Yuhei Natori

Experience and anatomical study of modified lengthening temporalis myoplasty for established facial paralysis

Lengthening temporalis myoplasty, reported by Daniel Labbé in 1997, is a unique and definite facial reanimation procedure that involves moving the whole temporal muscle anteroinferiorly and inserting its tendon directly into the nasolabial fold. In the present article, we report our experience in the use of his modified method of the procedure, which preserves the zygomatic arch by transecting the coronoid process through the nasolabial fold incision. We also describe our cadaveric study that aimed to elucidate a secure approach for coronoid process transection. We performed this procedure in five patients with permanent facial paralysis. To improve facial symmetry, we also performed several additional static reconstructions such as T-shaped double-sleeve fascia grafts for lower lip deformities. We were successful in achieving considerable static improvement at rest, immediately after the surgery, and the recovery of facial movement was apparent approximately 3 months after the surgery. With regard to the cadaveric study, we noted that the entry to the buccal fat region, which is also the pathway of the temporal fascia, was a narrow space, and a short transection of the medial upper edge of the masseter fascia would make it easy to locate the coronoid process. Therefore, for a safe and secure access to the coronoid process from the nasolabial fold, we believe that we should first expose the cranial side and continue to dissect along the side and lower edge of the maxilla to locate the medial upper edge of the masseter fascia. By transecting along its edge, we could easily access the coronoid process, located immediately behind it, and widen the pathway of the temporal fascia. This modified method is less invasive and simpler compared to the original procedure, and understanding the detailed anatomy for dissection would help surgeons perform this procedure more confidently.

Intraoperative Use of Indocyanine Green Fluorescence Angiography during Distally Based Radial Artery Perforator Flap for Squamous Cell Carcinoma of the Thumb.

Summary: Distally based radial artery perforator flap (DBRAPF) is useful for hand defects; however, the location of the perforator varies among individuals. Preoperative evaluation has been a problematic issue when performing this flap. A 64-year-old man developed squamous cell carcinoma on an old burn scar at the dorsal thumb and was referred to our clinic for further treatment. After wide resection of the tumor, including the long and short extensors of the thumb, we reconstructed the defect with DBRAPF. At that time, near-infrared fluorescence angiography with indocyanine green (ICG) was used to identify the position of the perforator. After injecting ICG intravenously, we could observe its uptake at approximately 5 cm proximal to the styloid process. We designed a 10 × 6 cm island flap with that uptake as pivot point. During flap elevation, the perforator could be confirmed at the point of uptake; the flap was then transferred to the defect by rotating the pedicle at the identified point. The vascularity of the flap could also be checked intraoperatively through ICG angiography. The tip of the flap that showed weak ICG fluorescence indicated epidermal necrosis. Nevertheless, the entire flap was viable and enabled good functionality without tumor recurrence and metastasis after 5 years. Using ICG angiography, DBRAPF could be performed smoothly, easily, and safely.

Effectiveness of platysma muscle flap in preventing Frey syndrome and depressive deformities after parotidectomy

BACKGROUND Frey syndrome (FS) or depressive deformity (DD) occurring after parotidectomy significantly reduces a patients quality of life. However, there seems to be no effective treatment strategy against these complications. In this study, we report our experience of using platysma muscle flap (PMF) to prevent the development of FS and DD after parotidectomy, and evaluate its effect subjectively and objectively. METHODS Superficial parotidectomy was performed for eight cases of parotid gland tumor, and a PMF was transferred to cover the site. The incidence of FS and DD were evaluated subjectively, using a questionnaire to the patients and board-certified reconstructive surgeons, and objectively, using Minors starch-iodine test. RESULTS In seven patients, the defect could be completely covered with PMF, and none of them developed FS or obvious DD. However, in one patient, the defect could be only partially covered, and the patient developed complications in the exact site that the flap did not cover. Overall scores from the questionnaire were high in relation to both cosmetic and functional perspectives from most of the patients and all the surgeons. No patients had major postoperative complications requiring revision. CONCLUSIONS PMF can be useful to cover the defect and prevent complications after parotidectomy. PMF is relatively easy to perform with fewer complications; however, a complete coverage of the defect should be ensured to obtain optimal results.

Massive myoepithelial carcinoma originating from the submandibular gland that was successfully treated with surgical excision, using a part of the lengthened skin as a local flap.

Summary: Myoepithelial carcinoma is rare and mostly originates from the major salivary glands. Sometimes, it is difficult to differentiate the benign from the malignant histologically, and its clinical behavior and histological features may vary. Here, we describe the case of a 55-year-old woman who presented with a massive myoepithelial carcinoma, which hung like a temple bell from her right side of the jaw, and she refused to go to the hospital for 3 years. Based on its size and location, we initially thought that, before surgical resection, neoadjuvant therapy would be necessary to reduce the tumor volume. However, after careful evaluation of the tumor characteristics (low-grade histology with outward expansion and little invasion of the adjacent tissues) and imaging findings, we decided that excision was possible. The tumor was encapsulated and had a clear border; it weighed 10.5 kg. By setting the incision line posterior to the equatorial plane and using the lengthened skin posterior to the tumor as a large local flap for the skin defect, we successfully reconstructed the skin defect without harvesting additional flap from other areas. No additional treatment was administered because a sufficient surgical margin was maintained, pathologically. She regained her daily life without recurrence or distant metastasis for 2 years. When treating a massive tumor, careful consideration of its characteristics and location is important, and in this case, we were able to use a simpler and less invasive treatment than we initially envisioned.

The availability of perifascial areolar tissue graft for deep cutaneous ulcer coverage

Soft tissue defects or skin ulcers associated with tendon or bone exposure located distally on the extremities are always difficult to treat. The introduction of the vacuum-assisted closure (VAC) and dermal templates has led to major changes in ulcer treatment strategies. However, it is necessary to find an alternative method to treat these defects when VAC is not available. Perifascial areolar tissue (PAT) is the loose connective tissue on the deep fascia that could be a candidate for repairing soft tissue defects or skin ulcers. Grafting PAT on the exposed bone or tendon, including a wide coverage of well-vascularized tissue surrounding the granulation tissue, can prepare the wound to be subsequently closed by a skin graft. In this study, the PAT was used in various situations and its optimal usage and outcomes were evaluated. A total of 13 PAT grafts were performed and were especially useful for covering narrow ulcers with narrow tendon exposure and filling fistula areas. In comparison to other cases, covering the exposed cortical bone ulcers seemed to be more difficult to perform. However, an option for these ulcers could be the exposure of bone marrow and usage of intraosseous blood flow. It was also possible for the simultaneous engraftment of PAT and skin in narrow areas and could be an alternative in cases of small concave ulcers or fistulae. The PAT graft is a simple and minimally invasive procedure that can be a good alternative when VAC is not available.

End-to-Side Neurorrhaphy as Schwann Cells Provider to Acellular Nerve Allograft and Its Suitable Application.

Axonal regeneration relies on support from proliferating host Schwann cells (SCs), and previous studies on acellular nerve allografts (ANGs) suggest that axons can regenerate into ANGs within a limited distance. Numerous studies have demonstrated that the supplementation of ANGs with exogenous factors, such as cultured SCs, stem cells, and growth factors, promote nerve regeneration in ANGs. However, there are several problems associated with their utilization. In this study, we investigated whether end-to-side (ETS) neurorrhaphy, which is an axonal provider, could be useful as an SC provider to support axonal elongation in ANGs. We found that ETS neurorrhaphy effectively promoted SC migration into ANGs when an epineurium window combined with partial neurectomy was performed, and the effectiveness increased when it was applied bilaterally. When we transplanted ANGs containing migrated SCs via ETS neurorrhaphy (hybrid ANGs) to the nerve gap, hybrid ANGs increased the number of regenerated axons and facilitated rapid axonal elongation, particularly when ETS neurorrhaphy was applied to both edges of the graft. This approach may represent a novel application of ETS neurorrhaphy and lead to the development of hybrid ANGs, making ANGs more practical in a clinical setting.

Expression of transforming growth factor-β1, -β2, and -β3 in plagiocephalic fused and patent coronal suture.

Background Craniosynostosis is a relatively rare disease. Recently, several studies have investigated the etiology of craniosynostosis using animal models; however, the etiology remains unknown. In this study, we examined transforming growth factor (TGF) &bgr;s immunostaining from coronal sutures in patients with plagiocephaly. Materials The examined materials were obtained from 3 patients who had undergone surgery for plagiocephaly. The sections were obtained from the normal patent side and the abnormal fused side of the coronal suture. The subjects included 2 girls and 1 boy with ages ranging from 1 to 4 years. Osteoblasts and connective tissue were observed with hematoxylin and eosin stain. Immunohistochemistry of the TGF-&bgr; isoforms was performed to investigate the difference between the patent and fused sutures. Results No connective tissue was observed in the fused suture. The osteoblasts in the patent suture were activated, whereas the osteoblasts in the fused suture were inactivated. The osteoblasts were positive for TGF-&bgr;1, -&bgr;2, and -&bgr;3. The periosteum tended to be positive for TGF-&bgr;2 and negative for TGF-&bgr;1 and -&bgr;3. There was no distinct difference between the patent and fused sutures in this study. Discussion In this study, all sutures had fused completely, and therefore, we may have missed the period when there are differences in protein manifestation. The modulation of the growth factor profile at the suture site may have a potential therapeutic value.

Microvascular Reconstruction of Free Jejunal Graft in Larynx-preserving Esophagectomy for Cervical Esophageal Carcinoma.

Background: Losing the ability to speak severely affects the quality of life, and patients who have undergone laryngectomy tend to become depressed, which may lead to social withdrawal. Recently, with advancements in chemoradiotherapy and with alternative perspectives on postoperative quality of life, larynx preservation has been pursued; however, the selection of candidates and the optimal reconstructive procedure remain controversial. In this study, we retrospectively reviewed our experience with free jejunal graft for larynx-preserving cervical esophagectomy (LPCE), focusing on microvascular reconstruction. Methods: Seven patients underwent LPCE for cervical esophageal carcinoma, and defects were reconstructed by free jejunal transfer subsequently. We collected preoperative and postoperative data of the patients and assessed the importance of the procedure. Results: We mostly used the transverse cervical artery as the recipient, and a longer operative time was required, particularly for the regrowth cases. The operative field for microvascular anastomosis was more limited and deeper than those in the laryngectomy cases. Two graft necrosis cases were confirmed at postoperative day 9 or 15, and vessels contralateral from the graft were chosen as recipients in both patients. Conclusions: Microvascular reconstruction for free jejunal graft in LPCE differed in several ways from the procedure combined with laryngectomy. Compression from the tracheal cartilage to the pedicle was suspected as the reason of the necrosis clinically and pathologically. Therefore, we should select recipient vessels from the ipsilateral side of the graft, and careful and extended monitoring of the flap should be considered to make this procedure successful.

The Fluorescent Intensity from the Transgenic Thy1–Yellow Fluorescent Protein 16 Mouse Correlates with the Amount of Regenerated Axons

1 Yuhei Natori, MD Hidekazu Yoshizawa, MD Daiki Senda, MD Hiroshi Mizuno, MD Ayato Hayashi, MD Department of Plastic and Reconstructive Surgery Juntendo University School of Medicine Tokyo 113-8421, Japan Sir: N regeneration has been electrophysiologically, histomorphometrically, and immunocytochemically evaluated.1 However, these techniques only evaluate the regeneration state at specific time points. Development of transgenic mice with axons constitutively expressing fluorescent proteins has enabled the serial imaging of regenerated axons in the same mice.2.3.4 However, it is unclear whether in transgenic mice, the intensity of axonal fluorescence correlates with the number of regenerated axons. We investigated the correlation between the intensity of fluorescence from regenerated axons and the histological number of regenerated axons in transgenic mice. We used Thy1–yellow fluorescent protein (YFP) 16 mice with all motor and sensory nerves constitutively expressing YFP fluorescence. They were housed in a central animal facility, and all procedures complied with protocols approved by the Juntendo University School of Medicine. After isoflurane anesthetization, the right sciatic nerve was exposed and crushed for 5 seconds using fine forceps. After 2 weeks, the mice were reanesthetized to reexpose the crushed sciatic nerve. Fluorescent images were obtained using a fluorescence stereomicroscope (Leica MZ 16; Leica DFC 300FX, Wetzalr, Germany) and evaluated using the Leica Application Suite Advanced Fluorescence image acquisition software. The distance of the regenerated axons in Thy1–YFP mice was evaluated based on the most advanced fluorescent point. We quantified the intensity 3 mm distal and proximal (▼) to the site where the nerve fluorescence intensity started to decrease (↓) (Fig. 1). The intensities of points A and B were evaluated as a ratio to the intensity of the undamaged initial nerve fluorescence (defined as 1). We obtained the nerve tissue samples from points A and B and conducted histological evaluations, such as axonal count, myelin thickness, and axon minor axis dimension at both points. The correlation coefficient r between the pixel fluorescence ratio and each histological parameter was calculated, and the following results were obtained: axon numbers in every field, r = 0.9673; mean myelin thickness, r = 0.8487; and mean axon minor axis, r = 0.905 (Fig. 2). In general, Thy1–YFP mice were evaluated for the position of the fastest growing fluorescence along the time axis, and sometimes, regeneration speed was calculated.2.3.5 Thus, we investigated the consistency between the intensity of fluorescence and histological evaluation of regenerated axons in the entire nerve. Correlation was noted for all histological values; it was stronger with the number of regenerated axons than the axon and myelin thickness. Therefore, the evaluation of intensity of fluorescence under specific conditions may be useful for the overall number of regenerated axons. However, the conditions of fluorescence imaging could be easily changed. Therefore, imaging must be performed under a uniform condition in a dark room, and the collagenous scar (thin but opaque) around the nerve should be atraumatically removed without any damages to the axons.5 Such technical aspects are important to obtain stable results. In conclusion, serial in vivo imaging in Thy1–YFP mice provides real-time insight into peripheral nerve regeneration, and it is useful for evaluating the overall number of regenerated axons that can be correlated with histological values.

Cylinder syringe suction: a simple and efficient technique for the evacuation of subcutaneous hematoma.

BackgroundSubcutaneous hematoma is commonly caused by trauma or surgery. Proper treatment of the condition is needed to avoid severe complications. The present paper introduces a simple technique of hematoma evacuation, called cylinder syringe suction (CSS). Experiments were also performed to determine the detailed mechanism underlying its effectiveness. MethodsThe CSS procedure was performed as follows. A cylindrical plastic cylinder syringe was used. Either a few stitches were removed or a very small incision was made on the site of the hematoma. The edge of the syringe was compressed to the skin, which was covered by a thin hydrocolloid dressing. Vacuum aspiration was enforced at the site of the wound or incision, and the hematoma was gradually aspirated.For the experiment, house rabbits were used. Hematoma evacuation was performed in 4 different ways, including needle aspiration alone (group 1), needle puncture followed by CSS (group 2), and creation of a small wound (5 mm) followed by needle aspiration (group 3) or CSS (group 4). The amount of evacuated hematoma and the suction pressure created by each of the 4 methods were compared. ResultsGroup 4 showed the highest suction pressure and the greatest evacuated amount of hematoma. High suction pressure was also obtained in group 1; however, the amount of evacuated hematoma was small as the other 2 groups. ConclusionThe CSS technique becomes effective mainly by creating high suction pressure, and the opening of a small wound enables the viscous coagula to pass through the skin.