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We seldom have difficulties in the selection of appropriate recipient arteries for microvascular free flap transfer in the head and neck region because many sizable branches (branch artery) of the external carotid artery (ECA) or subclavian artery are available. However, we occasionally encountered the lack of an appropriate recipient artery, especially in secondary reconstruction or reconstruction following the extensive ablation of recurrent cancer. For these challenging cases, we have used end-to-side arterial anastomosis directly to the ECA. Between July 1997 and December 2004, end-to-side anastomosis of the flap artery to the ECA was employed in 16 cases. The reason for its use included the marked size discrepancy between the jejunal artery and branch artery in 4 jejunal transfer cases, the lack of 2 appropriate recipient arteries for double free flap transfers in 1 case, and the lack of an available branch artery as a recipient due to poor regional conditions in 11 cases. Fifteen of 16 flaps underwent an uneventful postoperative course, except 1 whose flap artery was pressed by the submandibular gland and sustained thrombosis 3 days postoperatively. In this case, however, the flap survived perfectly after prompt thrombectomy and reanastomosis. Eventually, all 16 flaps survived completely. We reconfirmed the availability of end-to-side anastomosis to the ECA when a suitable branch artery is not available. Although end-to-side anastomosis to the ECA is laborious compared with end-to-end anastomosis, our newly developed short-thread double-needle microsuture combined with the back-wall-first technique helps to ensure easier anastomosis. Using this device, because all stitches are carried from inside the vessel to outside, the surgeon can place the first stitch at any point on the posterior wall and advance the next suture to the preferred site of the previous suture, and suturing can be performed more safely even in cases where the tunica intima is separated from the tunica media due to arteriosclerosis, previous irradiation, or surgery.

In living-donor liver transplantation (LDLT), reconstruction of the hepatic artery is challenging because the recipient artery is located deep in the abdominal cavity and the operating field is limited. Also, the hepatic artery of the graft is short and the recipient artery is occasionally damaged. To overcome these difficulties, we developed a double-needle microsuture technique for artery reconstruction. A total of 161 adult patients received 163 LDLTs using this new technique. The first suture was placed at the most difficult point in the artery to be visualized through the microscope. Each stitch was placed from the inner side of the arterial wall to the outer side. The posterior stitch was tied pulling toward the back. The subsequent sutures were advanced anteriorly on either side adjacent to the previous suture. Hepatic artery thrombosis occurred in 4 patients (2.5%), only 2 (1.2%) of which were associated with arterial reconstruction. Intimal dissection developed in the recipient artery in 2 patients (1.2%). Three (50%) of these 6 complications occurred more than 10 days after LDLT. In conclusion, this suturing technique allows for safe intimal adaptation even when the arterial tunica intima is separated from the tunica media, because all stitches are carried from inside of the vessel to the outside, contributing to more satisfactory results., (Copyright 2005 AASLD)

Patients with Apert syndrome show hypertelorism and midfacial hypoplasia, and their features are significantly improved through facial bipartition surgery. In addition, because patients with Apert syndrome demonstrate cranial deformity as well as other deformities, they require multiple surgical interventions throughout their development. We present herein a girl with Apert syndrome for whom subcranial facial bipartition was performed. We could not use the coronal approach because she had a terribly cicatricial scalp and wide calvarial defects caused by previous cranial surgeries carried out at another institution. Therefore, we used the glabellar reverse V-shaped approach and temporal approaches in place of the standard approach. She enjoyed a complication-free intraoperative and postoperative course, and left the hospital on postoperative day 10. Her midfacial segment was repositioned 6 mm anteriorly and 12 mm inferiorly on the cephalometric measurement. Her interpupillary distance was altered from 83 mm preoperatively to 76 mm postoperatively. The reverse V-shaped glabellar approach permits more relaxation of the nasal skin and nasal augmentation that is more reliable, although an inconspicuous scar remains in the prominent area. The temporal approach is also useful, enabling easy zygomatic arch osteotomy and secure pterygo-maxillary separation for pterygo-maxillary separation through an oral approach, allowing chiseling toward the skull base.

The extended upper lip island (EULI) flap has two advantages. It provides a wide mucosal surface, like that of the facial artery musculomucosal flap and does not leave a pedicle across the mouth. Aesthetic results with the EULI flap are almost as good as those with the cross-lip flap. An 89-year-old woman presented with squamous cell carcinoma of the lower oral vestibule. Full-thickness lower lip resection and marginal mandibulectomy, including resection of the surrounding gingiva and mucosa, were performed. The defect was reconstructed with an EULI flap that included the facial artery and vein. There were no severe postoperative complications, but two mild complications did occur: mild congestion of the distal end of the skin paddle and mucosa for two days after surgery and partial paralysis of the orbicularis oris and levator anguli oris muscles. The EULI flap is useful for extended lower lip reconstruction.

We evaluated 192 patients who had 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984-2003. The main postoperative complications were thrombosis, leaks, and stenosis. In this series, the rate of thrombosis was 7/201 (3.5%), that of leaks was 17/201 (8.5%), and that of stenosis was 25/201 (13.0%). When we assessed the relation between pre-existing conditions, surgical techniques, and these complications, we found only one significant difference: a history of alcohol misuse was associated with a reduction in the incidence of thrombosis. The surgical techniques did not affect the development of leaks or stenosis, which means that a complicated surgical technique is unnecessary.

The distinction between ectopic hamartomatous thymoma and sarcoma is difficult, and preoperative biopsy and intraoperative histopathological examination fail to give a definitive diagnosis. It is important to recognise ectopic hamartomatous thymoma as one of the differential diagnoses of a cervical tumour.

Pharyngoesophageal reconstruction using free jejunal transfer is a reliable procedure, but the achievement of perfect functional results is still challenging. We present a devised method. Jejunoesophageal anastomosis is performed after 2 longitudinal incisions are made at the side corners of the esophageal stump. This maneuver not only enlarges the size of the esophageal stump but also provides a "Z-plasty-like" effect, which reduces the risk of delayed stricture formation. The pharyngojejunal anastomosis is performed in an end-to-end manner. Irrespective of the highest point of the pharyngeal defect, a longitudinal incision is made at the edge of the jejunal graft corresponding to the midpoint of the back wall of the pharyngeal stump. With this concept, considerable longitudinal tension is placed on the posterior side of the jejunal graft, whereas moderate tension is placed on the anterior side of the graft, which prevents the fistula formation that tends to occur in the anterior suture line. Twenty patients underwent the reconstruction using this operative procedure. In all cases, postoperative deglutition was satisfactory without jejunal redundancy or constriction. We believe that our method can be applied in most cases of pharyngoesophageal defects, providing simple and reasonable reconstruction using free jejunal transfer with stable results.

We present a 64-year-old woman who had a congenital defect of the nasal septal cartilage and vomeral bone. She noticed her nasal tip was collapsed approximately 2 months before consultation. Computed tomography showed the absence of cartilaginous septum and vomeral bone, and radiograph showed a depression in the anterior nasal floor and hypoplasia of anterior nasal spine. She had no history of maxillofacial trauma, disease, or surgery in the midface. Fiberendoscopic examination of nasal cavity showed normal mucosa without signs of chronic inflammatory diseases such as Wegener's granulomatosis. Her intelligence was normal, and no anomaly was observed in the cranial region. Blood examination showed negative including serologic tests for syphilis. No other systemic findings were found, and none of her relatives were similarly afflicted. From these findings, we concluded that the patient did not have Binder's syndrome (or she has, at least, a new variant of Binder's syndrome). Rhinoplasty with cantilever costal cartilaginous graft was performed. The "hook-shaped part" was carved on the dorsal graft, which served to reduce the collapsed lateral cartilage. Eight months postoperatively, the flattened nose was well corrected with acceptable projection.

Introduction: Iliac bone grafts for nasal augmentation are characterized by resorption. In this article, the relationship between graft resorption and soft tissue retrusion is examined by cephalogram-based measurements., Methods: Ten patients with nasal deformity underwent iliac bone grafts to the nose and were monitored using cephalograms at intervals. On every image, three distances were measured; the tip height and the upper and lower lengths of the graft., Results: The upper length of the grafted bone reached 90% stability after 6 months, and the lower length reached 70% stability between 1 and 2 years postoperatively. At the tip, supported by the lower part of the grafted bone, the soft tissue projection reached 90% stability after 6 months., Discussion: The lower part of the iliac bone grafted onto the nasal dorsum supports the projecting soft tissue of the nasal tip. Thus subsequent resorption of the graft results in retrusion of the nasal tip. However, the degree of soft tissue retrusion was obviously less than the amount by which the supporting bone resorbed. It seems likely that the augmentation effect persists due to the formation of scar tissue.

The purposes of this study were to evaluate the results of the operative treatment of lateral ray polydactyly and to consider appropriate surgical procedures, especially focusing on the selection of the toe, lateral toe or medial toe, to be resected. Twenty-two patients with lateral ray polydactyly foot (25 individual feet) at an average of 71 months' follow-up were included in this study. Cases were classified morphologically into three types on the basis of Hirase's configuration. In addition, these types were divided into two subtypes, metatarsal and phalangeal, on the basis of radiographic evaluation of the level of duplication. The clinical evaluations of the reconstructed toe were performed, and these results were investigated according to their morphologic classification and excised toe group. The distinctive problem of medial toe excision is valgus deformity. Eight of 25 toes retained persistent valgus deformity, and all of these cases were in the medial toe excision group. On the other hand, a distinctive problem in lateral toe excision is postoperative pain. Two patients suffered from postoperative pain in phalangeal type cases in the lateral toe excision group, and the remaining medial toe had a medial protuberant middle phalanx. The pain occurred at that protuberant point. Based on their experiences, the authors created an algorithm for selection of the toe to be excised. In metatarsal type cases, from a functional perspective, the toe that has a radiographically dominant metatarsus should be retained. On the other hand, in phalangeal type cases, the authors give priority to shape rather than function, and they excise the morphologically smaller toe independent of the condition of the phalanx as viewed on radiography. If the medial toe and the lateral toe are approximately the same size, the authors excise the lateral toe to avoid valgus deformity. When the lateral toe has severe valgus deformity that seems unlikely to be correctable intraoperatively, the lateral toe should be considered for excision even if it is larger than the medial toe.