Hirokazu Uda

Brava and autologous fat grafting for breast reconstruction after cancer surgery.

Background: Although autologous fat grafting is widely accepted for breast reconstruction, its indications remain limited to minor contour deformities after reconstruction and small deformities after breast-conserving surgery. The authors describe a case series of total or nearly total breast reconstructions treated with the perioperative use of a vacuum-based external tissue expander (i.e., the Brava device) followed by autologous fat grafting. Methods: The authors assessed the clinical outcomes and aesthetic results in six nonirradiated total mastectomy cases and eight severely deformed irradiated breast-conserving surgery cases. Total Brava wearing time and skin complications were also investigated. Results: The number of fat grafting procedures required ranged from one to four, and the mean amount of fat grafted during each procedure was 256 cc (range, 150 to 400 cc). Postoperative fat lysis and cellulitis occurred in two cases (14.3 percent). Brava worked effectively for total mastectomy cases, and improvement in the total aesthetic score was significantly higher than that in the breast-conserving surgery cases. All patients wore the device for more than 8 hours/day. The most frequent skin complication was dermatitis [n = 11 (79 percent)], which occurred in all breast-conserving surgery cases. Conclusions: Brava was well tolerated by patients. Fat grafting with perioperative use of Brava is an alternative to total breast reconstruction in total mastectomy cases. However, for severely deformed breast-conserving surgery breasts treated with radiation therapy, the contracted skin was difficult to extend despite Brava use, and the results were less satisfactory. These cases also experienced a higher incidence of skin complications compared with the total mastectomy cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The transconjunctival approach for orbital bony surgery: in which cases should it be used?

The advantages and disadvantages of the transconjunctival approach were examined to determine its indication for orbital bony surgery. The transconjunctival approach was used in 22 patients. The average follow-up was 13 months. Two patients had an intraoperative lower eyelid laceration because of excessive traction. Lower eyelid retraction occurred in 5 patients after surgery, although only 1 of them required surgical repair. With a transconjunctival approach alone, the exposure of the orbital lateral wall is limited and incorporation of a lateral incision has been found to be necessary. Postoperative eyelid retraction seems to occur even in the transconjunctival approach. The transconjunctival approach is best indicated in cases with an orbital medial wall fracture because it provides much easier access than any cutaneous approach.

Treatment of lateral ray polydactyly of the foot: focusing on the selection of the toe to be excised.

&NA; The purposes of this study were to evaluate the results of the operative treatment of lateral ray polydactyly and to consider appropriate surgical procedures, especially focusing on the selection of the toe, lateral toe or medial toe, to be resected. Twenty‐two patients with lateral ray polydactyly foot (25 individual feet) at an average of 71 months’ follow‐up were included in this study. Cases were classified morphologically into three types on the basis of Hirases configuration. In addition, these types were divided into two subtypes, metatarsal and phalangeal, on the basis of radiographic evaluation of the level of duplication. The clinical evaluations of the reconstructed toe were performed, and these results were investigated according to their morphologic classification and excised toe group. The distinctive problem of medial toe excision is valgus deformity. Eight of 25 toes retained persistent valgus deformity, and all of these cases were in the medial toe excision group. On the other hand, a distinctive problem in lateral toe excision is postoperative pain. Two patients suffered from postoperative pain in phalangeal type cases in the lateral toe excision group, and the remaining medial toe had a medial protuberant middle phalanx. The pain occurred at that protuberant point. Based on their experiences, the authors created an algorithm for selection of the toe to be excised. In metatarsal type cases, from a functional perspective, the toe that has a radiographically dominant metatarsus should be retained. On the other hand, in phalangeal type cases, the authors give priority to shape rather than function, and they excise the morphologically smaller toe independent of the condition of the phalanx as viewed on radiography. If the medial toe and the lateral toe are approximately the same size, the authors excise the lateral toe to avoid valgus deformity. When the lateral toe has severe valgus deformity that seems unlikely to be correctable intraoperatively, the lateral toe should be considered for excision even if it is larger than the medial toe. (Plast. Reconstr. Surg. 109: 1581, 2002.)

Multidirectional Cranial Distraction Osteogenesis for the Treatment of Craniosynostosis

Background: Although many operative methods for the treatment of craniosynostosis exist, whether any difference in outcome could be associated with either the childs age at surgery or the extent of the operation remains to be elucidated. The authors have developed a method of distraction osteogenesis for craniosynostosis that uses a new multidirectional cranial distraction osteogenesis system. Methods: From 2003 to 2008, 26 selected patients with syndromic and nonsyndromic craniosynostosis were treated with this method. The ages of the patients ranged from 9 to 139 months (median, 27 months). The follow-up period ranged from 13 to 81 months (median, 49 months). Results: The postoperative course was uneventful in all cases. The mean blood transfusion was 20.9 ml/kg. The mean postoperative hospital stay was 12 days. Sixteen of 49 (32.7 percent) anchor pins used in the first eight patients loosened because of bone absorption during the consolidation period. After the authors altered the screw shape, loosening occurred in seven of 81 pins (8.6 percent) in the last 18 patients. Loosening occurred in 28 of 204 traction pins (13.7 percent) among all patients. The phase of activation ranged from 8 to 14 days (mean, 10.5 days) and the consolidation period ranged from 21 to 42 days (mean, 29 days). Conclusions: Overall, distraction osteogenesis with the multidirectional cranial distraction osteogenesis method is safe and effective. The authors conclude that the multidirectional cranial distraction osteogenesis method constitutes an excellent alternative for all phenotypes of syndromic or nonsyndromic craniosynostosis.

Comparison of abdominal wall morbidity between medial and lateral row-based deep inferior epigastric perforator flap

INTRODUCTION Although deep inferior epigastric perforator (DIEP) flap is associated with decreased abdominal morbidity, motor nerve damage during flap elevation cannot be ignored. We compared abdominal morbidity after elevation of DIEP flap with lateral row perforators (L-DIEP) and medial row perforators (M-DIEP) to determine the perforators associated with less abdominal morbidity. METHODS Women who underwent breast reconstruction with DIEP flaps (n = 49) were included in this study. Among them, M-DIEP and L-DIEP were harvested in 27 and 22 patients, respectively. Pre- and postoperative trunk flexor muscle ability (at 3 and 6 months after surgery) was measured prospectively in all patients using an isokinetic dynamometer. The patients were also investigated for postoperative pain, stiffness, activity, bulging, and lumbago. RESULTS At 3 months after surgery, a significant decrease in trunk flexor muscle ability was observed in the patients of the L-DIEP group, but they recovered well after further 3 months. However, the recovery tended to be weak. Similar results were obtained with respect to pain, stiffness, activity, bulging, and lumbago between the two groups at 6 months after surgery. CONCLUSIONS Dominant perforators for DIEP flap elevation should be chosen by considering flap viability. However, surgeons should be aware that elevation with L-DIEP is associated with a high risk of nerve injury, and may in turn result in short-term decreases in trunk flexor muscle ability. Therefore, precautionary methods should be taken by the surgeons to preserve the motor nerve with atraumatic dissection, especially during elevation with L-DIEP.

Shaping of the Unaffected Breast with Brava-Assisted Autologous Fat Grafting to Obtain Symmetry after Breast Reconstruction

BACKGROUND In breast reconstruction, symmetry is a vital issue. However, when the original breast is unusually shaped or the patient desires augmentation at the time of reconstruction, obtaining symmetrical breasts becomes difficult. OBJECTIVES The authors performed shaping of unaffected breasts by Brava-assisted autologous fat grafting to enhance breast symmetry, and evaluated the clinical results to validate this new approach. METHODS Brava-assisted autologous fat grafting was performed to the unaffected breasts of 12 patients who had undergone unilateral breast reconstruction. The procedure was used for augmentation in six patients and to correct ptosis, volume, and tuberous breast deformity in three, two, and one patient, respectively. Clinical outcomes were assessed in all 12 patients. RESULTS All patients could complete fat grafting within two sessions (one session in nine patients and two sessions in three patients). The mean volume of grafted fat per session was 211 cc in all patients. The mean retention rate of grafted fat was 58.9% in the 10 patients for whom the retention rate could be calculated using preoperative and postoperative magnetic resonance imaging (MRI). Postoperative MRI revealed small benign foci in two patients (16.7%), which were not palpable and did not become a clinical problem. A postoperative mammography revealed a small agglutinate calcification in one patient, which was determined to be benign through biopsy. CONCLUSIONS Shaping the unaffected breast by autologous fat grafting combined with Brava is predictable, effective, and feasible as an aesthetic adjunct to unilateral breast reconstruction to achieve breast symmetry. LEVEL OF EVIDENCE 4 Therapeutic.

The concept and method of closed reduction and internal fixation: a new approach for the treatment of simple zygoma fractures.

Background: The authors have developed a new minimally invasive surgical procedure for simple zygoma fractures, a closed reduction and internal fixation method, that uses a cannulated cortical screw system. Methods: From 2007 to 2012, 42 selected patients with simple zygoma fractures without ocular problems or shear at the zygomatic frontal portion were treated with this method. The mean age of the patients was 33 years (range, 13 to 77 years). Results: The authors achieved good repositioning, equivalent to results achieved with conventional procedures in all cases. No notable complication occurred except for minor infection in two cases. Mean operative time was 32 minutes (range, 19 to 58 minutes). Postoperative relapse was found only in the posterior direction (p < 0.001), but the distance of that was so small (mean, 0.47 mm) that it did not cause any problem clinically. Conclusions: Although further improvement might be needed, such as screw specification, the closed reduction and internal fixation method has many advantages: short operative time, less effect on soft tissue, maintenance of bone healing potential, and decreased postoperative pain and swelling. The authors concluded that this method has the potential to become a future surgical procedure for simple zygoma fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Orbitomaxillary Reconstruction Using a Combined Latissimus Dorsi Musculocutaneous and Scapular Angle Osseous Flap

Immediate reconstruction of orbitomaxillary defects is challenging for head and neck reconstructive surgeons. The primary goals of orbitomaxillary reconstruction are to cover the skin and mucosal defects, fill the defect space, and reconstruct the natural facial contour. This report describes 2 patients who underwent extended orbitomaxillectomy and immediate reconstruction using a combined latissimus dorsi musculocutaneous and scapular angle osseous free flap (LD-SA flap). The LD-SA flap has substantial advantages, such as providing structural support to the malar prominence, filling the large soft tissue defect, and preventing postoperative drooping of the cheek. The surgical technique is relatively straightforward, requires a shorter operative time, and produces less blood loss compared with other reconstruction approaches. The LD-SA flap is a useful option for extended orbitomaxillary defect reconstruction.

A Novel Technique That Protects the Lips during Orthognathic Surgery

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The oculocardiac reflex in aponeurotic blepharoptosis surgery

Abstract The purpose of this study was to investigate the correlation between the oculocardiac reflex (OCR) and blepharoptosis surgery for safe eyelid surgery. Fifty-four consecutive patients with bilateral aponeurotic blepharoptosis were enrolled in this study. Changes in electrocardiography (ECG) monitoring were recorded during surgery. Preoperative pressing on the globe and intraoperative stretching of the levator aponeurosis were also carried out and the occurrence rate of the OCR was recorded. A positive OCR was observed in 12 patients (22.2%) in the preoperative globe-pressing test, whereas a positive OCR was observed in 22 patients (40.7%) in the levator-stretching test. The levator-stretching test did not indicate a significant difference in the rate of heart rate decrease with respect to laterality. No correlation was observed between age and the occurrence of OCR. On the other hand, there was a significant difference in the percentage of heart rate decrease between patients with positive OCR and negative OCR as determined in the globe-pressing test (mean = 13.1% vs. 5.4%). During the practical operative manoeuvre, no bradycardia was observed in any case. This study confirmed that a rapid and strong traction of levator aponeurosis induces the OCR regardless of laterality and age. Atraumatic and gentle handling are essential to prevent OCR. The preoperative globe-pressing test may be an index of the OCR in reflex-prone patients. Intraoperative ECG monitoring will be useful for early onset detection, although positive OCR was not observed in any patient during the practical surgical manoeuvre.