Published papers

BACKGROUND:: Simultaneous tumor resection and cranioplasty with hydroxyapatite osteosynthesis are sometimes necessary in patients of skull neoplasms or skull-invasive tumors. However, the disadvantage of simultaneous surgery is that mismatches often occur between the skull defect and the hydroxyapatite implant. To solve this problem, the authors developed a customized template for designing the craniotomy line. METHODS:: Before each operation, the craniotomy design was discussed with a neurosurgeon. Based on the discussion, 2 hydroxyapatite implants were customized for each patient on the basis of models prepared using computed tomography data. The first implant was an onlay template for the preoperative cranium, which was customized for designing the osteotomy line. The other implant was used for the skull defect. Using the template, the osteotomy line was drawn along the template edge, osteotomy was performed along this line, and the implant was placed in the skull defect. RESULTS:: This technique was performed in 3 patients. No implant or defect trimming was required in any patient, good cosmetic outcomes were noted in all patients, and no complications occurred. CONCLUSION:: Use of predesigned hydroxyapatite templates for craniotomy during simultaneous skull tumor resection and cranioplasty has some clinical advantages: the precise craniotomy line can be designed, the implant and skull defect fit better and show effective osteoconduction, trimming of the implant or defect is minimized, and the operation time is shortened.

Our group developed the veno-accompanying artery fasciocutaneous (VAF) flap, which was a new concept of flap developed in the 1990s that depended on unnoticed blood supply. The VAF flap is a high versatility pedicle flap which can be created almost anywhere with cutaneous veins. However, distally based VAF flaps are prone to congestion in the peripheral part of the flap compared to proximally based flaps, and thus are unsuitable for large defects. The VAF flap cannot be used in infected sites or compression sites, because the blood supply of VAF flaps comes from arterioles accompanying the cutaneous veins. Therefore, we created a new concept of flap-the VAF-myocutaneous (mc) combined flap- to compensate for this drawback. The VAF-mc flap includes a portion of muscle to increase the blood supply to the flap. In this article, we describe the history of the discovery of the VAF flap and its recent modifications.

Background and aims: Recently novel picosecond duration lasers (ps-lasers) have been developed for the treatment of multicolored and recalcitrant tattoos, and safety and efficacy have been reported. We therefore hypothesized that the ps-laser could be an alternative treatment for dermal pigmented lesions and performed a retrospective review to evaluate the efficacy and safety of the ps-laser. Subjects and methods: A retrospective photographic review of 10 patients with dermal pigmented lesions was performed (ages from 4 months to 52 yr), 6 nevus of Ota, 3 ectopic Mongolian spots and 1 Mongolian spots. The patients were treated in the Ohshiro Clinic with picosecond 755 nm alexandrite laser (ps-Alex laser) and picosecond 1064 nm Nd:YAG laser (ps-Nd:YAG laser) from April 2014 to December 2015 (ps-Alex laser, 7 patients; ps-Nd:YAG laser, 3 patients, 1 to 3 treatment sessions). Improvement was evaluated as percentage of pigmentation clearance comparing the baseline findings with those at 3 months after the final treatment using a five category grading scale: Poor, 0-24%; Fair, 25-49%; Good, 50-74%; Excellent, 75-94%; and Complete, 95-100% improvement. Adverse events were also assessed. Results: All ten patients obtained clinical improvement ranging from fair to excellent. Treatment with the ps-Alex laser caused transient hyperpigmentation followed by improvement to complete resolution at 3 months follow-up. The ps-Nd:YAG laser caused severe transient erythema and swelling but no post-inflammatory hyperpigmentation. Conclusions: Our results suggest that the 755 nm and 1064 nm ps-lasers are efficacious for the treatment of dermal pigment lesions, with minimum adverse events.

BACKGROUND:: Posterior cranial vault distraction osteogenesis is a common treatment for syndromal patients of brachycephaly and oxycephaly. Although posterior distraction can increase intracranial volume, the flattened head phenotype is difficult to correct. The authors examined a new posterior distraction technique termed double-door distraction for improvement of the flattened head phenotype. METHODS:: From 2010 to 2013, 6 patients with flattened posterior craniums were operated on using the double-door distraction technique. The calvarial segment was cut at the midline and divided into 2 pieces. Distractors were then fixed in parallel to join the calvarial pieces. The distraction was initiated at a rate of 1.0?mm/day and continued until proper cranial form was confirmed by radiography and appearance. RESULTS:: The average surgery time was 2?hours 47?minutes and the amount of distraction ranged from 15 to 22?mm. An improved head shape and expanded cranial vault was achieved in all patients without any complications. CONCLUSIONS:: The double-door distraction technique is a useful technique not only for calvarial expansion, but also for correction of the flattened posterior cranium phenotype.

Aim The aim of this study was to evaluate the utility and efficacy of bioabsorbable hydroxyapatite and collagen complex for secondary bone graft in unilateral alveolar cleft. Patients and methods From August 2013 to January 2014, 15 patients with unilateral cleft lip and alveolar cleft were enrolled and randomly assigned to two blinded groups. In group I, a cancellous iliac bone graft was placed at the alveolar cleft. In group II, 0.5 ml of HA/Col was placed at the alveolar cleft, and the cancellous iliac bone was positioned in the remaining space. All patients underwent bone grafting with particulate cancellous bone and marrow taken from the anterior iliac crest. Results No complications were observed in any patient. The groups did not differ in age, cleft volume, or surgical duration. Intraoperative blood loss and patient-controlled intravenous analgesia (PCA) use were significantly lower in group II (p <0.05) in comparison to group I. The 1-month volume was 0.895 ml in group I and 0.482 ml in group II (p <0.05). When the 1-month volume in group II was adjusted for 0.5-ml volume of HA/Col, there was no significant difference in the 1-month volumes (p = 0.32). The 6- and 12-month volumes did not differ significantly between the groups (p = 0.768 and p = 0.165, respectively). Conclusion The autogenous bone was gradually absorbed, while the HA/Col was absorbed and replaced by the autogenous bone. Thus, HA/Col can be used as an iliac graft in alveolar bone graft procedures to reduce the amount of autogenous bone required from the crest, patient stress, and morbidity.

Background: The evidence-based recommendations in 2011 state that a negative-pressure wound therapy (NPWT) may be considered as an advanced wound care therapy for lower limb ulceration after successful revascularization. Since the grade of recommendation was determined by six articles which did not study patients with similar wound severity to critical limb ischemia (CLI), we investigated the patients with similar one. Methods: Of the 169 cases who were surgically treated for lower extremity wounds due to CLI between January 1, 2007, and December 31, 2013, nine cases satisfied the following criteria in our institute. There were patients on hemodialysis due to diabetic nephropathy among patients with CLI, and percutaneous transluminal angioplasty (PTA) was performed. These patients had foot gangrene, underwent debridement, and then underwent second-stage midfoot wound closure. Their wounds were completely healed. After performing debridement until the second-stage wound closure surgery, the localized wound therapy without NPWT in three patients (group 1) before health insurance covered NPWT in 2010 and using NPWT in six patients (group 2) thereafter. Results: The mean period until wound closure surgery after debridement was 55.7 ± 11.2 days in group 1 and 31.3 ± 6.6 in group 2. Significant difference in the number of days was observed between the two groups (p = 0.002). Conclusions: Period of time from debridement to the time of wound closure surgery was significantly shortened with NPWT after revascularization by means of PTA in CLI patients. Level of Evidence: Level IV, therapeutic study.

Healthcare providers treating wounds have difficulties assessing the prognosis of patients with critical limb ischemia who had been discharged after complete healing of major amputation wounds. The word "major" in "major amputation" gives the impression of "being more severe" than "minor amputation." Therefore, even if wounds are healed after major amputation, they imagine that prognosis after major amputation would be poorer than that after minor amputation. We investigated the prognosis of diabetic nephropathy patients 2 years after amputations. Those patients underwent dialysis as well as amputation following percutaneous transluminal angioplasty for their foot wounds. They were ambulatory prior to these surgeries. Among 56 cases of minor amputation, 45 were males and 11 were females, and mortality was 41.1%. The mortality of cases with and without a coronary intervention history was 53.1% and 25.0%, respectively (p=0.034). Among 10 cases of major amputation, 9 were males and 1 was female, and mortality was 60%. The mortality of cases with and without a coronary intervention history was 75.0% and 0%, respectively. Although we predicted poor prognosis in cases with major amputation, there was no significant difference in mortality 2 years after amputations (p=0.267). Thus far poor prognosis has been reported for major amputation. It might be due to inclusion of the following patients: patients with wounds proximal to ankle joints, patients with extensive gangrene spreading to the lower legs, patients with septicemia from wound infection and who died around the time of operation, and patients with malnutrition. The results of our present study showed that the outcomes at 2 years postoperatively were similar between patients with major amputations and those with minor amputations, if surgical wounds were able to heal. We should not estimate the prognosis by the level of amputation, rather we should consider the effect of coronary intervention history on prognosis.

Peroxisome proliferator-activated receptor γ (PPARγ) is a member of the nuclear receptor superfamily known for its anti-inflammatory and macrophage differentiation effects, as well as its ability to promote fat cell differentiation and reduce insulin resistance. Pioglitazone (Pio) is a PPARγ agonist used clinically as an anti-diabetic agent for improving insulin sensitivity in patients with diabetes. The objective of this study was to develop a drug delivery system (DDS) for the local release of Pio to promote wound healing. Pio of low aqueous solubility was water-solubilized by micelles formed from gelatin grafted with L-lactic acid oligomers, and incorporated into a biodegradable gelatin hydrogel. An 8-mm punch biopsy tool was used to prepare two skin wounds on either side of the midline of 8-week-old mice. Wounds were treated by the hydrogels with (Pio-hydrogel group) or without (control group) Pio, and the wound area were observed 1, 4, 7, and 14 days after treatment. In addition, a protein assay and immunohistological stain were performed to determine the effects of the Pio-hydrogel on inflammation and macrophage differentiation. The Pio-hydrogels promote wound healing. Moreover, Western blotting analysis demonstrated that treatment with Pio-hydrogels resulted in decreased levels of the cytokines MIP-2 and TGF-β, and increased levels of glucose-regulating adiponectin. It is concluded that Pio-incorporated hydrogels promote the proliferation and remodeling phases of wound healing, and may prove to be effective as wound dressings.

BACKGROUND: Dynamic graciloplasty has been proposed for anal reconstruction, but this method has 2 major drawbacks. First, an electrical device is required for control of the gracilis. The anastomosis with the pudendal nerve will provide more physiological control. Second, the limitation in the mobility of the muscle flap results in wrapping the anal canal with the muscle's distal portion, which is tendonlike and inelastic. Enhancing the mobility of the muscle flap will enable wrapping with the proximal, muscle-like, and extensible portion, possibly providing better sphincteric function. However, the basis for such an operative method is lacking. OBJECTIVE: The aim of this study is to provide the basis for the refined method of anal sphincter reconstruction by dynamic graciloplasty with pudendal nerve anastomosis and to verify the feasibility of lengthening the nerve to the gracilis muscle flap by dissecting into the muscle belly, detaching the gracilis muscle from its origin, and enhancing the mobility of the muscle flap. STUDY DESIGN: This is a retrospective, descriptive study. METHODS: The results from the anatomical study on 9 cadavers are reported. RESULTS: Tension-free anastomosis of the pudendal nerve and nerve to the gracilis was successfully performed in all the 9 cases: in 2 cases, by lengthening the nerve. The detachment of the muscle origin improved the mobility of the muscle flap, and the more proximal portion could be used for wrapping the anal canal, as confirmed in 4 cases. LIMITATIONS: The limited number of cases was a shortcoming of this study. CONCLUSIONS: By lengthening the nerve to the muscle, the gracilis can be used for anal sphincter reconstruction with pudendal nerve anastomosis, negating the need for an electrical device. By detaching the origin of the gracilis muscle, its proximal portion can be used to wrap the anal canal, possibly enabling a longer functional canal with stronger constricting force and better vascularity. These modifications to past methods may improve fecal continence after the operation.

Background: In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men. Objectives: The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men. Methods: Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI. Results: Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI. Conclusions: Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.

Preaxial prehallux is a rare clinical manifestation among patients with polydactyly. Few cases arising from tarsal bones have been reported. We present a case of a true prehallux occurring in a patient with a bilateral complete cleft lip, palate, and alveolus.

Objective: Currently, polyurethane foam dressings are commercially available from many manufacturers. However, the pressure-reducing effect is expected to differ by the formulation and combination of the main and secondary ingredients and by manufacturing method. In this study, we investigated the effects of pressure reduction using dressing materials with various structural characteristics, including polyurethane foam dressings based on the engineering point of view, focusing on the dry state. Method: Pressure was measured in a model that simulated compression on the sacral region in a decubitus position. Pressure was measured for different dressings: ten products, consisting of five types of material (polyurethane foam, hydropolymeric, Hydrofiber, hydrocolloid, and low-adherent absorbent). Results: All dressings used in this study showed significantly reduced pressure. ALLEVYN Non-Adhesive had the lowest pressure at 35.833 ± 1.155 mmHg, and DuoDERM Extra Thin CGF had the highest pressure at 66.867 ± 1.060 mmHg. The pressure of the control was 74.667 ± 1.405 mmHg. The other dressings were: ALLEVYN Adhesive: 44.233 ± 0.777 mmHg; ALLEVYN Gentle Border: 46.967 ± 1.537mmHg; Mepilex Border: 53.867 ± 0.231 mmHg; Biatain Silicone: 56.000 ± 0.520 mmHg; TIELLE: 57.267 ± 3.403 mmHg;Versiva XC: 65.900 ± 0.800 mmHg; DuoDERM CGF: 57.267 ± 1.007 mmHg; and Melolin: 53.433 ± 1.973 mmHg. Conclusion: The pressure-reducing effect of dressing differs not only by material type but also by product. That is, the pressure-reducing effect can differ even if the dressings are of the same material type, such as polyurethane foam. Our study investigated only the effect of materials and structural characteristics on the cushion of dressings in the dry state. Therefore, further investigation is needed to confirm the effect of pressure reduction by dressing to meet the conditions in the clinic. Declaration of interest: Authors have no conflict of interest to declare.

The components separation technique (CST) was first described in 1990 and involves elevating the external oblique muscle and medially advancing the muscle complex to close abdominal wall defects. Because this procedure is straightforward and does not require prosthetic materials to repair the defect, many surgeons have adopted it. However, some patients who undergo this technique develop Spigelian herniation or "lateral bulging", which is a projection deformity of the lateral abdominal wall. These patients may require prosthetic reinforcement to strengthen the abdominal wall due to the relaxing incision that is made during the CST. In this report, we describe a simple modification to improve the relaxing incision by substituting several short incisions for the traditional single, long incision in the external oblique fascia. These short incisions create a mesh-like pattern in the fascia, which preserves the strength of the lateral abdominal wall and may help prevent Spigelian herniation or lateral bulging. Although the separation of the external oblique muscle from the internal oblique muscle is slightly cumbersome compared to the traditional CST, the plane is avascular and sparsely connected, which allows separation using a finger or tools in our modified technique. Further studies are needed to confirm whether this technique is effective for large defects, although this simple modification may preserve the strength of the lateral abdominal wall without the need for prosthetic materials.

In some cases, skeletal and soft issue elements are required for chest wall reconstruction. Although muscle flaps and ribs are commonly used for achieving ideal reconstruction, deformation and loss of bone strength are unavoidable in such cases. In the present report, we describe a technique for chest wall reconstruction that can help avoid such donor site deformity. A 59-year-old woman with metastasis of a malignant mixed tumor in the parotid gland underwent resection from the sternoclavicular joint to the first and second ribs, including the manubrium and part of the sternum body. To achieve chest wall reconstruction, we used a pectoralis major flap along with two dual-partitioned ribs. In this modified procedure, instead of simply using the flaps with the whole ribs (which is common), we only used the anterior cortical portion of the ribs. This helped preserve the chest wall strength and prevented deformity at the donor site. At 7 months after surgery, the cut ribs in the reconstructed area and the original donor site appeared stable, without any complications, on computer tomography. Although the thickness of the bone used was half of that used with the conventional method, the skeletal strength was sufficient for her daily activities. Our modified method requires some additional effort for cutting the ribs, but the rest of the procedure involves the use of a conventional, simple rib-muscle flap. With this method, donor site deformity can be prevented, and the procedure can not only be adapted for chest wall reconstruction but also for other skeletal reconstructions that require the use of ribs.

The causes of idiopathic exophthalmos were still unknown. We used computed tomography to compare the orbital structures of patients with idiopathic exophthalmos and those of a healthy Japanese population. A total of 18 orbits (ranged 17-52 years) in idiopathic exophthalmos and 334 normal orbits (ranged 17-59 years) were included. On computed tomography, the eyeball and orbit sizes, lateral wall thickness and length, perpendicular distance from the interzygomatic line to the medial orbital rim, and the nasal cavity width were measured. No significant differences in eyeball or orbit sizes were found between the idiopathic exophthalmos and control groups (P<0.05). In contrast, the mean lateral wall thickness of the idiopathic exophthalmos group was significantly thicker than that of the control group (P>0.01). The lateral wall length was shorter with significant difference (P>0.05). The perpendicular distance and the width of the nasal cavity in the idiopathic exophthalmos group were longer with significant difference (P>0.05). The cause of idiopathic exophthalmos is compression of orbital contents by the medial wall expansion. The force of expansion of medial wall also influences the zygoma according to Wolff law.