論文

Background: In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap’s projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design. Methods: Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap. Results: The average flap thickness was 3.8 ± 1.7 (range 2.5–6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (β = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01). Conclusion: Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used. Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Synthetic hydroxyapatite (HAP) implants are common in craniofacial surgery; the major problem with HAP implants is fixation instability. An ultrasound-assisted pinned resorbable fixation system has recently been introduced. The authors hypothesized that this resorbable system could be used to fix HAP implants. The authors evaluated the optimal HAP porosity and resorbable pin using the pull-out test and microscopic analysis. Hydroxyapatite blocks were synthesized with 0% (dense type), 35% (fine pore type), and 50% (large pore type) porosity. Bioabsorbable pins of 4 sizes were tested: diameters of 1.6 or 2.1mm and lengths of 4 or 7mm. Among the 1.6mm diameter pins, the 7-mm length pins showed higher pull-out strength (large pore, 6.5±1.2 kgf; fine pore, 4.1±0.7 kgf; dense, 2.4±0.4 kgf) than the 4-mm length pins (large pore, 2.1±1.0 kgf; fine pore, 1.3±0.4 kgf; dense, 1.5±0.9 kgf) with all 3 HAP types (P<0.01). Among 2.1-mm diameter pins, all were removed from the large and fine pore HAP types without any resistance. Only three of seven 2.1×7mm pins inserted into the dense type HAP showed pull-out strength (3.9±2.1 kgf). Among all conditions, the 7-mm length, 1.6-mm diameter pin in large pore type HAP showed the highest pull-out strength. Microscopically, the large pore type HAP showed the liquefying pin flowing into the large pore adjacent to the pilot hole. By contrast, the fine pore and dense pore types of HAP did not allow flow, and the pins did not change in structure 3-dimensionally. The authors found that pull-out strength depends on HAP porosity, and pin length and diameter.

We present the case of a patient with severe postoperative scarring from surgical treatment for gastroschisis, with the intestine located immediately under the dermal scar. Although many patients are unsatisfied with the results of scar repair treatment, few reports exist regarding severe or difficult cases involving the surgical repair of postoperative scar contracture. We achieved an excellent result via simulation involving graph paper drawings that were generated using computed tomography images as a reference, followed by dermal scar de-epithelialization. The strategy described here may be useful for other cases of severe postoperative scar contracture after primary surgery for gastroschisis.

The purpose of this study was to evaluate the effectiveness of platelet-rich plasma (PRP) on the absorption of the bone graft in the alveolar cleft. Twenty-nine patients with alveolar clefts in unilateral cleft lip were examined; 6 were the control group and received iliac cancellous bone and marrow grafts without PRP, while the remaining 23 comprised the PRP group and received grafts with PRP. Quantitative evaluation of remaining bone was made by the computer-aided engineering with multidetector row computed tomography at 1 month and 1 year after surgery. Satisfactory bone bridging formation was observed in all patients. Two patients in control group and 1 patient in PRP group developed wound dehiscence with minor bone exposure. One year postoperatively, the canine was exposed and orthodontically guided into an ideal arch relation in all patients. The mean resorption ratio was 49.9 ± 17.2% and 44.9 ± 14.4% with no significant difference (P = 0.60). In conclusion, there is currently no evidence to suggest that autologous PRP is of value for effect on the bone resorption for alveolar bone graft.

Background Zygomatic fractures are some of the most frequently encountered facial fractures. However, the relationships between the trauma etiology, the zygomatic fracture patterns, and patient ages have not been described. Methods Patients treated for isolated malar fractures, between 2004 and 2011, at Keio University Hospital were reviewed in this study. Comparative statistical analyses were conducted, based on the classification of the zygomatic fractures, their causes, and patient ages; p < 0.05 was considered significant. Results In total, 113 patients, aged 16–82-years-old (mean age (SD), 39.8 (17.0)-years-old), including 74 men were analyzed. Patients in their teens and 20s had injuries that were predominantly sports-related (48.8%). With increasing age, the ratio of sports injuries decreased and the number of falls causing injury increased. The frequency of injuries caused by motor vehicle collisions remained reasonably constant across the age groups. Comparing the ratio of shear type fractures with patient ages revealed that 4/13 injuries among patients in their 20s and 30s were of this type, whereas the proportion of shear fractures increased in patients over 40 (17/28, p < 0.05). Conclusion The severities of the zygomatic fractures, their causes, and the associated patient ages were closely related. Based on this study, possible prevention strategies for zygomatic fractures need to be considered.

Background: Pedicled periosteal flaps are commonly used for tissue defects between the base of the skull and the midfacial area. This study aimed to clarify the 3-dimensional vascular distribution of temporal region flaps. Methods: Ten fresh cadavers were used. Full-thickness cranial flaps were elevated from the cranial bone and each layer was detached separately. Contrast enhancement of the full thickness of the scalp, macroscopic evaluation, and histologic analyses were performed. Radiographs were obtained and image analysis was performed using a 3-dimensional monitor. Results: The mean number of deep vessels extending from the parietal branch of the superficial temporal artery was 68.7, including 14.2 and 54.5 vessels on the proximal and distal sides, respectively. The mean number of deep vessels extending from the frontal branch of the superficial temporal artery was 71.6, including 17.6 and 54.0 vessels on the proximal and distal sides, respectively. There were significantly more perforating branches in the distal area than in the proximal area of both the frontal and parietal branches (P = 0.005). There was no significant difference in the number of perforating branches between the frontal and parietal branches. Conclusions: Contrast-enhanced images of the loose areolar tissue and periosteal layers revealed vessels that extended radially. We successfully identified the 3-dimensional structure of the perforating vessels peripheral to the temporal fossa. Our findings provide a theoretical foundation for the feasibility of elevating a periosteal/loose areolar tissue flap with a reliable blood supply without sacrificing the temporal muscle.

Summary: Lymphaticovenous anastomosis (LVA) is primarily performed for lymphedema of the lower extremities after surgical treatment of gynecologic cancer and lymphedema of the upper extremities after surgical resection of breast cancer; however, LVA for lymphedema due to malignant lymphoma has not been reported to date. We herein present a patient with severe lymphedema of the lower extremities due to refractory malignant lymphoma, which markedly improved with LVA. LVA could contribute to improve quality of life in patients with end-stage disease with lymphedema of the lower extremities due to refractory malignant lymphoma.