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Unilateral lambdoid synostosis (ULS) is a rare suture anomaly and its diagnosis and treatment remain controversial. We investigated how to improve their function and morphology through the review of two cases of ULS with improved function and morphology by the same unreported operative procedure. Moreover, we discussed the diagnosis and treatment of ULS. Case 1 involved a 15-month-old female, brought for consultation because of suspected right ULS. She was diagnosed with right lambdoid and squamous synostoses and approximately 15 mm descent of the cerebellar tonsil. Thus, we performed foramen magnum decompression, first cervical vertebra laminectomy, and skull lengthening. Case 2 involved an 18-month-old female. She also consulted for suspected right ULS. Computed tomography revealed right ULS and squamous synostosis and magnetic resonance imaging showed approximately 9 mm descent of the cerebellar tonsil. We performed foramen magnum decompression and skull lengthening. Both procedures included decompression of the foramen magnum. We enforced osteotomy of the affected side of the lambdoid suture by crossing the superior sagittal sinus and added horizontal osteotomy from the superior right squamous suture to the coronal suture. Three extension devices were placed, two and one in the lambdoid and squamous sutures, respectively. After skull extension and descent of the cerebellar tonsil, exertion of the left frontal bone was improved. In cases of ULS, the squamous suture fusion and the drooping of the cerebellar tonsils can be complicated. Extending the lambdoid suture upward and downward and decompressing the posterior cranial fossa may improve the morphological and functional prognoses.

Detailed studies have not been conducted on sound localization and speech perception in noise in patients with unilateral congenital aural atresia (UCAA).To evaluate the benefits of the use of the Vibrant Soundbridge (VSB) for UCAA by performing audiometric and sound localization tests.Four children with UCAA underwent VSB (VORP 503) implantation from 2018 to 2019. Speech perception tests in noise were conducted using the Japanese monosyllable test. The spatial configuration for speech testing consisted of speech presented from the front and noise presented into the normal ear (SThe children's speech perception in noise 6 months after VSB activation was significantly better than before activation (The benefits of VSB use in children with UCAA were revealed using audiometric and sound localization tests.

Since cellulitis is one of the most important factors for the prognosis of lymphedema, the prevention and prediction of cellulitis are considered to be critical in controlling lymphedema. We hypothesized that patients with lymphedema might show meteoropathy, as abdominal aortic aneurysm ruptures are considered to be influenced by climatic conditions, and the lymphatic system is one of the circulation systems. Thus, we aimed to determine if the onset of cellulitis in limbs affected by lymphedema is related to climatic conditions. We reviewed the clinical records of patients with lymphedema admitted for cellulitis at our institute between January 2007 and December 2017. We identified 40 patients, 25 of whom lived in the same area. We examined the association between the number of patient admissions according to season and meteorological data obtained from the Japan Meteorological Agency database. Thirteen of 25 patients were admitted in summer, whereas only one patient was admitted in winter. Both higher temperature and lower atmospheric pressure around the day of admission were associated with the occurrence of cellulitis. Lymphedema may be regarded as a meteoropathic disease, as climatic conditions were shown to be associated with cellulitis in limbs affected by lymphedema.

INTRODUCTION Treatment of patients with severe Pfeiffer syndrome types II and III is difficult. The purpose of this article is to present our method of overcorrecting midface advancement to improve airway problems in such patients. MATERIALS AND METHODS One boy and two girls with types II and III Pfeiffer syndrome and who underwent Le Fort III midface advancement using our previously described corrected cephalometric analysis and distraction system were included in the study. RESULTS The authors overcorrected by advancing the midface to make it look as similar as possible to an adult face. While the overcorrected midface advancement widened the upper airway spaces in the 3 patients, the tracheostomy that had already been placed during infancy could not be closed, probably because of an underlying tracheal abnormality or tracheomalacia. DISCUSSION Overcorrected midface advancement cannot enable tracheostomy closure, probably because of severe tracheal anomalies, such as tracheomalacia, below the tracheostomy. However, with the possibility of gradual improvement of the tracheomalacia with age, closure of the tracheostomy can eventually be expected. Therefore, efforts to close a tracheostomy should be pursued even if the probability of its removal is low. CONCLUSION Overcorrected midface advancement did not enable tracheostomy closure, probably because of severe tracheal anomalies such as tracheomalacia. However, the severe exophthalmos and angle III malocclusion were improved, and with the possibility of gradual improvement of the tracheomalacia with age, closure of the tracheostomy can eventually be expected. Therefore, efforts to close a tracheostomy should be pursued even if the probability of its removal is low.

Furlow double-opposing Z-plasty (FDOZ) as primary palatoplasty for the bilateral cleft lip and palate (BCLP) closure often leads to a palatal fistula formation in cases with wide clefts. We examined the utility of the calculated maximum closable cleft width to determine the feasibility of a direct palatal closure without lateral incisions. In this retrospective study, we analyzed consecutive patients with a BCLP who were treated for 5 years from 2009. In sixty-three BCLP patients, the following dimensions were measured preoperatively: an actual distance between maxillary tuberosities (Actual X); actual cleft height, calculated from the line joining the maxillary tuberosities to the cleft edge (Actual Y); and actual cleft width at the hard-soft palate junction (Actual Z) and calculated maximum cleft width requiring a direct closure (CMZ). Six months postoperatively, the relationships between the fistula occurrence and actual Z/CMZ were examined. Median values (interquartile range) of Actual X, Y, and Z and CMZ were 35.0 (33.0-39.0) mm, 7.0 (6.0-8.0) mm, 10.0 (8.0-11.0) mm, and 4.6 (2.7-5.7) mm, respectively. The median age at operation was 8.0 (7.0-17.0) months. Fistulae at the hard-soft palate junction developed postoperatively in three cases with more than a 10-mm cleft width (4.76%). A receiver operating characteristic (ROC) curve analysis indicated that actual Z was a better predictor of a postoperative fistula formation than CMZ. An actual cleft width was a better predictor of the fistula occurrence than a calculated maximum cleft width after FDOZ for a BCLP repair. The low fistula rate of FDOZ suggested that FDOZ could be used to close the palate with less than a 10-mm cleft width.

The aim of this study was to retrospectively estimate intervention outcomes and to establish suitable indications for autogenous tiered cartilage augmentation (ATCA) of the posterior pharyngeal wall for velopharyngeal insufficiency (VPI). The sample cohort comprised 17 consecutive patients with VPI (10 boys, 7 girls), excluding syndromic cases. Pre- and postoperative findings were comprehensively evaluated using a combination of speech assessment and lateral pharyngography (LPG). Hypernasality and consonant distortion were scored (normal: 0; mild: 1; moderate: 2; severe: 3). Velopharyngeal gap size at rest (AC) and at maximum closure (BC) were measured on LPG. All patients displayed improvements in velopharyngeal function and speech score, and no patients required re-operation. Pre- and postoperative hypernasality scores were 1.9 ± 0.5 and 0.6 ± 0.5, respectively (P .001). Pre- and postoperative consonant distortion scores were 1.9 ± 0.6 and 0.6 ± 0.5, respectively (P .001). Pre- and postoperative AC distances were 8.2 ± 3.4 mm and 5.9 ± 2.6 mm, respectively (P .001). Pre- and postoperative BC distances were 3.9 ± 2.4 mm and 0.3 ± 0.8 mm, respectively (P .001). Conclusions: ATCA appears effective for surgical treatment of VPI patients with a gap less than 10 mm.

Infantile immature teratoma located in the nasopharynx is a rare congenital tumor that is not easily removed. Three surgeries and chemotherapy for recurrence of the tumor have been performed since a male infant with a nasopharyngeal mass was born at a gestational age of 35 weeks. Extended maxillotomy combining Le Fort I osteotomy with midline palatal split was performed at 2 years and 6 months of age. Residual tumor left in the intracranial region had not increased as of 4 years of age. Careful follow-up is needed until the patient reaches adulthood.

Objective: To analyze congenital lateral maxillary growth for patients with bilateral cleft lip and palate (BCLP). Design: A retrospective study. Setting: Kanagawa Children’s Medical Center. Materials: Images from computed tomography (CT) of patients with BCLP and control patients that were previously used for treatment. Main Outcome Measures: The following landmarks were used: A, the posterior most point of the piriform aperture; B, the superior most point of the acoustic meatus; C, the point at which line A-B intersects the line drawn perpendicular from line A-B to the maxillary tuberosity; and D, the apical most point of the nasal bone. The following distances were then measured using these landmarks: (1) A-B distance; (2) A-C distance; (3) A-C/A-B; (4) the angle between lines A-B and A-D (∠BAD); and (5) B-D distance. Result: Mean A-B and A-C distances and A-C/A-B were significantly smaller in the BCLP group than in the control group ( P < .01 each). Mean ∠BAD was significantly larger in the BCLP group than in the control group ( P < .01). Mean B-D distance did not differ significantly between groups. Conclusions: Our results indicated that the lateral maxillary segments of patients with BCLP were more posterior than those of the control group, and segment length was shorter compared to the control group on 3D-CT analysis. The lateral maxillary segments of patients with BCLP were basically suggested to originally be underdeveloped.

Secondary upper limb lymphoedema is usually caused by lymphatic system dysfunction. Diagnosis is primarily based on clinical features. However, there are no distinct diagnostic criteria for lymphoedema. Although conventional lymphoscintigraphy is a useful technique to diagnose the severity of lymphoedema, the resultant data are two-dimensional. In this study, we examined the pathology of lymphoedema using single photon emission computed tomography-computed tomography lymphoscintigraphy (SPECT-CT LSG), a new technique that provides 3-dimensional information on lymph flow. We observed lymph flow pathways in the subcutaneous and muscle layers of the upper limbs. A significant positive correlation was found between the dermal back flow (DBF) type and the visualization of lymph nodes around the clavicle (p = 0.000266), the type of lymph flow pathways and the visualization of lymph nodes around the clavicle (p = 0.00963), and the DBF type and the lymph flow pathway (p = 0.00766). As the severity of lymphoedema increased, the DBF appeared more distally in the upper limb and the flow into the lymph nodes around the clavicle decreased, whereas the lymph flow pathways in the muscle layer became dominant. These findings demonstrate the features of lymphoedema pathology and the functional anatomy and physiology of the lymphatic system without the need for cadaver dissection.

A free fascioadipocutaneous flap obtained from the medial thigh is suitable for breast reconstruction in Asian women with a small-to-moderate breast size. In this region, both a medial circumflex femoral artery perforator flap (MCFAp flap) and a posterior medial thigh perforator flap (PMTp flap) are options, based on perforators from the deep femoral vessels. Here, we evaluated the anatomic basis of the medial circumflex femoral artery (MCFA) perforators from the medial circumflex femoral vessels. Between July 2010 and June 2014, 53 patients (55 flaps) underwent breast reconstruction using a fascioadipocutaneous flap from the medial thigh. MCFA perforators larger than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator locations, distance of the perforating point from the proximal thigh crease and anterior border of the gracilis muscle. The total number of perforators was 131, with a mean of 2.4. The number of perforators coursing through the gracilis muscle (gracilis perforators) was the largest, followed by septocutaneous perforator coursing between the adductor longus and gracilis muscle. The average perforating point was located 6.5 cm below the proximal thigh crease and 2.2 cm from the anterior border of the gracilis muscle. Of the 102 procedures performed since 2006, 15 flaps were elevated as MCFAp flaps and there was no major complication. In some cases, MCFA perforators are dominant in this region compared to PMT perforators. A perforator map can be helpful for identifying adequate MCFA perforators intraoperatively.

Tertiary breast reconstruction after a failed autologous procedure is often performed under various restrictions, posing considerable problems not only in the choice of alternative free flap but also in that of recipient vessels. This is a case report of a free contralateral latissimus dorsi myocutaneous flap combined with a silicone gel implant, with flap pedicle anastomosis to the contralateral internal mammary recipient vessels in a 46-year-old woman with right breast deformity. She underwent a right modified radical mastectomy and failed attempts of reconstruction at another hospital. The deep inferior epigastric artery perforator flap had already been harvested for the failed reconstruction and high-level interruptions of the internal mammary, thoracodorsal, and thoracoacromial vessels were revealed on preoperative three-dimensional computed tomography angiography; therefore, we selected a contralateral latissimus dorsi myocutaneous flap to supply the lower pole skin along with a silicone gel implant for volume in this tertiary breast reconstruction. However, weak blood flow in the ipsilateral internal mammary artery and exhaustion of all recipient ipsilateral vessels in previous attempts to salvage the failing deep inferior epigastric artery perforator flap necessitated the use of the contralateral internal mammary recipient vessels. A contralateral latissimus dorsi myocutaneous flap with contralateral internal mammary recipient vessel anastomosis appears to be a viable option in complicated cases with unavailable deep inferior epigastric artery perforator flap or ipsilateral recipient vessels.

Le Fort II and III procedures have generally been performed for syndromic craniosynostosis with midfacial hypoplasia and skeletal class III malocclusion. However, some patients have midfacial hypoplasia without malocclusion. Perinasal osteotomy was performed with distraction osteogenesis to move the midface forward in 2 patients (a 17-year old female patient with Crouzon-like disease and a 15-year-old female patient with Antely-Bixler syndrome) with mild midface hypoplasia without malocclusion. The success of the procedure was assured by 3 features: the intermaxillary sutures were fixed by a mini metal plate to prevent separation during distraction; the distraction wires were fixed through the bone of the piriform aperture with the mini metal plates to prevent the wires from coming off; and the osteotomy line was designed in front of the palatomaxillary suture to avoid suture damage. These were expected to secure the procedure. Perinasal osteotomy with distraction osteogenesis is considered one of the recommended procedures for mild midfacial hypoplasia as seen in mild syndromic craniosynostosis without malocclusion.

Background Contralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation. Methods Between October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline. Results Of 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively. Conclusions Unilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.

This procedure was developed for preservation of the rectus muscle components and deep inferior epigastric vessel after deep inferior epigastric perforator (DIEP) flap harvesting. A 53-year-old woman with granuloma caused by silicone injection underwent bilateral nipple-sparing mastectomies and immediate reconstruction with "mini-flow-through" DIEP flaps. The flaps were dissected based on the single largest perforator with a short segment of the lateral branch of the deep inferior epigastric vessel that was transected as a free flap for breast reconstruction. The short segments of the donor deep inferior epigastric vessel branch are primarily end-to-end anastomosed to each other. A short T-shaped pedicle mini-flow-through DIEP flap is interposed in the incised recipient's internal mammary vessels with two arterial and four concomitant venous anastomoses. Although it requires multiple vascular anastomoses and a short pedicle for the flap setting, the mini-flow-through DIEP flap provides a large pedicle caliber, enabling safer microsurgical anastomosis and well-vascularized tissue for creating a natural breast without consuming time or compromising the rectus muscle components and vascular flow of both the deep inferior epigastric and internal mammary vessels.

Background In free flap breast reconstruction, the retrograde limb of the internal mammary vein (IMV) is occasionally used as a second recipient vein. In this study, we evaluated the dynamic blood flow to the retrograde limb of the IMV (retrograde IMV) at the anastomosed site via indocyanine green (ICG) angiography Methods In 40 patients undergoing free flap breast reconstruction, we evaluated the dynamic blood flow as “stain(+)” if a stain by ICG was observed and, “flow(+)” if a smooth blood flow was recognized. Results Based on the ICG angiography, “stain(+)” was observed in all cases, but “flow(+)” was detected in only 72.5% of the cases. There was no severe complication. Conclusion This study shows that thrombosis is prone to occur in the second recipient vein in the 27.5% of the cases with no smooth flow, and therefore, the retrograde IMV may not function as a back-up in these cases. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Background and Objective Laser “toning” with a Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has recently been described to be effective for the treatment of melasma. Leukoderma is a refractory complication of laser toning for melasma, but it can be detected early with ultraviolet (UV) imaging. We assessed the relationship between leukoderma and the frequency or total number of laser toning sessions, as well as the effectiveness of UV imaging for detecting leukoderma. Materials and Methods The subjects included 147 patients who received at least five laser toning sessions. Subjects were classified into three groups according to the frequency of treatment (weekly for Group A1, fortnightly for Group A2, and monthly for Group B), and the incidence of leukoderma was compared among the three groups. In patients who developed leukoderma, the interval between clinical diagnosis and leukoderma detection on UV images (obtained with a Visia Evolution during every laser toning session) was determined to evaluate the effectiveness of UV imaging for the early detection of leukoderma. Results The overall incidence of leukoderma was 2% (3/147 patients): 3.8% (1/26 patients) in Group A1, 4% (2/49 patients) in Group A2, and 0% (0/72 patients) in Group B. There were no significant differences in the incidence of leukoderma relative to the frequency of laser toning. In two of the three patients who developed leukoderma, it was diagnosed clinically at the 20th and 21st laser toning session, whereas it was diagnosed by UV imaging at the 12th and 13th session. In the remaining 1 patient, leukoderma was detected clinically and by UV imaging at the 7th session. Conclusions There was no significant difference in the incidence of leukoderma related to the frequency of laser toning. This study showed that there are two types of leukoderma associated with laser toning. UV imaging was effective for the early detection of type 1 leukoderma, which seems to be related to the cumulative laser energy delivered, but not for detecting type 2 leukoderma, which may be due to direct phototoxicity. Lasers Surg. Med. 47:161–167, 2015. © 2015 Wiley Periodicals, Inc.

Background The free posterior medial thigh perforator flap is a fasciocutaneous flap on the posterior and medial thigh, based on perforators from the deep femoral vessels. In this study, the authors evaluated the anatomical basis of posterior and medial thigh perforators from the deep femoral vessels. Methods Between June of 2006 and May of 2012, 67 patients underwent breast reconstruction using the posterior medial thigh flap. Perforators greater than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator diameters, perforator locations, pedicle length, and distance of the perforating point from the proximal thigh crease. Results Of 70 flaps, 69 survived, but one developed total necrosis. The total number of perforators was 272, and the mean number was 3.9. The number of perforators coursing through the adductor magnus muscle was largest, followed by those coursing between the adductor magnus and semimembranosus muscle septocutaneously. Musculocutaneous perforators from the adductor magnus were located more proximally than the septocutaneous perforators between the adductor and semimembranosus muscle. Conclusions The posterior medial thigh flap is suitable as a first-line option for breast reconstruction in women with a small to moderate breast size. This flap provides enough large perforators to support a soft-tissue transfer from the posterior and medial thigh. Clinical question/level of evidence Therapeutic, IV.

Treatment of fracture of the naso-orbitoethmoid (NOE) complex is difficult. There are not only aesthetic issues but also functional consequences related to the lacrimal system. Because prophylactic lacrimal intubation for such fractures remains controversial, we have assessed the effectiveness of intraoperative lacrimal intubation to prevent epiphora as a result of such injuries. Thirteen patients diagnosed with craniomaxillofacial fractures including fractures of the NOE complex were included in the study; 10 had unilateral fractures and 3 bilateral. Computed tomography (CT) showed all patients had displaced fragments that had the potential to damage the lacrimal duct. In 7 patients the fractures included the canthal region and in 6 they did not. All patients were treated by open reduction and internal fixation under general anaesthesia, followed by intraoperative lacrimal intubation unilaterally or bilaterally as required. Lacrimal intubation with a silicone tube was successful in all 13 patients (16 sides). The tube was removed 2-9 months (mean 3.8) postoperatively and no subsequent epiphora were seen during follow-up (mean (3-29 months) 11.3 months). Lacrimal intubation for at least 2 months may prevent epiphora caused by injury to the nasolacrimal system after fractures of the NOE complex.

A free fascioadipocutaneous flap obtained from the medial thigh is suitable for breast reconstruction in Asian women with a small-to-moderate breast size. In this region, both a medial circumflex femoral artery perforator flap (MCFAp flap) and a posterior medial thigh perforator flap (PMTp flap) are options, based on perforators from the deep femoral vessels. Here, we evaluated the anatomic basis of the medial circumflex femoral artery (MCFA) perforators from the medial circumflex femoral vessels.Between July 2010 and June 2014, 53 patients (55 flaps) underwent breast reconstruction using a fascioadipocutaneous flap from the medial thigh. MCFA perforators larger than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator locations, distance of the perforating point from the proximal thigh crease and anterior border of the gracilis muscle.The total number of perforators was 131, with a mean of 2.4. The number of perforators coursing through the gracilis muscle (gracilis perforators) was the largest, followed by septocutaneous perforator coursing between the adductor longus and gracilis muscle. The average perforating point was located 6.5 cm below the proximal thigh crease and 2.2 cm from the anterior border of the gracilis muscle. Of the 102 procedures performed since 2006, 15 flaps were elevated as MCFAp flaps and there was no major complication.In some cases, MCFA perforators are dominant in this region compared to PMT perforators. A perforator map can be helpful for identifying adequate MCFA perforators intraoperatively.

Summary Background Total orbital floor reconstruction with sheet-shape materials is available for the treatment of extensive and crushed-type blowout fractures. Simple blowout fractures, on the other hand, require only manual reduction without fixation. Although several types of blowout fractures do not require total reconstruction, some fixation is usually necessary. Methods Eighteen cases of blowout fracture were treated with transzygomatic Kirschner wire fixation between 2002 and 2009. This technique was applied to simple fracture cases in which periorbital soft tissue re-herniated through the floor defect into the maxillary sinus after manual reduction, despite improvement of the extra-ocular muscle entrapment. The wire was used to directly support the fracture segment in five cases and used together with a maxillary sinus anterior wall bone graft in 13 cases. Results Mean follow-up was 12.5 months. Mild diplopia remained as a subjective symptom in one case. None of the cases developed major complications or conspicuous scars on the cheek. Conclusions Transzygomatic Kirschner wire fixation for blowout fracture has the advantages of precise and rigid fixation of all parts of the inferior floor, minimal morbidity without requiring an orbital approach and long-term safety without artificial remnants. This technique can be applied for the treatment of simple blowout fractures.

Background: For patients with senile ptosis, aesthetic blepharoplasty can be combined with ptosis surgery. However, the amount of skin excision necessary in blepharoplasty is not clearly defined by measurements of the upper eyelids. Objectives: The authors preoperatively evaluate the amount of skin to be excised in blepharoplasty. Methods: Fifty patients with bilateral senile ptosis were included in this study. The amount of skin to be excised from the upper eyelids was selected based on preoperative measurements of redundant skin, equivalent to the maximum lid height (MLH) while manually stretching the eyelid upwards minus resting lid height (RLH) with the eyes closed passively. Ptosis surgery (such as plication of the aponeurosis) followed blepharoplasty. Results: Preoperatively, mean MLH was 35 mm on the right and 36 mm on the left. Mean RLH was 25 mm bilaterally. The mean amount (height) of excised skin was 10 mm on the right and 11 mm on the left. At six months postoperatively, mean MLH and RLH were 29 and 23 mm on both sides, respectively. Significant differences between pre- and postoperative MLH and RDH were seen on both sides ( P < .001). No complications due to overexcision were observed, but revision was performed for two patients with asymmetry of the lid folds and five patients with recurrence of drooping. Conclusions: Preoperative measurements of upper eyelid heights (stretched and at rest) appear useful in determining the amount of skin excision required in blepharoplasty for senile ptosis. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Arteriovenous malformation (AVM) in the maxillofacial region is a rare, but potentially life-thereatening vascular lesion. Although AVM is usually diagnosed on angiography, the procedure is very invasive. We report the identification of AVM and feeding vessels on three-dimensional CT angiography (3D-CTA), which is minimally invasive.A 21-year-old man with a right buccal swelling was referred to our hospital. AVM was diagnosed on the basis of clinical signs and examinations such as ultrasonography, MR imaging, MR angiography, and CT. Angiography was not done. The vascular lesion was fed by two arteries (facial artery and infraorbital artery) in the right buccal region, clearly demonstrated on 3D-CTA. The patient underwent resection of the lesion and simultaneous reconstruction with a local flap. There was no evidence of recurrence 6 months after surgery.Three-dimensional CTA can identify feeding vessels and assess the extent of AVM. This method is useful for surgical planning, as well as preoperative diagnosis.

When prepping for navigation surgery, a reference frame must be fixed to the patient’s head with a Mayfield clamp, bone anchor, headset, or headband. Fixation of the clamp or bone anchor with a screw or head pins is invasive, whereas use of a headband or headset is noninvasive. However, during orbital surgery for blowout fractures or orbital tumors, surgeons or instruments can interfere between the reference frame and the optical tracking navigation system, even if using noninvasive fixation. We used an occlusal splint for noninvasive fixation of a reference frame in orbital navigation surgery to overcome the problems. A surgeon could operate without interferences between the reference frame and the optical tracking navigation system during orbital navigation surgery. We recommend the use of an occlusal splint for noninvasive fixation of a reference frame in orbital navigation surgery.

In free flap breast reconstruction, the retrograde limb of the internal mammary vein (IMV) is occasionally used as a second recipient vein. In this study, we evaluated the dynamic blood flow to the retrograde limb of the IMV (retrograde IMV) at the anastomosed site via indocyanine green (ICG) angiographyIn 40 patients undergoing free flap breast reconstruction, we evaluated the dynamic blood flow as "stain(+)" if a stain by ICG was observed and, "flow(+)" if a smooth blood flow was recognized.Based on the ICG angiography, "stain(+)" was observed in all cases, but "flow(+)" was detected in only 72.5% of the cases. There was no severe complication.This study shows that thrombosis is prone to occur in the second recipient vein in the 27.5% of the cases with no smooth flow, and therefore, the retrograde IMV may not function as a back-up in these cases.

Background: For reconstructing moderate-to-high projection breasts in nulliparous patients with insufficient abdominal tissue or prior abdominal surgeries, a unilateral inferior gluteal artery perforator (IGAP) flap is an alternative procedure. In patients with slim hips, however, unilateral gluteal tissue is insufficient and inferior gluteal crease displacement may develop postoperatively. Donor-site asymmetry is also a major disadvantage. In these circumstances, bilateral IGAP flaps provide sufficient tissue without significant gluteal deformity. Methods: We retrospectively reviewed 20 patients who underwent unilateral breast reconstruction using bilateral IGAP flaps by a single surgeon between November 2007 and December 2012. A quantitative outcome assessment was performed and compared with that of 22 unilateral IGAP flap patients operated on by the same surgeon. Results: Twenty patients underwent reconstruction with 40 IGAP flaps. Of the 40 flaps, 39 survived and 1 developed total necrosis due to repeated venous thrombosis. In 15 of 20 patients, the size of reconstructed breast was comparable to that of the contralateral breast. Final inset flap weight was 462.3 g for bilateral flaps and 244.3 g for unilateral flaps. Total operating time was 671.1 minutes (bilateral flaps) and 486.8 minutes (unilateral flaps). Conclusions: Use of bilateral IGAP flaps for breast reconstruction helps to avoid asymmetry of the inferior buttock volume and shape. Bilateral flaps provide sufficient tissue volume and allow for reconstruction of a breast comparable to the unaffected side. In patients with moderate-to-high projection breast whose abdominal tissue cannot be used for reconstruction, IGAP flaps may be a suitable alternative.

Laser "toning" with a Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has recently been described to be effective for the treatment of melasma. Leukoderma is a refractory complication of laser toning for melasma, but it can be detected early with ultraviolet (UV) imaging. We assessed the relationship between leukoderma and the frequency or total number of laser toning sessions, as well as the effectiveness of UV imaging for detecting leukoderma.The subjects included 147 patients who received at least five laser toning sessions. Subjects were classified into three groups according to the frequency of treatment (weekly for Group A1, fortnightly for Group A2, and monthly for Group B), and the incidence of leukoderma was compared among the three groups. In patients who developed leukoderma, the interval between clinical diagnosis and leukoderma detection on UV images (obtained with a Visia Evolution during every laser toning session) was determined to evaluate the effectiveness of UV imaging for the early detection of leukoderma.The overall incidence of leukoderma was 2% (3/147 patients): 3.8% (1/26 patients) in Group A1, 4% (2/49 patients) in Group A2, and 0% (0/72 patients) in Group B. There were no significant differences in the incidence of leukoderma relative to the frequency of laser toning. In two of the three patients who developed leukoderma, it was diagnosed clinically at the 20th and 21st laser toning session, whereas it was diagnosed by UV imaging at the 12th and 13th session. In the remaining 1 patient, leukoderma was detected clinically and by UV imaging at the 7th session.There was no significant difference in the incidence of leukoderma related to the frequency of laser toning. This study showed that there are two types of leukoderma associated with laser toning. UV imaging was effective for the early detection of type 1 leukoderma, which seems to be related to the cumulative laser energy delivered, but not for detecting type 2 leukoderma, which may be due to direct phototoxicity.

Lipoma is a common tumor found anywhere on the body. However, reports of large lipoma of the submandibular region, particularly extending into the parapharyngeal space, are rare. To remove tumor of the parapharyngeal space, many authors recommend a transcervical or transparotid-cervical approach. We report a case of lipoma of the submandibular region that extended into the parapharyngeal space which was removed with small invasion using a transmandibular approach.

Background Subperiosteal hematoma of the orbit is one of the rare lesions that cause exophthalmos after craniomaxillofacial trauma. Presently, there is no consensus for how to treat this disease. Although some reports have suggested a conservative type of therapy, others have recommended surgical treatments be done during the early stages. Case presentation This case report provides details on the clinical course of a 9-year-old girl with subperiosteal hematoma of the orbit. In this particular patient, a rare case of ipsilateral subfrontal extradural hematoma was also observed. Due to our performing the surgical intervention during the subacute stage, functional complications as well as cosmetic problems were avoided. Conclusion Our results demonstrate that surgical treatments for subperiosteal hematoma of the orbit should be delayed until it can be confirmed that a patient has no other complications. On the other hand, once it has been confirmed that the patient has no other existing problems, immediate surgical therapy with a small skin incision followed by the setting of a drain is recommended in order to achieve an early resolution and avoid complications.

i l ractures of the orbital floor are common midfacial fractures. lthough conventional approaches such as the subciliary or ransconjunctival approach are usually used for such fracures, the endoscopic transantral approach is safe and reliable n suitably selected patients1 and has recently been used as inimally invasive treatment.1,2 Improvement of ocular movement after the repair of a racture of the orbital floor is generally confirmed by the orced duction test. However, such improvement is more ifficult to assess after the endoscopic transantral approach ithout direct visualisation of soft tissues above the orbital oor, because the assessment depends on the surgeon’s skill nd experience and there are few objective indicators. We eport the use of a dial tension gauge to assess quantitaively the intraoperative improvement of ocular movement fter endoscopic transantral repair of a fracture of the orbital oor. Under general anaesthesia, 5/0 nylon is sutured to the nsertion of the inferior rectus muscle so that the globe is ot injured by the conjunctiva being grasped at the inserion. This procedure is not as traumatic as multiple trials of

Auteur(s) : Hiroyuki Fujita1, Hidefumi Wada1, Katsuji Koiwa1, Kazunori Yasumura2, Tadashi Kamada3, Zenro Ikezawa1 1Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Fukuura 3-9, Kanazawa, Yokohama, 236-0004, Japan 2Department of Plastic Reconstructive Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan 3Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, [...]