Yasushi Sugawara

One-stage transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new alternative.

&NA; The two‐stage method combining neurovascular freemuscle transfer with cross‐face nerve grafting is now a widely accepted procedure for dynamic smile reconstruction in cases with long established unilateral facial paralysis. Although the results are promising, the two operations, about 1 year apart, exert an economic burden on the patients and require a lengthy period before obtaining results. Sequelae such as hypoesthesia, paresthesia, and conspicuous scar on the donor leg for harvesting a sural nerve graft also cannot be disregarded. To overcome such drawbacks of the two‐stage method, we report a refined technique utilizing one‐stage microvascular free transfer of the latissimus dorsi muscle. Its thoracodorsal nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches. Reinnervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster than that of the two‐stage method. In our present series with 24 patients, 21 patients (more than 87 percent) believed that their results were excellent or satisfactory, which also compares well with the results of the two‐stage method combining free‐muscle transfer with cross‐face nerve graft. (Plast. Reconstr. Surg. 102: 941, 1998.)

SPRING MEDIATED DYNAMIC CRANIOFACIAL RESHAPING: Case report

A new technique of using implantable springs as an adjunct after corrective surgery for craniofacial malformations is presented. A 6-month-old boy with multiple premature craniosynostoses and extreme turricephaly underwent surgery of limited extensiveness but supplemented with a set of indwelling springs for gradual postoperative skull reshaping. At spring removal three months later the skull was normalised both clinically and on cephalogram. A 5-year-old boy with Apert syndrome, severe midface retrusion, exorbitism, and sleep apnoea underwent a monobloc full face disjunction without repositioning, but was fitted with two springs for postoperative facial advancement. Three months postoperatively cephalometric analysis revealed 14 mm advancement at incisor level and at least 16 mm in the frontal region. There was no more exorbitism or clinically noticeable midface retrusion. Sleep studies revealed that the sleep apnoea was significantly improved, meaning complete cure except when sleeping flat on the back. It was concluded from these first clinical applications of spring assisted craniofacial distraction that springs hold significant promise for the future in many respects.

Gradual cranial vault expansion for the treatment of craniofacial synostosis : A preliminary report

To treat craniosynostosis, skull reshaping (such as fronto-orbital advancement) is widely performed. Surgical techniques have improved, however several problems still remain, such as postoperative relapse, late resorption, and infection. The main reason for this is probably (1) that the “craniotomized” bone for changing skull contour is used as free bone grafts and (2) that dead space between the reshaped bone and dura is created. We have developed a new method in which cranial bone is expanded gradually, together with the dura, using expansion devices. With this approach there is no extradural dead space postoperatively and the cranial bone segment remains vascularized. We have performed this procedure in 2 patients with Crouzons disease and in 1 patient with sagittal synostosis. In the Crouzons patients, osteotomies were performed to form a one-piece fronto-orbital bony complex without detaching the bone from the dura, and three expansion devices were applied. In the patient with sagittal synostosis, bilateral temporoparietal osteotomies were done in the same fashion and two expansion devices were applied. Expansion was started on the fourth postoperative day at a rate of about 1 mm per day. After obtaining the proper expansion, the devices were removed and the bone segments were fixed with miniplates and screws. All patients showed good results without any complications.

Complications associated with gradual cranial vault distraction osteogenesis for the treatment of craniofacial synostosis.

Distraction osteogenesis has become a standard technique for craniomaxillofacial reconstruction. The authors performed gradual cranial vault distraction osteogenesis in 19 patients with craniosynostosis to study the outcome and complications of this procedure. Postoperative infections developed around the shaft puncture wounds in four patients, including one who required surgical removal of the device. Advanced bone was deformed in one patient. In another, the expansion device was exposed, resulting in a postoperative scar. Despite these complications, the cranium was successfully expanded in all patients.

Treatment strategies for fibrous dysplasia.

In fibrous dysplasia (FD), growth of the lesions usually arrests around early adolescence. However, in some cases, it continues even after this period, and it is not clear under what kind of conditions this growth continues. If this continued growth could be predicted, it would provide a vital assessment tool to determine when bone contouring should be performed. We were able to find numerous reports about FD concerning surgical procedures, but only a small number included long-term postoperative follow-up. In this paper, we investigated 11 patients with FD who were available for a postoperative follow-up longer than a 10-year period. Of these 11 patients, 6 were male and 5 were female, and the mean initial assessment age was 17.9 years. Three cases were diagnosed as Albright syndrome, 3 as monostotic, and 5 as polyostotic. Regrowth after the operation occurred in 9 of the 11 patients. Among these, growth was arrested in 5 patients at the average age of 23 years, and growth is still being observed in the remaining 4 patients including 3 patients with Albright syndrome. No statistically significant difference was detected between the affected bones and the age of growth arrest, mean age of growth arrest, and sex. Consequently, we believe it is best to perform bone contouring subsequent to growth arrest other than Albright syndrome. When growth continues indefinitely in patients with the polyostotic type, as with Albright syndrome, recurrence of the disease and the resultant deformities are predicted, so complete resection and reconstructive surgery is recommended.

Reconstruction of the umbilicus using a single triangular flap

Many techniques for reconstruction of an absent umbilicus have been described; however, none has achieved a perfect result. We report a new alternative for constructing an umbilicus using a conical flap and present two representative clinical cases. Our technique creates an umbilicus with sufficient depth with good results, including maintenance of depth after more than 1 year.

Brava and autologous fat grafting for breast reconstruction after cancer surgery.

Background: Although autologous fat grafting is widely accepted for breast reconstruction, its indications remain limited to minor contour deformities after reconstruction and small deformities after breast-conserving surgery. The authors describe a case series of total or nearly total breast reconstructions treated with the perioperative use of a vacuum-based external tissue expander (i.e., the Brava device) followed by autologous fat grafting. Methods: The authors assessed the clinical outcomes and aesthetic results in six nonirradiated total mastectomy cases and eight severely deformed irradiated breast-conserving surgery cases. Total Brava wearing time and skin complications were also investigated. Results: The number of fat grafting procedures required ranged from one to four, and the mean amount of fat grafted during each procedure was 256 cc (range, 150 to 400 cc). Postoperative fat lysis and cellulitis occurred in two cases (14.3 percent). Brava worked effectively for total mastectomy cases, and improvement in the total aesthetic score was significantly higher than that in the breast-conserving surgery cases. All patients wore the device for more than 8 hours/day. The most frequent skin complication was dermatitis [n = 11 (79 percent)], which occurred in all breast-conserving surgery cases. Conclusions: Brava was well tolerated by patients. Fat grafting with perioperative use of Brava is an alternative to total breast reconstruction in total mastectomy cases. However, for severely deformed breast-conserving surgery breasts treated with radiation therapy, the contracted skin was difficult to extend despite Brava use, and the results were less satisfactory. These cases also experienced a higher incidence of skin complications compared with the total mastectomy cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The transconjunctival approach for orbital bony surgery: in which cases should it be used?

The advantages and disadvantages of the transconjunctival approach were examined to determine its indication for orbital bony surgery. The transconjunctival approach was used in 22 patients. The average follow-up was 13 months. Two patients had an intraoperative lower eyelid laceration because of excessive traction. Lower eyelid retraction occurred in 5 patients after surgery, although only 1 of them required surgical repair. With a transconjunctival approach alone, the exposure of the orbital lateral wall is limited and incorporation of a lateral incision has been found to be necessary. Postoperative eyelid retraction seems to occur even in the transconjunctival approach. The transconjunctival approach is best indicated in cases with an orbital medial wall fracture because it provides much easier access than any cutaneous approach.

Skeletal analysis of craniofacial asymmetries in plagiocephaly (unilateral coronal synostosis)

Why do the craniofacial bones grow asymmetrically in patients with plagiocephaly (unilateral coronal synostosis)? We obtained three-dimensional skeletal replicas of two patients with the condition and analysed the deformities of the facial bones. From this analysis we deduced that the asymmetric deformation of the facial bones in these patients was caused by a combination of three rotations: rotation of the calvaria toward the affected side because of premature synostosis of the coronal and sphenofrontal sutures; rotation of the facial bones on the horizontal plane toward the unaffected side caused by anterior displacement of the TM (temporomandibular)-joint on the affected side; and downward rotation of the facial bones toward the unaffected side caused by inferior displacement of the TM-joint on the affected side.

Fronto-orbital advancement by distraction: the latest modification.

In 1996 the authors performed the first fronto-orbital advancement by distraction osteogenesis in a patient with coronal synostosis, and they have refined the surgical technique since then. Their latest technique has the following features: 1) the osteotomy lines are almost identical to those of conventional fronto-orbital advancement except for the lack of supraorbital osteotomy and tongue-in-groove osteotomy; 2) burr holes are placed at the pterion just behind the sphenoid wing and at the bregma lateral to the anterior fontanel bilaterally, and another burr hole is placed on the glabella 1 cm above the nasion; 3) to gain access to the lateral portion of the anterior cranial base, a 7- to 10-mm-wide segment of bone is removed at the pterion using rongeurs; 4) the sphenoid ridge is widely removed; and 5) osteotomy is performed using a Gigli saw and rongeurs. They report their latest technique.