Tomohisa Nagasao

Morphological analysis of the upper eyelid tarsus in asians

Purpose:The present study aims to evaluate morphologic variations of the upper tarsus in Asians. Methods:Measurements of superior-inferior and medial-lateral lengths were performed on 54 embalmed cadavers. The superior-inferior length of the tarsus was measured at the central and lateral parts. On the basis of the measured values, shapes of the tarsi were evaluated and categorized. Results:The tarsi were classified into 3 morphologic categories—the sickle, triangular, and trapezoid types. The upper margins of the sickle, triangular, and trapezoid type tarsi present round, triangular, and flat lines, respectively. Among the 54 examined specimens, 29 (55.6%), 16 (29.6%), and 9 (16.7%) belonged to the sickle, triangular, and trapezoid groups, respectively. Conclusions:The upper eyelid tarsi present morphologic variations with the Asian population. In performing surgical correction of blepharoptosis or surgical production of double-folds, this individual variation should be taken into consideration.

Rotation arc of pedicled anterolateral thigh flap for abdominal wall reconstruction: How far can it reach?

PURPOSEnThe aim of this study was to elucidate the extent to which pedicled anterolateral thigh (ALT) flaps can reach in reconstruction of abdominal wall defects.nnnMETHODSnA total of 60 pedicled ALT flaps were raised from cadavers and were experimentally transferred to the abdominal region. The distance between the umbilicus and the most cranial point of the flap after transfer was defined as cranially reachable distance (CRD). Three issues were evaluated: (1) the difference in the CRD when the flap pedicle was positioned superficial or deep into the rectus femoris (RF) and sartorius (SA) muscles; (2) the difference in the CRD in those cases where the main artery of RF arises from the descending branch of the lateral femoral circumflex artery, and is preserved or severed; and (3) maximum values of CRD.nnnRESULTSn(1) CRD was significantly greater when the pedicle was passed deep into the muscles (-2.5xa0±xa03.8 SD cm) compared with superficial (-5.8xa0±xa03.3 SD cm), indicating placement of pedicles beneath the two muscles enables additional extension. (2) CRD was significantly greater for the severed condition (-0.3xa0±xa04.0 SD cm) than for the preserved condition (-3.3xa0±xa04.1 SD cm), indicating severing the main artery of RF allows additional extension. (3) Out of the 60 specimens, the CRD was cranial to the umbilicus in 17 flaps, indicating pedicled ALT flaps can reach the umbilicus in less than one-third (17/60) of cases.nnnCONCLUSIONnPedicled ALT flaps can reliably reach regions inferior to the umbilicus. However, for defects superior to the umbilicus, other reconstructive options should be considered.

Capsule formation can make secondary reconstruction of the dura mater unnecessary after cranial infection

Purpose:Defects of the dura mater caused by surgical intervention are often reconstructed using artificial substitutes such as polytetrafluoroethylene membrane (Gore-Tex in commercial name). In cases where secondary infection develops after the initial operation, the artificial substitute used in the primary surgery needs to be removed, and the cranial defect should be covered with tissues abundant in blood supply. The present study discusses the necessity of secondary reconstruction of the dural defect in the recovery operation. Methods:A retrospective study was conducted on 12 patients in whom artificial substitute was exposed because of necrosis of the overlying tissues due to infection or radiation. In recovery operations, the artificial substitute was removed, and the conditions of the underlying defects were evaluated. Results:In all cases, capsule formation had developed to cover dural defects underneath the infected artificial substitutes. The capsules were transparent and watertight, presenting no leakage of cerebrospinal fluid. After coverage of the defect regions using free-flap transfer, no patient developed postoperative complications in follow-up periods of at least 6 months. Conclusions:Capsule formation occurs under artificial substitutes after replacement of the dura mater. Because the capsules retain the cerebrospinal fluid, replacement of the artificial materials is unnecessary in the secondary operation.

Thoracic outlet syndrome after the Nuss procedure for pectus excavatum: Is it a rare complication?

OBJECTIVEnThe present study aims to elucidate the frequency of thoracic outlet syndrome after the Nuss procedure for pectus excavatum and the conditions in which thoracic outlet syndrome is likely to develop.nnnMETHODSnA retrospective study including 85 pectus excavatum patients (58 males and 27 females) was conducted. Thoracic outlet syndrome was defined as a condition in which the patient has numbness, lassitude, or pain of the upper limbs at rest or during motion of the upper limbs. The frequency of the thus-defined thoracic outlet syndrome was evaluated in 85 patients. Age, sex, Haller indices, and the positions of the correction bars were compared between the patients who developed thoracic outlet syndrome and those who did not.nnnRESULTSnPreadolescent patients (18 out of 85) did not develop postoperative thoracic outlet syndrome. In total, 15.2% of adult male patients (7 out of 46) and 33% of adult female patients (7 out of 21) developed postoperative thoracic outlet syndrome. For both male and female groups, Haller indices were significantly greater for patients who had postoperative thoracic outlet syndrome than for those who did not. Correction bars were generally placed at higher intercostal spaces in patients who developed postoperative thoracic outlet syndrome than in those who did not.nnnCONCLUSIONnA considerable percentage of adult patients develop thoracic outlet syndrome after the Nuss procedure for pectus excavatum. Maturity of the thoracic wall, femininity, severity of the deformity (represented by greater Haller indices), and placement of correction bars at superior intercostal spaces are risk factors for postoperative thoracic outlet syndrome.

Scoring of Deformed Costal Cartilages Reduces Postoperative Pain after Nuss Procedure for Pectus Excavatum

OBJECTIVEnThe present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients.nnnMETHODSnA total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (nu2009=u200924); those who received no such scoring were categorized as the Non-Scoring Group (nu2009=u200922). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups.nnnRESULTSnThe maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days).nnnCONCLUSIONnHigh stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced.

Effective scoring of scapha prevents helix irregularity in prominent ear correction — A biomechanical study

BACKGROUNDnAs the antihelix is created in the operation for prominent ear, the helix often presents irregularities. This biomechanical study aims to elucidate effective techniques to prevent these irregularities.nnnMETHODSnFinite element models were produced simulating 10 prominent ears. The scaphas of the 10 models were thinned to simulate scoring or abrasion of the cartilage. The thinning was conducted in four fashions. In the first group, no thinning was conducted (Non-Scoring Models); in the second group, the upper half of the scapha was thinned (Upper-Scoring Models); in the third group, the lower half of the scapha was thinned (Lower-Scoring Models); in the fourth group, the whole scapha was thinned (Whole-Scoring Models). Mattress sutures were applied to create the antihelix to simulate Mustardes in-suture technique. Thereafter, transformation of the helixs contour was evaluated.nnnRESULTSnIrregularity developed on the upper region of the helix with Non-Scoring and Lower-Scoring Models; the degree of the upper-regions irregularity was reduced with Upper-Scoring Models and Whole-Scoring Models. Although the edge of the helix moved in the posterior-medial direction with other type models, it moved in the anterior direction with Whole-Scoring Models.nnnCONCLUSIONnIrregularity of the upper region of the helix can be prevented by performing scoring or abrasion of the upper part of the scapha. The prominence of the helix and width of the auricle are adjustable by varying the areas of the scapha receiving scoring or abrasion. These findings are useful in improving operative outcomes in the treatment of prominent ears.

Transformation of keloids is determined by stress occurrence patterns on peri-keloid regions in response to body movement

Keloids gradually change their shapes as they grow. We hypothesize that the change of keloid morphology reflects the incremental change of the stress patterns occurring in peri-keloid regions due to movement of the keloid-carrying body part. To examine the validity of this hypothesis, we used three-dimensional finite element analysis to calculate the stresses occurring in the peri-keloid regions of keloids on the chest in response to respiratory movement. The stresses concentrate at the peri-keloid regions close to the bilateral ends of the keloids. By reviewing this result in reference to our hypothesis, we can explain why keloids on the chest are likely to present crab or butterfly shapes. Although we know that keloids grow in response to mechanical stresses, our hypothesis differs from existing ones in that it focuses on morphological transformation. Our hypothesis is helpful for physicians in performing treatment for keloids, because they can predict what part of a keloid is likely to grow and perform preventive treatment in reference to the hypothesis.

Effects of platelet-rich plasma on tissue-engineered vascularized flaps in an in vivo chamber

AIMSnWe investigated the reproducibility of creating a vascularized tissue flap in an in vivo tissue engineering chamber by incubating a vascular pedicle imbedded in a collagen sponge with activated platelet-rich plasma (aPRP) and basic fibroblast growth factor (bFGF).nnnMETHODSnCollagen sponge soaked with saline (control group), bFGF (Group 1), aPRP (Group 2), and aPRP/controlled release bFGF (Group 3) was implanted with a saphenous arteriovenous pedicle into a tissue engineering chamber, located subcutaneously in the groin of rabbits. After 4 weeks of implantation, the contents in the chamber were harvested for volumetric and histological analyses.nnnRESULTSnThe total volume of generated tissue in Group 3 was the largest among the Groups (control group vs. Group 3, pu2009<u20090.01). The volume of the pedicle vascular bundle/adipose tissue component was larger in Groups 1 and 3 than that in the control group (pu2009<u20090.05 and pu2009<u20090.01, respectively). The inflammatory tissue volume was larger in Groups 2 and 3 (control group vs. Group 3, pu2009<u20090.05). In a smaller long-term study, inflammatory tissue at 4 weeks was gradually replaced by the adipose tissue within 8 weeks.nnnCONCLUSIONnPRP-induced inflammatory reactions were considered to be necessary to stimulate cell migration into the chamber, leading to more tissue regeneration with abundant cell components. We conclude that PRP contributes to the reproducibility of preparing vascularized flaps in an in vivo chamber.

Preservation of deep-layer fat of lateral zones prevents postoperative seroma after TRAM-flap harvesting for breast reconstruction: a retrospective study

Abstract Objective: The present study elucidates whether or not preserving fat tissues deeper than the Scarpa’s fascia in zone 3 and zone 4 reduces postoperative fluid collection after harvesting the transverse rectus-abdominis muscle (TRAM) flap. Methods: Thirty-one patients for whom breast reconstruction with free TRAM flaps had been performed were included in the study. Fat tissues deeper than the Scarpa’s fascia in zone 3 and zone 4 were addressed in two ways. With 17 patients, these tissues were preserved on the abdominal wall; with 14 patients, these fat tissues were harvested as part of the TRAM flap. The former and latter groups were named the Preservation Group and Non-Preservation Group, respectively. Drainage tubes were placed at the donor site until daily drainage became less than 20u2009ml, at which time the tubes were removed. The total amount of postoperative fluid drained from the donor site and the days required before tube removal were compared between the two groups. Results: The total volume of drained fluid was significantly greater for the Non-Preservation Group (444u2009±u200948.2u2009ml) than for the Preservation Group (230u2009±u200921.9u2009ml); the period before removal of drainage tubes was significantly longer for the Non-Preservation Group (12.4u2009±u20090.84 days) than for the Preservation Group (7.6u2009±u20090.55 days). Conclusion: Preservation of deep-fat tissues in zone 3 and zone 4 reduces postoperative fluid exuded from the donor site, and enables earlier removal of drainage tubes. For cases where optimal breast shape can be achieved without these fat tissues, the fat tissues should be preserved.

Nummular Eczema of Breast: A Potential Dermatologic Complication after Mastectomy and Subsequent Breast Reconstruction.

Purposes. The present paper reports clinical cases where nummular eczema developed during the course of breast reconstruction by means of implantation and evaluates the occurrence patterns and ratios of this complication. Methods. 1662 patients undergoing breast reconstruction were reviewed. Patients who developed nummular eczema during the treatment were selected, and a survey was conducted on these patients regarding three items: (1) the stage of the treatment at which nummular eczema developed; (2) time required for the lesion to heal; (3) location of the lesion on the reconstructed breast(s). Furthermore, histopathological examination was conducted to elucidate the etiology of the lesion. Results. 48 patients (2.89%) developed nummular eczema. The timing of onset varied among these patients, with lesions developing after the placement of tissue expanders for 22 patients (45.8%); after the tissue expanders were replaced with silicone implants for 12 patients (25%); and after nipple-areola complex reconstruction for 14 patients (29.2%). Nummular eczema developed both in periwound regions (20 cases: 41.7%) and in nonperiwound regions (32 cases: 66.7%). Histopathological examination showed epidermal acanthosis, psoriasiform patterns, and reduction of sebaceous glands. Conclusions. Surgeons should recognize that nummular eczema is a potential complication of breast reconstruction with tissue expanders and silicone implants.