Nobuyuki Mitsukawa

Dual midfacial distraction osteogenesis: Le Fort III minus I and Le Fort I for syndromic craniosynostosis.

&NA; Midfacial hypoplasia has been corrected by Le Fort III or monobloc forward advancement in one stage in syndromic craniosynostosis, but recently developed distraction osteogenesis has been in use. Whereas the amount of forward mobilization in Le Fort III conventional osteotomy is determined by the preplanned fabricated interdental splint, that in Le Fort III distraction is determined by the positions of the inferior orbital rim, malar complex. and nose. Therefore, the forward mobilization of the upper part of the midface may sometimes be insufficient when one focuses on the final occlusion, and the occlusion might not be satisfied when the forward mobilization is sufficient. Correction of the midfacial hypoplasia should be considered differently in the upper and lower portions of the midface. The upper portion contains the inferior orbit and nose, and the lower portion contains the occlusal structure of the maxillary dentoalveolar portion with the mandible. Separating the midface into two portions and conducting the distraction osteogenesis in both portions separately in different amounts and vectors of distraction is described in this article. Although distraction of the upper portion of the midface can be conducted in one direction with an internal device, distraction of the lower portion of the midface is preferred for conduction by a controllable device because of the need to obtain the preferred occlusion. To obtain better functional and aesthetic results in midfacial distraction in adults and adolescents with syndromic craniosynostosis, dual Le Fort III minus I and Le Fort I midfacial distraction osteogenesis was performed in four cases (in two patients with Crouzon syndrome and in two patients with Apert syndrome). Two females and two males are described (age range, 13 to 26 years). An internal device was used for the upper portion of the midface and an external device was used for the lower portion. The amount of distraction ranged from 14 to 21 mm in the upper portion of the midface and from 11 to 18 mm in the lower portion. No particular complications were noticed over a follow‐up period of 10 to 38 months (average follow‐up, 19.8 months).

Early diagnosis and risk factors for lymphedema following lymph node dissection for gynecologic cancer.

Background: Although early diagnosis is important for selecting an effective surgical treatment for secondary lymphedema, an efficient screening test for detecting early-stage lymphedema has not yet been established. Serial changes of lymphatic function before and after lymph node dissection and risk factors for secondary lymphedema are important indicators. Methods: A prospective cohort observational study was conducted with 100 consecutive gynecologic cancer patients who underwent pelvic lymph node dissection. Lymphatic function was assessed by noninvasive lymphography using indocyanine green fluorescence imaging on a routine schedule. Earliest findings after lymphadenectomy and risk factors for lower leg lymphedema were investigated. Results: Atypical transient dermal backflow patterns were observed in an early postoperative period in 50 cases, all of which disappeared within 3 months. Of these patterns, the splash pattern was observed in 31 patients, of which five improved to normal following a natural course. In contrast, the stardust pattern was observed in 27 patients, and none had improved with conservative therapy. Postoperative radiotherapy was a significant risk factor for the stardust pattern. Conclusions: All patients who undergo lymphadenectomy for gynecologic malignancies should be examined for secondary lower extremity lymphedema by qualitative evaluation methods on a routine schedule to determine the earliest possible diagnosis. Because the splash pattern on indocyanine green lymphography is a reversible lymphatic disorder following a natural course, surgical treatments are not recommended. The decision regarding surgical treatment can be made after observing the stardust pattern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Three-dimensional cranial expansion using distraction osteogenesis for oxycephaly.

Oxycephaly is associated with raised intracranial pressure as a result of the fusion of multiple cranial sutures. We have performed an effective and less invasive cranial expansion by means of three-dimensional cranial distraction for the treatment of oxycephaly with suspicion of increased intracranial pressure. We describe two oxycephaly cases and the surgical technique of three-dimensional cranial expansion using distraction osteogenesis.

Comparison of Vascularized Supraclavicular Lymph Node Transfer and Lymphaticovenular Anastomosis for Advanced Stage Lower Extremity Lymphedema

BackgroundVascularized lymph node transfer has become a popular surgical option to improve lower extremity lymphedema (LEL), although potential donor sites are limited. The free supraclavicular flap with deep cervical lymph nodes has been recently associated with a minimal risk of secondary lymphedema caused by donor site dissection. However, the effectiveness of this procedure has not yet been evaluated. MethodsVascularized supraclavicular lymph node transfer (VSLNT) was performed for patients with International Society of Lymphology late stage II or more severe LEL. The results were compared with lymphaticovenular anastomosis (LVA) performed for patients with the same stages of severity. To evaluate improvement in lymphatic function, indocyanine green lymphography and lymphoscintigraphy were performed. ResultsVascularized supraclavicular lymph node transfer was performed in 13 limbs of 13 patients. The results were compared with 43 limbs of 33 patients who underwent multiple LVA. No severe complications were observed in either group. Improvement in lymphatic function, as measured by the LEL index, was 26.5 ± 4.4 and 21.2 ± 2.0 in the VSLNT and LVA groups, respectively. Lymphatic function was improved in 7 cases in the VSLNT group and 10 cases in the LVA group. ConclusionsVascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage LEL. Lymphaticovenular anastomosis is also effective, but to a lesser degree than VSLNT. However, LVA is less invasive and requires a shorter hospital stay.

A reflectable case of obstructive sleep apnea in an infant with Crouzon syndrome.

Obstructive sleep apnea has recently drawn attention as a cause of sudden death among infants. Life-threatening obstruction of the upper airway is encountered in patients with syndromic craniosynostosis. Early definitive management of obstructive sleep apnea can conquer this critical situation. Although early tracheostomy can solve the problem, successful early midfacial distraction has been reported. In this report, a reflectable case of sudden death caused by a severe obstructive sleep apnea attack at home just before the midfacial distraction, during the waiting period for the surgery of midfacial distraction, is described. The authors stress the importance of preoperative care of the upper airway and the early definitive treatment using distraction osteogenesis for midfacial hypoplasia in infantile syndromic craniosynostosis.

A Case of Improved Obstructive Sleep Apnea by Distraction Osteogenesis for Midface Hypoplasia of an Infantile Crouzon's Syndrome

We performed Le Fort III midfacial advancement with gradual distraction using internal devices on a 2-year 5-month-old boy with Crouzons syndrome with associated severe obstructive sleep apnea. The device was not activated until 7 days after surgery, after which the distraction was initiated, 1 mm per day, and the midface was advanced 4 mm intraoperatively and distracted 12 mm postoperatively. A total advancement of 16 mm was obtained. The obstructive sleep apnea improved remarkably after the distraction. In infants and younger children with associated severe obstructive sleep apnea, advancement by distraction osteogenesis of the midface in Le Fort III maxillary osteotomy will be initially indicated to obviate tracheostomy improving the upper airway obstruction.

Clinical success of mandibular distraction for obstructive sleep apnea resulting from micrognathia in 10 consecutive Japanese young children.

In recent years, obstructive sleep apnea has gained attention as one of the causes of sudden death in young children. There have been some reports, mainly from the United States and Europe, that mandibular distraction osteogenesis is effective as a treatment for obstructive sleep apnea syndrome caused by micrognathia in young children. However, there has not been any report yet in Japan. In this study, we performed mandibular distraction osteogenesis using internal devices in 10 young children with obstructive sleep apnea. To enable distraction to be performed smoothly without any difficulties, we modified a surgical procedure by adding an osteotomy of the coronoid process to a vertical ramus osteotomy. Postoperative evaluations using cephalograms and polysomnography were performed, and great improvements were observed. As a result, all patients either avoided or were weaned from tracheostomy, and very good results were obtained similar to those in reports from the United States and Europe. We report our experience in Japan.

Early midfacial distraction for syndromic craniosynostotic patients with obstructive sleep apnoea.

Syndromic craniosynostosis is known to be associated with various obstructive respiratory disorders, including sleep apnoea. We performed early midfacial distraction in 11 syndromic craniosynostotic patients with obstructive respiratory apnoea and obtained good results. There were four patients with Crouzon syndrome, three patients with Pfeiffer syndrome and four patients with Apert syndrome. Their ages ranged from 7 months to 3 years, 9 months (mean: 2 years, 5 months). Midfacial distraction was performed using an internal or external device to improve obstructive respiratory disorders, such as sleep apnoea, and to avoid tracheostomy. Evaluation was performed by comparison of the pre- and postoperative polysomnograms (PSGs) and cephalograms. All patients had markedly improved respiratory disorders during sleep and avoided tracheostomy. Preoperative PSGs and cephalograms were compared with those from 1 year to 1 year, 6 months postoperatively. The postoperative PSGs and cephalograms showed marked improvements compared with preoperative PSGs and cephalograms. Syndromic craniosynostotic patients have facial bone hypoplasia, particularly of the maxilla. The tongue and parapharyngeal soft tissue become enlarged, and the enlarged tissues can cause airway obstruction. In this study, marked improvements were observed in physical evaluation using PSGs and morphological evaluation using cephalograms. Early midfacial distraction is thought to be a very useful method to reconstruct a large pharyngeal cavity, enlarge the airway, improve obstructive respiratory disorders and to avoid tracheostomy. It is important to select a device suitable for each case when surgery and distraction are performed.

Hybrid of distraction osteogenesis unilateral frontal distraction and supraorbital reshaping in correction of unilateral coronal synostosis.

Unicoronal synostotic plagiocephaly is routinely treated by intracranial wide frontal and bilateral supraorbital reshaping. Recent advancement of distraction osteogenesis in craniofacial surgery has extended to patients with craniosynostosis. Although a controversy remains between conventional osteotomy and reshaping and application of the distraction technique in surgical treatment of craniosynostosis, there have been several positive clinical reports on distraction techniques for nonsyndromic and syndromic craniosynostosis. Unicoronal distraction applied successfully to a case of frontal plagiocephaly has been described. The authors report a procedure: hybrid of unilateral frontal distraction and supraorbital reshaping on the affected side for frontal synostotic plagiocephaly. This procedure was conducted on four typical unicoronal synostotic plagiocephaly cases (patient age range, 9–14 months; all patients female) with successful results. No particular complications were encountered in any of the four cases with a follow-up period that ranged from 18 to 53 months.

New treatment for cystic lymphangiomas of the face and neck: cyst wall rupture and cyst aspiration combined with sclerotherapy.

Abstract Cystic lymphangioma is a congenital malformation occurring most frequently in the necks of infants and young children. It is histologically benign, but the lesion can extend deep into the tissue. Thus, surgical treatment is often difficult. In recent years, OK-432 sclerotherapy has become the first-line therapy for cystic lymphangioma, and many reports have discussed its effectiveness. However, it is difficult to achieve a complete response to OK-432 in polycystic cases and cases with small cystic areas, and it is sometimes ineffective. In the current study, we performed a new combination therapy on 5 cases of cystic lymphangioma of the face and neck. In this combination therapy, we ruptured the cyst wall of lymphangioma using a liposuction device and subsequently used OK-432 to induce inflammation and to cause adhesion of cyst walls. The combination therapy produced very good results. None of the patients had any major complication or recurrence. All patients had lymphangiomas that markedly reduced in size. This new method can be performed regardless of the cyst type of lymphangioma and is thought to be a useful therapy.