Miyuki Uehara

Algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps.

Background In case of composite cranial defect including the dura mater, the cranial bone, and the scalp, the fascial component of the anterolateral thigh flap can be used for dural reconstruction. However, the advantages and applications of the fascial component depending on the type of defect have not been thoroughly discussed. We made the algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps. Patients and Methods Six cases of composite cranial defects were reconstructed using free anterolateral thigh flaps with the fascial component. The type of method used was classified into 3 types. Type 1 involves separating the fascia from the flap completely and using it as a nonvascularized component. In type 2, the fascia is not separated from the flap and is instead used as a vascularized component. Type 3 involves separating the vascularized adipofascial component from the skin paddle and using it as a chimeric pattern flap. The algorithm for determining the type of fascial component is applied depending on the condition of the defect. Results All flaps were transferred successfully in every case. In 4 cases, the type 1 method was used. The type 2 and 3 methods were used in 1 case each. Cranial bone reconstruction was performed in 3 cases. There were no major complications after the procedures. Conclusions The fascial component is useful for dural reconstruction. The type of fascial component used is selected depending on the condition of the defect.

Asynchronous osteoradionecrosis of the mandible treated with sequential fibula osteoseptocutaneous flaps: a report of two cases.

Osteroradionecrosis of the mandible is one of the most serious complications of radiotherapy in head and neck cancer. Once osteoradionecrosis of the mandible has been established, conservative therapy is often useless. Two cases of asynchronous bilateral osteoradionecrosis of the mandible are presented. In both cases, successful reconstruction was performed with 2 free fibula osteoseptocutaneous flap transfers from both legs. We believe that adequate debridement, with removal of dead or hypovascular bone and surrounding soft tissue, followed by vascularized composite bone grafts, is the key for a successful outcome. In our cases, the oral function after 2 reconstructive surgeries with the fibula osteoseptocutaneous flap was acceptable. Furthermore, the patient could walk without difficulty.

Three-dimensional visualization of the human face using DICOM data and its application to facial contouring surgery using free anterolateral thigh flap transfer

One of the main challenges faced by surgeons performing reconstructive surgery in cases of facial asymmetry due to hemifacial atrophy or tumor surgery is the restoration of the natural contour of the face. Soft-tissue augmentation using free-flap transfer is one of the most commonly used methods for facial reconstruction. The most important part of a successful reconstruction is the preoperative assessment of the volume, position, and shape of the flap to be transplanted. This study focuses on three cases of facial deformity due to hemifacial progressive atrophy or tumor excision. For the preoperative assessment, digital imaging and communications in medicine (DICOM) data obtained from computed tomography was used and applied to a three-dimensional (3D) picture software program (ZedView, LEXI, Tokyo, Japan). Using computer simulation, a mirror image of the unaffected side of the face was applied to the affected side, and 3D visualization was performed. Using this procedure, a postoperative image of the face and precise shape, position, and amount of the flap that was going to be transferred was simulated preoperatively. In all cases, the postoperative shape of the face was acceptable, and a natural shape of the face could be obtained. Preoperative 3D visualization using computer simulation was helpful for estimating the reconstructive procedure and postoperative shape of the face. Using free-flap transfer, this procedure facilitates the natural shape after reconstruction of the face in facial contouring surgery.

A rare case of pigmented epithelioid melanocytoma on the penis as a divided nevus

Sixteen cases of “divided” or “kissing” nevus on the genital mucosa have been reported [1-7], including one case of divided melanoma on the penis [3]. Pigmented epithelioid melanocytoma is a borderline melanocytic tumor encompassing epithelioid blue nevus, with or without Carney complex, and most tumors previously considered so-called “animal-type melanomas”[8]. Although rare pigmented epithelioid melanocytoma or epithelioid blue nevus on the penis has been reported [9], we found no reports [...]

Choice of recipient vessels for nasal ala reconstruction using a free auricular flap

Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods using retrograde free auricular flaps by including both retrograde and antegrade superficial temporal vessels to enhance the venous drainage of the flap. Based on our experience and the findings of previous reports, we developed an algorithm to insert free auricular flaps for use in nasal ala reconstruction, and to select the recipient vessels. Eight free auricular flaps were transferred in seven cases. In all cases, one artery anastomosis and two venous anastomoses were performed. The facial artery was used as the recipient artery at the nasolabial fold in five cases, and the proximal stump of the superficial temporal artery was used as the recipient vessel via a vein graft in two cases. The facial vein at the nasolabial fold was used in six cases, and the facial vein at the mandible via a vein graft was used in one case. In all cases, the angular vein at the medial canthus was available and used as the second recipient vein. The key to success with free auricular flap transfer for nasal ala reconstruction is to select the proper recipient vessel. We believe that our algorithm and procedure will increase the rate of successful operations.

Two cases of congenital aplasia cutis with dermal melanocytosis.

Dear Editor, Congenital aplasia cutis is a heterogeneous group of disorders in which there is congenital absence of skin. The scalp is the most frequent location for this entity and some patients also have defects of the bone. Two main clinical variants of the scalp lesions can be observed: (i) small round to oval punched out areas with an atrophic, membrane-like surface with or without a hair collar sign; and (ii) larger, irregular, stellate defects that heal with a scar-like surface intermingled with areas where skin appendages are preserved. We herein report two cases of congenital aplasia cutis, which belong to the first category, and were concomitant with dermal melanocytosis. In case 1, a 15-year-old Japanese male visited our clinic because of two alopecia lesions on his parietal region. He was born after normal gestation and delivery, and there were no remarkable findings in his family history. During his postnatal life, he was affected by pneumothorax, ocular hypertension and immunoglobulin A nephropathy at age 0, 12 and 14 years respectively. At age 1, he had received a skin biopsy from the area of his two alopecia lesions on his scalp at another hospital. From a histological examination, he was diagnosed as having blue nevus and organoid nevus. When he was 16 years old, he visited us and, on physical examination, two alopecia lesions both of 10 mm in size were observed on the midline along the sagittal suture (Fig. 1a,b). There was no hair collar sign, which is a ring of coarse and long hair surrounding a congenital scalp nodule and is a sign of membranous aplasia cutis. An examination using computed tomography revealed no cranial bone defect under the alopecia lesions, except for an excavation deformity of his left cranial bone. The two skin lesions were totally excised and the defects were closed with Z-plasty. Histopathological examination revealed faintly-stained dermal collagen and paucity and disorientation of hair follicles in the specimens. Dermal melanocytes were observed in the upper and even in the lower dermis (Fig. 2a,b). We re-examined previously biopsied specimens and observed the same histopathological findings, and therefore we diagnosed these two congenital alopecia regions to be congenital aplasia cutis with dermal melanocytosis. In case 2, an 11-year-old Japanese male visited us because of an alopecia lesion on his occipital area. Although the lesion was not noticed when he was born, a purple-red tiny macule was observed at age 1, and the lesion gradually increased in size and turned brown. On physical examination, a brown-colored alopecia macule, which was dark in the center with a few vellus hairs and was 7 mm · 4 mm in size, was observed on his occipital region (Fig. 1c). No hair collar sign was observed. With surface microscopy, brown-colored pigmentation with darker graduation toward the center was observed (Fig. 1d). A histopathological examination revealed dermal melanocytosis in the upper dermis and horizontal growth of a few of terminal hairs (Fig. 2f,g). Although the pathogenesis of aplasia cutis may be different in the various clinical forms (i.e. the disturbance of the vascular flow, trauma or infection in utero), the most fascinating hypothesis is the result of incomplete closure of the ectodermal fusion line. The following findings support this theory: (i) the distribution of alopecia lesions in some cases along the fusion lines, like case 1; (ii) the cranial segment of the neural tube closes in a multifocal pattern; and (iii) the mammalian neural tube in the region of posterior cranium closes by a membranous growth, which resemble membranous aplasia cutis. The association of dermal melanocytosis and aplasia cutis is very rare, and we could find only one similar case report. In line with the abovehypothesis,wesupposed that the glial tissuecontainingmelanocytes remained as an embryonic remnant under the epidermis, at the lesion, and that hair germ could not be induced because of this unique subepidermal connective tissue. We examined this hypothesis by staining using antibodies against glial fibrillary acidic protein (GFAP), which is a marker for glial cells and is not expressed by mature melanocytes. The staining method used was as follows: antigen was retrieved by heating the samples in an autoclave at 121 C

Evaluation of the effects of a polyglycolic acid–collagen tube in the regeneration of facial nerve defects in rats:

Purpose: The purpose of this study was to assess the utility of a polyglycolic acid–collagen tube and to investigate its possible application in the field of facial nerve reconstruction. Methods: Wistar rats were used in this study. In the operation, a periauricular incision was made to expose the buccal and marginal branches of the facial nerve. Gaps of 10 mm were created by resection of a part of the nerve into the marginal branches and the buccal branch of the left facial nerve. The left marginal branch gap was bridged with a 10-mm polyglycolic acid–collagen tube or an autograft. At 12 weeks after the operation, nerve regeneration was assessed based on clinical, histopathological, and electrophysiological evaluations. Result: The functional recovery of the vibrissal muscle was observed with the polyglycolic acid–collagen tube. However, the functional recovery obtained with the use of the polyglycolic acid–collagen tube was inferior to that obtained with an autograft. Conclusion: We found that polyglycolic acid–collagen tubes could be applied in facial nerve gap reconstruction. However, further improvements will be necessary to achieve results that are equivalent to those obtained with autografts.

Comparative analysis of mamushi (Gloydius blomhoffii) bite patients indicates that creatinine kinase levels/white blood cell count trends reflect severity

There has been no indicator that allows an early quantitative evaluation of the severity of a mamushi snake (Gloydius blomhoffii) bite. Because the number of severe mamushi bite cases is much fewer than non‐severe cases, a formal case–control study is difficult. Therefore, we tried to generate a preliminary quantitative, real‐time index for its severity by referring to published reports of severe mamushi bite cases.

Effect of concurrent mental nerve reconstruction at the same time as mandibular reconstruction using a fibula osteoseptocutaneous flap

The damage of inferior alveolar nerve causes some functional problem including numbness of lower lip and drooling. During segmental mandibulectomy, inferior alveolar nerve commonly resected, therefore, it is ideal to reconstruct the nerve to get better functional result. Sensory recovery was assessed after mandibular reconstruction using free fibula osteoseptocutaneous flap in thirteen cases. In six cases, the mental nerve reconstruction was performed simultaneously, and in seven cases, the mental nerve reconstruction was not performed. In the case that the mental nerve was reconstructed simultaneously, unilateral mental nerve reconstruction was performed in five cases, and bilateral mental nerve reconstruction was performed in one cases. More than one year after the reconstruction, sensory recovery was assessed and compared between the group that the mental nerve was reconstructed and the group that was not reconstructed. Our results showed almost a normal sensory recovery of the lips on the reconstructed side more than one year after the reconstruction in reconstructed group. In contrast, sensory recovery was poor in non-reconstructed group and non-reconstructed side. These results showed that mental nerve reconstruction at the same time as mandibular reconstruction affects the postoperative mandibular function. The sural nerve can be harvested from the same donor site of the free fibula osteoseptocutaneous flap and such mental nerve reconstruction with nerve grafting can be completed within an hour. Most cases of mandibular reconstruction using a free fibula osteoseptocutaneous flap transfer can therefore be candidates for mental nerve reconstruction at the time of mandibular reconstruction.

Three cases of elastofibroma with immunohistochemical analysis of microfibrillar components

Abstract