Published papers

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.

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 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.

Conclusion: Reconstruction of the carotid artery using the superficial femoral vein (SFV) is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement. Objectives: To evaluate the effectiveness of carotid artery reconstruction using the SFV. Methods: Ten patients with malignant tumors involving the carotid artery underwent carotid artery resection followed by reconstruction with the SFV. The SFV between the deep femoral vein and branches to the great saphenous vein and deep femoral vein at the popliteal region was used as a reconstructive vessel. Results: The mean length and diameter of the grafted SFVs were 13.9 cm and 11.2 mm, respectively. The mean time for acquisition of SFV was 18 min. Ultrasonography measurements indicated that the mean lumen diameter of the common carotid artery was 8.37 mm. None of the patients experienced any permanent neurologic complications. The 2-year and 5-year overall survival rates were 60% and 40%, respectively. En bloc resection of the cancer and involved carotid artery followed by reconstruction with the SFV provides effective locoregional control. Our results indicated no postoperative vascular graft thrombosis and no donor site complications.

Reconstructive surgery for tumor resection, trauma, and congenital anomaly involves volume augmentation with autologous tissue transfer. However, a healthy region is damaged as a donor site, and the autologous tissue is transferred like a patchwork to the recipient site. We have attempted to induce adipogenesis activity in artificial biomaterial that is injectable with an injection needle for soft tissue augmentation. First of all, the optimal dose of pioglitazone hydrochloride was examined with adipo-precursor cells in terms of the proliferator-activated receptor-g mRNA expression levels affected by reagent in vitro. Then, salmon collagen with pioglitazone was adjusted in terms of the dose and the salmon collagen was injected into mouse back using an injection needle in vivo. At 4 weeks after implantation, the pioglitazone collagen gel was substituted by mature adipocytes in comparison with the case for control collagen gel without pioglitazone. These results are indicative of the possibility of promoting adipogenesis using collagen with pioglitazone as an adipose-inductive substance.

Introduction: Dural and anterior cranial base reconstruction is essential in the surgical resection of a craniofacial tumor that extends from the paranasal sinuses to the subdural space. Watertight reconstruction of vascularized tissue is essential to prevent postoperative liquorrhea, especially under conditions that prevent wound healing (e.g., postoperative irradiation therapy).Method: We successfully treated two cases of olfactory neuroblastoma by endoscopic-assisted craniotomy with primary dural closure and anterior cranial base reconstruction using a multi-layered flap technique. Dural defects were closed using temporal fascia or fascia lata in a conventional fashion, immediately after detaching the subdural tumor, in order to isolate and prevent contamination of subdural components and cerebrospinal fluid (CSF) from the tumor and nasal sinuses. Tumor removal and anterior cranial base reconstruction were performed without any concern of CSF contamination after dural closure by craniotomy and endoscopic endonasal approach (EEA). Vascularized pericranial flaps (PCF) and nasoseptal flaps (NSF) were used simultaneously as doubled-over layers for reconstruction.Results: The tumor was completely removed macroscopically and the anterior cranial base was reconstructed in both cases. CSF leak and postoperative meningitis were absent. Postoperative and irradiation therapy courses were successful and uneventful.Conclusions: This multi-layered anterior cranial base reconstruction consisted of three layers: a fascia for dural plasty and double-layered PCF and NSF. This surgical reconstruction technique is suitable to treat craniofacial tumors extending into the subdural space through the anterior cranial base dura mater.

OBJECTIVES The objective of our study was to investigate the effectiveness of reconstructing the carotid artery using a superficial femoral vein (SFV). METHODS Ten patients with malignant tumours involving the carotid artery underwent carotid artery resection and reconstruction with the SFV. We use the SFV between the deep femoral vein and perforator branches to the great saphenous vein or deep femoral vein at the popliteal region reconstructive vessel. RESULTS The mean length and diameter of the grafted SFVs were 13.9 and 11.2 mm, respectively. The mean time for SFV acquirement was 18 min. The mean cerebral ischaemic period was 23.1 min. Nine patients did not experience any neurological complications. One patient experienced slight temporary hemiparesis. There was no postoperative vascular graft thrombosis. Donor site complications did not occur. CONCLUSIONS Reconstructing the carotid artery using an SFV is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement. © 2014 The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

The purpose of this study was to evaluate the initial defect and the outcome of bone grafts for unilateral alveolar cleft. To determine the absorption of the bone graft in patients with unilateral cleft, computer-aided engineering (CAE) with multi-detector row computed tomography (MDCT) was used. MDCT scans of 29 patients were taken immediately preoperatively and at 1 month and 6 months postoperatively. The patients underwent bone grafting between 8 and 14 years of age using iliac crest bone grafts. Three-dimensional models were created in each period, and the defect at the alveolar cleft and volume of the bone graft were determined in each patient using CAE. Cleft volume and success of alveolar bone grafting were significantly correlated (P < .01). Alveolar clefts with cleft palate required more bone volume than those without cleft palate (P < .01), but the resorption rate did not significantly differ between alveolar clefts with and without cleft palate (0.48 ± 0.14 and 0.49 ± 0.18, respectively; P = .93). In conclusion, three-dimensional reconstruction of bone grafts using CAE based on MDCT provides a valuable objective assessment of graft volume.

Objective: In any immediate reconstruction of the maxillofacial defect after total maxillectomy, the defect is often covered with a flap, however, dentures cannot be maintained stably by the flap, because of the high mobility and large amount of displacement of the flap under pressure. Therefore, we developed a method in which a muscle flap is transplanted without creating a skin island in the oral cavity and a denture is immediately fixed with titanium screws, and obtained favorable results. Patients and methods: The subjects were 9 patients who underwent resection for maxillary sinus cancer. In all patients, a free rectus abdominis muscle flap was used for the reconstruction and the raw surface of the muscle tissue was left in the oral cavity without creating a skin island. Dentures that had been made preoperatively were fixed on the remaining palate and alveolus with titanium screws for one month, so that they covered the muscle tissue. Results: Good palatal morphology was formed without hanging down after epithelialization of the surface of the muscle tissue. In comparison with the preoperative levels, the masticatory and conversational functions recovered to 77% and 90%, on average. Conclusions: Our method is considered to be one of the useful reconstruction methods for maxillofacial defects.

Patients and methods: Eight patients who failed to respond to at least 2 years of medical treatment and who underwent blepharoptosis surgery, from January 2008 to December 2011, were enrolled in this study. Medical records, photographs, and questionnaire results regarding postoperative status were evaluated. Of the eleven procedures performed, four involved frontal suspension, four involved external levator advancement, one involved nonincisional transconjunctival levator advancement, and two involved subbrow blepharoplasty with orbicularis oculi muscle tucking. The margin reflex distance improved postoperatively in seven patients.Purpose: Currently, only a few reports have recommended surgery as a suitable treatment for blepharoptosis associated with myasthenia gravis. The present study aims to introduce our surgical criteria, surgical options, outcomes, and precautions for medically refractory myasthenic blepharoptosis.Results: Seven patients had very minimal scarring, and one had minimal scarring. Five patients showed no eyelid asymmetry, one had subtle asymmetry, and two had obvious asymmetry. Seven patients were very satisfied, and one patient was satisfied with the overall result. Postoperative complications included mild lid lag with incomplete eyelid closure, prolonged scar redness, and worsened heterophoria. No patient experienced postoperative exposure keratitis or recurrent blepharoptosis during the study period.Conclusion: Our results indicate that blepharoptosis surgery is effective for patients with myasthenia gravis, especially those with residual blepharoptosis despite multiple sessions of medical treatments. We recommend that neurologists and surgeons collaborate more systematically and discuss comprehensive treatment plans to increase the quality of life for patients with myasthenia gravis.

Head and neck squamous cell carcinoma (HNSCC) includes both morphological and functional cellular heterogeneity, as would be expected if it arose from dysregulated stem or progenitor cells as opposed to the simple clonal expansion of a mutated cell; however, stemness molecule expression levels and distribution in HNSCC remain unclear. To clarify this, stemness molecule expressions were determined in HNSCC, as well as their properties and prognosis. Two proto-oncogenic chromatin regulators, Bmi-1 and high-mobility-group A2 (Hmga2), were identified in 12 pair cases of HNSCC tumor regions by comparison with their non-cancerous background tissues using cDNA microarray. Both Bmi-1 and Hmga2 are known to promote stem cell self-renewal by negatively regulating the expressions of Ink4a and Arf tumor suppressors. Despite similar targets, Bmi-1 protein was expressed in an early cancerous region and HMGA2 protein was expressed in a region showing more progression. Similarly, Bmi1 expression had no significance with regard to overall survival (P=0.67), whereas HMGA2 expression was associated with decreased overall survival (P=0.05). Quantitative real-time reverse transcription polymerase chain reaction analyses also correlated with protein levels. These findings suggest that Bmi-1 is an early detection marker to distinguish cancerous from non-cancerous regions, whereas HMGA2 is presumed to be a tumor prognosis marker. Among our HNSCC analyses, these stemness molecules expressed fewer primitive rare cells in the tumor than all other cells in the tumor. HNSCC cells with high expression of stemness molecules partly behave like stem cells. © 2013 USCAP, Inc All rights reserved.

Rupture of the Achilles tendon is a very common trauma. Reconstruction of a chronic Achilles tendon defect is challenging for reconstructive surgeons, and several methods have been described. The ideal reconstruction would result in the patients resuming the activity level they were accustomed to before the injury. In our patient, the Achilles tendon was reconstructed using the gracilis muscle flap, and the flap was fixed using a fragment of the tibial bone, yielding satisfactory results. In this report, we describe this procedure employed and provide a description of the case. © 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Surgeon.

Full-thickness lower lip defects most often occur due to tumour resection or injury. Because the lower lip is important for both eating and speaking, reconstruction of the region must restore the structure and function of the tissue. Here, we describe a new procedure to reconstruct the lower lip, using a 'wing flap': a mental V-Y rotational advancement flap that contains the mental nerve. This flap can preserve the sensory innervation of the lower lip, and it allows effective reconstruction of the muscle sling. We have employed this method twice and have obtained good aesthetic and functional outcomes. No special technique is required to reconstruct the lip using this flap, and it yields a satisfactory outcome. Thus, we recommend it as an effective method for reconstruction in wide lower lip defects. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The key points in minimum invasive surgery for zygomatic fractures are the appropriate reduction and prevention of relapse with a minimum number of fixation devices. To this end, we propose the following principles: 1) the first step in the decisiontree is to diagnose the fracture pattern of the zygomaticofrontal suture on CT, 2) avoid the lower-lid approach as far as possible, and 3) a T-bar screw instead of simple elevatorium is used where necessary to enable precise reduction.

Background: Choline is a new PET tracer that is useful for the detection of malignant tumor. Choline is a precursor of the biosynthesis of phosphatidylcholine, a major phospholipid in the cell membrane of eukaryotic cells. Malignant tumors have an elevated level of phosphatidylcholine in cell membrane. Thus, choline is a marker of tumor malignancy.Method: The patient was a 51-year-old man with repeated recurrent hemangiopericytoma in the skull base. We performed Choline-PET in this patient after various treatments and compared findings with those of FDG-PET.Results: Choline accumulated in this tumor, but FDG did not accumulate. We diagnosed this tumor as residual hemangiopericytoma and performed the resection of the residual tumor. FDG-PET is not appropriate for skull base tumor detection because uptake in the brain is very strong.Conclusion: We emphasize the usefulness of Choline-PET for the detection of residual hemangiopericytoma in the skull base after various treatments, compared with FDG-PET. © 2012 Yokoyama et al; BioMed Central Ltd.

We present a case involving a late diagnosis of chondroblastoma of the temporal skull base involving the temporomandibular joint (TMJ). Following an initial misdiagnosis and unsuccessful treatment over a period of 5 years, the patient was referred to our department for further evaluation and possible surgical intervention for occlusal abnormalities, trismus, clicking of the TMJ, and hearing impairment. Based on preoperative immunochemical studies showing positive reaction of multinucleated giant cells for S-100 protein, the final diagnosis was chondroblastoma. The surgical approach - postauricular incision and total parotidectomy, with complete removal of the temporal bone, including the TMJ via the extended middle fossa - was successful in preserving facial nerves and diminishing clinical manifestations. This study highlights a misdiagnosed case in an effort to underline the importance of medical examinations and accurate differential diagnosis in cases involving any tumor mass in the temporal bone. © 2011 S. Karger AG, Basel.

In cases of morbid obesity, excessive soft tissue in the abdomen forms an apron-like deformity called panniculus because of rapid weight loss due to cancer. In laparotomy with stoma aimed at cancer resection, obesity is reported as a major risk factor of stoma complications, one of the most frequent of which is necrosis. In one patient in whom a laparotomy was performed through a midline incision, the authors also carried out an abdominal dermolipectomy aimed at reducing distortion of the abdominal wall in relation to the stoma. This procedure provided two important advantages for stoma surgery, stability, and better postoperative care by the patient.

Recent advances in regenerative medicine have opened up the option of materials used for transplantation. However, only a few studies have examined the take of transplanted tissues. We attempted to establish a functional bed for transplanted tissues using growth factors. A cylinder-type silicone substrate (spacer) was coated with a photoreactive gelatin containing basic fibroblast growth factor. This spacer was transplanted into the dorsal subdermal layer in a rabbit. After 2 and 4 weeks, the capsule formed around the spacer was histologically assessed for use as a transplant bed. In addition, after 2-4 weeks of spacer grafting, autologous fat was transplanted into the capsule. After 4 more weeks, the grafted fat was assessed immunohistochemically to evaluate the capsule as a functional bed for transplantation. In the groups pretreated with growth factors, proliferation of blood vessels was observed in the capsules. After fat grafting, a pattern of overall necrosis was observed in controls. However, good proliferation of blood vessels and favorable fat take were observed in the groups pretreated with growth factors. Necrosis, however, was found at the center of the grafted fat. We conclude that a vascularized transplant bed was useful for promoting take of the grafted fat. © 2006 by the Wound Healing Society.