Shunsuke Yuzuriha

Minor-form, microform, and mini-microform cleft lip: anatomical features, operative techniques, and revisions.

Background: Whatever method of closure, a cleft lip scar extends along the full labial height. A smaller scar is possible in repair of limited forms of incomplete cleft lip. This retrospective study was undertaken to define the subgroups of lesser-form cleft lip, describe technical alternatives, and review results of repair. Methods: The senior author’s (J.B.M.) registry was searched for patients with lesser-form cleft lip, defined by the extent of vermilion-cutaneous dysjunction as either minor-form, microform, or mini-microform. Techniques for repair of these three anatomical variants were examined and the revisions were analyzed. Results: Of 393 patients with unilateral incomplete cleft lip, 59 lesser-form variants were identified. Minor-form clefts (n = 20), defined as a defect extending 3 mm or more above the normal Cupid’s bow peak, were repaired by rotation-advancement. Microform clefts (n = 28), defined as a vermilion-cutaneous notch less than 3 mm above the normal peak, were corrected by double unilimb Z-plasty. Mini-microform clefts (n = 11), defined as a disrupted vermilion-cutaneous junction without elevation of the bow peak, were repaired by vertical lenticular excision. Primary nasal correction was necessary in all minor-form and microform types and in some mini-microform types. In all three lesser-forms, the rate of nasolabial revision was relatively low in comparison with that for unilateral complete cleft lip. Conclusions: The extent of disruption at the vermilion-cutaneous junction defines minor-form, microform, and mini-microform cleft lip. These anatomical designations determine the method of nasolabial repair and correlate with types and frequency of revision.

Etiology and pathogenesis of aponeurotic blepharoptosis

How and why aponeurotic blepharoptosis develops was investigated in terms of the relationship between the levator aponeurosis and Mueller’s muscle functioning as the muscle spindle of the levator muscle. A total of 200 consecutive patients with moderate to severe acquired blepharoptosis completed questionnaires regarding their history of physical irritations to the eyelids, and intraoperative conditions of the levator aponeurosis and Mueller’s muscle were evaluated. Several kinds of physical irritations to the eyelids were reported, such as habitual rubbing of the eyelids, contact lens usage, cataract surgery, and continuous rubbing of the eyelids while crying all night. The two main findings for aponeurosis were that it was disinserted from the tarsus, resulting in a large amount of play between the aponeurosis and the tarsus, and that the aponeurosis and Mueller’s muscle were attenuated and elongated. The authors believe that rubbing may have caused disinsertion as well as attenuation and elongation of the aponeurosis, which result in transmission failures between the levator muscle and the tarsus as well as between the levator muscle and the mechanoreceptor of Mueller’s muscle, leading to clinical blepharoptosis.

Differential Long-Term Stimulation of Type I versus Type III Collagen After Infrared Irradiation

BACKGROUND The dermis is composed primarily of type I (soft) and type III (rigid scar‐like) collagen. Collagen degradation is considered the primary cause of skin aging. Studies have proved the efficacy of infrared irradiation on collagen stimulation but have not investigated the differential long‐term effects of infrared irradiation on type I and type III collagen. OBJECTIVE To determine differential long‐term stimulation of type I and type III collagen after infrared (1,100–1,800 nm) irradiation. METHODS AND MATERIALS In vivo rat tissue was irradiated using the infrared device. Histology samples were analyzed for type I and III collagen stimulation, visual changes from baseline, and treatment safety up to 90 days post‐treatment. RESULTS Infrared irradiation provided long‐term stimulation of type I collagen and temporary stimulation of type III collagen. Treatment also created long‐term smoothing of the epidermis, with no observed complications. CONCLUSIONS Infrared irradiation provides safe, consistent, long‐term stimulation of type I collagen but only short‐term stimulation in the more rigid type III collagen. This is preferential for cosmetic patients looking for improvement in laxity and wrinkles while seeking smoother, more youthful skin. The authors have indicated no significant interest with commercial supporters.

Long-term histological comparison between near-infrared irradiated skin and scar tissues

Background and objective: Our previous histological studies indicated that near-infrared (NIR) irradiation stimulates collagen proliferation in rat and human skin for 3 months. High collagen density in the dermis and smoothing of the epidermis were observed in irradiated rat skin, and appeared to last up to 6 months. Epidermal smoothness in irradiated rat skin seems to resemble scarring. Here, we performed a long-term histological comparison between NIR (1100 to 1800 nm) irradiated skin and scar tissues. Materials and methods: Rat skin was irradiated using a NIR device. Scar tissues were harvested from wounded areas and were compared with irradiated skin. Histological changes up to 180 days post-treatment were evaluated with hematoxylin and eosin, Azan-Mallory staining, and collagen type I and III staining. Results: In nonirradiated control skin, the dermis showed a low density of type I and III collagen, the surface of the epidermis was rough, and no significant changes were observed over time. In irradiated skin, both type I and III collagen increased significantly, and persisted up to 180 days. The density of type I collagen was significantly higher than that of type III collagen, whereas type I and III collagen of the control group did not differ significantly. Epidermis was thickened for 30 days, and epidermal smoothness persisted up to 180 days. In scar tissues, the density of type III collagen was higher than that of type I collagen. The number of fibroblasts remained high and the glial fibrils were dense until 180 days after injury compared with irradiated skin. Significant increases in both type I and III collagen and epidermal flattering persisted until 180 days. Conclusions: NIR irradiation induced high collagen density in the dermis, resulting in long-term epidermal smoothness without scar formation. Results indicated that NIR irradiation provides safe, consistent, and long-term effects of skin rejuvenation.

Non-thermal cytocidal effect of infrared irradiation on cultured cancer cells using specialized device

As infrared penetrates the skin, thermal effects of infrared irradiation on cancer cells have been investigated in the field of hyperthermia. We evaluated non‐thermal effects of infrared irradiation using a specialized device (1100–18000 nm with filtering of wavelengths between 1400 and 1500 nm and contact cooling) on cancer cells. In in vitro study, five kinds of cultured cancer cell lines (MCF7 breast cancer, HeLa uterine cervical cancer, NUGC‐4 gastric cancer, B16F0 melanoma, and MDA‐MB435 melanoma) were irradiated using the infrared device, and then the cell proliferation activity was evaluated by 3‐(4,5‐dimethylthiazol‐2‐yl)‐5‐(3‐carboxymethoxyphenyl)‐2‐(4‐sulfophenyl)‐2H‐tetrazolium (MTS) assay. Proliferation of all the cancer cell lines was significantly suppressed by infrared irradiation. Total infrared output appeared to be correlated with cell survival. Increased temperature during infrared irradiation appeared not to play a role in cell survival. The maximum temperature elevation in the wells after each shot in the 20 and 40 J/cm2 culture was 3.8°C and 6.9°C, respectively. In addition, we have shown that infrared irradiation significantly inhibited the tumor growth of MCF7 breast cancer transplanted in severe combined immunodeficiency mice and MDA‐MB435 melanoma transplanted in nude mice in vivo. Significant differences between control and irradiated groups were observed in tumor volume and frequencies of TUNEL‐positive and Ki‐67‐positive cells. These results indicate that infrared, independent of thermal energy, can induce cell killing of cancer cells. As this infrared irradiation schedule reduces discomfort and side effects, reaches the deep subcutaneous tissues, and facilitates repeated irradiations, it may have potential as an application for treating various forms of cancer. (Cancer Sci 2010)

Disinsertion of the levator aponeurosis from the tarsus in growing children.

&NA; To confirm when the levator aponeurosis is disinserted and how the disinsertion is compensated for in growing children, the earliest and latest photographs of the same children were the subjects of a retrospective comparative study regarding upward displacement of the superior palpebral crease and the eyeball in the palpebral fissure. Ninety‐four children (48 boys and 46 girls) were selected from 615 patients with cleft lip and palate who were followed for more than several years at our outpatient clinic and whose 58,000 photographs were digitized. The earliest and latest photographs of the patients were taken in primary gaze position; the former, taken at less than 3 years of age, and the latter, taken at more than 6 years of age, were selected for this study. The intervals between the two photographs ranged from 3 to 14 years (mean, 9.61 years; SD, 3.11). The superior palpebral crease moved upward parallel with the growth of the children (p < 0.0001) as well as with the length of the growth period (p = 0.0141). The lower eyelid did not move downward (p < 0.0001). The eyeball also displaced upward parallel with growth (p < 0.0001) and with the length of the growth period (p = 0.0302). The more the superior palpebral crease was displaced upward, the more the eyeball was displaced upward (p = 0.0005). The levator aponeurosis may be likely to disinsert from the tarsus in growing children, thus requiring compensatory, excessive contraction of the levator muscle, which may cause upward displacement of the superior palpebral crease. Subsequently, excessive contraction of the superior rectus muscle in conjunction of the levator muscle may rotate the eyeball upward, which may incline the head. When the head is not inclined in the primary gaze position, compensatory contraction of the inferior rectus muscle to maintain the horizontal visual axis may displace the eyeball upward in the orbit by means of the inferior suspensory ligament of Lockwood. (Plast. Reconstr. Surg. 106: 563, 2000.)

Vermilionplasty using medical tattooing after radial forearm flap reconstruction of the lower lip

Vermilionplasty using medical tattooing was performed after radial forearm flap reconstruction of the lower lip in 2 patients. This technique is easy to perform in the outpatient setting, does not involve sacrifice of tissue, and results in an acceptable aesthetic outcome. We recommend vermilionplasty with medical tattooing as the procedure of choice after lip reconstruction with a distant flap.

Objective assessment of skin rejuvenation using near-infrared 1064-nm neodymium: YAG laser in Asians

Background We reported previously that near-infrared (NIR) irradiation provides long-lasting stimulation of elastin, and is efficient for skin rejuvenation. Many studies have indicated the efficacy of various types of laser, but did not include sufficiently objective evaluation. Therefore, we evaluated the efficacy of NIR laser treatment not only subjectively but also objectively. Methods Fifty Japanese patients were treated with a NIR 1064-nm neodymium: YAG laser. Objective computer assessments were performed by Canfield VISIA Complexion Analysis for improvement of dilated pores, skin texture, and wrinkles. The volunteers then provided subjective assessments. Histological evaluations of elastin were performed by Victoria blue staining up to 90 days post-treatment in four Japanese volunteers. Results Mean pretreatment percentiles of dilated pores, skin texture, and wrinkles were 51.08 ± 24.82, 54.7 ± 26.33, and 58.02 ± 28.61, respectively. Mean post-treatment percentiles of dilated pores, skin texture, and wrinkles were 53.58 ± 23.89, 58.58 ± 24.44, and 62.2 ± 25.39, respectively. All objective computer assessments evaluated by percentiles in dilated pores, skin texture, and wrinkles showed significant improvement after NIR laser treatment. Ninety-six percent, 100%, and 98% of volunteers reported satisfaction with the improvement of dilated pores, skin texture, and wrinkles, respectively. NIR laser treatment appeared to increase the amount of elastin at day 30, which then decreased slightly but was still elevated at day 90 compared with nonirradiated controls on day 0. Thickening of the epidermis was detected on day 30, and epidermal smoothness persisted for up to 90 days. No treatment-related adverse events were observed. Conclusions NIR irradiation increased elastin in the dermis, and achieved skin rejuvenation. The results indicated that NIR irradiation provides safe and effective long-term stimulation of elastin, which is beneficial for improving dilated pores, skin texture, and wrinkles.

Asymmetrical Bilateral Cleft Lip : Complete or Incomplete and Contralateral Lesser Defect (Minor-Form, Microform, or Mini-Microform)

Background: Complete or incomplete cleft lip can be associated with a contralateral lesser form of incomplete cleft lip, constituting an asymmetrical bilateral malformation. Methods: The cleft lip registry was searched for patients with complete or incomplete cleft lip and contralateral minor-form, microform, or mini-microform defects. Methods of repair were documented and results were assessed by reviewing photographs and recording revisions. Results: Of 309 patients with bilateral cleft lip, 72 patients (23 percent) had asymmetrical cleft lip, with 40 patients having contralateral minor-form, microform, or mini-microform defects. All infants with complete cleft lip and palate on the greater side underwent preoperative dentofacial orthopedic alignment, nasolabial adhesion, and gingivoperiosteoplasty. Infants with a contralateral minor-form defect (n = 7) had second-stage, synchronous bilateral nasolabial repair. Contralateral microform defects (n = 6) were not addressed during rotation-advancement repair on the complete/incomplete side; the later repair was a double unilimb Z-plasty. Contralateral mini-microform defects (n = 27) were corrected by vertical lenticular excision and, if necessary, alar base Y-V advancement, either synchronously with closure on the greater side or at another stage. The revision rate correlated with the degree of preoperative asymmetry. The most common revisions were augmentation of the median tubercle and free margin on the lesser side and repositioning of the lower lateral cartilage and alar base on the greater side. Conclusions: The operative strategy for repair of an asymmetrical bilateral cleft lip is determined by the extent of the vermilion-cutaneous dysjunction on the lesser side. Synchronous bilateral nasolabial repair is indicated for a contralateral minor-form defect. Correction of a contralateral microform or mini-microform defect is usually deferred to achieve symmetry.

Frontalis suspension with fascia lata for severe congenital blepharoptosis using enhanced involuntary reflex contraction of the frontalis muscle

Increased stretching of the mechanoreceptors in Muellers muscle induces involuntary reflex contraction of the ipsilateral frontalis muscle. We used this neurophysiological mechanism during surgery on 50 patients with severe unilateral or bilateral congenital blepharoptosis that does not have the levator muscle but has Muellers muscle. To facilitate contraction of the superior rectus muscle to sufficiently stretch the mechanoreceptors in Muellers muscle, transverse fibrous tissues that restrict the stretching are medially and laterally incised. Without fascial or muscular advancement, the fascia lata was grafted as far between the frontalis muscle and the tarsus as possible. After 15.5% postoperative shrinkage of the grafted fascia lata, all 50 patients involuntarily elevated their ptotic eyelids over the pupillary centre on primary gaze without severe lagophthalmos on eye closing. Forty-five patients could lift the upper eyelid over the pupillary centre even on upward gaze. Our procedure appeared to enhance the involuntary reflex contraction of the ipsilateral frontalis muscle, providing satisfactory dynamic retraction of the upper eyelid through fascia lata. We consider our procedure an alternative for reconstructing not only severe congenital blepharoptosis but also severe acquired blepharoptosis after orbital trauma or orbital tumour resection, in patients who do not have or lose the levator muscle while the Muellers muscle, the superior rectus muscle and the trigeminal proprioceptive nerve function to induce involuntary reflex contraction of the frontalis muscle.