal phenotypes of EWS. It remains to be clarified whether the multiple perineural cysts in the patient were associated with EWS or coincidental. The current observation might contribute to an expanded understanding of the clinical consequences of loss-of-function of cadherin 11.

Here, we describe the case of an 80-year-old woman who presented with cranial dermoid cyst causing orbital disfigurement. The cyst was treated successfully with ethanol sclerotherapy and has shown no growth for 1 year.

A drain tube is commonly inserted during breast reconstruction surgery. This leads to a scar in addition to the scar on the breast. This study was performed to investigate how patients feel about the drain scar and to clarify its ideal location. A questionnaire survey about the drain scar was distributed to 38 consecutive breast reconstruction patients and a total of 104 female doctors and nurses engaged in breast reconstruction. The drain scars were evaluated using the Japan Scar Workshop (JSW) Scar Scale. A total of 32% of the patients expressed some anxiety about the drain scar. Patients who were anxious about the drain scar had higher scores on the JSW Scar Scale than those who were not anxious. Younger doctors and nurses preferred the drain scar to be on the side of the chest, while older doctors and nurses preferred the drain scars to be at the axilla. About a third of the patients had some anxiety associated with their drain scar after breast reconstruction surgery, and this anxiety level was correlated with objective assessment of the scar. Thus, more patient involvement or the provision of more information regarding drain placement is required.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Background In fingertip replantation with arterial anastomosis alone, many external bleeding techniques have been described to satisfy venous outflow, and some patients require blood transfusions. We used a pulp tissue reduction method to avoid the need for external bleeding techniques and blood transfusions. Methods We examined 18 fingers in cases of Ishikawa's subzone II, III, and IV amputation that were replanted with artery-only anastomosis and pulp tissue reduction from April 2003 to March 2018. The method consisted of pulp tissue reduction to the level of the fingerprint core, bone fixation without gaps to promote venous drainage through bone marrow, and pinprick testing twice a day. Prostaglandin E1 and/or urokinase were administered intravenously, but no other anticoagulants were used systemically or locally. Postoperatively, only the pinprick test was performed twice a day for 5 days. Results The patients ranged in age from 26 to 74 years (mean, 47 years). There were 13 men and 5 women. The total success rate was 89% (16/18). Of the 2 salvage failures, one was due to venous congestion and the other was due to arterial insufficiency. The survival rates of Ishikawa's subzone II, III, and IV amputation were 100% (4/4), 71% (5/7), and 100% (7/7), respectively. No blood transfusions were required in any of the cases. The Semmes-Weinstein test was performed for 14 of 18 fingers: the result was blue in 11 fingers and purple in 3 fingers. Conclusions The pulp tissue reduction method resulted in a high success rate without the need for external bleeding or blood transfusions. Fingertip replantation with artery-only anastomosis, a pulp tissue reduction method, is effective for replant survival when subcutaneous venous repair is impossible because a reduced pulp volume may facilitate replant survival under conditions of irregular venous drainage, such as bone marrow drainage.

Background Although several investigations have described the safety, utility, and precision of magnetic resonance lymphography (MRL) as a preoperative examination for lymphaticovenular anastomosis (LVA), it is unclear how much MRL assistance impacts LVA results. The present study aimed to clarify the outcome of MRL-assisted LVA for leg lymphedema using body water measurements obtained by bioelectrical impedance analysis. Methods The water reductive effect of MRL-assisted LVA in female secondary leg lymphedema patients was compared with that of non-MRL-assisted controls in this retrospective study. In the MRL-assisted group, all LVA candidates underwent MRL prior to surgery, and the lymphatic vessels to be anastomosed were primarily determined by MRL findings. The body water composition of the treated legs was assessed before LVA and at 6 months postoperatively using a multi-frequency bioelectrical impedance analyzer. Results Twenty-three patients in the MRL-assisted study group and an equal number in the non-MRL-assisted control group were analyzed. Although mean leg water volume before LVA, mean excess water volume of the affected leg before LVA, and number of anastomoses created were comparable between the groups, the water volume reduction (1.02 L versus 0.49 L; 95% confidence interval [CI]: 0.03–1.03, p Conclusion Preoperative MRL-assisted lymph vessel visualization and selection appeared to significantly enhance the water reductive effect of LVA for International Society of Lymphology classification stage 2 leg lymphedema. MRL also helped to reliably identify lymphatic vessels for anastomosis. Without increasing the number of anastomoses, LVA could be performed more effectively by better detecting stagnant lymphatic vessels using MRL.

Laser speckle flowgraphy (LSFG) is a new device that can measure skin blood flow and capture the movement of erythrocytes. However, there are a few reports on the use of LSFG to estimate skin blood flow, especially in the lower extremities. We aimed to compare plantar skin blood flow between patients with and without peripheral arterial disease (PAD) to discern the extent to which LSFG could accurately predict PAD. We prospectively measured the plantar skin blood flow in 28 patients with PAD and 37 participants without PAD at two hospitals from 2017 to 2021, using the ankle-brachial index (ABI) and LSFG. We partitioned the plantar into 12 parts: digits 1-5, medial metatarsal, middle metatarsal, lateral metatarsal, medial arch, middle arch, lateral arch, and heel, and compared the difference between the two groups and the area under the curve (AUC) of each point. Statistical analyses were performed to determine the sensitivity, specificity, false-positive rate, and false-negative rate at high accuracy points of AUC and ABI. There was a significant difference among the 12 points between the two groups, and the ratio using toe 1 and toe 5 was highly accurate. The ratio using toe 1 indicated higher sensitivity (89 vs. 82%), higher false-positive rate (22 vs. 4%), lower specificity (81 vs. 97%), and an equivalent false-negative rate (9 vs. 12%) to that of the ABI. These findings could facilitate the use of LSFG to estimate the skin blood flow condition in the plantar skin. Our results indicate that measuring toe 1 using LSFG could be used to somewhat assess PAD.

Fistula recurrence is high after secondary follow-up operation to close the fistula after primary palatal surgery. Therefore, preventing fistula recurrence is important. Here, we describe the technique of closing palatal fistula after palatal surgery with a buccal fat graft in 2 cases. We elevate the mucosal flap around the palatal fistula, suture the nasal mucosa, transplant the buccal fat between the nasal and oral mucosa for the palatal fistula after palatal surgery, and suture the oral mucosa. Palatal fistula did not recur after surgery. This method is simple and useful for suturable fistula and does not require a local flap.

Background Although lymphedema is fundamentally abnormal accumulation of excess water in the extracellular space, previous studies have evaluated the efficacy of physiological bypass surgery (lymphaticovenular anastomosis [LVA]) for lymphedema without measuring water volume. This study clarified the water reductive effect of LVA using bioelectrical impedance analysis (BIA). Methods The efficacy of LVA for unilateral lower-limb lymphedema was evaluated using BIA in a retrospective cohort. The water volume of affected and unaffected legs was measured using multifrequency BIA before and after LVA. Preoperative measurements were undertaken after compression therapy for at least 3 months. The follow-up period after LVA was a minimum of 6 months. Results Thirty consecutive patients with unilateral lower-limb lymphedema were enrolled. The mean water volume reduction of the affected leg by LVA (ΔLBW) was 0.86 L (standard deviation [SD]: 0.86, median: 0.65) with a mean number of 3.3 anastomoses (SD: 1.7). The mean reduction rate of edema was 45.1% (SD: 36.3). Multiple linear regression analysis revealed water volume difference between the affected and unaffected legs before LVA (excess LBW) as the strongest predictor of ΔLBW (R 2 = 0.759, p Conclusion The LVA reduces the volume of accumulated body water in lower-limb lymphedema. As excess LBW most strongly predicted the amount of water volume reduction by LVA, body water volume measurement by BIA before LVA might identify patients with low excess LBW not expected to benefit from LVA, regardless of apparent differences in limb circumference.

Background: This case–control retrospective study focused on the extracellular water ratio (%ECW) of lymphedemic limbs measured by bioelectrical impedance analysis (BIA) as a possible indicator of ...

Background We previously examined the water reductive effect of lymphaticovenular anastomosis (LVA) using bioelectrical impedance analysis (BIA) measurement on lower-limb lymphedema and revealed mean water volume reduction and edema reduction rate by leg LVA to be 0.86 L and 45.1%, respectively. This study aimed to clarify the water reductive effect of LVA on arm lymphedema and compare its results with those for leg lymphedema.Patients and Methods The efficacy of LVA for unilateral arm lymphedema was evaluated using BIA in a retrospective cohort. Limb circumference and arm body water volume (ABW) of the affected and unaffected arms were measured before and after LVA. Mean water volume reduction (ΔABW) and edema reduction rate by arm LVA were compared with values for leg LVA cited from our previous report as a historical control.Results Nineteen consecutive patients were enrolled. The mean ΔABW and edema reduction rate by BIA were 0.267 L and 46.0%, respectively. The decreasing rate of ABW by BIA was significantly larger than those of the upper extremity lymphedema index and sum of 5 circumferences measurement methods. ΔABW could be predicted by a regression line based on the preoperative water volume difference between affected and unaffected limbs. The mean edema reduction rates for arm and leg LVA were comparable.Conclusion The water reductive effect of LVA on upper-limb lymphedema was demonstrated by BIA assessment. BIA can reflect the effect of LVA more sensitively than conventional objective measurements and may facilitate the interpretation of LVA results. Although water volume reduction by arm LVA was less than that by leg LVA, the edema reduction rates were comparable.

In orbital floor fracture, diplopia often persists post-operatively. This study evaluated the association between pre-operative parameters concerning the extent of the injury and post-operative diplopia, using multivariate analysis. A retrospective computed tomography analysis and chart review was performed for patients with punched out orbital floor fracture, who underwent operations during the period from April 2011 to March 2018. Five parameters were evaluated: the number of upward arrows on the Hess chart (representing compensatory overaction of the non-injured eye), time interval to surgery, muscular subscores, fracture area, and swelling rate of the inferior rectus muscle. Of the 32 patients, 9 (28%) had post-operative diplopia; pre-operative diplopia was completely restored in 23 (72%) patients by 6 months after surgery. Univariate analysis found statistically significant differences in the number of upward arrows on the Hess chart, time interval to surgery, muscular subscores, and fracture area. Logistic regression analysis demonstrated that only the number of upward arrows displayed a significantly increased risk for post-operative diplopia (odds ratio, 15.3; 95% confidence interval, 2.0-117.0; P = 0.008). Excessive overaction of the non-injured eye predicted persistent diplopia by 6 months post-operatively. Surgical intervention may be insufficient to achieve full recovery from diplopia and disturbances of ocular motility in some patients.

Summary: Background: Heterotopic ossification (HO) occurs frequently in the elbow in burn patients, and extends beyond the anatomical structure. HO of the elbow can cause joint contracture and adversely affect activities of daily living.Currently, there is no effective prophylaxis for HO as the precise underlying mechanism remains unknown. Therefore, there is no choice but to treat HO after it has developed. To date, however, no effective standard treatment has been reported, and therefore treatment methods vary between different facilities. Surgical resection is widely accepted as the only therapeutic option once HO limits functional mobility of the elbow. Purposes: Based on past reports, we examined our cases and recommend effective therapeutic strategies. We posed the following three questions: (1) Is the surgical intervention effective or detrimental for elbow ankylosis due to HO? (2) What is the best timing for the intervention? (3) What is the most effective postoperative rehabilitation plan? Methods: We treated three patients with complete ankylosis of the elbow due to HO after severe burn injury using different protocols. Results: Surgery was performed in two cases and rehabilitation therapy was commenced immediately from the first postoperative day. Both patients showed improvement in the active range of motion in their elbow joints. The other patient did not undergo surgery, and his elbows became fixed in the completely extension position. Conclusion: Surgical resection is beneficial for elbow ankylosis due to HO after burn injury. Although the exact surgical timing is still controversial, we recommend that surgery should be performed as soon as possible after improving the skin condition around the elbow and confirming the maturation of HO on radiographs. Early rehabilitation and pain control are also important after surgery. Keywords: Heterotopic ossification, Burn, Surgical resection, Elbow, Rehabilitation, Ectopic bone

BACKGROUND This study was conducted to evaluate the incidence and early predictive factors of the development of protuberant umbilicus in pediatric umbilical hernia patients. METHODS In this retrospective visual and chart review, patients younger than 3 months with umbilical hernias who initially visited Ina Central Hospital from April 2011 to March 2017 and were followed until they started to walk (at the age of 1 year) were evaluated. The umbilici of the patients at the age of 1 year were classified into two types based on their appearance: concave and protuberant umbilici. Single-factor and logistic regression analyses of the association between the appearance of the umbilicus at the age of 1 year and various clinical data were performed. RESULTS Of the 103 patients, 72% had concave umbilici, and 28% had protuberant umbilici. Single-factor analysis showed significant differences in the umbilical shapes at the initial visit (P < 0.001) and straining habit (P < 0.001). The most ideal logistic regression model demonstrated that umbilici of the highly inflated balloon type (odds ratio, 27.00; 95% confidence interval odds ratio, 5.60-130.08) and crescent type (odds ratio, 14.34; 95% confidence interval odds ratio, 4.22-48.77) were more likely to develop into protuberant umbilici. CONCLUSIONS Umbilical shapes at the initial visit can be used to predict the future development of protuberant umbilici in pediatric patients with umbilical hernias.

Summary Background Precise mapping of functional lymphatic vessels is essential for successful lymphaticovenular anastomosis (LVA). This study aimed to clarify the precision of magnetic resonance lymphography (MRL) in detecting lymphatic vessels prior to LVA. Methods Eighteen patients with leg lymphedema were recruited for this prospective study. All patients underwent MRL before LVA to obtain three-dimensional coordinates of lymphatic vessels from MRL images. The precision of MRL for detecting lymphatic vessels was evaluated and compared with those of other contrast techniques. Results Twenty legs from 18 patients were analyzed. A total of 40 skin incisions were made, 32 of which were determined by MRL. The precision of MRL to detect lymphatic vessels was 94%. With the addition of MRL, the number of lymphatic vessels identified preoperatively was increased as compared with indocyanine green lymphography (ICG-L) alone. Assuming a detection sensitivity of MRL for lymphatic vessels of 1, those of other contrast techniques were 0.90 for ICG-L under microscopy, 0.73 for patent blue staining, and 0.43 for ICG-L before incision. Whereas ICG-L before incision could not detect lymphatic vessels at depths greater than 17.0 mm, all deeper anastomosed lymphatic vessels were identified by MRL. Conclusion Lymphatic vessels enhanced on MRL can be reliably identified intraoperatively. MRL is a promising preoperative examination in LVA that can selectively depict suitable lymphatic vessels even in deep tissue layers.

Objective: The skin stapler is a useful device to fix skin grafts to the wound bed. However, complications often occur, possibly because of failure in removing staples. We have used a transparent dressing, Mepitel One (Mölnlycke Health Care), to solve this problem. Methods: We performed stapling on the surface of the dressing to fix the skin grafts in 14 cases with burn wounds or other skin defects. Tie-over dressing or negative pressure wound therapy (NPWT) dressing was then applied. Results: All staples could be removed without missing them at the same time as removing the transparent dressing. Conclusion: Stapling through the transparent dressing on skin grafts is a safe and useful method to prevent missing staples and to allow monitoring of the wound condition. Keywords: Skin graft, Staple, Transparent dressing

Introduction: A number of issues, such as delayed epithelialization and ulcer outbreak, may occur after epithelialization, especially in patients with skin vulnerability. This case report examines whether our method involving small-slice thin-thickness skin harvesting in a net pattern can enhance stable epithelialization at skin graft donor sites without complications, even in patients with skin vulnerability. Patients and methods: The study population consisted of five patients with skin vulnerability. The causes of injury were trauma and peripheral arterial disease (PAD). The study population included no patients with burn injuries. We applied a new skin harvesting method in these patients from July 2011 to December 2016. Thin-thickness skin grafts as small slices were harvested from the lateral thigh using a small freehand dermatome. Intact skin gaps between the harvested areas were preserved in a net pattern. The donor site was monitored continuously. Results: The mean size of the donor site was 122.9 cm2, and that of the recipient site was 206.9 cm2. The mean period until epithelialization was 13.2 days with a range of 11–15 days without ulcer outbreak. Hypertrophic scars and pigmentation occurred in one patient each. There were no other complications in this case report. Conclusion: Small-slice thin-thickness skin harvesting in a net pattern is a very simple and useful skin harvesting method for dealing with thin, loose, and fragile skin. This method can be adapted to some burn patients with skin vulnerability because it can reduce the complications at the donor site and it allows harvesting multiple times at the same site. Keywords: Skin graft, Donor site, Wound healing, Net pattern, Skin vulnerability

Breast augmentation for women with asymmetric pectus excavatum (PE) has a characteristic problem in that surgeons need to select implants while considering the left-right difference in breast volume, contour, and position. We herein report a 33-year-old woman with severe asymmetric PE who presented with residual breast asymmetry after chest wall correction using the Nuss procedure. Her right breast appeared hypoplastic and the right anterior chest wall remained depressed. Augmentation of the right breast with a silicone implant was performed, selecting the inserted implant preoperatively with the assistance of three-dimensional (3D) simulation. The breast asymmetry and anterior chest wall depression were improved to a natural appearance. Three-dimensional simulation represents an advantageous way to preoperatively select optimal implants for breast augmentation in asymmetric PE women with breast asymmetry. Level of Evidence: 5

Background A 76-year-old woman presented with rheumatoid lymphedema (RL) distal to the left elbow after 20 years of affliction with rheumatoid arthritis (RA). Although the RA was controlled by medication, the patient could not receive full-scale compression therapy for her edema with a medium-pressure compression sleeve (pressure: 20–25 mm Hg) due to hand dysfunction caused by long-term RA. Methods Lymphaticovenular anastomosis (LVA) was performed after compression therapy with a low-pressure sleeve (14–18 mm Hg) proved ineffective for edema relief. Two anastomoses were created in a side-to-end fashion at the cubital fossa. Results The edema improved rapidly after LVA and was maintained with a low-pressure compression sleeve. Conclusion LVA represents a treatment option for remaining RL in RA treatment. As some RL patients are ineligible for full-scale compression therapy due to hand dysfunction caused by RA, LVA may help to reduce RL and enable edema management using a low-pressure compression garment without concern for hand dysfunction.

Summary: Closing a scalp wound with skin defects is challenging because the scalp skin lacks extensibility and closing it tends to result in a remarkable, widespread, hairless scar. Absorbable symmetric barbed suture device (Stratafix Symmetric; Ethicon, USA) allows wound closure using a pulling motion alone and provides a strong and secure closure for the high-tension area. We used this device to close wide scalp defects easily without tension and with minimized sequential scalp alopecia. The aim of this study was to show our experiences with using this technique. From January 2017 to March 2019, our relaxing suture technique was performed in 7 pediatric patients with scalp alopecia due to various lesions that ranged 23.0 ± 6.5 mm. After resecting the lesions, the galea was sutured using the 3-0 absorbable symmetric barbed suture via a running subcutaneous suture technique. The widespread wound edges were approximated by pulling the suture device. Wound closure was completed with galeal suturing and a superficial suture. We evaluated the width of the postoperative hairless scar at the final follow-up. In all 7 patients, we could approximate the widespread wound edges by pulling alone. Subsequently, the wounds could be closed without tension or difficulty. The mean width of the postoperative hairless scar was 3.3 ± 0.8 mm (range: 1.9–4.3 mm), and no complication was detected during the follow-up period. Our new relaxing suture technique using an absorbable barbed suture with symmetric anchors is a supportive and additional way to help close scalp defects.

Objective: No active treatment is required in the majority of cases of infantile hemangioma (IH), while they proliferate and involute without sequelae. However, ulceration, bleeding, or destruction/obstruction of important structures may occur in 10% of cases during the proliferating phase. These lesions lead to a disfigured appearance with redundant skin, fibrofatty residuum, protruding surface, drooping, and scarring. This study focused on prevention and management of disfiguring scars in involuted IH. Approach: A retrospective photography and chart review were performed for patients with IH who visited our hospital (Shinshu University Hospital). Results: The study population consisted of 107 patients with IH. The lesions were located on the head and neck (59.8%), trunk (27.1%), upper limb (7.5%), or lower limb (5.6%). Twenty-four patients (22.4%) underwent surgical excision of the disfigured lesion after involution. The percentage of surgical interventions was highest for lesions in the head and neck area (28.9%) compared with other regions. The fibrofatty tissue and redundant skin after involution of each lesion were partly resected and sutured. All suture lines were finally set on the wrinkle line or the anatomical borderline. Innovation: Although total excision of the lesion was impossible in some cases, a natural surface contour was obtained. The operative scar was not visible in the residual damaged skin after involution. Conclusion: Effective preventive therapies during the proliferating phase are required to avoid tissue damage due to hyperexpansion of the surrounding tissue and surface breakdown to present excellent cosmetic results in patients with IH.

Objective: In unilateral cleft lip and palate, the reconstructed nasal floor is sometimes uplifted regardless of the reconstructive method used. We used a 5-0 absorbable anchoring suture, the oronasal transfixion suture (ONT suture), to fasten the reconstructed nasal floor to the orbicularis oris muscle to prevent this deformity. This study was performed to evaluate the effects of the ONT suture. Design: Blind retrospective study of photography and chart review. Setting: Shinshu University Hospital, tertiary care, Nagano, Japan. Private practice. Patients: Ninety-three consecutive patients with unilateral complete cleft lip and palate who had undergone primary nasolabial repair in our department and affiliated hospitals between 1999 and 2011 participated in this study. Finally, 45 patients were included. Interventions: The ONT suture was put in place at the time of primary nasolabial repair. Main Outcome Measure: The height of the nasal floor was evaluated on submental view photographs at 5 years old. Results: The ONT suture was applied in 21 patients. The height of the nasal floor on the cleft side was significantly closer to that on the noncleft side with the ONT suture than without the ONT suture ( P = .008). Conclusions: The ONT suture is effective to prevent uplifted nasal floor deformity on the cleft side// in unilateral complete cleft lip and palate at the time of primary nasolabial repair.

Summary Background Nasal fracture is the most common type of facial fracture treated by plastic surgeons. Here, we clarify the postoperative deformities that frequently remain after closed reduction of fresh nasal bone fracture by three-dimensional computed tomography (3D-CT). Methods Hundred consecutive cases of fresh nasal bone fracture in patients treated between May 2010 and January 2016 were examined. After closed reduction, the overall appearance of the arch formed by the nasal bone and maxillary process was evaluated as ‘Excellent’, ‘Good’ or ‘Fair’. Patients were also asked about their overall satisfaction with the operation, and the responses were classified as ‘Satisfied’, ‘Neutral’ or ‘Dissatisfied’. Results Eighty-six patients underwent 3D-CT examination both at the time of the initial consultation and 3 months after the operation. The results were ‘Excellent’ in 69 patients and ‘Good’ in 17 patients, with none of the patients having only ‘Fair’ results. Convex bone deformities on one side were seen in all six bilateral type fractures evaluated as ‘Good’. All patients classified as ‘Excellent’ reported being ‘Satisfied’ with the results, but some patients classified as ‘Good’ gave a ‘Neutral’ evaluation regarding their satisfaction. Conclusions The residual deformities seen in bilateral type fractures were most notable, and they were all convex bone deformities on one side. Plastic surgeons should use ultrasonography or other reliable new methods in addition to visual inspection during the operation to successfully treat the region of the convex fracture.

Previously, bilateral lateral vermilion border transposition flaps were reported to correct whistling lip deformity in patients with cleft lip. This study examined the long-term outcome in these patients and modified the procedure. Here, the use of this procedure is reported in 69 cleft lip patients. The follow-up period after the operation ranged from 4-14 years. In addition to the standard method, a unilateral flap was applied for asymmetrical vermilion and small bilateral flaps were applied to loosen the transverse tightness of the vermilion. The asymmetry of the tightness was improved in all patients. The reconstructed tubercle diminished in volume gradually over a few years postoperatively. Secondary deformities after its use were subtly everted tubercle during smiling (18.8%) and irregularities on the labial-free margin (21.7%). They were corrected by minor follow-up revision. Although it is necessary to wait several years until the postoperative shape has stabilised, this is a simple and widely available method to reconstruct a naturally-shaped vermilion in cleft lip patients.

We observed greater postoperative shrinkage of grafted fascia lata without peritendinous areolar tissue (PAT) than with PAT in blepharoptosis surgery. In this article, we sought to evaluate the influence of PAT on tendon grafts.Pairs of anterior tibial tendons with or without PAT were grafted onto the backs of 12 adult Wistar rats. The cephalic and caudal ends of the tendons with or without PAT were fixed tightly on the fascia of the erector spinae muscles with 6/0 polypropylene sutures. A 7-mm distance was maintained between the sutures. Changes in the length between the sutures as well as changes in the histology of the tendons with or without PAT were evaluated at 1 and 5 months after grafting.The mean lengths of the grafted tendons with PAT at 1 and 5 months after grafting were significantly longer than those without PAT at 1 and 5 months after grafting, respectively (5.4 mm and 4.5 mm vs. 3.8 mm and 2.9 mm, respectively; Wilcoxon signed-rank test; P0.05). The grafted tendons without PAT displayed central necrosis and scar formation, whereas those with PAT displayed no alteration in the tissue properties.At both 1 and 5 months after grafting, the grafted tendons with PAT were significantly longer and survived better than those without PAT. Tendon grafts with PAT had increased survival of the endotendinous tissue and diminished postoperative shrinkage, since the vascular network of the PAT potentially contributes to early revascularisation of the graft.

Summary Stretching of mechanoreceptors in Mueller's muscle induces reflexive contraction of not only the levator muscle but also the frontalis muscle as two different eyelid-opening muscles. Previously, we reported that fine neural myelinated structures, acting as mechanoreceptors, were found in the proximal Mueller's muscle. Since there is a risk of misunderstanding that the middle and distal Mueller's muscle does not contain mechanoreceptors and can be invalidated or resected, the accurate distribution of myelinated trigeminal proprioceptive nerve fibres as mechanoreceptors in Mueller's muscle was refined horizontally in this study. We explored 10 whole Mueller's muscles between the levator muscle and the tarsus of the upper eyelids obtained from five Japanese cadavers. The specimens were serially sliced along the horizontal plane and stained with HE, S-100 protein to determine the presence of Schwann cells, and smooth muscle actin antibody to determine the presence of Mueller's smooth muscle fibres. Although all myelinated nerve fibres in the intermuscular connective tissues among the sympathetically innervated Mueller's multi-unit smooth muscle fibres may not correspond to the proprioceptive nerve fibres, the nerve bundles consisting of multiple myelinated nerve fibres were well distributed in the proximal Mueller's muscle, and single myelinated nerve fibres were well distributed in the middle and distal Mueller's muscle. We believe that the mechanoreceptors in Mueller's muscle consist of myelinated proprioceptive nerve fibres with nerve endings possibly attached to collagen fibres in the intermuscular connective tissues present among Mueller's smooth muscle fibres. As the myelinated nerve fibres innervate the middle and distal Mueller's muscle to a greater extent than those in the proximal Mueller's muscle, the former may be more important as mechanoreceptors than the latter and should not be invalidated or excised during surgery for treatment of blepharoptosis to prevent reduction of reflexive contraction of the levator and frontalis muscles.

Complete or incomplete cleft lip can be associated with a contralateral lesser form of incomplete cleft lip, constituting an asymmetrical bilateral malformation.The cleft lip registry was searched for patients with complete or incomplete cleft lip and contralateral minor-form, microform, or mini-microform defects. Methods of repair were documented and results were assessed by reviewing photographs and recording revisions.Of 309 patients with bilateral cleft lip, 72 patients (23 percent) had asymmetrical cleft lip, with 40 patients having contralateral minor-form, microform, or mini-microform defects. All infants with complete cleft lip and palate on the greater side underwent preoperative dentofacial orthopedic alignment, nasolabial adhesion, and gingivoperiosteoplasty. Infants with a contralateral minor-form defect (n = 7) had second-stage, synchronous bilateral nasolabial repair. Contralateral microform defects (n = 6) were not addressed during rotation-advancement repair on the complete/incomplete side; the later repair was a double unilimb Z-plasty. Contralateral mini-microform defects (n = 27) were corrected by vertical lenticular excision and, if necessary, alar base Y-V advancement, either synchronously with closure on the greater side or at another stage. The revision rate correlated with the degree of preoperative asymmetry. The most common revisions were augmentation of the median tubercle and free margin on the lesser side and repositioning of the lower lateral cartilage and alar base on the greater side.The operative strategy for repair of an asymmetrical bilateral cleft lip is determined by the extent of the vermilion-cutaneous dysjunction on the lesser side. Synchronous bilateral nasolabial repair is indicated for a contralateral minor-form defect. Correction of a contralateral microform or mini-microform defect is usually deferred to achieve symmetry.

When increased contraction of the levator muscle accompanied by the superior rectus muscle compensates for aponeurotic blepharoptosis, increased contraction of the inferior rectus muscle for foveation retracts the lower eyelid through the capsulopalpebral fascia, showing the lower sclera. We hypothesized that in patients with aponeurotic blepharoptosis, the capsulopalpebral fascia excessively retracts the posterior lamella of the lower eyelid alone while keeping the anterior lamella unretracted, especially in patients with both weak extension of the capsulopalpebral fascia to the pretarsal anterior lamella and increased contraction of the orbicularis oculi muscle, resulting in entropion. Aponeurotic reinsertion to the tarsus for the upper eyelid improved entropion in 15 younger patients. Surgical disinsertion of the capsulopalpebral fascia from the tarsus and creation of a cicatricial connection between the pretarsal skin and the tarsus for the lower eyelid corrected entropion in 15 elderly patients. Both procedures also corrected the lower scleral show.

We have created an alternative method for tracheal reconstruction. Our new surgical procedure using a deltopectoral flap combined with a costal cartilage graft and mucosal graft for tracheal reconstruction allows us to achieve reconstruction of the tracheal mucosa, the tracheal cartilage, and the covering skin with adequate subcutaneous tissue. In one case, a tracheostenosis was reconstructed with a deltopectoral flap combined with a costal cartilage graft. In the other case, a tracheal defect was reconstructed with a deltopectoral flap combined with a costal cartilage graft and palatal mucosal graft. Although the operation is a multistage procedure, our method provides satisfactory clinical results. Thus, we believe that our method is useful for the surgical treatment of large tracheal defects.

The authors report a successful reconstruction of the total upper eyelid in conjunction with the gliding surface of the extraocular muscles. A 21-year-old woman sustained an inner layer defect of her right upper eyelid together with avulsions of the superior levator palpebrae muscle and the superior orbital fat. Her right superior rectus muscle was exposed, and no orbital fat was seen in the space between the muscle and the orbital roof. To preserve eye movement, a gliding surface between the superior rectus muscle and the orbital roof had to be reconstructed. Total upper lid reconstruction was performed using a radial forearm flap with a hard palate mucosal graft. The gliding surface was reconstructed with an adipofascial flap obtained from the forearm. Despite lack of levator function, the patient could raise her eyelid approximately 5 mm by using only the superior rectus muscle without frontalis suspension.

The effects of an ointment containing prostaglandin E1 ·α-cyclodextrin clathrate compound (PGE1 · CD ointment) on wound healing were evaluated in an ischemic rabbit ear model. The PGE1 · CD ointment (30 µg/g, ca. 50 mg) was applied to surgical ulcers 6 mm in diameter on ischemic ears in Japanese-White rabbits for 2 weeks. The rate of reduction in wound size was 15.0 mm2/week in the PGE1 treated group and 5.3 mm2/week in the control group during the first week. During the following week, the rate was 9.6 mm2/week in the PGE1 treated group and 13.5 mm2/week in the control group. Much more granulation tissue was found in wounds in the PGE1-treated group than in the control group. These findings showed that topical application of PGE1 · CD ointment improved wound healing under ischemic conditions during the first week of treatment. They also indicate that PGE1 · CD ointment may be clinically useful as a topical agent for treatment of ischemic skin ulcers during the early stages of inflammation.

The definitive version is available at www.blackwell-synergy.com, As infrared penetrates the skin, thermal effects of infrared irradiation on cancer cells have been investigated in the field of hyperthermia. We evaluated non-thermal effects of infrared irradiation using a specialized device (1100-18000 nm with filtering of wavelengths between 1400 and 1500 nm and contact cooling) on cancer cells. In in vitro study, five kinds of cultured cancer cell lines (MCF7 breast cancer, HeLa uterine cervical cancer, NUGC-4 gastric cancer, B16F0 melanoma, and MDA-MB435 melanoma) were irradiated using the infrared device, and then the cell proliferation activity was evaluated by 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) assay. Proliferation of all the cancer cell lines was significantly suppressed by infrared irradiation. Total infrared output appeared to be correlated with cell survival. Increased temperature during infrared irradiation appeared not to play a role in cell survival. The maximum temperature elevation in the wells after each shot in the 20 and 40 J/cm2 culture was 3.8 degrees C and 6.9 degrees C, respectively. In addition, we have shown that infrared irradiation significantly inhibited the tumor growth of MCF7 breast cancer transplanted in severe combined immunodeficiency mice and MDA-MB435 melanoma transplanted in nude mice in vivo. Significant differences between control and irradiated groups were observed in tumor volume and frequencies of TUNEL-positive and Ki-67-positive cells. These results indicate that infrared, independent of thermal energy, can induce cell killing of cancer cells. As this infrared irradiation schedule reduces discomfort and side effects, reaches the deep subcutaneous tissues, and facilitates repeated irradiations, it may have potential as an application for treating various forms of cancer., Article, CANCER SCIENCE. 101(6):1396-1402 (2010)

We have proposed a hypothetical mechanism to involuntarily sustain the effective eyelid retraction, which consists of not only voluntary but also reflexive contractions of the levator palpebrae superior muscle (LPSM). Voluntary contraction of fast-twitch fibres of the LPSM stretches the mechanoreceptors in Mueller's muscle to evoke trigeminal proprioception, which induces continuous reflexive contraction of slow-twitch fibres of the LPSM through the trigeminal proprioceptive nerve fibres innervating the mechanoreceptors in Mueller's muscle via the oculomotor neurons, as a tonic trigemino-oculomotor reflex. In the common skeletal mixed muscles, electrical stimulation of the proprioceptive nerve, which apparently connects the mechanoreceptors in muscle spindles to the motoneurons, induces the electromyographic response as the Hoffmann reflex. To verify the presence of the trigemino-oculomotor reflex, we confirmed whether intra-operative electrical simulation of the transverse trigeminal proprioceptive nerve on the proximal Mueller's muscle evokes an electromyographic response in the LPSM under general anaesthesia in 12 patients. An ipsilateral, phasic, short-latency response (latency: 2.8+/-0.3 ms) was induced in the ipsilateral LPSM in 10 of 12 subjects. As successful induction of the short-latency response in the ipsilateral LPSM corresponds to the Hoffmann reflex in the common skeletal mixed muscles, the present study is the first electromyographic verification of the presence of the monosynaptic trigemino-oculomotor reflex to induce reflexive contraction of the LPSM. The presence of the trigemino-oculomotor reflex may elucidate the unexplainable blepharoptosis due to surgery, trauma and tumour, all of which may damage the trigeminal proprioceptive nerve fibres to impair the trigemino-oculomotor reflex.

Increased stretching of the mechanoreceptors in Mueller's muscle induces involuntary reflex contraction of the ipsilateral frontalis muscle. We used this neurophysiological mechanism during surgery on 50 patients with severe unilateral or bilateral congenital blepharoptosis that does not have the levator muscle but has Mueller's muscle. To facilitate contraction of the superior rectus muscle to sufficiently stretch the mechanoreceptors in Mueller's muscle, transverse fibrous tissues that restrict the stretching are medially and laterally incised. Without fascial or muscular advancement, the fascia lata was grafted as far between the frontalis muscle and the tarsus as possible. After 15.5% postoperative shrinkage of the grafted fascia lata, all 50 patients involuntarily elevated their ptotic eyelids over the pupillary centre on primary gaze without severe lagophthalmos on eye closing. Forty-five patients could lift the upper eyelid over the pupillary centre even on upward gaze. Our procedure appeared to enhance the involuntary reflex contraction of the ipsilateral frontalis muscle, providing satisfactory dynamic retraction of the upper eyelid through fascia lata. We consider our procedure an alternative for reconstructing not only severe congenital blepharoptosis but also severe acquired blepharoptosis after orbital trauma or orbital tumour resection, in patients who do not have or lose the levator muscle while the Mueller's muscle, the superior rectus muscle and the trigeminal proprioceptive nerve function to induce involuntary reflex contraction of the frontalis muscle.

To differentiate between congenital and aponeurotic blepharoptosis, we investigated whether upgaze with stretching of the mechanoreceptor of Mueller muscle increases involuntary reflex contraction of the levator slow-twitch muscle fibers. In 50 cases each of unilateral congenital blepharoptosis and of asymmetric aponeurotic blepharoptosis, the mean increases by upgaze in the upper eyelid margin to the line between the medial and lateral canthi as upper eyelid retraction distance (UERD) of the ptotic eyelid 0.4 mm and 2.9 mm, respectively. These were significantly smaller and significantly larger than those of the corresponding nonptotic eyelid, 2.0 mm and 2.3 mm, respectively.Worsening of ptosis on upgaze is common in congenital ptosis and is an abnormal differentiating sign, lacking the involuntary reflex contraction. Improvement of ptosis on upgaze is common in aponeurotic blepharoptosis and likely represents a normal physiological process, restoring the involuntary reflex contraction.

We previously reported that a lower positioned transverse ligament, which was identified just above the fusional line between the orbital septum and the levator aponeurosis or anteroinferiorly in the upper orbital fat space, determines the lower position of the preaponeurotic fat, and restricts the upper eyelid retraction causing the external features that define the appearance of the Mongoloid eye. Because the narrow palpebral fissure of the Mongoloid eye is composed of the restricted upper eyelid and the restricted lower eyelid, we surmised that the ligamentous tissue, which is analogous to the lower positioned transverse ligament in the upper eyelid, might also exist in the lower eyelid.

Paralysis of the frontalis muscle causes ipsilateral brow ptosis and contralateral hypermotility of the non-paralytic frontalis muscle in Oriental patients. In this paper, we describe an effective way of correcting such asymmetry by using blepharoplasty with aponeurotic fixation, and three case reports were presented. This procedure makes it possible to reduce the hypermotility of the non-paralytic frontalis muscle, and symmetry of the brows can be achieved easily with minimal brow lift. All three patients had symmetrical brows six months postoperatively. Although we think that brow ptosis may recur eventually, if symmetry is obtained as a result of minimal brow lift, we think that our method can delay recurrence.

Cotton gauze with alpha cyanoacrylate was used for alveolopalatal wound dressing after alveolar bone grafting to treat 93 alveolar clefts in 74 cleft patients to reduce mechanical injuries, tension for wound dehiscence, and adhesion of food remnants. T-shaped cotton gauze was put on the gingivoperiosteal flaps and was impregnated with cyanoacrylate. The procedure required no preoperative preparation and its intraoperative execution took less than 5 minutes. The gauze with cyanoacrylate was removed approximately 1 week after surgery. No infection was observed at any of the operational sites, but tiny fistulas developed at four of them. The mean bone graft score was 1.4 point. No complications such as thermal injury resulted from the use of cyanoacrylate. Gauze impregnated with cyanoacrylate proved to be a convenient and dependable dressing for alveolopalatal wounds resulting from gingivoperiosteoplasty for alveolar bone grafting.

A 50-year-old woman suffered deep burns to the face, neck, chest, back and extremities. Total reconstruction of the eyelids and nose was undertaken nine months after injury. A forearm flap was utilized for resurfacing and was followed by debulking, costal cartilage grafting, and reconstruction of the eyebrows. The thinness and adaptability of the forearm flap allowed for exact reconstruction of the eyelids and nose. The forearm flap imparted equal colour and texture to the area that could not be covered with a flu mask. The flu mask may be used to diminish the strangeness of the reconstructed face. This reconstruction has improved the patient's quality of life immediately.

Vermilionplasty using medical tattooing was performed after radial forearm flap reconstruction of the lower lip in 2 patients. This technique is easy to perform in the outpatient setting, does not involve sacrifice of tissue, and results in an acceptable aesthetic outcome. We recommend vermilionplasty with medical tattoing as the procedure of choice after lip reconstruction with a distant flap.

Yohei Tanaka1,2, Kiyoshi Matsuo1, Shunsuke Yuzuriha11Department of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Japan; 2Clinica Tanaka Plastic and Reconstructive Surgery and Anti-aging Center, Matsumoto, JapanBackground and objective: Our previous histological studies indicated that near-infrared (NIR) irradiation stimulates collagen proliferation in rat and human skin for 3 months. High collagen density in the dermis and smoothing of the epidermis were observed in irradiated rat skin, and appeared to last up to 6 months. Epidermal smoothness in irradiated rat skin seems to resemble scarring. Here, we performed a long-term histological comparison between NIR (1100 to 1800 nm) irradiated skin and scar tissues.Materials and methods: Rat skin was irradiated using a NIR device. Scar tissues were harvested from wounded areas and were compared with irradiated skin. Histological changes up to 180 days post-treatment were evaluated with hematoxylin and eosin, Azan-Mallory staining, and collagen type I and III staining.Results: In nonirradiated control skin, the dermis showed a low density of type I and III collagen, the surface of the epidermis was rough, and no significant changes were observed over time. In irradiated skin, both type I and III collagen increased significantly, and persisted up to 180 days. The density of type I collagen was significantly higher than that of type III collagen, whereas type I and III collagen of the control group did not differ significantly. Epidermis was thickened for 30 days, and epidermal smoothness persisted up to 180 days. In scar tissues, the density of type III collagen was higher than that of type I collagen. The number of fibroblasts remained high and the glial fibrils were dense until 180 days after injury compared with irradiated skin. Significant increases in both type I and III collagen and epidermal flattering persisted until 180 days.Conclusions: NIR irradiation induced high collagen density in the dermis, resulting in long-term epidermal smoothness without scar formation. Results indicated that NIR irradiation provides safe, consistent, and long-term effects of skin rejuvenation.Keywords: near-infrared irradiation, long-term effects, collagen, scar, skin rejuvenation