Shigehiko Kawakami

Treatment of Craniosynostosis by Distraction Osteogenesis

Purpose: Craniosynostosis patients treated with one-stage cranioplasty often have bleeding from the dura mater, fluid collection in the extradural space, and poor wound healing due to skin overstretching. To avoid these complications, we began using distraction osteogenesis. To determine the advantages and disadvantages of the procedure, we retrospectively compared distraction osteogenesis with conventional cranioplasty. Patients and Results: We treated 24 patients with fronto-orbital advancement. Fifteen had one-stage cranioplasty; 9 received distraction osteogenesis. The one-stage operation patients averaged 25.5 months of age at surgery, 289 min of operating time, and 154 ml of intraoperative blood loss. For the distraction group, the average age was 16.6 months, average operating time was 196 min, and average blood loss was 76 ml. Conclusions: Compared with one-stage cranioplasty patients, distraction osteogenesis patients had significantly less intraoperative bleeding and shorter operating times. The disadvantages of distraction treatment were the need for multiple surgeries, prolonged hospitalization, wound infection, and dislocation of the distraction device.

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.

Golden Proportion for Maxillofacial Surgery in Orientals

The facial position and balance of eyes, nose, and mouth in typical Japanese individuals were investigated, based on the golden proportion for each of these relationships. We found that Japanese tend to have a longer upper lip and shorter chin length compared with Caucasians. We believe that this tendency represents a general facial characteristic of the Oriental population. Each ratio obtained from determinations by our method was used for preoperative and postoperative aesthetic analysis in maxillofacial surgery. This method is considered useful because it permitted us to understand quantitatively the positional relationship and the balance of eyes, nose, and mouth in the face and to make comparisons with typical subjects.

The superficial temporal and retromandibular veins as guides to expose the facial nerve branches

The superficial temporal vein and retromandibular vein were used as a guide to expose facial nerve branches in the parotid gland, and this procedure was applied to open reduction of mandibular condyle fractures (14 patients) and to superficial parotidectomy (6 patients). The advantages of this method are as follows: It is very easy to identify the superficial temporal vein as a guide, and it produces very little surgical stress because the procedure for exposing the facial nerve branches through the course of the vein is the same as the procedure for exposing the condyle and elevating the superficial lobe of the parotid gland.

The estimation of tissue loss during tangential hydrosurgical debridement.

Abstract The preservation of healthy tissue during surgical debridement is desirable as this may improve clinical outcomes. This study has estimated for the first time the amount of tissue lost during debridement using the VERSAJET system of tangential hydrosurgery. A multicenter, prospective case series was carried out on 47 patients with mixed wound types: 21 (45%) burns, 13 (28%) chronic wounds, and 13 (28%) acute wounds. Overall, 44 (94%) of 47 patients achieved appropriate debridement after a single debridement procedure as verified by an independent photographic assessment. The percentage of necrotic tissue reduced from a median of 50% to 0% (P < 0.001). Median wound area and depth increased by only 0.3 cm2 (6.8%) and 0.5 mm (25%), respectively. Notably, 43 (91%) of 47 wounds did not progress into a deeper compartment, indicating a high degree of tissue preservation.

Facial Protection Masks After Fracture Treatment of the Nasal Bone to Prevent Re-injury in Contact Sports

T he incidence of fracture of the nasal bone is highest in fractures of facial bones caused by sporting activities. Most fractures of the nasal bone are treated by closed reduction. Fractured nasal bones are internally or externally fixed. Internal fixation is performed by gauze packing or using wire. The internal fixation using wire reported in 1997 by Burm et al is useful for the treatment of fractures in athletes because early nasal respiration is possible. Plaster splints are used for external fixation. However, the strength of external splints is not sufficient to resist strong external forces experienced in contact sports, such as soccer, rugby, and basketball. Return to contact sport activities early after surgery has a risk of re-fracture, and causes fear in patients with fracture of the nasal bone. Therefore, we prepared an inexpensive facial guard, which can be produced by craniofacial surgeons themselves, for patients who wished to return to contact sport activities soon after surgery. In some patients, a combination of internal fixation using wire and application of a facial guard was performed.

Treatment for chronic abscess after cranioplasty: reconstruction of dura maters using the anterolateral thigh flap with fascia lata.

Although artificial dura maters such as Gore-Tex® are used in cranioplasty, the use of artificial products occasionally results in the formation of infectious lesions. Recently, we encountered two patients who underwent brain surgery and contracted infection from artificial dura maters used for cranioplasty. To treat the postoperative infection, we prepared a vascularized fascia lata attached anterolateral thigh flap that could be applied to the infected wounds in the reconstruction of dura maters and obtained satisfactory results. The present study demonstrated that fascia lata attached anterolateral thigh flaps were useful for reconstructing intractable cranial fistulae complicated by infection. The disadvantages of our surgical technique were the impossibility of simultaneous bone reconstruction and the difficulty in creating a watertight closure of fascia and dura mater, although leakage of cerebrospinal fluid was not observed so far.

Syndromic Craniosynostosis with Elbow Joint Contracture

This paper reports a new type of syndromic craniosynostosis that was diagnosed by DNA analysis of the patient’s fibroblast growth factor receptor (FGFR) genes. At birth, a male infant had ocular proptosis, a pseudotail, and obstructed respiration. He developed craniosynostosis, craniofacial dysmorphism, hydrocephalus, and bilateral contracture of his elbow joints. His treatment included fronto-orbital advancements and a ventriculoperitoneal shunt. Genetic analysis revealed that he was heterozygous for a missense mutation in exon 9 of the FGFR2 gene that resulted in an amino acid substitution of cysteine for serine at residue 351 (Ser351Cys). Seven cases with this mutation had previously been reported. All had severe craniosynostosis with midface hypoplasia, elbow joint contracture, developmental retardation, and early death.

Use of skin staples to fix film dressings on scalp donor wounds in patients with burns.

Split-thickness skin grafts (STSGs) from the scalp have been used in large burns. The donor site wounds are usually covered using occlusive dressings, such as film dressings because they contribute to reduce donor site pain and infection under exudative crust and to enhance re-epithelialization. However, it is not always easy to fix such film dressings to the scalp because of the presence of hair. In this paper, we report the use of skin staplers to fix the film dressings. Eight donor sites in four patients were dressed in this way. The patients had 50-78% of the body burned, all of them survived. The mean healing time for the donor sites was 6.8 days. Three patients had their scalps re-harvested several times (range two to three times). There were no infections nor secondary skin ulcers at the donor sites. The technique of this dressing is very simple and speedy, thus we recommend the use of skin staplers to fix the film dressing to scalp donor wounds in patients with burns.

Troubleshooting distraction osteogenesis for craniosynostosis.

Purpose: We previously reported that distraction osteogenesis is less invasive and gives greater skull advancement compared to conventional cranioplasty [Akai et al: Pediatr Neurosurg 2006;42:288-292]. In this study, we analyzed the distraction osteogenesis process and tried to identify and solve various technical problems. Patients and Results: We operated on 22 patients, 5 syndromic and 17 nonsyndromic. During treatment, we encountered several problems: (i) dural laceration during craniotomy (2 cases), solution: repair by suturing with fascia; (ii) skull fracture at sphenofrontal or coronal sutures (2 cases), solution: completed distraction; (iii) device dislocation during distraction (1 case), solution: the device was secured to the skull with stainless wire; (iv) wound issues around shaft and device (3 cases), solution: treated with antibiotic ointment. Discussion: (1) Extra caution is needed to avoid dural damage at frontal bottom burr holes. (2) Completion of craniotomy should be confirmed by checking if the bone flap moves in sync with brain pulsation. The craniotomy line should be placed forward of coronal sutures. (3) For patients younger than 2 years, employ clamp-type devices. (4) Shafts should be cut short enough to prevent their tips from exerting pressure or puncturing the scalp from beneath. Conclusions: The distraction osteogenesis technique has complications that may not occur in conventional one-stage cranioplasty. In this study, neither age at operation nor distraction distance were significant causes of complications during distraction osteogenesis.