Takuya Onizuka

Lower leg reconstruction using a sural fasciocutaneous flap.

The fasciocutaneous flap in the lower leg has been widely used since Ponténs 1981 report. The cutaneous artery running along the sural nerve—known as the superficial sural artery—has an important role in the blood supply of the fasciocutaneous flap in the lower leg as stated by Haertsch. The superficial sural artery has great variation with regard to its location and the origin of the vessel. The cutaneous artery is intimately connected to the sural nerve or the lateral sural nerve. It may run along the sural nerve or along the lateral sural nerve. We examined this vessel in 10 cadaver dissections and applied it in 17 clinical cases of pedicled, island, and free flaps. The island sural fasciocutaneous flap is particularly versatile for the reconstruction of the soft tissue defect around the knee joint. The operative procedure involving the island fasciocutaneous flap and the characteristics of this sural fasciocutaneous flap are described.

A case of supernumerary nostril.

A very rare case of supernumerary nostril is reported. This case is different from previously reported cases, because this accessory nostril was located nearer the nasal septum than the natural nostril and its opening was on the same level as the natural one. Although its cause and development are only speculative due to the small number of reported cases, a new hypothesis is proposed and discussed, since our findings are contradictory to previous literature.

Palate morphology in children with cleft palate with palatalized articulation.

This study was designed to examine postoperatively morphological characteristics of the palate of children with cleft palate with palatalized articulation. Palate morphology was measured in children with good velopharyngeal closure function after surgery, who were classified in Hellmans Dental Age II A group with unilateral cleft lip and palate, and the groups of children with palatalized articulation (CP-P) and normal articulation (CP-N) were compared. The results showed that the group of children with palatalized articulation was characterized by small palatal volume. In particular, there was narrowing and shortening of the anterior palate, and the palate was shallow. It was surmised that morphology may be one cause of palatalized articulation. Accordingly, it is important that early tongue-clicking movements are encouraged in patients exhibiting narrow palate morphology.

Use of a free conchal cartilage graft for closure of a palatal fistula : an experimental study and clinical application

In order to establish an operative procedure for the closure of palatal fistulas, the usefulness of free conchal cartilage grafts was confirmed through animal experiments, and a clinical application of this procedure was attempted. In the animal experiment, an oronasal penetrating fistula 10 mm in diameter was formed in the hard palate of 33 rabbits. One month later, the size of the palatal fistula decreased to 2 to 3 mm in diameter in all the rabbits. These rabbits were divided into two groups. Group 1 (n = 8) was used as a control group. In group 2 (n = 25), the palatal fistula was closed by an autograft of conchal cartilage, and the conchal cartilage graft site was observed for a period of 16 weeks. In 75 percent (6 of 8) of group 1, the palatal fistula persisted even after 1 year, but in 96 percent (24 of 25) of group 2, the palatal fistula was closed. The palatal fistula closure procedure using a conchal cartilage graft was found to be remarkably effective (x2 = 10.9, p < 0.001). In the clinical application, a fistula closure procedure with the use of conchal cartilage grafts was attempted in 24 patients with palatal fistulas. The procedure was modified into three types according to the size of the palatal fistula. For type I (diameter less than 2 mm) a conchal cartilage graft was created as in the animal experiment. For type II (2 to 5 mm in diameter), a palatal fistula closure procedure was used employing both a small hinge flap and a conchal cartilage graft. For type III (diameter more than 5 mm), a palatal fistula closure procedure was used employing a large hinge flap, a conchal cartilage graft, and a local mucosal flap. The results in the 24 patients showed a palatal fistula closure rate of 100 percent (8 of 8) for type I, 87.5 percent (7 of 8) for type II, and 87.5 percent (7 of 8) for type III, for an overall closure rate of 91.7 percent (22 of 24). Based on the foregoing clinical results, it is concluded that palatal fistula closure with the use of a conchal cartilage graft is extremely simple and reliable. (Plast. Reconstr. Surg. 91:433, 1993.)

Heterotopic nasopharyngeal brain tissue associated with cleft palate.

OBJECTIVE The occurrence of extracranial brain tissue is rare. Most of the literature describes cases in which it is located around the nose and throat and has been classified as nasal glioma. Even more unusual is heterotopic brain tissue in the nasopharynx. We were able to find only 17 previously reported cases. Of these 17 cases, 6 had heterotopic brain tissue located in a cleft palate. This report comments on the identification and treatment of heterotopic brain tissue associated with cleft palate without connection to the central nervous system. Our case subject is a 10-month-old girl diagnosed with heterotopic nasophranygeal brain tissue associated with cleft palate. RESULTS Excision and palatoplasty were performed conjunctively with excellent results. CONCLUSIONS Simultaneous excision of heterotopic nasopharyngeal brain tissue and palatoplasty of the cleft palate is an excellent option for treatment of these cases.

Operations for Microforms of Cleft Lip

Microform cleft lip is a mild expression of cleft lip and may be difficult to repair. Its severity may be defined by the degree of downward depression of the nostril rim, skin striae of the upper lip, notching of Cupids bow, and deformity of the vermilion border. Variation in surgical repair is reported for each type of microform cleft lip.

The contour lines of the upper lip and a revised method of cleft lip repair.

Many techniques for cleft lip repair have been reported, but these techniques do not consider the contour lines of the upper lip and, in fact, destroy them. The upper lip has complicated contour lines including the vermilion free margin, vermilion border, upper lip horizontal groove (upper lip groove), philtrum (dimple and columns), nostril sills, and nasolabial grooves. Incision lines should be designed so that the postoperative scars do not cross these contour lines. We feel that our incision lines and postoperative scars provide better aesthetic results and diminish hypertrophic scar formation.

Congenital bilateral zygomatico-mandibular fusion with mandibular hypoplasia

We report a very rare case of congenital bilateral zygomatico-mandibular fusion with mandibular hypoplasia. Soon after birth, the patient underwent tracheotomy because of upper airway obstruction. At the age of one and a half years, reconstruction of the temporomandibular joint and lengthening of the ramus with a costochondral graft were performed. Only a few cases of congenital bony syngnathia revealed in this case have been described in the literature.

A mirror image of the first and second branchial arch syndrome associated with cleft lip and palate in monozygotic twins.

A rare case of monozygotic twins revealing a mirror image of the first and second branchial arch syndrome with accessory ear and hemifacial microsomia, associated with unilateral cleft lip and palate, is presented. Although the concordance and/or discordance rate of monozygotic or dizygotic twins with cleft lip and palate is well reported, that of twinning of the first and second branchial arch syndrome has been very rarely described. First and second branchial arch syndrome occurs sporadically but cleft lip and palate are strongly related to the influence of environmental factors with a considerable hereditary tendency. The study of twinning of congenital anomalies is important in the investigation of the pathogenesis of genetic and environmental effects. The twins were diagnosed as monozygotic with almost complete certainty by ABO blood typing, HLA typing, finger prints, and DNA typing. Concordance was noticed, which suggests a hereditary tendency. Since concordance in these monozygotic twins was exhibited by a precise mirror image of first and second branchial arch syndrome, spinal scoliosis and cleft lip and palate, it is possible that an environmental factor induced these complex anomalies.

Comparative study of reverse flow island flaps in the lower extremities--peroneal, anterior tibial, and posterior tibial island flaps in 25 patients.

The reverse flow island flap is one of the most versatile reconstructive procedures in the lower extremity. There are three major arteries, the peroneal, the anterior tibial, and the posterior tibial artery, and a reverse flow island flap pedicled by each vessel and its intermuscular cutaneous perforators is available. Twenty-five reverse flow island flaps were clinically applied for soft tissue defects in the lower leg (10 peroneal, 8 anterior tibial, and 7 posterior tibial flaps). We report a comparative study of the characteristics and indications of the peroneal, anterior tibial, and posterior tibial reverse flow flaps. We conclude that the anterior tibial reverse flow flaps are more likely, without venous anastomosis, to become congested and necrose than the peroneal and posterior tibial flaps.