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Follow-up of aneurysms treated with stent-assisted coil embolization has been performed using digital subtraction angiography (DSA) because in time-of-flight magnetic resonance angiography, metal artifacts from the stent often affect visualization.To confirm whether ultrashort echo time (TE) MRA may be an alternative for DSA during follow-up.Patients with unruptured aneurysms initially treated with stent-assisted coil embolization between April 2019 and March 2021 were enrolled. After 3 months of treatment, follow-up DSA and ultrashort TE MRA were performed. All images were independently reviewed by neurosurgeons to evaluate in-stent flow and rated from 1 (not visible) to 4 (excellent). Aneurysmal embolization status was assessed as complete obliteration, residual neck, or residual aneurysm. Ultrashort TE MRA findings were classified as evaluative or nonevaluative state based on the presence of metal artifacts. We investigated the types of aneurysms that were evaluative and the agreement between ultrashort TE and DSA.Overall, 89 aneurysms were examined, of which 74% (n = 66) were classified as evaluative on ultrashort TE. Significant differences were observed in size and stent type. Evaluative cases had an aneurysm size of7 mm (P = .0007) and a higher rate of Neuroform Atlas (P = .0006). The rate of agreement between ultrashort TE with evaluative state and DSA was 95%.Ultrashort TE MRA could evaluate an embolization status treated with stenting, and the findings are in excellent agreement with those of DSA. Aneurysms measuring7 mm and treated with Neuroform Atlas are evaluative on ultrashort TE, and DSA might not be necessary.

An 82-year-old Japanese woman without underlying disease was admitted to our hospital 3 days after she noticed lower-limb weakness. At presentation, she had lower-leg motor paralysis with mild upper-limb paresis and left Ramsay Hunt syndrome. Cerebrospinal fluid (CSF) findings revealed moderate pleocytosis. A polymerase chain reaction for varicella zoster virus (VZV) DNA in CSF was positive. MRI using 3D Nerve-VIEW (Philips) and contrast T

Background Histological differentiation between hypertrophic scars (HSs) and keloids has been considered difficult. In this study, we analyzed differences in the 3-dimensional tissue architecture between HSs and keloids using focused ion beam/scanning electron microscopy (FIB/SEM). Methods Five specimens each of normal skin, normotrophic scars (NSs), HSs, and keloids were investigated. Three sites in each specimen were observed by FIB/SEM tomography, resulting in an observation of 15 sites per tissue type. We identified fibroblasts and macrophages and assessed the contact ratio and the mode of intercellular contact (planar contact or point contact). The significance of differences among the 4 tissue types was determined by Fisher exact test. Results In normal skin, contact between fibroblasts and macrophages was observed at all 15 sites, and the mode of contact was always planar. There was contact at 87% of the NS sites (planar: point = 80%: 7%). In HSs, contact was seen at 80% of the sites (planar: point = 20%: 60%). In keloids, contact was found at only 15% of the sites (planar: point = 7.5%: 7.5%). The intercellular contact ratio showed no significant differences among normal skin, NSs, and HSs; however, a significant difference was noted between these tissues and keloids. The intercellular contact mode also showed no significant difference between normal skin and NSs, but a significant difference between these tissues and HSs. Conclusions These histopathologic findings suggest that FIB/SEM tomography is useful for distinguishing between HSs and keloids and can provide important knowledge for understanding the pathogenesis of keloids.

Fenestration of a vertebral artery(VA)is a rare anomaly that has occasionally been associated with the formation of saccular aneurysms, whereas dissection of a limb of the fenestrated artery is an extremely rare occurrence. We report the case of a ruptured dissecting aneurysm of a fenestrated VA. A 56-year-old man presented with acute-onset headache followed by respiratory failure. Computed tomography(CT)revealed diffuse subarachnoid hemorrhage, and CT angiography(CTA)demonstrated fenestration of the left VA and a fusiform aneurysm of the dorsolateral limb of the fenestrated VA. CT after injection of contrast medium revealed dissection of a limb of the fenestrated VA. A comparison of the 3-dimensional digital subtraction angiogram obtained 2 days later with the initial CTA showed that the dissecting aneurysm had shrunk. Coil embolization of the dissecting limb of the fenestrated VA was achieved, and the patient was discharged without neurologic deficit. Further advancements in neuroimaging modalities will provide more opportunities to treat dissecting aneurysms of fenestrated VAs. The relevant clinical characteristics of VA fenestration and the treatment options for a dissecting aneurysm of a limb of the fenestrated VA are also discussed in this report.

Because thinning of the pectoralis major myocutaneous flap is impossible due to blood circulation, it is difficult to produce thin flaps. Although the pectoral flap and the deltopectoral flap are the best flaps that provide a highly desirable color-texture match to facial skin, their reach is restricted and they require resection in 2 stages. The purpose of this paper is to develop a new method of elevating a flap and to resolve these problems.First, include the third intercostal perforating branch of the internal thoracic artery in the skin paddle and, outward therefrom, design a skin paddle of the pectoral flap in accordance with the shape of the defect. After a skin incision along the design, elevate the pectoral flap pedicled with the third intercostal perforating branch. Then, after cutting the third intercostal perforating branch at the lower surface of the pectoralis major muscle, harvest the approximately 5- to 6-cm-wide pectoralis major muscle in the lateral direction. In doing so, it is important to include in the harvested muscle body of the pectoralis major muscle the muscular branch of the third intercostal perforating branch, the branch of thoracoacromial artery, as well as the true anastomosis of both. Thereafter, elevate the entire flap, with the thoracoacromial artery for vascularization, and move it to the head and neck region via the subclavian route. In this way, the pectoral perforator flap pedicled with the pectoralis major muscle flap (PP flap) is elevated. As for the deltopectoral perforator flap with the pectoralis major muscle flap (DPP flap), after elevating the deltopectoral flap pedicled with both the second and third intercostal perforating branches of the internal thoracic artery, carry out the same flap elevation operations.The PP flap was used in 4 cases and the DPP flap was used in 1 case. In all cases, the flaps were completely grafted and quite satisfactory, functional, as well as demonstrating good cosmetic results.Unlike the conventional pectoralis major myocutaneous flap, the PP flap does not contain in its skin paddle the pectoralis major muscle and the mammary gland, making it possible to produce a thin flap. In addition, the development of this method has now substantially extended the reach of the flap, thereby making it possible for the PP flap to reach the oropharyngeal region and for the DPP flap to reach the frontal region at a single time. Originally, the skin over the precordium is relatively thin and flexible and provides a desirable color-texture match to facial and neck skin; therefore, it is believed that this method may serve as an extremely useful means in the future in the functional and cosmetic reconstruction of the head and neck region.

The purpose of this study was to overcome the disadvantages associated with the shortness of the vascular pedicle of subscapular system combined flaps when performing the maxillary reconstruction procedure. Combined flaps of the subscapular artery system were used for maxillary reconstruction. A latissimus dorsi myocutaneous flap, a scapular fasciocutaneous flap, and two kinds of scapular bone flaps were elevated as combined flaps. Next, the circumflex scapular artery (CS) and vein were cut off from the combined flaps and anastomosed to the serratus anterior branch, thereby establishing chimeric flaps. Then, maxillary reconstruction was performed using these flaps. We encountered two patients who underwent maxillectomy for maxillary cancer. Satisfactory improvements in facial shape were obtained in both cases. In cases in which combined flaps of the subscapular artery system are used for maxillary reconstruction, the biggest problem is that the vascular pedicle does not reach the recipient vessel in the neck due to the shortness of the CS. Therefore, vein grafts are generally performed to extend the flaps to the maxilla. Our novel procedure has the great advantages of long vascular pedicles and high flexibility in setting the flaps without the use of vein grafts.

Facial reanimation surgery using a free muscle flap for facial paralysis, in which gracilis muscle flap was used, was first reported by Harii1 in 1976. Subsequently, many muscle flaps for the surgery have been reported, such as latissimus dorsi (LD) muscle,2–4 rectus abdominis muscle,5 rectus femoris muscle,6 abductor hallucis muscle,7 internal oblique muscle,8 biceps femoris muscle,9 and pectoral minor muscle.10 Currently, in Asian countries, the LD muscle flap is the most commonly used among these muscle flaps because it has a long vascular pedicle and nerve. However, the LD muscle flap has 1 problem, that is, its thickness. In surgery, if the LD muscle flap is to be transplanted without thinning in the subcutaneous pocket of the cheek, (1) insertion of the muscle flap inside the pocket may be difficult due to its thickness, (2) convex deformation occurs due to its thickness, and (3) contraction of the muscle flap is too strong, and problems such as facial expression becoming asymmetrical in shape when the patient smiles occur. Therefore, in many cases, a method to shave the LD muscle flap before transplanting is followed, leading to substantially satisfactory results being stably obtained.2,3 However, there are no reports clearly indicating to what degree the muscle flap may be safely shaven. The purpose of this study is to anatomically investigate the three-dimensional route of the thoracodorsal artery, vein, and nerve inside the LD muscle used for facial reanimation and to clarify the degree to which the muscle flap may be safely shaven.

当院頭蓋底外科チームで行った鼻副鼻腔悪性腫瘍に対する頭蓋底手術29例の臨床的検討を行った。原発部位は篩骨洞12例，鼻腔8例，上顎洞6例，前頭洞3例で，組織型は扁平上皮癌が19例，嗅神経芽細胞腫が4例，横紋筋肉腫が2例，腺癌・腺様嚢胞癌・未分化癌・軟骨肉腫が1例ずつであった。検討項目は当院の治療方法，予後，術後合併症，硬膜浸潤の有無とした。全体の死因特異的5年生存率は59%であった。転帰は生存17例，原発巣死8例，合併症死2例，他因死2例であった。術後合併症は6例（21%）に認めた。硬膜浸潤は13例（45%）に認め，硬膜内浸潤は2例（6%）に認めた。頭蓋底手術により頭蓋底悪性腫瘍の予後は改善し，チーム医療により安全性も向上した。

Background and Aims: A small mass of melanocytic nevi on the face is commonly treated by surgical resection. This method is associated with cosmetic complications, such as scarring and scar contracture. The use of CO2 Laser treatment to avoid these complications is increasing. However, scarring or recurrence may still occur after CO2 Laser treatment. To resolve these problems, we developed a new Combined Laser Therapy (CLT) protocol using three laser instruments.Subjects and Methods: We used CO2 Laser, Nd:YAG Laser and Q-Switched Ruby Laser. The first treatment was a minimal mass reduction using CO2 Laser. The surface is covered with carbonized tissue. The second treatment with Nd:YAG Laser which removes the carbonized tissue, because the laser specifically absorbs black chromatophores. Finally, any surviving nevus cells containing melanin are destroyed with Q-Switched Ruby Laser.Results: This method was used for 12 cases presenting with small masses of melanocytic nevi on the face. The maximum size of the mass was 20 mm. All cases resulted in a cosmetic improvement and there was no scarring or recurrence. Either satisfactory or greatly improved cosmetic results were obtained in all cases.Conclusions: We think that the wound healing without scarring observed in all of our cases is related to the administration of both CLT and auto-simultaneous Low reactive Level Laser Therapy (LLLT) in these cases. Therefore, this method may provide the better treatment than surgical resection in the future.

Summary Background The objective of the current study is to elucidate the three-dimensional vascular distribution as far as the peripheral areas of a latissimus dorsi musculocutaneous flap and to establish a safe procedure for creating it. Methods A lead oxide with gelatin-contrast agent was injected into fresh cadavers and the angiosomes in the muscle and skin were examined in detail. Results In the muscle, three vascular territories were observed. The first vascular territory was formed by the thoracodorsal artery, the perforating branches of the ninth intercostal artery and those of the tenth intercostal artery located in the lateral part of the muscle. The second vascular territory was formed by the perforating branches of the tenth intercostal artery located in the medial part of the muscle, those of the 11th intercostal artery and the subcostal artery. The third vascular territory was formed by perforating branches of the first and second lumbar arteries. In the dorsal skin above the muscle, two vascular territories were observed. The first vascular territory was formed by perforating cutaneous branches of the thoracodorsal artery, perforating branches of the ninth through 11th intercostal arteries and the scapular circumflex artery. The second vascular territory was formed by perforating branches of the subcostal artery and the first and second lumbar arteries. Conclusions When using a latissimus dorsi musculocutaneous flap with the thoracodorsal artery as a pedicle, the flap can be safely elevated as far as the inferior border of the 12th rib where perforating branches of the subcostal artery are distributed. At the same time, skin above the muscle can be safely harvested up to the iliac crest. It is essential, however, that the skin paddle includes perforating branches of the ninth intercostal artery or perforating branches of the 10th intercostal artery in the lateral part of the muscle.

Objective Craniofacial resection (CFR) for advanced sinonasal malignant tumors (SNMTs) is mandatory for radical resection. Surgeons must be aware of perioperative complications and long-term outcome because this procedure is extremely invasive, especially when the tumor involves the anterior skull base. Methods Thirty-eight consecutive surgical patients with advanced SNMT of T4 stage or Kadish stage C (31 men and 7 women; mean age, 55 years; range: 19–76 years) treated with CFR in the past 28 years were followed up for 59.4 months. In cases of unilateral orbital extension, en-bloc resection was achieved using several neurosurgical techniques (extended CFR) from 2005 onwards. Herein, we evaluated the safety and effectiveness of surgery by comparing survival data between 2 time periods (first stage: 1984–2004, second stage: 2005–2012). Results Squamous cell carcinoma was the most common histological type observed (65.8%), followed by esthesioneuroblastoma (15.8%). Using a combination of adjuvant radiation therapy, the 5-year overall survival and the 5-year disease-specific survival rates were 55.5% and 59.4%, respectively. Sarcomatous histology was a poor prognostic factor. The 5-year disease-specific survival rate was 48.9% in the first stage and improved to 82.1% in the second stage ( P = 0.057); this was related to improvements in local control rate. Conclusions CFR and postoperative radiotherapy are safe and effective for treating advanced SNMTs. Extended CFR, including radical orbital exenteration, may contribute to good long-term outcomes. A diverse surgical team may help perform radical resection and reconstruction in patients with advanced tumors.

This experimental 60 frames-per-sec progressive-scan HDTV camera has 1, 920 × 1, 080 pixels and three CCDs for RGB color. The horizontal CCD of the camera was driven at 148.5 MHz, and the transfer efficiency of the CCD cell was about 99.98%. A 2/3-inch 2.2-million pixel FIT (Frame Interline Transfer) CCD for an interlaced HDTV camera was used for the progressive scanning. This involved using multiple FIT drives and storing the odd numbered picture lines in the field memory and the even numbered picture lines in the vertical signal transfer CCD. The horizontal and vertical resolutions of this camera were each about 1000 TV lines (TVLs), and the vertical MTF (Modulation Transfer Function) response was about 57% on 700 TVLs and 30% on 1000 TVLs. A computer simulated conversion from a progressive to an interlaced image that used images acquired by this experimental camera reproduced an alias-suppressed interlaced image.

We devised a cube advancement flap and reported its usefulness for treating defects of the face. Here we report its use to treat five cases of extensive scarring of the limbs with similar satisfactory results.

Correction of severe short nose is a distressing problem for plastic surgeons. It is difficult to simultaneously lengthen the 3 components of the nose, which are the outer skin envelope, the framework, and the mucosal lining. We developed a new method to lengthen the nose more than 10 mm definitively and safely, which was performed using the technique of distraction osteogenesis.The procedure involves a 2-stage operation. At the first stage, boat-shaped iliac bone is grafted on the dorsum. More than 6 months later, the second-stage operation is performed. The grafted bone is cut horizontally in the center, and the distraction device is applied to it. Distraction osteogenesis is started after a latency period of 14 days and performed at a rate of 0.6 mm once daily. The distraction device is replaced by a special attachment (Ribbond; Ribbond Inc) during the 3-month consolidation period.Our method was applied for 2 patients with congenitally and posttraumatic severe short nose, respectively. The total amount of distraction osteogenesis was 12.6 and 13.8 mm, respectively. The profiles of both of the patients improved, and they were satisfied with the results.The method we developed is an entirely new approach to the correction of severe short nose. Furthermore, it was determined that nonvascularized grafted iliac bone could be lengthened by distraction osteogenesis. Our new method was a very effective and definitive technique and could become a mainstream procedure for the correction of severe short nose.

Background Although the use of free flaps has become a major option for head and neck reconstruction, the pectoralis major myocutaneous flap still plays an important role because of its advantages and its convenience as a pedicle flap located adjacent to head and neck lesions. However, there remain two problems with the pectoralis major myocutaneous flap, namely, the difficulty in preparing a small, thin skin paddle with stable blood circulation for small defects and, particularly for female cases, sacrifice of the breast. The authors report a new method of preparing a pectoralis major myocutaneous flap to solve these problems. Methods A skin paddle is designed just above the third intercostal perforating branch of the internal thoracic artery. The pectoralis major myocutaneous flap, including the muscular branch of the third intercostal perforating branch in its muscle, is elevated. The pectoralis major myocutaneous flap is moved to the reconstruction site through the subclavian route. Results This method was used for 11 cases with small defects in the head and neck caused by lesions. Slight marginal necrosis was observed in one case, but the other skin paddles took completely. There was no infection or fistula formation, and almost satisfactory functional results were obtained in all cases. Deformity in donor sites that included a breast was also minimal. Conclusions With this method, it was possible to prepare the pectoralis major myocutaneous flap using a small, thin skin paddle with stable blood circulation. Breast deformation, particularly in female cases, was also kept to a minimum.

In adult cases of bilateral cleft lip nasal deformity, an esthetically satisfying result can not be obtained only by manipulation inside the nose with the nasal tip pointing upward. The nasal tip should be made in a more anterior direction for nasal esthetic improvement. Additional tissue beyond the nose is needed, and the forked flap is a useful method in such cases. However, the blood circulation of long and narrow flaps containing the scar, especially after open rhinoplasty, is unstable. We have developed a new long and narrow forked flap that has a more stable blood circulation. The forked flap was made using two subcutaneous pedicles attached to the periphery of the each flap. We applied this flap to five adult cases of bilateral cleft lip nasal deformity. Four of the cases had the scar associated with the flying bird incision, and one case required no treatment after the primary repair. All the flaps took without signs of partial necrosis. In all cases, the nasal tip was projected forward with adequate columella elongation, and the profile was esthetically improved. In the final stage of correction for adult cases of bilateral cleft lip nasal deformity, this method, making maximum use of the tissue containing the scar in not only the white lip but also the vermilion, is very effective. It is very important to obtain nasal esthetic improvement for the adult patient with bilateral cleft lip nasal deformity.