Taku Maeda

Combination of Tessier clefts 3 and 4: Case report of a rare anomaly with 12 years' follow-up

Tessier cleft types 3 and 4 are both rare craniofacial anomalies. Here we present the first case of a girl born with a combined anomaly of Tessier clefts 3 and 4 with severe bilateral cleft lip, a displaced premaxilla, and three-dimensional underdevelopment of the hard and soft tissues of the maxilla and zygoma. This type of rare facial cleft poses a major operative challenge. Over a period of years, presurgical alveolar molding with an active appliance was followed by seven operations. A satisfactory esthetic outcome was obtained. A multidisciplinary approach to treatment with a plastic surgeon in charge of the operations and an orthodontist in charge of the cleft deformity is essential.

Esthetic and safe lower lip reconstruction of an asymmetric defect due to cancer resection: a modified Webster method combined with a nasolabial flap.

t o d c p l g s t s m The lower lip is a common site prone to squamous cell carcinoma, which arises in the facial region. Although numerous techniques for reconstructing the excised lip region have been well-documented, refinements to reconstructive techniques are continuously being investigated. In 1960 Webster et al reported on a reconstructive procedure for the lower lip using cheek and lip advancement flaps with esthetic and functional results (Fig 1). Unlike post-traumatic reconstructions, laterality of the primary tumor and regional lymph node metastases should be taken into consideration when using the surrounding local tissue to avoid unpredictable locoregional recurrences. However, few reports have addressed the relationship between laterality of the defect and reconstructive method. We present a novel method, originating from the Webster method that is limited to treating asymmetric full-thickness defects that are occasionally encountered in the clinical setting.

Reconstruction of low hairline microtia of Treacher Collins syndrome with a hinged mastoid fascial flap

Treacher Collins syndrome (TCS) is a rare genetic disorder leading to congenital craniofacial malformations. Although this syndrome presents with various symptoms, corrective surgery for bilateral microtia with low hairline is one of the most challenging operations given the complex contours of the external ear. In this technical note, a novel, simple procedure for dealing with the low hairline by using a hinged mastoid fascial flap simultaneously with costal cartilage grafting is described. Several techniques for the reconstruction of low hairline microtia have been reported previously, such as skin graft, skin flap, and tissue expander, but the high number of repeat operations and residual scars remain problematic. As a simultaneous procedure with framework grafting, the use of a temporoparietal flap with skin grafting is popular; however, its drawbacks include the operative scar, decreased hair growth, and hair thinning. Patients with TCS show anatomical variations of the superficial temporal vessels supplying the temporoparietal flap. In contrast, due to the high vascularity of the mastoid fascia, the mastoid fascial flap can be elevated safely and easily as an anteriorly, posteriorly, superiorly, or inferiorly based flap.

Correction of Anophthalmic Enophthalmos with a Three-Staged Procedure: Two Case Reports

Surgical correction of an anophthalmic enophthalmos secondary to inappropriate repair of the eye socket involves several difficult aesthetic issues associated with long-term use of a poorly fitting prosthetic eye. In this paper, we present two cases of anophthalmic enophthalmos. During the treatment of the first patient, unsatisfactory cosmetic problems including lower eyelid retraction, hypoglobus, and severe upper eyelid ptosis were revealed. Accordingly, a three-staged procedure was performed on the second patient, including autologous augmentation of the eye socket, correction of lower eyelid retraction with a cartilage graft, and a frontalis sling procedure to correct upper eyelid ptosis.

Review and proposal of regional surgical management for melanoma: revisiting of integumentectomy and incontinuity dissection in treatment of skin melanoma

BackgroundPast studies showed that integumentectomy and incontinuity could be effective procedures in the surgical management of melanoma patients. The present study reports on the historical background of these procedures. In addition, we analyze the ICG assisted integumentectomy and incontinuity techniques and algorithms that we had created when performing this procedure.MethodIn accordance with our algorithm, we performed ICG assisted integumentectomy/incontinuity procedures on 17 patients with stage III melanomas between 2008 and 2016. We also investigated the locoregional recurrence rate in a control group comprising 60 patients at stage III without using the algorithm.ResultsThe former group exhibited a tendency of locoregional recurrence rate suppression. Melanoma cells in the dissected intervening tissue were microscopically identified in 2 out of 17 cases.ConclusionsOur ICG assisted integumentectomy or incontinuity procedures could be effective in controlling locoregional recurrence rates in melanoma cases. Moreover, our method can be generally applied because the dissection is only performed within the lymphatic pathway region identified using indocyanine green.

Promising long-term outcomes of the reused skin-graft technique for chronic gluteal hidradenitis suppurativa

BACKGROUND The reused skin-graft technique can be used to treat chronic gluteal hidradenitis suppurativa, but long-term outcomes and the reliability of the technique have not been reported. METHODS In a retrospective review of 18 men with chronic gluteal hidradenitis suppurativa (age range, 18-68 years) treated with a reused skin graft between June 2004 and March 2012, we evaluated disease severity (Hurley classification system), skin-graft thickness, the need for an additional normal skin graft, histological findings and recurrence rate at the surgical site. RESULTS The mean duration of follow-up was 61.3 months (range, 17-113 months). Five cases were classified into severity group I, 12 cases into severity group II and one case into severity group III. The range of skin-graft thicknesses was 0.013-0.020 inches. An additional donor site was unnecessary in 10 cases (three cases in group I (60%) and seven cases in group II (58.3%)). Histological examination indicated that a buried epidermal cyst could cause chronic gluteal hidradenitis suppurativa recurrence, although none of the patients experienced recurrence at the surgical site during follow-up. CONCLUSION The reused skin-graft technique is reliable for chronic gluteal hidradenitis suppurativa resection, and it shows promising long-term outcomes.

Successful conservative management of a large congenital scalp and skull defect.

The authors report a case of a female baby born with large congenital scalp and skull defects with exposure of the cranial arachnoid mater. The female patient was delivered by Caesarean section following diagnosis of a large cranial skin defect by ultrasound. The skin defect was present at the time of birth, measured 8.5  cm × 8.0  cm, and involved the full thickness of the cranium. The cranial arachnoid mater was exposed and veins running on the surface of the brain were observed. There was no means to cover the large defect surgically and conservative treatment was initiated. Complete epithelialization of the scalp defect was acquired without fatal problems. In the course of treatment, Mepilex Transfer was very effective. The repair of congenital defects of the scalp and skull is a major challenge not only because of the rarity but also because of severe morbidity. A surgical or conservative approach is chosen according to the situation. This rare case highlights two important clinical issues: that the congenital defects of the scalp and skull could not be managed with a surgical approach and in its place, a conservative approach using the special dressing Mepilex Transfer proved highly effective.

Utility of the method using the tsukisui device to control intraoperative bleeding applied to neurofibroma resection.

Summary: The resection of neurofibromas in Von Recklinghausen’s disease [neurofibromatosis type 1 (NF-1)] is frequently complicated due to size, location, hypervascularity, and tissue friability. A repeat resection, however, is necessary for patients with functional problems such as unexpected tumor bleeding or with changes in esthetic appearance. This report describes application of the method using the Tsukisui device to resecting NF-1 tumors while minimizing blood loss. The method using the Tsukisui device was applied for the resection of 8 NF-1 tumors (5 patients), and intraoperative blood loss, operative time, and postoperative complications were recorded. In all cases employing this method, intraoperative blood loss was <360 ml (10–360 ml), and none of the patients developed postoperative hematoma or other notable bleeding complications. The method using the Tsukisui device, which provided excellent hemostasis and was associated with few complications, shows promise for application to neurofibroma resection.

Immune-mediated antitumor effect of a transplanted lymph node: Antitumor effect of a transplanted lymph node

Lymph node (LN) transplantation is a recognized method for reconstruction of the lymphatic system and is used in the clinical setting to treat lymphedema. However, it is unclear whether transplanted LNs contribute to immune surveillance. In our study, we investigated whether a single transplanted non‐vascularized LN, defined as a tumor‐draining transplanted lymph node (TDTLN), could exert an immune‐mediated antitumor effect. LN and lung metastases and primary tumor enlargement were evaluated in mice that were inoculated with B16‐F10‐luc2 melanoma cells in a hind limb footpad without (group 1) and with (group 2) popliteal lymph node (PLN) resection and in mice that underwent LN transplantation after PLN resection (group 3). The function of a TDTLN (group 3) and a tumor‐draining popliteal lymph node (TDPLN; group 1) was evaluated in the context of cancer. LN and lung metastases were significantly aggravated by PLN resection but were significantly decreased by LN transplantation. Immunohistochemistry showed that the TDTLNs retained T‐cells and B‐cells and fluorescence‐activated cell sorting analysis confirmed expansion of lymphocytes in these nodes; however, the degree of expansion in TDTLNs was different from that in TDPLNs. Expression of cytokines associated with immunostimulation was confirmed in the TDTLNs as well as in the TDPLNs. One of the differences in the immune‐mediated antitumor effect of the TDPLNs and TDTLNs was ascribed to a difference in the site of lymphocyte homing to peripheral LNs through high endothelial venules. Non‐vascularized LN transplantation had an immune‐mediated antitumor effect.

Wound Care: Maggot Debridement Therapy

Maggot debridement therapy (MDT) has long been used to treat various wounds or ulcers. Although the mechanisms underlying MDT are not completely understood, laboratory studies have clarified the various effects of larval secretions/excretions. The most noticeable change in maggot-treated wounds is debridement. Other characteristics include microbial death (disinfection) and accelerated wound healing (growth stimulation). Recently, it has been reported that the amino acid-like compounds present in maggot excretions/secretions may mediate wound healing by stimulating angiogenesis. In the clinical setting, MDT for critical limb ischemia has been reported to lead to an increase in skin perfusion pressure, which serves as an index of peripheral circulation in the skin and subcutaneous tissue. Laboratory and clinical findings to date suggest that ischemic ulcer is a good candidate for MDT.