Mine Ozaki

Experience of sclerotherapy and embolosclerotherapy using ethanolamine oleate for vascular malformations of the head and neck

Sclerotherapy is effective in the treatment of vascular malformations. However, in lesions with relatively high blood flow, its effect is not always adequate. We therefore developed a three-grade classification of vascular malformations to facilitate the selection of treatments according to vascular flow. We also developed the technique of embolosclerotherapy, in which transarterial embolisation is done before sclerotherapy to control blood flow in the lesion during sclerotherapy. We now have 14 years’ experience with 112 cases of vascular malformations of the head and neck treated with sclerotherapy. Results were evaluated with pretreatment and post-treatment photographs, and reduction of volume was calculated on findings from magnetic resonance imaging. Clinical improvement in 110 cases was graded as excellent in 32 (29%), good in 48 (43%), fair in 19 (17%), and poor in 11 (10%). In 84 cases, mean rate of reduction of volume was 35%. The most common complication was haemolytic haemoglobinuria (n=37, 33%). Our results suggest that this three-grade classification is useful to judge resistance to sclerotherapy and decide on treatment. Our experience indicates that ethanolamine oleate (EO), with or without arterial embolisation, was effective using our classification of vascular dynamics. We consider EO to be equivalent or superior to other sclerosants such as ethanol.

Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for periorbital skin hyperpigmentation in Asians.

Background: Periorbital skin hyperpigmentation, so-called dark circles, is of major concern for many people. However, only a few reports refer to the morbidity and treatment, and as far as the authors know, there are no reports of the condition in Asians. Methods: A total of 18 Japanese patients underwent combined therapy using Q-switched ruby laser to eliminate dermal pigmentation following topical bleaching treatment with tretinoin aqueous gel and hydroquinone ointment performed initially (6 weeks) to reduce epidermal melanin. Both steps were repeated two to four times until physical clearance of the pigmentation was confirmed and patient satisfaction was achieved. Skin biopsy was performed at baseline in each patient and at the end of treatment in three patients, all with informed consent. Clinical and histologic appearances of periorbital hyperpigmentation were evaluated and rated as excellent, good, fair, poor, or default. Results: Seven of 18 patients (38.9 percent) showed excellent clearing after treatment and eight (44.4 percent) were rated good. Only one (5.6 percent) was rated fair and none was rated poor. Postinflammatory hyperpigmentation was observed in only two patients (11.1 percent). Histologic examination showed obvious epidermal hyperpigmentation in 10 specimens. Dermal pigmentation was observed in all specimens but was not considered to be melanocytosis. Remarkable reduction of dermal pigmentation was observed in the biopsy specimens of three patients after treatment. Conclusion: The new treatment protocol combining Q-switched ruby laser and topical bleaching treatment using tretinoin and hydroquinone is considered effective for improvement of periorbital skin hyperpigmentation, with a low incidence of postinflammatory hyperpigmentation.

Thermal effect of illumination on microsurgical transfer of free flaps: experimental study and clinical implications.

The light source of a modern operating microscope gives a clear operative field, but the possibility of thermal impairment by the strong light is substantial. We aimed to elucidate the potential risk of such strong light on transfer of free flaps and the optimal application of light. First, the thermal effect of clinically used microsurgical illumination was examined by direct irradiation of a thermometer. Secondly, the thermal influence on living tissue of microsurgical light was evaluated using a model of vascularised and non-vascularised pedicled groin flaps in rats. Thirdly, the influence of strong light on the transfer of free flaps was investigated using a model of a free groin flap in rats. Fourthly, histological alteration was investigated by a light microscopy and scanning electron microscopy. With direct irradiation of a thermometer, temperatures reached values in excess of 80 °C with maximal xenon light illumination from 20 cm. The mode of illumination significantly influenced the results of free flaps. Prolonged irradiation of the vascular pedicle in particular resulted in an increase in the number of failures, supposedly caused by venous occlusion. Bright illumination contributed to efficient microvascular procedures, but we confirmed its potential risk. Our findings may benefit all surgeons engaged in transfer of free flaps, as potential impairment caused by excessive operative irradiation is prevented simply by recognition of its harm.

Efficacy and evaluation of safety of sclerosants for intramuscular venous malformations: clinical and experimental studies.

Abstract Excision of intramuscular venous malformations may damage intact functional muscles, and sclerotherapy is an alternative way of relieving symptoms. Several sclerosants are available, but selection of the optimal one is controversial. We report our clinical experiences of sclerotherapy, and experimental studies in rats that investigated muscular damage after injection of various sclerosants. For the clinical study, 10 patients with intramuscular venous malformations were reviewed who had been treated by sclerotherapy using ethanolamine oleate. The rate by which the volume reduced was assessed quantitatively using findings from magnetic resonance imaging (MRI). Pain was cured or improved in all cases, and volume reduced on imaging analysis. There were no severe complications such as renal failure or thromboembolism. For the experimental study, 62 Wistar rats were used to investigate the toxicity of sclerosants on the intact-muscle by injecting three types of sclerosants (100% ethanol, 5% ethanolamine oleate, and 1% polidocanol). After the injection of each sclerosant into the anterior tibial muscle, the daily measurement of the circumference of the legs, histological and morphological alterations in the muscles, and maximal isometric tetanic tension, were investigated. Swelling was most prominent with ethanolamine oleate, while destruction and atrophy of the muscle were most prominent after injection of ethanol. In the clinical study, the efficacy of 5% ethanolamine oleate was at least equivalent or possibly superior to that of 100% ethanol. In the experimental study, ethanol had a more detrimental effect on muscles than the other agents. We consider that ethanolamine oleate is the most suitable sclerosant for the treatment of intramuscular venous malformations.

Subcutaneous Injection of Normal Saline Prevents Cutaneous Complications of Ethanol Sclerotherapy for Superficial Vascular Lesions: An Experimental Study

BACKGROUND Percutaneous sclerotherapy is an effective therapeutic option for the treatment of venous malformations. Absolute ethanol is used as a sclerotic agent because of its effectiveness but is often avoided for treatment of superficial lesions because of the possible risk of cutaneous necrosis. OBJECTIVE A preclinical experimental study was performed to validate whether the cytotoxic effects of ethanol on surrounding healthy tissues could be diminished with prophylactic subcutaneous injection of normal saline above the vascular lesion immediately after intraluminal injection of ethanol by dilution. METHODS AND MATERIALS The effect of normal saline dilution on cytotoxicity of ethanol to the main cells of the skin (fibroblasts and keratinocytes) were assessed using 3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide colorimetric assay. Effects of subcutaneous injection of normal saline immediately after intraluminal ethanol injection were assessed in a newly developed animal experimental model using the rabbit auricular vein. RESULTS Cytotoxic effects of ethanol were decreased by saline dilution in vitro. Subcutaneous injection of normal saline after intraluminal injection of ethanol prevented the cutaneous ulceration observed in all cases without subcutaneous injection of normal saline in our animal model. CONCLUSION Subcutaneous injection of normal saline appears effective for preventing cutaneous complications after ethanol sclerotherapy for superficial vascular lesions. The authors have indicated no significant interest with commercial supporters.

Comparison of Nasal Septum and Ear Cartilage as a Graft for Lower Eyelid Reconstruction.

AbstractIn lower eyelid reconstruction, several types of grafts from the nasal septum, ear cartilage, buccal mucosa, and hard palate mucosa have been used for an inner layer of the lower eyelid, but there have been no studies comparing these grafts. The authors retrospectively reviewed our cases of lower eyelid reconstruction, and compared chondromucosal grafts from the nasal septum (N = 8) and ear cartilage grafts (N = 10) for an inner layer of the lower eyelid. The authors observed no significant difference in operative time, blood loss, or length of hospital stay between the “nasal septum” and “ear cartilage” groups. The final results were aesthetically and functionally satisfactory in both groups. In the nasal septum group, 1 patient suffered from perforation of the nasal septum and another patient suffered from nasal bleeding postoperatively. There were no donor site complications in the ear cartilage group. These findings indicate that both a chondromucosal graft from the nasal septum and an ear cartilage graft are good grafts for an inner layer of the lower eyelid. Regarding the donor site, however, an ear cartilage graft has the advantage of a lower complication rate.

Transzygomatic coronoidectomy as a treatment for pseudoankylosis of the mandible after transtemporal surgery

Pseudoankylosis of the mandible after a transtemporal operation is rare. In patients with severely limited mouth opening, a transzygomatic approach is the approach of choice. We report a case of pseudoankylosis of the mandible that was successfully treated by transzygomatic coronoidectomy.

Detrimental influences of intraluminally-administered sclerotic agents on surrounding tissues and peripheral nerves: An experimental study

Abstract The minimally-invasive nature of sclerotherapy makes it one of the first treatment options for venous malformations, although treatment-related complications, such as peripheral nerve paralysis, have been reported in some clinical cases. However, no studies of the aetiology of the detrimental effects of intraluminally-administered sclerotic agents on the surrounding tissues, including the peripheral nerves, have yet been published. This study therefore investigated the influences of intraluminally-administered sclerotic agents on the tissues surrounding the injection site using a newly-developed rat femoral vein model. Using this model, the effects of absolute ethanol, 5% ethanolamine oleate, and 1% polidocanol were compared histologically with those of normal saline controls. Fluorescein isothiocyanate-conjugated agents were administered and the leakage of sclerotic agents through the venous wall was evaluated by fluorescence microscopy. Damage to the adjacent femoral nerve was quantitatively evaluated by counting the numbers of axons in cross-sections. All the sclerotic agents caused vascular wall injuries and leakage into the surrounding tissues. The number of axons in the femoral nerve was significantly reduced following administration of absolute ethanol or 5% ethanolamine oleate, compared with normal saline. The results of this study suggest that sclerotic agents commonly leak out the vascular lumen, and some agents can cause adjacent nerve injury. It is important to be aware of this type of complication of sclerotherapy for venous malformations when selecting appropriate therapeutic interventions.

Alteration of arterial blood flow after free muscle transfer.

To investigate blood flow alterations and their determinants after free flap transfer, we focused on a vascularized latissimus dorsi muscle segment for reconstruction of the paralyzed face as an ideal model, since the vascular pedicle and type of flap are identical among patients. Seventeen patients were studied using color Doppler ultrasonography at 6 time points from before the operation to >1 month postoperatively. The influences of preoperative facial arterial flow volume, volume of muscle, and duration of ischemia on postoperative pedicle arterial flow were analyzed. Arterial flow volume decreased dramatically after revascularization and remained constantly low in comparison with preoperative blood flow volume. The shape of the blood velocity waveform reflecting downstream vascular impedance changed, but recovered to the baseline state within 6 days. Preoperative flow volume and transferred muscle weight correlate with postoperative flow volume for 6 days postoperatively. The duration of ischemia was not influential.

Temporary Suspension of Acute Facial Paralysis Using the S-s Cable Suture (medical U&a, Tokyo, Japan)

For a treatment of facial paralysis, suture suspension of soft tissue is considered effective due to its less invasiveness and relatively simple technique, with minimal bruising and rapid recovery. However, suture suspension effect may not last for a long period of time. We obtained good outcome with temporary static suture suspension in 5 cases of severe facial paralysis in the intervening period between the onset of paralysis and expected spontaneous recovery. We used the S-S Cable Suture (Medical U&A, Tokyo, Japan), which was based on the modification of previously established method using the Gore-Tex cable suture originally reported by Sasaki et al in 2002. Because of the ease of technique and relatively strong lifting capability of the malar pad, we recommend it as a useful procedure for a patient suffering acute facial paralysis with possible spontaneous recovery for an improved quality of life by the quick elimination of facial distortion.