Miyuki Kishibe

A Case of Beare-Stevenson Cutis gyrata Syndrome Confirmed by Mutation Analysis of the Fibroblast Growth Factor Receptor 2 Gene

This paper reports a case of Beare-Stevenson cutis gyrata syndrome confirmed by DNA analysis of the patient’s fibroblast growth factor receptor (FGFR) genes. At birth, the patient had ocular proptosis, a red nevus with skin tags on her forehead and an umbilical stump. She developed craniosynostosis, craniofacial dysmorphism and hydrocephalus. Her treatment included forehead and facial advancement and a ventriculoperitoneal shunt. Analysis of the FGFR genes revealed that she was heterozygous for a missense mutation in exon 10 for the FGFR2 protein, resulting in an amino acid substitution of cysteine for tyrosine at residue 375 (Tyr375Cys). This is the fourth case of Beare-Stevenson cutis gyrata syndrome confirmed by mutation analysis of the FGFR genes.

Incidence of lower eyelid complications after a transconjunctival approach: influence of repeated incisions.

Abstract Although many authors have described advantages of the transconjunctival approach, few reports describe risks of postoperative lower eyelid complications with repeated incisions. The objective of this study was to investigate whether the incidence of postoperative lower eyelid complication using the transconjunctival approach was different, depending on the time of incision. Patients who underwent orbital bony surgery at the Kanazawa Medical University Hospital between 1996 and 2012 were reviewed. Patients were divided into a group that underwent single transconjunctival incision and a group that underwent repeated incisions. Intraoperative and postoperative complications, including eyelid ectropion, entropion, and scleral show, were compared between the groups. A total of 154 transconjunctival incisions were made in 145 patients (mean age, 35.6 y; 99 men and 46 women), who were observed for a mean of 14 months (range, 6–97 mo). Two patients had eyelid lacerations with inferior lacrimal canaliculus injuries. Lower eyelid malposition requiring operative correction occurred in 3 of the 140 patients in group A (2.1%) and in 3 of the 14 patients in group B (21.4%) (P = 0.01). The total postoperative complication rate in patients with a single incision was 5.0% (n = 7), and that for repeated incisions (2–5 times) was 35.7% (n = 5) (P = 0.001). The total complication rate of transconjunctival incision was slightly high. Although repeated incision cases were significantly more frequent, the eyelid could be corrected without visible scarring although eyelid complications occurred.

Correction of Late Posttraumatic Enophthalmos Using an Antral Balloon.

AbstractEnophthalmos is the posterior displacement of the ocular globe within the bony orbit. Correction of late posttraumatic enophthalmos is one of the most challenging surgical procedures. We have performed a corrective procedure for late enophthalmos using an antral balloon, with or without minimal bone grafting. All orbital contents were separated from the bone fragments, infraorbital nerve, and mucosa of the maxillary antrum. The remaining orbital floor was fractured by the surgeons digital pressure from the maxillary antrum. The antral balloon was placed in the maxillary antrum and inflated under direct vision from inside the orbit. After a consolidation period, the patient underwent antral balloon removal. A total of 5 patients underwent repair of late enophthalmos using this antral balloon technique. The median time from initial injury was 14 months (range, 6–90 months). The median antral balloon placement duration was 76 days (range, 53–106 days). Satisfactory symmetries were achieved in 4 patients. Mild residual enophthalmos remained in 1 patient, who had an orbital framework deformity and was missing the entire orbital bony floor preoperatively and who required simultaneous bone grafting. The ideal indication for our technique was the need for orbital floor reconstruction, without an orbital framework deformity. This technique could avoid autogenous bone grafting or permanent alloplastic implantation, which may cause a foreign body reaction, chronic inflammation, and migration. We believe that our new technique is one of the least invasive corrective procedures for late posttraumatic enophthalmos.

Perifascial areolar tissue grafting for treating syndactyly with bone fusion in patients with Apert syndrome.

Abstract Complete syndactyly with bone fusion in patients with Apert syndrome was treated using perifascial areolar tissue (PAT) grafts via a two-stage surgery (i.e. bone separation using inter-bone PAT graft insertion followed by web separation and reconstruction with full-thickness skin grafts). This technique is easy and created nail folds for fingertips.

Intraoperative acquired pressure ulcer on lower lip: a complication of rhinoplasty.

Device-related pressure ulcers are not rare. However, few studies have reported pressure ulcers of the lower lip. We encountered 2 patients with an intraoperative pressure ulcer on the lower lip caused by an endotracheal tube during rhinoplasty. A 46-year-old man showed a deviated nose and nasal obstruction. Surgery was performed under general anesthesia with endotracheal intubation. The surgery time was 270 minutes. A 23-year-old man also showed a deviated nose and nasal obstruction. Surgery was performed under general anesthesia in the same fashion. The surgery time was 273 minutes. A preformed endotracheal tube was inserted and positioned over the mandible and secured with polyurethane film intraoperatively. Both patients had pressure ulcers on their lower lip. One showed a slightly visible scar. Care must be taken to avoid ulcers of the lower lip in rhinoplasty patients.

Repair of orbital fracture: the antral balloon with implantable reservoir technique.

AbstractThe antral balloon technique is a useful procedure for the treatment of orbital fracture. Its advantages include being able to apply it without any donor-site morbidity. However, the saline injection catheter, which is inserted nasally from the natural ostium, sometimes causes discomfort. We present our new antral balloon technique with an implantable reservoir dome. This technique did not cause patient discomfort because no saline injection catheter was inserted nasally. It contributed to long-term placement of the antral balloon. Of 30 patients, satisfactory symmetries were achieved in 27 patients and the others required subsequent calvarial bone grafting for correction because of residual enophthalmos.

A Perifascial Areolar Tissue Graft With Topical Administration of Basic Fibroblast Growth Factor for Treatment of Complex Wounds With Exposed Tendons and/or Bones

ABSTRACT The management of wounds with tendon and/or bone exposure is challenging because of the insufficient blood supply to the wound bed. We describe our experience with 19 patients using a perifascial areolar tissue (PAT) graft with topical administration of basic fibroblast growth factor (bFGF) in the treatment of complex wounds with exposed tendons and/or bones in the extremities. Using a PAT graft is minimally invasive and technically easy, and the donor site is relatively preserved. However, PAT grafts for the treatment of a complex wound with large areas of exposed tendons and/or bones have sometimes failed to survive because of insufficient vascularization of the wound bed. Therefore, topical administration of bFGF, which promotes angiogenesis, was added to the graft. All grafts showed good graft survival and successfully covered the tendons and bones. Topical administration of bFGF accelerated vascularization in the PAT graft and facilitated wound healing by increasing the blood supply to the wound bed and achieved success with the PAT graft. In conclusion, using a PAT graft with topical administration of bFGF is a suitable option for the treatment of complex wounds with a large proportion of exposed tendons and/or bones. With minimal damage to the tissues near the wound, the PAT graft can be a useful option for limb salvage and could become a valuable tool for reconstructive surgeons. Level of Clinical Evidence: 4

The Double Volar Flap Technique for Aesthetic Repair of Syndactyly and Polysyndactyly of Toe without Skin Grafting.

Background: Aesthetic repair of syndactyly of the toes is desirable because patients may have psychological concerns about its appearance. There are 2 important factors for the aesthetic repair of syndactyly of the toe. One is to hide the operative scar from the visual site (dorsal site), whereas the other is to create an interdigital space close to the normal anatomical skin characteristics (2 general types of skin: glabrous and hairy). Methods: In total, 12 patients (4 males and 8 females) with 15 syndactylous webs were operated on by using the double volar flap technique. The following 3 local flaps were designed with this technique: an M-shaped flap designed on the dorsal side of the interdigital region (flap A) and double volar flaps (flaps B and C) designed on the volar side of the interdigital region. Flap A was used for reconstruction of the web slope, whereas flaps B and C were used for reconstruction of the proximal sidewall of toes. Results: The corrected toes showed a deep and natural interdigital commissure with no exposure of skin grafts or conspicuous scars on the dorsal visible side. The scars on the volar side were also inconspicuous. Conclusions: The double volar flap method for repair of syndactyly and polysyndactyly of the toes has the same advantages as those of the local flap method, in addition to an optimum aesthetic result through matching with the normal anatomical skin characteristic of the interdigital space and hiding of the operative scar from the visual site.

Treatment of Localized Involutional Lipoatrophy after Local Injection of Corticosteroids into a Keloidal Scar with Fat Injection

Sir: I is reported that localized involutional lipoatrophy improves or completely heals naturally within 1 year in the majority of cases.1 However, there are no signs of improvement in some cases, and surgical treatment is necessary for them. We treated localized involutional lipoatrophy after local injection of corticosteroids into a keloidal scar with autologous fat injection. A 24-year-old woman presented with a keloidal scar on her left upper arm. We first performed surgical removal and postoperative 15-Gy-electron-beam irradiation to prevent recurrence. The postoperative scar was slightly raised and displayed redness 6 months after the excision of the keloidal scar. We then administered local intracutaneous corticosteroid (triamcinolone acetonide) injections to the proximal and distal sides of the scar once a month for 5 months. At month 7 after the last administration, she visited us with a 45 × 15 mm concave area present on the distal side of the scar (Fig. 1). Magnetic resonance imaging (MRI) revealed thinning of the fatty layer of the subcutaneous tissue in this region without inflammation of the surrounding tissues. Our diagnosis was localized involutional lipoatrophy caused by local injection of corticosteroids. Thus, we performed autologous fat injection 4 months after the diagnosis. Under local anesthesia, the fat injection was performed according to the method reported by Coleman.2 Autologous fat was obtained from the lower abdomen, and a total of 5.5 cm3 of refined fatty tissue was injected into the concave area. MRI at 3 months after the fat injection revealed that the injected fatty tissue was not distinguishable from the circumambient subcutaneous tissue. One year after the fat injection, no concavities or pigmentation was detected on physical examination except for a raised red scar overlaying the injected fatty tissue (Fig. 2). According to Dahl et al3 in 1996, local injection of corticosteroids or antibiotics was present in 62% of cases of localized involutional lipoatrophy. All of the patients except for one 5-year-old boy were

Aggressive remodelling with pedicled skin flaps of the volar surface for the release of contractures of the fingers

Abstract We treated contractures of fingers with one or several pedicled skin flaps on one or both sides of the scar, depending on the site and spread of the scar. The length of the flap was equivalent to half the circumference of the unaffected finger, or the distance between bilateral midlateral lines. The width of the flap was the same as the distance between the scar and the midlateral line. A subcutaneous pedicle including one or several vessels is left at the proximal or distal end of each flap. After the scar has been excised the flaps are rotated about 90° and both ends of the flaps are sutured on the bilateral midlateral line. The skin defect that remains between the flaps is covered with a full-thickness skin graft from the non-weight-bearing area of the sole. In all cases, the flaps and skin grafts survived perfectly. Because of the flexibility of the subcutaneous flaps, the skin defects are effectively divided to avoid recontraction without disadvantages such as excess trimming of normal skin, extensive dog ears, or formation of scars on the dorsal surface. The method seems to be less invasive than the procedures used currently, and to yield a satisfactory aesthetic appearance.