Ikkei Tamada

Effectiveness of additional transmalar Kirschner wire fixation for a zygoma fracture

Background: The purpose of this study was to verify the effectiveness of transmalar Kirschner wire fixation as additional fixation for the treatment of zygoma fractures. Methods: The authors compared two methods for zygoma fixation at the frontozygomatic suture from both theoretical and clinical viewpoints: miniplate fixation (plate fixation) and miniplate fixation with an additional transmalar Kirschner wire fixation (wire plus plate fixation). For the theoretical study, the authors produced zygoma fractures on 20 skull simulation models; these were generated on the basis of computed tomographic data of actual dry skulls. In their simulation surgery, they fixed the fractured zygoma with the above-mentioned two fixation methods, producing 20 plate fixation models and 20 wire plus plate fixation models. A 10-kgf load was then applied on the fractured zygoma in the anteroposterior and superoinferior directions. Finally, the stresses around the fixation screws and the deviation of the zygoma were calculated using finite element analysis. For the clinical study, the authors compared the postoperative zygoma alignment based on computed tomography of six patients treated with plate fixation and eight patients treated with wire plus plate fixation using a visual analogue scale. Results: In the theoretical study, the wire plus plate fixation models demonstrated a significant decrease in both the stresses around the screws and the deviation of the fractured bone compared with the plate fixation models. In the clinical study, the visual analogue scale scores for the wire plus plate fixation group were significantly higher than those for the plate fixation group. Conclusion: Because the additional transmalar Kirschner wire fixation can effectively increase the stability of the fractured zygoma that has been fixed with one miniplate, it should be recommended as an effective technique for the treatment of complicated zygoma fractures.

A 25-year review of cases with submucous cleft palate

OBJECTIVES To evaluate the effect of diagnostic and operative time on velopharyngeal closure in submucosal cleft palate (SMCP). METHODS SMCP patients treated at the Keio University School of Medicine from 1986 to 2011 were enrolled as subjects. Clinical data were obtained, including patient sex, age at diagnosis, and operative age, occasion of diagnosis, accompanying deformities, speech test results before and 6 months after palatoplasty, and pharyngeal flap usage after palatoplasty. RESULTS Data were available for 16 patients, with a mean diagnostic age of 51.1 months (range: 0-132 months). The clinical presentations were bifid uvula in 4 patients and speech dysfunction in 11. The cases suspected from bifid uvula were diagnosed significantly earlier than those with speech dysfunction (19.5 versus 56.8 months, p<0.01). Velopharyngeal closure was improved in 6 cases, and the average age of these patients at surgery was significantly lower than that of the other patients (46.7 versus 79.8 months, p<0.05). A pharyngeal flap was performed in 7 cases (43.8%). The pharyngeal flap usage rate in cleft palate patients other than those with SMCP was significantly lower than that of SMCP patients (3.5% versus 43.8%, p<0.01). CONCLUSIONS Early discovery and surgical correction is vital for improving postoperative speech outcomes in SMCP patients. This requires educating physicians about SMCP and future studies regarding simple and effective SMCP screening methods.

Dynamic total skull remodeling by a combination of morcellation craniotomy with distraction osteogenesis: the MoD procedure.

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

Maxillary-driven simultaneous maxillo-mandibular distraction for hemifacial microsomia.

We treat hemifacial microsomia with a combination of surgery and orthodontic treatment during the growth period, resulting in early improvement in facial asymmetry and the induction of normal growth. We previously used gradual distraction of the mandibular ramus for Pruzanskys type II classification (Pruzansky, 1969). In type II cases, the maxilla should also be treated actively as, using this technique, improvement of the occlusal plane is difficult to achieve, resulting in a cross bite and difficulties in post-operative orthodontic treatment-especially in older patients. Morphologically, the mandibular angle region of the operative side is flat, and the angle of the mouth remains elevated. We performed mandibular-driven simultaneous maxillo-mandibular distraction while the occlusion was maintained using intermaxillary anchorage. However, mandibular-driven distraction tended to elongate the face because the mandible only elongated downwards and the mandibular ramus did not reach the glenoid. Furthermore, external distraction devices produce significant distress for patients until removal of the device and cause scars on the face. We developed a new internal distraction device with a variable angle and performed maxillary-driven simultaneous maxillo-mandibular distraction using this device. The result was morphologically satisfactory and solved the above problems. Because the patient was in the growth period, careful follow-up and induction to normal growth were important while the inferior growth of the affected side was monitored.

Advantages of open treatment for syndactyly of the foot: Defining its indications

For the repair of syndactyly of the foot, skin grafting is often used to close the skin defect, but open treatment is not common. However, with grafting, an additional scar at the donor site and patchwork-like scar at the recipient site are inevitable. Our aim was to describe the process of epithelialisation and define the indications for open treatment of syndactyly of the foot. The open treatment was used on 16 webs. The texture of epithelialised surface resembled volar skin; the visible scar was mainly at the dorsal edge; and web creep occurred predominantly on the volar side and resembled the natural slope of the commissure. Open treatment is better than skin grafting because of better match of texture without a patchwork-like scar, and it is indicated in cases of simple incomplete syndactyly of the foot that extends proximal to the distal interphalangeal joint.

Cleft palate repair using a marginal musculo-mucosal flap.

Objective: To describe a modified procedure consisting of a mucoso-periosteal flap palatoplasty with a marginal musculo-mucosal flap (3M flap). This is also the first report of a primary repair for complete cleft palate using the 3M flap. We describe the lengthening effect of the nasal mucous layer of the soft palate and evaluate the fistula formation rate associated with this method. Methods: This procedure has been performed on 21 patients with unilateral complete clefts and on 27 patients with incomplete clefts. A mucoso-periosteal flap raised from the hard palate was used mainly for closure of the cleft and not for the push-back. The 3M flap repaired the deficit of the nasal mucosa, making sure that the soft palate was lengthened. Intravelar veloplasty was performed also. Results: The dimension of the nasal mucosal defect that can be filled with the 3M flap is 10 to 12 mm in length, oriented anterior-posterior, and 15 to 20 mm wide. Oronasal fistula formation was recognized in only 3 of 48 cases (2 of 21 complete clefts, 1 of 27 incomplete clefts) and were located at the hard-soft palate junction at the anterior portion of the 3M flap. Conclusions: This method has the theoretical advantages of (1) preventing fistula formation by filling the tissue deficiency with the 3M flap; (2) achieving better velopharyngeal function due to elongation of the soft palate and retropulsion of the muscular bundle, utilizing the 3M flap; and (3) minimizing maxillary growth retardation by adopting a non–push-back method of hard palate repair.

Outcome analysis of morcellation craniotomy with distraction osteogenesis for scaphocephaly

Background: Techniques for sagittal synostosis correction continue to evolve, thus resulting in improved outcomes and minimized morbidity. Spring-assisted cranioplasty and strip craniotomy with postoperative helmet usage are simple minimally invasive surgeries. However, these procedures are only useful in younger patients (generally up to 9 months of age); older children usually undergo total cranial remodeling, which is more stressful. We have developed a procedure combining morcellation craniotomy with distraction osteogenesis (MoD), which we have been performing since 2000. Here, we describe and evaluate this method of treatment. Methods: Seven patients who underwent MoD for isolated sagittal synostosis were followed for 10 years postoperatively. The control group consisted of 7 patients who had undergone total cranial remodeling in the period immediately preceding the MoD operations. Cephalography, clinical examinations, medical record data and medical photographs were used to evaluate and compare the 2 groups. Results: In comparison with total cranial remodeling, the MoD procedure resulted in a significantly shorter mean operation time and a significantly lower mean blood transfusion volume. The postoperative cephalic index was not significantly different between the MoD (75.8 ± 0.9) and the control groups (75.6 ± 1.4), and satisfactory cranial shape volumes were achieved without serious complications. Conclusion: The MoD procedure is a safe, effective and reliable technique for dynamic total skull remodeling with minimal morbidity. It can be used to improve upon previous surgical concepts for treating scaphocephaly, particularly in older patients.

Surgical creation of a Cupid's bow using W-plasty in patients after cleft lip surgery

The three-dimensional contour of the Cupids bow is extremely important from a cosmetic standpoint, and many patients with bilateral or unilateral cleft lip require revision or reconstruction of the Cupids bow.A number of surgical techniques have been reported for creating the Cupids bow, among which the methods of Gillies and Onizuka are the most widely known. In the methods of Gillies and Onizuka, the dog-ear can result in excessive volume in the vermilion notch, raising the trough in the Cupids bow and leading to regression during the post-surgical period. We have improved upon these techniques using the W-plasty and have obtained satisfactory results that preserve the white skin roll. In our method, the left and right prominence of the Cupids bow is created through an incision of the white lip, while the central trough is created through a curvilinear incision of the vermilion mucosa. At the two sites of the white lip tissue and the curvilinear incision of the central vermilion tissue, the white skin roll is preserved as much as possible. In patients where the Gillies method had been used, the Cupids bow tended to be flattened gradually after surgery. We report on the details of our method and the case reports using the technique.

Involvement of the sphenosquamosal suture for unilateral coronal synostosis

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

Evaluation of Three Cases Using a Novel Titanium Mesh System-Skull-Fit with Orbital Wall (Skull-Fit WOW)-For Cranial Base Reconstructions.

Cranial base reconstructions associated with tumor resections around the orbital wall often require that both the upper and lateral orbital walls be reconstructed during a single procedure. Previously, we used titanium mesh plates that were preoperatively fabricated based on three-dimensional models. Although these plates are precise and do not increase the probability of infection, we still had to use autologous bones to reconstruct the orbital walls. Recently, we developed a new titanium mesh plate-called Skull-Fit(®)-with orbital wall (Skull-Fit WOW(®)), enabling us to reconstruct the cranial base and orbital walls without bone grafts. Here, we report on three reconstruction cases in which the novel titanium mesh-orbital wall system was used. In all three cases, the customized titanium mesh system performed satisfactorily with little, if any, complications.