論文

Objective: To describe a 1-step nasal reconstruction technique for use in lieu of a paramedian forehead flap that is usually raised at the location of the supratrochlear artery. Methods: Using angiography in 10 fresh cadavers, we confirmed the arterial anatomy of the nasal and forehead regions to refine the paramedian forehead flap. Based on the anatomical data, we performed nasal reconstruction in 6 patients who had a full-thickness defect of the nasal ala or who needed alar base reconstruction with an island paramedian forehead flap based on the angular artery. Results: From the anatomical study, we confirmed a rich network among the supratrochlear, dorsonasal, and angular arteries around the medial canthus. In the clinical cases, the subcutaneous pedicle was tunneled beneath the skin, without conspicuous bulkiness. For all patients, the operation was completed in 1 stage, and the flaps healed without evidence of necrosis. Conclusions: By moving the pedicle downward, a fullthickness nasal defect can be reconstructed in 1 stage that includes the alar lining or alar base with the paramedian forehead flap. This avoids restriction of the rotation arc, particularly when the alar lining or alar base is also needed for reconstruction.

Backgrounds: The degree to which the jejunum can reach upward is a significant consideration in cervical oesophagus reconstruction with vascularised free jejunum transfer using the thoracoacrominal vessels as recipient vessels. The present study aims to elucidate this issue. Materials and methods: In 30 fresh cadavers, the thoracoacrominal vessels were dissected, and the jejunums were harvested, carrying the second branches of the superior mesenteric arteries and veins as their pedicles. After the mesenteric vessels were anastomosed to the thoracoacrominal vessels, the jejunums were advanced to their maximum upward degree, and the positions of the oral ends were evaluated referring to the hyoid bone. The evaluation was performed under three conditions. In the first condition, the jejunums were simply advanced. In the second condition, tension of the mesenteriums was reduced by incising their serosa. In the third condition, mesenterial incision was also performed, and the anastomosed pedicles were placed under the clavicles. Results: The jejunums can reach superior to the hyoid bone by 2.1 ± 1.5 SD cm for males and by 1.9 ± 1.5 SD for females. By incising the mesenteric serosa, these distances can be extended by about 2 cm for males and 1 cm for females. Further extension of 2 cm can be obtained for both sexes by placing the pedicle under the clavicle. Conclusion: With patients whose neck regions lack vessels available for vascular anastomosis, the thoracoacrominal vessels are used in free jejunum transfer for cervical oesophagus reconstruction. The findings of the present study are useful in planning this type of reconstruction.

Background: Nasal tip features of cleft lip nose cannot be defined well using conventional measurement methods. Therefore, we developed a new method in which vertical nasal tip (the pronasale) position is evaluated based on the Frankfurt-Horizontal plane. This measurement was applied to bilateral cleft lip patients in early childhood. Methods: Cone beam computed tomography (CT) records of bilateral cleft lip patients after primary rhinoplasty aged from 5 to 8 years (n = 13) were investigated retrospectively. As age-matched controls, data from a normal group (n = 17) and complete unilateral cleft lip group after primary rhinoplasty (n = 19) were included. In each group, nasolabial angle (β), nasal tip angle (α), nasal width (al-al), columellar length (sn-c′), nasal tip protrusion (sn-prn), and vertical nasal tip position (sn′-prn′/sn′-n′) were investigated. Results: With the exception of vertical nasal tip position and nasal width, the measurement data of the bilateral cleft lip patients were acceptable. In the bilateral cleft lip group, however, vertical nasal tip position was significantly higher and nasal width was significantly larger than those in the normal and unilateral groups (P < 0.0001 and P = 0.0298; P = 0.0001 and P = 0.0002, respectively). Conclusions: In cleft lip nose, the lower lateral cartilage that normally composes the nasal tip domes is splayed out, causing cephalic positioning of the pronasale. Nasal tip collapse was more severe in bilateral cleft lip than in the unilateral group. These results were compatible with the fact that many bilateral cleft lip patients require augmentation rhinoplasty after adolescence even after primary rhinoplasty.

Telecanthus, which is the lateral displacement of the medial canthus, can be a congenital deformity or can occur after facial trauma. Several epicanthoplasty methods have been described, but the orbitonasal angle and appropriate shape cannot be reconstructed in Asians. We solved this problem by using a dog-ear effect. This article describes a new design for epicanthoplasty and its results.

Le Fort distraction osteogenesis is sometimes applied to improve the facial appearance in craniofacial dysostosis or cleft lip and palate. Distraction devices are generally classified into external and internal types. The movement of external distractors can be controlled easily but their large size and the need for a facial mask cause much psychological stress to the patient. Internal distractors are smaller and better tolerated, but they are not easily controllable and removal is difficult. We designed an internal distraction device to eliminate the problems of the currently available distractors -Nakajima's angle-variable internal distraction (NAVID) system - and aimed to assess its clinical applicability. Between 2000 and 2010, we treated 16 patients with the NAVID system: Le Fort I, III, III + I and IV distractions were performed in three, five, four and four patients, respectively. Distraction was started after a 1-week latency period. Then, the exposed rod was cut, and the distractors were left in place for 3 months or more as retention devices, and thereafter removed. All patients showed satisfactory occlusion and facial aesthetics. Open bite during the consolidation period was the main complication. In conclusion, the NAVID system is safe, effective and reliable for all types of Le Fort distraction osteogenesis.

Cranial base reconstructions associated with tumor resections around the orbital wall often require that both the upper and lateral orbital walls be reconstructed during a single procedure. Previously, we used titanium mesh plates that were preoperatively fabricated based on three-dimensional models. Although these plates are precise and do not increase the probability of infection, we still had to use autologous bones to reconstruct the orbital walls. Recently, we developed a new titanium mesh platecalled Skull-Fit®with orbital wall (Skull-Fit WOW®), enabling us to reconstruct the cranial base and orbital walls without bone grafts. Here, we report on three reconstruction cases in which the novel titanium mesh-orbital wall system was used. In all three cases, the customized titanium mesh system performed satisfactorily with little, if any, complications.

We treat hemifacial microsomia with a combination of surgery and orthodontic treatment during the growth period, resulting in early improvement in facial asymmetry and the induction of normal growth. We previously used gradual distraction of the mandibular ramus for Pruzansky's type II classification (Pruzansky, 1969). In type II cases, the maxilla should also be treated actively as, using this technique, improvement of the occlusal plane is difficult to achieve, resulting in a cross bite and difficulties in post-operative orthodontic treatment - especially in older patients. Morphologically, the mandibular angle region of the operative side is flat, and the angle of the mouth remains elevated. We performed mandibular-driven simultaneous maxillo-mandibular distraction while the occlusion was maintained using intermaxillary anchorage. However, mandibular-driven distraction tended to elongate the face because the mandible only elongated downwards and the mandibular ramus did not reach the glenoid. Furthermore, external distraction devices produce significant distress for patients until removal of the device and cause scars on the face. We developed a new internal distraction device with a variable angle and performed maxillary-driven simultaneous maxillo-mandibular distraction using this device. The result was morphologically satisfactory and solved the above problems. Because the patient was in the growth period, careful follow-up and induction to normal growth were important while the inferior growth of the affected side was monitored.

A 10-year-old girl presented with facial asymmetry associated with bulging of the right fronto-orbital region with no symptoms. Computed tomography demonstrated enlargement of the right zygomatic, frontal, ethmoid, and sphenoid bones. Abnormal proliferation of the bone had obliterated the sphenoid, right frontal sinus, and right ethmoid sinuses. These radiological findings suggested right optic nerve compression due to fibrous dysplasia. Right optic canal decompression was performed. In preparation for recurrence, the resulting bone defect in the right orbital roof was reconstructed using the outer table of the split lesion bone. The removed frontal bone was divided into intact and lesioned parts, and the intact part was returned. The lesioned part was split and the outer table graft used to reconstruct the frontal region. A temporal musculopericranial flap was used to form a barrier between the opened ethmoid sinus and cranial cavity. A protrusion appeared on the left forehead 10 years later, and was shaved to improve the aesthetic appearance. The patient was followed up for a total of 23 years. The use of dysplastic bone involves the risk of recurrence, but the period of recurrence is delayed and the progression stops after adolescence, so the second operation involved only shaving for aesthetic appearance. This procedure is one of the treatments of choice because of easy reconstruction, easy revision, and good results.

Background: To achieve optimal outcomes in reduction malarplasty, the area of zygoma from which volume should be reduced must be accurately identified. This anatomical study aims to evaluate the location of the zygoma region that contributes most to the protrusion of the cheek. MethodS: The morphology of the zygoma was studied on 121 Japanese adults (73 men and 48 women). The midpoint of the inferior orbital rim, zygomaticomaxillary junction, the junction between the frontal process and the zygomatic arch, and the lateral orbital rim were marked to be used as anatomical reference points. Then, a vertical plane intersecting the anterior and posterior edges of the zygoma was marked. The point of the zygoma most distant from the plane was defined as the summit of the zygoma. Three-dimensional measurement using graphic software was performed, and the positional relationships between the summit and the four reference points were evaluated. Results: In terms of horizontal position, the summit is located lateral to the lateral orbital rim and medial to the junction between the frontal process and the zygomatic arch. Regarding vertical position, the summit exists at higher positions in men than in women. Conclusions: The summit of the zygoma is located medial to the junction of the frontal process and zygomatic arch. Therefore, bone incision lines should be placed medial to the posterior edge of the frontal process in reduction malarplasty; effective correction of the protrusion cannot be achieved solely by detachment of the zygomatic arch. The summit is located higher for men than for women. Therefore, bone incision lines should be placed higher for men than for women.

We present a patient with preauricular tags, preauricular and branchial pits, stenosis of the external auditory canals, mild hearing loss, and mild developmental delay who had a de novo 19p13.12 submicroscopic deletion. The size of the deletion was 760-kb, extending from 15,300,338 to 16,064,271 (hg18; NCBI Build 36.1). Our finding supports the notion that 19p13.12 represents a unique microdeletion syndrome characterized by branchial arch defects and the concept of exclusion mapping indicates that the putative locus for the branchial arch development is included in the 0.8-Mb interval defined by the deletion in the presently reported patient.