Yasuyoshi Tosa

A novel approach for preventing the development of persistent vasospasms after microsurgery for the extremities: intermittent topical lidocaine application.

Vasospasm is often encountered after harvesting the recipient artery in tissue transfer surgery, particularly in the extremities. Further, after anastomosis, thrombosis is a major complication arising due to vasoconstriction. Therefore, we decided to apply lidocaine topically on the recipient artery to prevent postoperative vasospasm. We had applied lidocaine topically on the recipient artery in seven patients with persistent vasospasm before the completion of the surgery. After surgery, 0.2 mL lidocaine (4%) was directly applied on the vascularized region every 15 minutes for the first 3 hours, every 30 minutes for the next 3 hours, and every 1 hour for the next 18 hours. Although four patients experienced a disturbance in the blood flow immediately after the surgery, they showed improvements after lidocaine application. In three of these four patients, vasospasm was also suspected to occur at 15 minutes after the surgery; however, topical application of lidocaine was found to be effective in these patients. Thrombosis was not observed in any case. We believe that if the site of lidocaine application is appropriate, even a small dose of low-concentration lidocaine (4%) can produce an adequate effect. Moreover, the intervals between lidocaine applications should be carefully considered.

Medial plantar venous flap technique for volar oblique amputation with no defects in the nail matrix and nail bed

BACKGROUND Skin grafting is a simple technique used during volar oblique amputation; however, it is not appropriate to use this technique if the bone or tendon is exposed. Moreover, in volar oblique amputation, if the severed section is large and elongated, skin grafting makes the lack of volume conspicuous, and reconstruction with a V-Y advancement flap occasionally results in a nail deformity that resembles a parrots beak. We used a medial plantar venous flap for the correction of large volar oblique amputation. METHODS Reconstructive surgery was performed on patients with volar oblique amputation in whom the proximal severed volar regions extended from the nail matrix to the distal interphalangeal (DIP) joint. The medial plantar venous flap was harvested, the distal subcutaneous vein or communicating vein of the medial plantar area was anastomosed to the proper digital artery, and the proximal vein of the flap was anastomosed to the dorsal subcutaneous vein of the stump of the digit. RESULTS The flaps survived in all the patients. At 12 months after the surgery, all the treated fingers had attained a good shape. Patients who underwent reconstruction with medial plantar venous flaps attained good sensory restoration. CONCLUSION In volar oblique amputation, if the remaining nail matrix and nail bed are uninjured, then patients can expect the restoration of shape, function and sensory input after surgery. In this study, we used the medial plantar venous flap for large volar oblique amputation cases and obtained good results.

Direct skeletal traction for Le Fort I halo distraction replacing an intraoral dental splint and connecting traction hook.

To obviate dental inconveniences after Le Fort I halo distraction using an intraoral dental splint and connecting traction hook, the authors initiated direct skeletal traction using an traction wire at the parapyriformis buttress area. Halo distraction using this procedure was conducted for 11 cleft lip and palate patients (age range, 13–21 years; 6 females and 5 males). Distraction amount ranged from 11 to 15 mm. A satisfactory occlusion was obtained in all patients. All 11 patients complained of pain during the distraction period, but it was controlled by regular oral intake of the usual amount of analgesics. No other particular complications were encountered during the postoperative follow-up of 8 to 18 months. This form of direct skeletal traction proves effective for Le Fort I halo distraction.

Changes in the blood flow and prevention of vasospasm of the femoral artery by topical application of lidocaine in rats.

Free-tissue transfer with anastomosis has become an important microsurgical technique. Sometimes vasospasm occurs after anastomosis. We examined the changes in blood flow and the effect on the treatment of vasospasm of the femoral artery of rats. The rat models of vasospasm were generated by topical application of epinephrine. We topically applied 2% lidocaine as a single dose (0.2 mL) and a continuous infusion (1.0 mL/h). Our results suggest that although the effect lasts for a short period, a single application of 2% lidocaine has a rapid effect and is effective for treating a sudden manifestation of vasospasm. In contrast, continuous topical application may be more effective for maintaining the blood flow and preventing vasospasm. Therefore we believe that persistent vasospasm should first be treated with several topical applications of lidocaine; if this helps improve the condition, continuous topical application can be subsequently used as a preventive measure.

Simultaneous hybrid of maxillary Le Fort I halo distraction and mandibular set-back for patients with severe cleft jaw deformity.

One of the surgical tactics and retrospective chart review of clinical cases are described for severe maxillo-mandibular discrepancy. The recently developed Le Fort I Halo distraction combined with mandibular sagittal splitting osteotomy is initially carried out simultaneously. Materials include six adult patients revealing severe jaw deformity with mandibular prognathism somehow ranging from 17-19 years of age. The required adjustment of the maxillo-mandibular discrepancy ranged from 14-23 mm to obtain the preferred occlusion. The simultaneous combination of over 10-mm maxillary Le Fort I Halo distraction with mandibular set-back secured rigidly by sagittal splitting was accomplished. The amount of mandibular set-back ranged from 4-6 mm. The amount of maxillary Le Fort I halo distraction ranged from 10-17 mm (Table 1). The retention period of the halo brace was 21-22 days. In addition, the Delair type of face mask was used for 3-4 months as a night splint for consolidation after removal of the halo brace. Satisfactory maxillary distraction and mandibular set-back as planned preoperatively was obtained in all six cases. No particular postoperative complications were noticed. Compared with standard Le Fort I advancement for cleft patients, more advancement can be obtained easily with halo distration, particularly in cases where a large amount of advancement >10 mm is required. This combination is worthwhile for a severe cleft jaw deformity, and is an alternative for standard double jaw osteotomy.

Le Fort III distraction osteogenesis of midface-retrusion in a case of Hajdu Cheny syndrome.

Le Fort III maxillary distraction osteogenesis using the RED system and advancement genioplasty was successfully performed for the midfacial retrusion and to eliminate severe snoring during sleep in a rare case of Hajdu Cheny syndrome. This syndrome is characterized by slowly progressive systemic osseous dysplasia, exhibiting craniofacial disfigurements and other skeletal deformity, but no description is found in a plastic surgical treatment up to now. A rare entity of this syndrome is also presented.

Mandibular Symphyseal Contouring in Mild Mandibular Prognathism

Kölles mandibular segmental osteotomy, with extraction of the bilateral first bicuspids, is often used in cases of mild mandibular prognathism. While mandibular prognathism is usually corrected by mandibular ramus osteotomy and the mandible is set back en bloc, the premolar region alone is set back by segmental osteotomy, retaining the protruding mental area. In Asians, particularly, the protruding chin is not preferred by our concepts of beauty. In mandibular segmental osteotomy, the entire mandibular symphyseal shape should be considered. Mandibular symphyseal contouring constitutes setting back the premolar region by segmental osteotomy, recession genioplasty, and chiseling out the protruding middle portion of the protruding chin. In 18 series of mild manibular prognathism in Asians patients, this procedure was used and satisfactory aesthetic results were obtained.

A New Surgical Approach for Tessier No. 4 Facial Cleft Reconstruction: Lip-Rescue Flap

AbstractCraniofacial clefts are rare, severe challenges for surgeons about which there is limited literature. Tessier Number 4 (No. 4) clefts are one of the most complex craniofacial anomalies and present difficulties in surgical treatment. The most-common deformities associated with Tessier No. 4 clefts are displacements of the lower eyelids, medial canthus, and ala and decreased distance between the lower eyelids and lips. In surgery to correct these deformities, the greatest challenges are the design and the placement of the landmarks and incisions. Because of its relative rarity and wide range of severity, no definitive operative methods have been accepted for Tessier No. 4 facial cleft. The present study presents a new lip-rescue flap technique as an alternative approach for reconstructing Tessier No. 4 facial clefts.