Yoshiaki Hosaka

Microdissected thin perforator flaps: 46 cases.

The development of the perforator flap has enabled sacrifice of the muscle and the main vessels to be minimized by means of a meticulous technique of dissection and anastomosis.1– 6 Furthermore, by applying this meticulous technique to the dissection of small vessels in the adipose layer, the first author (Kimura) has established the method of elevating a uniformly thin perforator flap accurately. This procedure was named “microdissection” and reported in an article entitled “A Microdissected Thin Tensor Fasciae Latae Perforator Flap” in 2002.7 That article reported 11 cases of microdissected thin tensor fasciae latae perforator flap; the present follow-up reports 46 cases of four types of perforator flap. Microdissection can be used with all types of perforator flaps in principle, and the four types of perforator flaps used clinically by the authors—the tensor fasciae latae perforator flap, the anterolateral thigh perforator flap, the deep inferior epigastric artery perforator flap, and the thoracodorsal artery perforator flap—are discussed in this article as a follow-up study. Uniform thinness is a merit common to all four of these flaps; however, the properties of individual flaps are distinct, and their comprehension is a key to achieving high-quality reconstructions. The choice of flap depends on the length and caliber of the pedicle, the condition of the flap skin, and the consideration of donor-site morbidity. OPERATIVE PROCEDURE

Dual midfacial distraction osteogenesis: Le Fort III minus I and Le Fort I for syndromic craniosynostosis.

&NA; Midfacial hypoplasia has been corrected by Le Fort III or monobloc forward advancement in one stage in syndromic craniosynostosis, but recently developed distraction osteogenesis has been in use. Whereas the amount of forward mobilization in Le Fort III conventional osteotomy is determined by the preplanned fabricated interdental splint, that in Le Fort III distraction is determined by the positions of the inferior orbital rim, malar complex. and nose. Therefore, the forward mobilization of the upper part of the midface may sometimes be insufficient when one focuses on the final occlusion, and the occlusion might not be satisfied when the forward mobilization is sufficient. Correction of the midfacial hypoplasia should be considered differently in the upper and lower portions of the midface. The upper portion contains the inferior orbit and nose, and the lower portion contains the occlusal structure of the maxillary dentoalveolar portion with the mandible. Separating the midface into two portions and conducting the distraction osteogenesis in both portions separately in different amounts and vectors of distraction is described in this article. Although distraction of the upper portion of the midface can be conducted in one direction with an internal device, distraction of the lower portion of the midface is preferred for conduction by a controllable device because of the need to obtain the preferred occlusion. To obtain better functional and aesthetic results in midfacial distraction in adults and adolescents with syndromic craniosynostosis, dual Le Fort III minus I and Le Fort I midfacial distraction osteogenesis was performed in four cases (in two patients with Crouzon syndrome and in two patients with Apert syndrome). Two females and two males are described (age range, 13 to 26 years). An internal device was used for the upper portion of the midface and an external device was used for the lower portion. The amount of distraction ranged from 14 to 21 mm in the upper portion of the midface and from 11 to 18 mm in the lower portion. No particular complications were noticed over a follow‐up period of 10 to 38 months (average follow‐up, 19.8 months).

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.

A reflectable case of obstructive sleep apnea in an infant with Crouzon syndrome.

Obstructive sleep apnea has recently drawn attention as a cause of sudden death among infants. Life-threatening obstruction of the upper airway is encountered in patients with syndromic craniosynostosis. Early definitive management of obstructive sleep apnea can conquer this critical situation. Although early tracheostomy can solve the problem, successful early midfacial distraction has been reported. In this report, a reflectable case of sudden death caused by a severe obstructive sleep apnea attack at home just before the midfacial distraction, during the waiting period for the surgery of midfacial distraction, is described. The authors stress the importance of preoperative care of the upper airway and the early definitive treatment using distraction osteogenesis for midfacial hypoplasia in infantile syndromic craniosynostosis.

A Case of Improved Obstructive Sleep Apnea by Distraction Osteogenesis for Midface Hypoplasia of an Infantile Crouzon's Syndrome

We performed Le Fort III midfacial advancement with gradual distraction using internal devices on a 2-year 5-month-old boy with Crouzons syndrome with associated severe obstructive sleep apnea. The device was not activated until 7 days after surgery, after which the distraction was initiated, 1 mm per day, and the midface was advanced 4 mm intraoperatively and distracted 12 mm postoperatively. A total advancement of 16 mm was obtained. The obstructive sleep apnea improved remarkably after the distraction. In infants and younger children with associated severe obstructive sleep apnea, advancement by distraction osteogenesis of the midface in Le Fort III maxillary osteotomy will be initially indicated to obviate tracheostomy improving the upper airway obstruction.

Construction of Synthetic Dermis and Skin Based on a Self-Assembled Peptide Hydrogel Scaffold

Using biocompatible peptide hydrogel as a scaffold, we prepared three-dimensional synthetic skin that does not contain animal-derived materials or pathogens. The present study investigated preparation methods, proliferation, and functional expression of fibroblasts in the synthetic dermis and differentiation of keratinocytes in the epidermis. Synthetic dermis was prepared by mixing fibroblasts with peptide hydrogel, and synthetic skin was prepared by forming an epidermal layer using keratinocytes on the synthetic dermis. A fibroblast-rich foamy layer consisting of homogeneous peptide hydrogel subsequently formed in the synthetic dermis, with fibroblasts aggregating in clusters within the septum. The epidermis consisted of three to five keratinocyte layers. Immunohistochemical staining showed human type I collagen, indicating functional expression around fibroblasts in the synthetic dermis, keratinocyte differentiation in the epidermis, and expression of basement membrane proteins. The number of fibroblasts tended to increase until the second week and was maintained until the fourth week, but rapidly decreased in the fifth week. In the synthetic dermis medium, the human type I collagen concentration increased after the second week to the fifth week. These findings suggest that peptide hydrogel acts as a synthetic skin scaffold that offers a platform for the proliferation and functional expression of fibroblasts and keratinocytes.

Clinical success of mandibular distraction for obstructive sleep apnea resulting from micrognathia in 10 consecutive Japanese young children.

In recent years, obstructive sleep apnea has gained attention as one of the causes of sudden death in young children. There have been some reports, mainly from the United States and Europe, that mandibular distraction osteogenesis is effective as a treatment for obstructive sleep apnea syndrome caused by micrognathia in young children. However, there has not been any report yet in Japan. In this study, we performed mandibular distraction osteogenesis using internal devices in 10 young children with obstructive sleep apnea. To enable distraction to be performed smoothly without any difficulties, we modified a surgical procedure by adding an osteotomy of the coronoid process to a vertical ramus osteotomy. Postoperative evaluations using cephalograms and polysomnography were performed, and great improvements were observed. As a result, all patients either avoided or were weaned from tracheostomy, and very good results were obtained similar to those in reports from the United States and Europe. We report our experience in Japan.

Finger Palmar Surface Reconstruction Using Medial Plantar Venous Flap: Possibility of Sensory Restoration Without Neurorrhaphy

Background:Because plantar anatomic features are similar to those of the palmar surface of the finger, palmar surface finger reconstruction using a medial plantar venous flap enables grasping without slippage, results in strength that can withstand friction, and provides a cushioning effect. Furthermore, sensory restoration is thought to be excellent due to the similarity of the tissues. Methods:We performed finger palmar surface reconstruction in 6 patients using venous flap without harvesting the medial plantar subcutaneous nerve branch and assessed the sensory restoration using a static 2-point discrimination test (s-2PD), moving 2-point discrimination test (m-2PD), and Semmes-Weinstein test (S-W test). Results:The mean s-2PD at 12 months after surgery was 8.6 mm, the mean m-2PD was 6.00 mm, and the S-W test score was 3.84–3.22 Conclusion:These findings indicate that sensory improvement can be obtained by finger palmar surface reconstruction without grafting of the medial plantar subcutaneous nerve branch to the digital nerve.

Hybrid of distraction osteogenesis unilateral frontal distraction and supraorbital reshaping in correction of unilateral coronal synostosis.

Unicoronal synostotic plagiocephaly is routinely treated by intracranial wide frontal and bilateral supraorbital reshaping. Recent advancement of distraction osteogenesis in craniofacial surgery has extended to patients with craniosynostosis. Although a controversy remains between conventional osteotomy and reshaping and application of the distraction technique in surgical treatment of craniosynostosis, there have been several positive clinical reports on distraction techniques for nonsyndromic and syndromic craniosynostosis. Unicoronal distraction applied successfully to a case of frontal plagiocephaly has been described. The authors report a procedure: hybrid of unilateral frontal distraction and supraorbital reshaping on the affected side for frontal synostotic plagiocephaly. This procedure was conducted on four typical unicoronal synostotic plagiocephaly cases (patient age range, 9–14 months; all patients female) with successful results. No particular complications were encountered in any of the four cases with a follow-up period that ranged from 18 to 53 months.