Atsuomi Saiga

Early midfacial distraction for syndromic craniosynostotic patients with obstructive sleep apnoea.

Syndromic craniosynostosis is known to be associated with various obstructive respiratory disorders, including sleep apnoea. We performed early midfacial distraction in 11 syndromic craniosynostotic patients with obstructive respiratory apnoea and obtained good results. There were four patients with Crouzon syndrome, three patients with Pfeiffer syndrome and four patients with Apert syndrome. Their ages ranged from 7 months to 3 years, 9 months (mean: 2 years, 5 months). Midfacial distraction was performed using an internal or external device to improve obstructive respiratory disorders, such as sleep apnoea, and to avoid tracheostomy. Evaluation was performed by comparison of the pre- and postoperative polysomnograms (PSGs) and cephalograms. All patients had markedly improved respiratory disorders during sleep and avoided tracheostomy. Preoperative PSGs and cephalograms were compared with those from 1 year to 1 year, 6 months postoperatively. The postoperative PSGs and cephalograms showed marked improvements compared with preoperative PSGs and cephalograms. Syndromic craniosynostotic patients have facial bone hypoplasia, particularly of the maxilla. The tongue and parapharyngeal soft tissue become enlarged, and the enlarged tissues can cause airway obstruction. In this study, marked improvements were observed in physical evaluation using PSGs and morphological evaluation using cephalograms. Early midfacial distraction is thought to be a very useful method to reconstruct a large pharyngeal cavity, enlarge the airway, improve obstructive respiratory disorders and to avoid tracheostomy. It is important to select a device suitable for each case when surgery and distraction are performed.

A case of Crouzon syndrome treated by simultaneous bimaxillary distraction

In general, midfacial hypoplasia can be a cause of airway obstruction in patients with syndromic craniosynostosis, such as Apert syndrome and Crouzon syndrome. There have been recent reports indicating that Le Fort III midfacial distraction is effective in improvement of respiratory conditions. Our report describes a Crouzon syndrome case with repeated obstructive sleep apnea (OSA) and chronic respiratory disorder. The patient underwent not only midfacial distraction but also mandibular distraction to improve their respiratory conditions. The postoperative respiratory conditions markedly improved, and satisfactory improvements of the occlusal conditions and facial appearance were achieved. In recent years, there have been some reports in which maxillomandibular advancement or maxillomandibular distraction was performed on adults with severe OSA. However, no reports have been made on simultaneous distraction of the midface and mandible for patients with syndromic craniosynostosis. This report will present such a case in a child in whom good results were obtained. The patient was a ten-year-old boy with Crouzon syndrome, and his family history was non-contributory. During infancy, the patient underwent cranioplasty and ventriculo-peritoneal shunt surgery at the neurosurgery department. At age 2 years, he underwent Le Fort III midfacial distraction using an internal device. However, recurrence of OSA was observed. Preoperative polysomnography (PSG) showed an apnea-hypopnea index (AHI) of 29.6, and severe OSA was observed. The patient had a small mandible, narrow pharyngeal space, and severe glossoptosis during sleep. The respiratory disorder was determined to be caused by not only by maxillary hypoplasia but also by mandibular hypoplasia. Thus, Le Fort III distraction using a halo device (Blue Ddevice: W. Lorenz, Jacksonville, FL) and mandibular distraction using an internal device (W. Lorenz, Jacksonville, FL) were performed simultaneously (Figure 1). A few days after surgery, the maxilla and mandible were distracted at a rate of 1 mm per day. The amount of distraction was determined, taking into account the patient’s occlusal conditions, maxillary and mandibular solid models, and respiratory conditions which were checked on a regular basis. As a result, the midface was distracted 19 mm and the mandible 13 mm. Postoperatively, the hypoplastic midface and mandible were enlarged. The patient had an uneventful postoperative course and only slight pain with no major complications. Halo device removal and internal device removal were performed one month and six months after completion of distraction, respectively. Postoperatively, the treatment was continued with orthodontic treatment. Presently at 4 years after surgery, postoperative AHI is 4.2, indicating major improvement in the respiratory condition. Preand postoperative cephalograms were analyzed. Preoperatively, sella-nasion-subspinal (SNA)

Two-stage repair for severe proximal hypospadias using oral mucosal grafts: combination of a modified Bracka method and a modified Byars flap method.

AbstractOne-stage repair is a conventional treatment of hypospadias. If hypospadias is severe as in the scrotal type and perineal type, penile curvature sometimes cannot be corrected by dorsal midline plication alone. In addition to resection of the urethral plate, ventral grafting becomes necessary for insufficient skin and subcutaneous tissue. In recent years, there has been renewed interest in 2-stage repair for such severe cases and salvage of failed cases with scarring. In the present study, novel 2-stage urethroplasty was performed in 6 cases to repair severe proximal hypospadias which required resection of the urethral plate. This novel method consisted of a combination of a modified Bracka method using oral mucosal grafts and a modified Byars flap of the dorsal foreskin. Good results were obtained using this novel method.

Special distraction osteogenesis before bone grafting for alveolar cleft defects to correct maxillary deformities in patients with bilateral cleft lips and palates: Distraction osteogenesis performed separately for each bone segment

INTRODUCTION Patients with bilateral cleft lips and palates have premaxillary protrusion and characteristic jaw deformities involving three-dimensional malposition of the premaxilla and bilateral maxillary bone segments. This study examined patients with bilateral cleft lips and palates who had deviation and hypoplasia of the premaxillas and bilateral maxillary segments. Before bone grafting, the patients were treated with special distraction performed separately for each bone segment using a halo-type external device. This report describes this novel treatment method which produced good results. MATERIAL AND METHODS The subjects were five patients with severe jaw deformities due to bilateral cleft lip and palate. They were treated with maxillary Le Fort I osteotomy and subsequent distraction performed separately for each bone segment using a halo device. In three of five patients, premaxillary osteotomy was not performed, and osteotomy and distraction were performed only for the right and left lateral segments with severe hypoplasia. RESULTS All patients achieved distraction close to the desired amount. The widths of the alveolar clefts were narrowed, and satisfactory occlusion and maxillary arch form were achieved. After the surgery, three of five patients underwent bone grafting for bilateral alveolar cleft defects and the bone graft survival was satisfactory. CONCLUSIONS This method had many benefits, including narrowing of alveolar clefts, improvement of maxillary hypoplasia, and achievement of a good maxillary arch form. In addition, subsequent bone grafting for alveolar cleft defects was beneficial, dental prostheses were unnecessary, and frequency of surgery and surgical invasiveness were reduced. This method is a good surgical procedure that should be considered for patients with bilateral cleft lips and palates who have premaxillary protrusion and hypoplasia of the right and left lateral segments.

Surgical treatment for congenital curved nail of the fourth toe.

AbstractSince congenital curved nail of the fourth toe (CNFT) was reported by Iwasawa et al in 1991, there have been only 19 cases of CNFT in 6 reports, which were from Japan and Taiwan. We performed surgery on 4 patients with CNFT and report here good results. There has been no previous detailed report on surgical treatment for this condition. This report will describe the treatment, mainly the surgical procedure.

Clinical application of Nuss procedure for chest wall deformity in Poland syndrome

A 6-year-old girl with Poland syndrome was diagnosed with loss of hard and soft tissue on her affected chest. She required chest reconstruction to protect her thorax and improve her developmental delay. We applied a titanium device used for children with funnel chest to her, resulting in good shape. By using this device, we avoided sacrificing healthy rib and muscle; she could save the tissue for secondary surgery in puberty. The device made it possible to support the growth of her thoracic frame and has kept it in good shape. Also, 66 months after removing the device, her chest contour has been maintained. We evaluated the change of her chest frame by comparing the preoperative and postoperative CT index and found the result quite an improvement. We suggest that our technique would be easy, of low invasiveness, and safe for treatment of thoracic deformity in school age.

Hair braiding method to prevent hair from entering the operating field on the scalp.

AbstractIn scalp and cranial surgeries, it had been conventional to shave hair for surgical manipulations and prevention of infection. In recent years, it has been conventional to perform surgeries with minimal hair shaving. Such a method has been found to have a low risk of infection, and it takes into account esthetic considerations for patients. However, since long hair can become a hindrance to surgery, it is essential to preoperatively manage such hair and maintain a clear operating field. In this study, we braided patients’ long hair to obtain a good operating field during scalp or cranial surgery. The advantages of our method are that it can be performed easily in a short period of time, does not require special instruments, and does not damage hair because rubber bands are used minimally. It is a useful method that minimizes shaving of long-haired patients for surgeries of the head and reduces cumbersome steps.

Backward distraction osteogenesis in a patient with severe mandibular micrognathia.

Abstract Maxillary skeletal prognathism can involve severe mandibular micrognathia with marked mandibular retrognathism or hypoplasia. For patients with such a condition, a conventional treatment is mandibular advancement by sagittal split ramus osteotomy (SSRO). This procedure has problems such as insufficient advancement, instability of jaw position, and postoperative relapse. Thus, in recent years, mandibular distraction osteogenesis has been used in some patients. Mandibular distraction has many advantages, but an ideal occlusion is difficult to achieve using this procedure. That is, 3-dimensional control cannot be attained using an internal device that is unidirectional. This report describes a case of severe mandibular micrognathia in a 14-year-old girl treated using backward distraction osteogenesis. This procedure was first reported by Ishii et al (Jpn J Jaw Deform 2004; 14:49) and involves a combination of SSRO and ramus distraction osteogenesis. In the present study, intermaxillary fixation in centric occlusion was performed after osteotomy, and proximal bone segments were distracted in a posterosuperior direction. This procedure is a superior surgical technique that avoids the drawbacks of SSRO and conventional mandibular distraction. However, it applies a large load to the temporomandibular joints and requires thorough management. Thus, careful evaluation needs to be made of the indication for backward distraction osteogenesis.

Urethroplasty Using Diverticular Tissue for Hypospadias

The patient was a 3‐year‐old with hypospadias. Urethroplasty was performed as a two‐stage procedure, but a severe urethral stricture occurred due to a postoperative infection and the patient was virtually in urinary retention. An emergency cystostomy was performed, and thereafter urethral reconstruction was performed. A large urethral diverticulum had formed in the scrotum. The inner wall of the diverticulum was found to be completely epithelialized and well vascularized. Therefore, it was elevated as a skin flap and a neourethra was reconstructed up to the glans region using the diverticular tissue.

Protocol of surgical indications for scar contracture release before childbirth: Women with severe abdominal scars after burn injuries

Abstract It is difficult to determine if women with severe abdominal burn scar contractures can have uneventful pregnancies and births. There are few reports involving the relationship between severe abdominal scar contractures and pregnancy/childbirth. Furthermore, all of these reports are based on retrospective studies. The present study focused on women with severe abdominal burn scar contractures with desired fertility. This study investigated whether or not normal childbirth is possible, the necessity of scar contracture release, and the delivery method. In addition, a protocol developed by this hospital was prospectively evaluated. Surgery was indicated in women with scars covering ≥75% of the total abdominal area. The scarred area in the upper abdomen, superior to the navel, was considered particularly important. The protocol of this study serves merely as a reference, and future studies are needed with an increased number of cases.