Objective Analysis of Age-Related Changes in the Superficial Musculoaponeurotic System in Japanese Females Using Computed Tomography

Background

The superficial musculoaponeurotic system (SMAS) is an anatomical structure involved in facial aging.

Objectives

This study focused on SMAS thickness and aimed to establish age-related changes in SMAS thickness.

Methods

A total of 100 adult Japanese female participants (aged 20-79 years) were enrolled in the study. The participants were divided into 3 age groups: Y, M, and E, comprising 20 to 39, 40 to 59, and 60 to 79 years, respectively. Anatomical structures were used as landmarks to standardize the SMAS analysis sites. The SMAS in a fixed analysis area (FAA) was quantified using multi-detector computed tomography (MDCT), and the relationship between SMAS thickness and age, as well as BMI, was analyzed.

Results

In 96 participants (four were excluded due to imaging artifacts), a moderate yet significant negative correlation was found between the average (A)-SMAS thickness within the FAA and age. The A-SMAS thickness in groups M and E was significantly lower than that of group Y, and the mean value of group E was significantly lower than that of group M. SMAS thickness was greater in the young population. The SMAS gradually became thinner with aging. A statistically significant correlation was not found between SMAS thickness and BMI.

Conclusions

Using MDCT technology, age-related changes in SMAS were successfully analyzed. This highly objective analysis method corroborated the aesthetic surgical knowledge of the SMAS features related to facial aging. In clinical applications, our findings may help elucidate the mechanisms involved in facial aging.

Level of Evidence 3

Basic Consideration for Facial Aging: Age-Related Changes of the Bony Orbit and Orbicularis Oculi Muscle in East Asians

BACKGROUND

Age-related changes in the periocular areas are mainly caused by anatomic changes of the bony orbit and orbicularis oculi muscle (OOM). To achieve effective rejuvenation, it is necessary to understand the age-related aspects of these anatomic changes.

OBJECTIVES

The aim of this study was to analyze the configuration of the bony orbit and OOM with computed tomography (CT) and to evaluate the effects of aging on these structures.

METHODS

A total of 220 orbits and OOMs of 110 Japanese participants (55 males, 55 females) aged 20 to 87 years were enrolled. The long diameter of the orbits, orbital ellipticity, OOM thickness, and OOM attachment to the inferior orbital rim were analyzed. These variables were statistically evaluated for their relationship with age.

RESULTS

The long diameter of the orbit was significantly longer in those over than in those under 60 years, with a moderate and significant positive correlation between orbital ellipticity and age. OOM thickness and age showed a strong negative correlation. The degree of OOM attachment to the inferior orbital rim decreased significantly with age.

CONCLUSIONS

This study showed that age-related changes of the bony orbit in Japanese individuals tended to be the same as those in Caucasians, but there were differences in the degree of changes observed. As a new finding in the Japanese population, the OOM not only thins with aging, but also gradually loosens from the facial bone. In the elderly, only the nasal side of the OOM was attached to the bone. In clinical applications, this knowledge could contribute to the development of cosmetic surgeries.

Factors that influence the postoperative upper eyelid position following surgery for involutional blepharoptosis

External levator advancement is commonly performed for involutional blepharoptosis repair; however, it is difficult to predict the postoperative upper eyelid position (UEP) accurately in blepharoptosis surgery. The purpose of this study was to determine the factors that influence postoperative UEP following surgery for involutional blepharoptosis. We retrospectively studied 40 Japanese women (80 eyelids) who underwent bilateral external levator advancement surgery. We used digital analysis software to measure the UEP and the eyebrow position from straight-gaze view photographs. Statistical analysis was performed to determine the correlation between postoperative UEP and related factors, including age, levator function, amount of levator advancement, anatomical fixed position, and preoperative and intraoperative UEP. We also compared UEP changes in mild, moderate, and severe ptosis groups. Levator function affected both preoperative and postoperative UEP. The amount of levator advancement and the anatomical fixation position on the aponeurosis did not affect the postoperative UEP. However, both preoperative (r = 0.49) and intraoperative (r = 0.55) UEPs affected the postoperative UEP. In cases of severe ptosis, there was significant re-drooping after surgery, while in cases with mild ptosis, the intraoperative eyelid position was maintained or slightly elevated. In involutional blepharoptosis, the degree of preoperative and intraoperative UEP contributed to the postoperative eyelid position. These data suggested that the levator muscle function is a major contributing factor in the pathogenesis of involutional blepharoptosis.

A Novel Autologous Micrografts Technology in Combination with Negative Pressure Wound Therapy (NPWT) for Quick Granulation Tissue Formation in Chronic/Refractory Ulcer

Negative pressure wound therapy (NPWT) has been commonly used over the years for a wide range of chronic/refractory lesions. Alternatively, autologous micrografting technology is recently becoming a powerful modality for initiating wound healing. The case presented is of a patient with a lower leg ulcer that had responded poorly to NPWT alone for three weeks. Consequently, the patient was put on a combination therapy of NPWT and micrografting. After injection of a dermal tissue micrografts suspension into the entire wound bed, NPWT was performed successively for two weeks, resulting in fresh granulation tissue formation. Thereafter, the autologous skin graft was taken well. This case study indicates that for a chronic/refractory ulcer patient with poor NPWT outcome, combination therapy using micrografting treatment and NPWT could rapidly initiate and enhance granulation tissue formation, creating a favorable bedding for subsequent skin grafting.

Nuss procedure for pectus excavatum in a patient with cleidocranial dysplasia

Cleidocranial dysplasia is an autosomal skeletal disorder resulting from delayed or abnormal ossification of bony growth. Pectus excavatum independently presented in a 9-year-old boy with cleidocranial dysplasia and was corrected using the Nuss procedure. There were no perioperative complications, and the post-operative course was uneventful. Although there were concerns regarding extraordinary late consolidation or remodeling of the bony thorax, placement of a Nuss plate for 5 years and 6 months improved the patient's concave deformity without re-depression.

Presurgical naso-alveolar molding paired with cheiloplasty to treat median cleft lip deformity in holoprosencephaly

We report median cleft lip in an infant girl with lobar-typed holoprosencephaly who underwent presurgical naso-alveolar molding and subsequent cheiloplasty. At seven months postoperatively, we observed an upper lip with natural cupid-bow-shape formed with a nasal dome and two nostrils separated with reconstructed columella, which were maintained for eight years.

Acceleration Mechanisms of Skin Wound Healing by Autologous Micrograft in Mice

A micrograft technique, which minces tissue into micro-fragments >50 μm, has been recently developed. However, its pathophysiological mechanisms in wound healing are unclear yet. We thus performed a wound healing study using normal mice. A humanized mouse model of a skin wound with a splint was used. After total skin excision, tissue micro-fragments obtained by the Rigenera protocol were infused onto the wounds. In the cell tracing study, GFP-expressing green mice and SCID mice were used. Collagen stains including Picrosirius red (PSR) and immunohistological stains for α-smooth muscle actin (αSMA), CD31, transforming growth factor-β1 (TGF-β1) and neutrophils were evaluated for granulation tissue development. GFP-positive cells remained in granulation tissue seven days after infusion, but vanished after 13 days. Following the infusion of the tissue micrograft solution onto the wound, TGF-β1 expression was transiently upregulated in granulation tissue in the early phase. Subsequently, αSMA-expressing myofibroblasts increased in number in thickened granulation tissue with acceleration of neovascularization and collagen matrix maturation. On such granulation tissue, regenerative epithelial healing progressed, resulting in wound area reduction. Alternative alteration after the micrograft may have increased αSMA-expressing myofibroblasts in granulation tissue, which may act on collagen accumulation, neovascularization and wound contraction. All of these changes are favorable for epithelial regeneration on wound.

Efficacy and safety of oral propranolol for infantile hemangioma in Japan

BACKGROUND

There have been few reports on the efficacy and safety of oral propranolol at 3 mg/kg/day for infantile hemangioma (IH) in Japanese patients.

METHODS

A multicenter, open-label phase III study was conducted to evaluate the efficacy and safety of oral propranolol solution in Japanese infants aged 35-150 days with proliferating IH. Thirty-two patients were enrolled in the study, received propranolol solution for 24 weeks at 3 mg/kg/day, and completed the study.

RESULTS

The success rate (complete or nearly complete resolution) at week 24 (primary endpoint) was 78% (95%CI: 60-91%). The improvement rate since the previous visit was 100% (32/32) after week 5. Overall, the IH surface area, maximum diameter, and color intensity all decreased over time. Consistency in assessment between the centralized and the investigator on-site assessments was observed in 26 patients. Of the 32 patients, 11 needed further treatment other than the study drug. The incidence of adverse events (AE) and drug-related AE was 97% and 31%, respectively. AE that occurred in ≥two patients were either typical of propranolol use (such as blood pressure decrease) or common events in infants. AE that resulted in dose reduction were observed in two patients, but no serious AE or AE that led to study drug discontinuation were observed.

CONCLUSION

Oral propranolol solution at 3 mg/kg/day is effective and safe in Japanese IH patients.

The neck burn scar contracture: a concept of effective treatment

A neck scar contracture can severely and negatively affect the function of mastication, phonic, or breathing and result in neck pain and issues with esthetics. The best way is of course to avoid such contracture by means of non-surgical treatment such as use of a growth factor. The basic fibroblastic growth factor is clinically well proven in decreasing scar formation and improving healing. There are numerous reconstructive methods for neck contracture, especially when the lesions are relatively limited in part of the neck. However, a very severe and full circumferential scar contracture requires extensive reconstruction. The thin groin flap is one of the answers and well matches with the tissue texture and maintains the flexibility. Even with extensive burns and delayed reconstructions due to resuscitation first, the groin area is well preserved and can be safely harvested by dual vasculature systems of the superficial circumflex iliac artery and superficial epigastric artery, which warrant more reliability compared to the perforator flaps in this area. More demanding and stringent forms of the neck burn scar contracture are the sequelae of radiation. A radiation burn or radiation injury can be progressing and hard to heal. Adipose-derived stem cells can reverse the scar contracture as the surrounding tissue is softened and can accelerate wound healing. In this review, different types of neck burn scar contracture and reconstructive methods are summarized, including innovative use of bFGF and ADSCs in the management of difficult wound healing and scar contracture.

Increased drug resistance of meticillin-resistant Staphylococcus aureus biofilms formed on a mouse dermal chip model

Purpose

Meticillin-resistant Staphylococcus aureus (MRSA) biofilm formation in humans is of serious clinical concern. Previous in vitro studies have been performed with biofilms grown only on inorganic substrates; therefore, we investigated the vancomycin (VCM) resistance of MRSA biofilms grown on skin tissue.

Methodology

We established a novel tissue substrate model, namely MRSA grown on segments of mouse skin tissue (dermal chips, DCs), and compared its resistance capacity against VCM with that of MRSA biofilms grown on plastic chips (PCs).

Results/Key findings

For one MRSA isolate, we found that the VCM MIC was identical (1.56 µg ml⁻¹) for planktonic cultures and for biofilms-formed on PCs (PC-BF), although the minimum bactericidal concentration (MBC) increased to 6.25 µg ml⁻¹ in PC-BF. On the contrary, the MIC and MBC for biofilms formed on DCs (DC-BF) significantly increased (25 and 50 µg ml⁻¹, respectively). Furthermore, the minimum biofilm-eradicating concentration was higher for DC-BF (100 µg ml⁻¹) than for PC-BF (25 µg ml⁻¹). Using six MRSA strains, we found that in PC-BF, the c.f.u. number decreased with increasing VCM concentration, whereas in DC-BF, it greatly increased until the MIC was reached, accompanied by the formation of large colonies, thicker bacterial walls and the presence of many mitotic cells.

Conclusion

Our results indicate that the VCM resistance of MRSA was greater in DC-BF. We conclude that DCs may provide a specific environment for MRSA that enhances bacterial growth under cytotoxic VCM concentrations, and might be useful for the study of skin wound infections and the effects of antimicrobial drugs.

Biofilm-Forming Methicillin-Resistant Staphylococcus aureus Survive in Kupffer Cells and Exhibit High Virulence in Mice

Although Staphylococcus aureus is part of the normal body flora, heavy usage of antibiotics has resulted in the emergence of methicillin-resistant strains (MRSA). MRSA can form biofilms and cause indwelling foreign body infections, bacteremia, soft tissue infections, endocarditis, and osteomyelitis. Using an in vitro assay, we screened 173 clinical blood isolates of MRSA and selected 20 high-biofilm formers (H-BF) and low-biofilm formers (L-BF). These were intravenously administered to mice and the general condition of mice, the distribution of bacteria, and biofilm in the liver, lung, spleen, and kidney were investigated. MRSA count was the highest in the liver, especially within Kupffer cells, which were positive for acid polysaccharides that are associated with intracellular biofilm. After 24 h, the general condition of the mice worsened significantly in the H-BF group. In the liver, bacterial deposition and aggregation and the biofilm-forming spot number were all significantly greater for H-BF group than for L-BF. CFU analysis revealed that bacteria in the H-BF group survived for long periods in the liver. These results indicate that the biofilm-forming ability of MRSA is a crucial factor for intracellular persistence, which could lead to chronic infections.

Osteosarcoma of the patella mimicking giant cell tumor: imaging features with histopathological correlation

Patellar tumors represent an uncommon etiology of anterior knee pain and their diagnosis is often delayed. We present an unusual case of conventional osteosarcoma arising in the patella of a 47-year-old man. The patient presented with a 1-year history of increasing anterior knee pain and swelling. Plain radiographs revealed a multi-locular lytic lesion in the inferolateral side of the patella. Computed tomography scans demonstrated an intraosseous lytic lesion with cortical thinning/breakthrough anteriorly. On magnetic resonance imaging, the lesion exhibited low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images. Fluid-fluid levels were also observed on T2-weighted images. Contrast-enhanced fat-suppressed T1-weighted images demonstrated strong enhancement of the lesion. These imaging features were suggestive of a benign condition; however, the diagnosis of osteosarcoma was confirmed by histopathology. After neoadjuvant chemotherapy, a wide resection with a free anterolateral thigh flap was performed. The patient subsequently underwent adjuvant chemotherapy and had no evidence of local recurrence or distant metastasis six months after surgery. Our case highlights the difficulty in the diagnosis of patellar osteosarcoma and the importance of performing a biopsy before definitive treatment.

Infection mechanism of biofilm-forming Staphylococcus aureus on indwelling foreign materials in mice

Indwelling foreign-body infections are a critical medical problem, especially in immunocompromised patients. To examine the pathogenicity of biofilm-forming bacteria settling on foreign materials, mice implanted with plastic discs were infected with Staphylococcus aureus. After opening a wide subcutaneous pocket on the dorsal side of mice with or without temporal leukocytopenia, a plastic sheet was placed in the left subcutaneous space; subsequently, bacteria in a planktonic state were dispersed over the subcutaneous space. Bacterial numbers were examined 7 days after inoculation. In subcutaneous tissue on the right, S. aureus was found only in leukocytopenic mice. Meanwhile, bacteria were detected on the plastic and neighbouring tissue in both leukocytopenic and normal mice; however, colony-forming analysis indicated that leukocytopenic mice possessed significantly more bacteria. Tissue reaction against bacteria was pathologically examined. Invading S. aureus induced severe inflammation. In transient leukocytopenic mice, bacterial microcolonies formed on the plastic as well as in the developed necrotic tissue - both of which were shielded from inflammatory cell infiltration - result in bacteraemia. These results indicate that biofilm-forming S. aureus settling on indwelling foreign material are tolerant against host immunity and assault neighbouring tissue, which may lead to chronic wound infection.

A new sternum elevator reduces severe complications during minimally invasive repair of the pectus excavatum

INTRODUCTION

Although the Nuss procedure for pectus excavatum is widely employed, a variety of complications have been reported with relatively high frequency; those that involve cardiac and pericardial injuries can be life threatening. To reduce such dangers, we present here a newly developed sternal elevator.

MATERIALS AND METHODS

The elevator is horseshoe shaped. Its elevator side has the same curvature as a Nuss introducer, so that interference between devices is minimal and no extra skin incision is needed for the elevator insertion. The elevator holds the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer.

RESULTS

The authors have used the elevator for 61 pectus excavatum cases between March 2004 and December 2009 without any major complications. The entire process of substernal tunneling was endoscopically observed, which eliminated any blunt and blind dissection, even in a significantly depressed funnel chest case. With the device, the sternum was effectively elevated again for the placement of the second plate in 30 cases.

CONCLUSION

Our newly developed sternum elevator makes the Nuss procedure safer and more affordable without introducing any extra scarring.

Myxoid liposarcoma of the ankle: a case report

Myxoid liposarcoma occurs predominantly in the deep soft tissues of the extremities, and tends to metastasize to a wide range of soft tissue or bone locations. We report a case of myxoid liposarcoma arising in the ankle of a 19-year-old man. A diagnosis of myxoid liposarcoma was made by open biopsy, and a wide resection requiring plastic surgical reconstruction was performed. Cytogenetic analysis of the resected tumor exhibited a reciprocal translocation t(12;16)(q13;p11) as the sole anomaly, which is found in more than 90% of myxoid liposarcoma cases. The patient had no evidence of local recurrence or metastasis within 7 years of follow-up. Although myxoid liposarcoma is rare in the ankle, it should be considered in the differential diagnosis of a painless soft tissue mass in this region.

Accessing the Orbital Roof via an Eyelid Incision: The Transpalpebral Approach

THIS ARTICLE OUTLINES A NEW SURGICAL TECHNIQUE FOR ACCESSING THE ORBITAL ROOF: the transpalpebral approach. It involves making an incision on the double fold of the upper eyelid, then dissecting the orbital septum and the orbicular muscle of the eye. This exposes the orbital roof and enables the surgeon to approach without a coronal incision of the scalp; the direct eyelid incision provides adequate workspace. We use this approach in three orbital roof fractures and one orbital hemangioma. This orbital approach offers a simpler surgical technique, a less invasive one, and still provides excellent exposure of the superior orbital cavity.

Involvement of Na+/Ca2+ Exchanger Type-1 in Ischemia-Induced Neovascularization in the Mouse Hindlimb

The Na+/Ca2+ exchanger (NCX) is considered to be involved in endothelial nitric oxide (NO) production and endothelium-dependent vasorelaxation, but little is known about the physiological and pathological roles of endothelial NCX in these processes. We examined the role of NCX1 in neovascularization in mice with hindlimb ischemia. Unilateral hindlimb ischemia was induced surgically in wild-type and heterozygous NCX1 knockout mice (NCX1+/-) mice. We found that in NCX1+/- mice, blood flow recovery was significantly augmented compared with that in wild-type mice. N(G)-nitro-L-arginine methyl ester treatment eliminated enhanced angiogenesis observed in NCX1+/- mice. These results suggest that NCX1 is involved in eNOS-dependent angiogenesis.

Analyzing the Vascular Architecture of the Free TRAM Flap Using Intraoperative Ex Vivo Angiography

BACKGROUND

Using ex vivo intraoperative angiography to analyze 14 flaps from 12 breast reconstruction patients, the authors investigated the vascular architecture of free transverse rectus abdominis musculocutaneous (TRAM) flaps nourished by the deep inferior epigastric artery.

METHODS

Contrast medium was injected through the deep inferior epigastric artery and flaps were radiographed to observe their vascular patterns.

RESULTS

TRAM flaps showed one or two segmental arteries stained on their ipsilateral side (zones 1 and 3) and serving as the flap's axial artery. These segmental arteries directly connect to the large perforators (axial perforators) and emerge not only from the paraumbilical perforators but also from the caudal branches of the deep inferior epigastric artery. Arterial density is always lower in the contralateral area (zones 2 and 4) than in the ipsilateral area (zones 1 and 3).

CONCLUSIONS

Because the cephalic half of zone 2 and all of zone 4 remain unstained, these areas are prone to skin or fat necrosis, especially in high-risk patients. Ex vivo angiography, by providing specific information about the individual flap and by reflecting its flow physiology, enables one to observe and to chart the vascular architecture of free TRAM flaps nourished by the deep inferior epigastric artery.

Double pennant technique: elongating the helix using rim flaps to correct the constricted ear

In a Tanzer group 2B or group 3 constricted ear, the short helix must be elongated with additional tissues. To do this, we have developed a new method of surgical repair using 2 pennant-shaped rim flaps. Six constricted ear patients underwent correctional ear plasty using this method. Four of the deformities were Tanzer group 2b and 2 were group 3. Our surgical procedure elongated the patients' helix from 7 to 22 mm, leaving them with smooth curvature and a good color match to the adjoining skin.

Emergence of vancomycin resistance during therapy against methicillin-resistant Staphylococcus aureus in a burn patient--importance of low-level resistance to vancomycin

OBJECTIVES

Staphylococcus aureus with low-level resistance to vancomycin (VLSA) which could develop into vancomycin-resistant S. aureus (VRSA) is most important. However, VLSA is difficult to detect by standard laboratory methods. We describe here improved methods to detect VLSA.

METHODS

Three methicillin-resistant S. aureus (MRSA) strains, designated Fu6, Fu10, and Fu18, were sequentially isolated from the burn wound site of a patient, during vancomycin therapy. The properties of these strains were compared with those of reference strains Mu3 and Mu50 (previous resistant isolates from other patients).

RESULTS

The isolated strains, Fu10 and Fu18, had identical phenotypes and genotypes. The vancomycin resistance of Fu10 was equivalent to that of strain Mu3, whereas Fu18 had much higher vancomycin resistance than Fu10 and Mu3, although reaching the level of Mu50. Fu18 showed similar growth to Mu50 on gradient gels and on Mu3 medium.

CONCLUSIONS

Our data indicate that the VLSA developed vancomycin resistance during exposure to vancomycin in vivo. The population analysis of tested VLSA and vancomycin intermediately resistant S. aureus (VISA) indicates that a penem at relatively low concentrations induced a significant increase in the number of vancomycin-resistant subpopulations. Furthermore, we confirmed that gradient gel analysis and Mu3 medium are simple and useful methods for the detection of VLSA judged as VSSA by its conventional MIC alone.

Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps

In this study, the vascular architecture of rectus abdominis free flaps nourished by deep inferior epigastric vessels was investigated using an ex vivo intraoperative angiogram. Oblique rectus abdominis free flaps were elevated and isolated from the donor site. In 11 patients, the vascular architecture of these flaps was analyzed before the flap was thinned. Radiographic study identified an average of 2.1 large deep inferior epigastric arterial perforators in each flap. In nine of the 11 flaps, the axial artery was visible. In four flaps, the axial artery originated from the perforator of the lateral branch of the deep inferior epigastric artery; in five others, it originated from the medial branch. In each flap, the angle of the axial perforator from its anterior rectus sheath in the vertical plane was measured; its mean was 50.6 degrees. All flaps survived, although three showed partial necrosis in the distal portions. In two of these three flaps, the axial artery was not visible in the angiograms, and the third revealed a one-sided distribution of axial flap arteries. Using ex vivo intraoperative angiography, the architecture of the individual flap, its axial perforator, and its connecting axial flap vessel could be investigated. This information can help the surgeon safely thin and separate the flap.

A comparison of thinning and conventional free-flap transfers to the lower extremity

This study compares the application of conventional free flaps and thinning flaps to the lower extremities. Thirty patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a conventional flap group, reconstructed using conventional free flaps (15 cases), and a thinning flap group, reconstructed using thinning flaps (15 cases). Postoperative complications, long-term results, and revisional surgery were studied in the two groups. Although survival after surgery was the same in both, in the conventional flap group, 11 patients required secondary revisional surgery, the excessive bulk of the flap resulting in poor aesthetics and difficulty in wearing shoes. The conventional flap group also required longer treatment. In the thinning flap group, only 5 of 15 patients received secondary revisional surgery. As a reconstruction material for the lower extremities, thinning flaps are both aesthetically and functionally superior to conventional bulky flaps.

A case report of caudal regression syndrome associated with an intraspinal arachnoid cyst

We report here a rare case of caudal regression syndrome associated with an intraspinal arachnoid cyst. The patient was a 6-month-old baby girl with multicomplex congenital abnormalities: sacrococcygeal dysgenesis and ventral curvature, large terminal cyst (myelocystocele), spinal arachnoid cyst, cerebellar hypertrophy (suspected), high imperforate anus, partial dysgenesis of the large intestine, omphalocele, atresia of the vagina, bilateral incomplete ureter duplication, incomplete pseudoduplicated bladder and bilateral talipes equinovarus. We performed plastic repair of the myelocystocele and perineal lesion for caudal regression syndrome and partial removal of the cyst wall for the intraspinal arachnoid cyst. She has been well for 3 years postoperatively, and her mental development is normal.

Drill-hole guide for internal fixation of fractures of the mandibular condyle

We have developed a drill-hole guide valuable in accurately positioning the fracture of the mandibular ramus. It operates by introducing a Kirschner wire through the fracture stump from the mandibular angle to the condyle. A 2.0- to 2.4-mm-diameter Kirschner wire is drilled into the ramus from below and proceeds up to the condylar fragment through the stump of the fracture. With this guide, 15 patients with 23 subcondylar fractures underwent open reduction with Kirschner wire fixation. In each case, wire, by means of a pinning technique, was inserted accurately from the mandibular angle to the repositioned condyle.

Modification of the gluteus maximus V-Y advancement flap for sacral ulcers: the gluteal fasciocutaneous flap method

We designed a modified gluteus maximus V-Y advancement flap method for closing a sacral ulcer. The purposes of our method were to simplify the surgical procedure and to avoid a functional deficit of the gluteus maximus muscle that was sacrificed by the conventional method. After excising the sacral ulcer, the V-Y advancement flap is marked on the bilateral buttock. Fascial incision of the gluteus maximus is made at the same incision in the skin. One-third of each medial flap is elevated as a fasciocutaneous flap by dissecting the layer between the fascia and the muscle at the parasacral region. The flaps are then moved medially and sutured. We operated on 24 patients with sacral ulcers using this technique. The patients included 19 with a sacral pressure sore and 5 with a radiation ulcer on the sacrum. Eighteen ambulatory patients also were included in this group. The results showed no flap necrosis in any patient. No functional deficit of the gluteus maximus muscle was observed postoperatively in the ambulatory patients. Average blood loss was 250 ml during the procedure. We conclude that the gluteus V-Y advancement flap as a fasciocutaneous flap is superior to the conventional musculocutaneous flap method.

An elastic plastic splint to compress the ear after reconstruction using a temporoparietal fascial flap

We designed a new splint that is used to compress the ear after reconstruction using the temporoparietal fascial flap method to reduce postoperative swelling rapidly. The splint, which is made of an elastic plastic material, was applied to 3 patients with an acquired ear defect. The application period using this splint was from 10 days after surgery up to 3 to 6 months. Swelling of the reconstructed ear subsided rapidly after application of the splint. The contour was then enhanced in all patients. We were able to apply compression to the region as required, using a sponge attached to the splint. The splint is soft enough to remain in place, even if the patient continues regular activities. We conclude that the elastic plastic splint is useful to compress the ear after reconstruction using the temporoparietal fascial flap method.

Treatment of scalp arteriovenous malformation

We report seven patients with scalp arteriovenous malformations, including two patients with lesions > 10 cm in diameter, who were successfully treated. The principal complaint of each patient was a deforming mass. Each of four patients had a history of blunt traumatic injury. The lesions, each consisting of the nidus, feeders, and draining veins, evolved in all patients. The nidus consisted of fistulae, which exhibited various angioarchitectures as revealed by angiography. A hemangiomatous component was histologically recognized in one patient. In five patients, in whom the lesions were relatively small and whose nidi included only large fistulae, the malformations were remedied by surgical intervention alone or were cured with embolization alone using liquid adhesives. In the two patients with lesions > 10 cm, the nidi consisted of numerous large fistulae and plexiform fistulae in one patient and plexiform fistulae and a hemangiomatous component in the other patient. These patients were treated with a combination of transarterial embolization and surgical intervention. Preoperative embolization greatly reduced blood loss during resection. Total excision and scalp reconstruction using a soft tissue expander were performed in both patients. The cosmetic results were excellent in all of the patients, and no recurrence has been recognized during the follow-up period, which ranges from 31 to 99 months. The treatment of scalp arteriovenous malformations should strive to improve deforming features and to attain a permanent cure. Because each nidus includes a variety of anomalous angioarchitectural features, there should be different means and a combination of treatments for each patient. Embolization alone could be adequate treatment in relatively small lesions, the nidi of which consist only of several large fistulae. For malformations with more extensive, large fistulae or with anomalous components other than large fistulae, a combined endovascular and surgical approach and scalp reconstruction seems to be the best treatment.

A new method for the relief of adult phimosis

Infantile circumcision is not ordinarily performed in Japan. Adult circumcision causes esthetic problems with scarring and color change, especially in Asian patients. We report our experience with 10 adults who underwent a new method of surgery for correction of phimosis via a longitudinal incision of the prepuce along the constricted area ventrally to release constriction, followed by transverse closure of the wound; removal of excess skin by pinching at the dorsal root of the penis, incising circumferentially except for 2 cm. of ventral skin, and closing the dorsal wound. Functional results in all cases were satisfactory and preputial constriction was fully relieved. Cosmetic results were superior to those of conventional circumcision and dorsal slit methods of adult circumcision because contrasting coloration was obscured behind pubic hair and scarring was coincidental with or beneath the pubic hairline.

Activation of endogenous thromboxane A2 biosynthesis mediates presynaptic inhibition by endothelin-3 of dog stellate ganglionic transmission

Effects of endothelin-3 on ganglionic transmission were investigated in dog cardiac sympathetic ganglia. Positive chronotropic responses to preganglionic stellate stimulation were inhibited by endothelin-3 (0.5-2 micrograms) given directly to the ganglia through the artery. To find possible inhibitory effects of the peptide at presynaptic sites, acetylcholine released from the isolated stellate ganglia was determined. The amount of acetylcholine released during preganglionic stimulation was reduced by exposure to endothelin-3 (10(-9) to 10(-6) M). A similar reduction of acetylcholine release was observed after application of a stable thromboxane A2, a thromboxane A2/prostaglandin H2 receptor agonist, U-46619, and prostaglandin E2 at concentrations from 10(-8) to 10(-4) M, but not by the same concentrations of prostaglandins F2 alpha and I2. The reduction elicited by endothelin-3 was unaffected by a phospholipase C inhibitor, neomycin, or a protein kinase C inhibitor, H-7, but was antagonized by pretreatment with phospholipase A2 inhibitors, dexamethasone or methylprednisolone, and by cyclooxygenase inhibitors, aspirin and indomethacin. In addition, the reduction also was antagonized by pretreatment with a thromboxane A2 synthetase inhibitor, OKY-046, and a specific thromboxane A2 receptor antagonist, S-145, but not by a specific prostaglandin E2 receptor antagonist, SC-19220. Furthermore, endothelin-3 (10(-7) M) stimulated the OKY-046- and indomethacin-sensitive formation of thromboxane A2 in the ganglia. These results indicate that endothelin-3 inhibits the sympathetic ganglionic transmission by reducing acetylcholine release at preganglionic terminals and that this inhibition seems to involve activation of endogenous thromboxane A2 production.

Increase of acetylcholine release by nebracetam in dog cardiac sympathetic ganglion

The effects of nebracetam (4-aminomethyl-1-benzylpyrrolidine-2-one hemifumarate, WEB 1881FU), a potential cognitive enhancer, on acetylcholine release from the preganglionic nerve terminals were investigated in the isolated dog stellate ganglia. Acetylcholine release from the isolated ganglia by preganglionic stimulation (5 Hz) was enhanced in the presence of nebracetam, 10(-7) to 10(-5) M. The release was decreased to a certain extent by bethanechol, 10(-5) M, and this decrease was completely antagonized by AFDX-116 (10(-5) M), a selective M2 muscarinic antagonist, but was unaffected by nebracetam (10(-6) M). Under the depleted condition of acetylcholine induced by pretreatment with hemicholinium-3 (10(-5) M) in combination with prolonged preganglionic stimulation, the release was increased to a degree by nebracetam or choline alone and was markedly increased in the presence of both nebracetam and choline. Nebracetam did not directly act on choline acetyltransferase activity, but acetylcholine formation was stimulated in the isolated ganglion incubated with the agent at 10(-6) M and in the ganglion isolated from the dog to which nebracetam, 5 mg/kg, was previously administered i.v. Uptake of choline in the isolated ganglia was not altered by nebracetam (10(-6) M) but was enhanced under the depleted conditions. These findings suggest that nebracetam enhances acetylcholine release from presynaptic sites of dog stellate ganglia not by blocking presynaptic M2 muscarinic autoreceptors but by accelerating acetylcholine formation, and by increasing choline uptake when acetylcholine is depleted.

Presynaptic facilitation by the new nootropic drug nebracetam, of ganglionic muscarinic transmission in the dog cardiac sympathetic ganglion

Effects of nebracetam (4-aminomethyl-1-benzylpyrrolidine-2-one hemifumarate, WEB 1881 FU, CAS 118607-07-1), a new nootropic drug, on impulse transmission in the cardiac sympathetic ganglia were studied in spinal dogs by monitoring heart rate as an indicator of the ganglionic function. The ganglionic stimulants were given directly into the cardiac sympathetic ganglia through the right subclavian artery (i.a.). Nebracetam, 5 mg/kg, i.v. caused a slight and temporal increase in heart rate. After nebracetam, the frequency-response curves of heart rate for preganglionic stellate stimulation (0.25-4 Hz) were not altered in the untreated and atropine-pretreated animals, but the curves (2.5-40 Hz) were shifted to the left in the hexamethonium-pretreated animals. The enhancement of ganglionic muscarinic transmission was dose-dependent on nebracetam i.v. at doses ranging from 0.5 to 15 mg/kg, with a maximal effect at 5 mg/kg. This enhanced muscarinic transmission by nebracetam was almost abolished after subsequent administration of pirenzepine 0.5 mg/kg i.v. The enhancement in the muscarinic transmission by nebracetam was also eliminated after depletion of acetylcholine at preganglionic sites caused by treatment with hemicholinium-3 in combination with preganglionic stimulation. Furthermore, nebracetam failed to affect dose-dependent post-ganglionic stimulation by McN-A-343 (1-32 micrograms), 1,1-dimethyl-4-phenylpiperazinium (1-32 micrograms) and angiotensin II (0.1 and 0.2 micrograms) administered i.a. directly to the ganglia. These results suggest that nebracetam facilitates the ganglionic muscarinic transmission through acting on presynaptic sites.

Endothelin-3 inhibits ganglionic transmission at preganglionic sites through activation of endogenous thromboxane A2 production in dog cardiac sympathetic ganglia

The effects of endothelin-3 (ET-3) on ganglionic transmission of dog cardiac sympathetic ganglia and possible mechanisms involved were investigated in vivo and in vitro. Positive chronotropic responses to preganglionic stellate stimulation and those to dimethylphenylpiperazinium as well as McN-A-343 administered to the ganglia were inhibited by ET-3. The amount of acetylcholine released by preganglionic stimulation was reduced dose dependently after exposure to ET-3. The reduction elicited by ET-3 was antagonized by pretreatment with phospholipase A2 inhibitors (dexamethasone and methylprednisolone) and cyclooxygenase inhibitors (aspirin and indomethacin). In addition, the reduction of acetylcholine release was similarly induced by exposure to exogenously applied STA2, a stable thromboxane A2 analogue; U-46619, a TXA2/PGH2 receptor agonist; and prostaglandin E2. Furthermore, the reduction produced by ET-3 was antagonized by pretreatment with a thromboxane A2 synthetase inhibitor (OKY-046) and a specific thromboxane A2 receptor antagonist (S-145), but not by a specific prostaglandin E2 receptor antagonist (SC-19220). These results indicate that ET-3 inhibits the sympathetic ganglionic transmission via reducing acetylcholine release from the presynaptic nerve terminals of ganglia and that this inhibition involves the activation of endogenous thromboxane A2 production.

[Antihypertensive effect of naftopidil (KT-611), a novel alpha 1-adrenoceptor antagonist, in freely moving experimental hypertensive rats and dogs]

The antihypertensive effect of naftopidil (KT-611) following single oral administration was investigated in normotensive Wistar Kyoto rats (WKY), spontaneously hypertensive rats (SHR), DOCA-Salt hypertensive rats (DHR), 2-kidney 1-clip renal hypertensive rats (RHR) and Grollman type renal hypertensive dogs with 1-kidney (RHD); and it was compared with that of the selective alpha 1-adrenoceptor antagonist prazosin. The blood pressure and heart rate were measured under the unanesthetized, unrestrained state through an arterial catheter that was chronically implanted into the abdominal aorta. In SHR and WKY, both KT-611 (10 and 30 mg/kg, p.o.) and prazosin (1 and 3 mg/kg, p.o.) markedly inhibited the pressor response to the alpha 1-adrenoceptor agonist phenylephrine (3 micrograms/kg, i.v.). KT-611 (10 to 100 mg/kg, p.o.) showed a dose-dependent hypotensive effect in SHR, DHR and RHR but not in WKY. The hypotensive effect of KT-611 reached maximum at 0.5-1 hr, lasted for 4-6 hr and was more potent in DHR and RHR than in SHR. The potency of KT-611 was 1/10-1/30 weaker than that of prazosin. In RHD, single oral administration of KT-611 (1 to 10 mg/kg) caused a dose-dependent and long-lasting hypotensive effect. These results suggest that KT-611 has a long-lasting hypotensive effect in experimental hypertensive animal models.

Correction of a chest wall deformity utilizing latissimus dorsi with a turnover procedure

Infraclavicular hollowing and the abnormal anterior axillary fold are often seen in patients with Poland's syndrome and related conditions. The operative procedure described in this article corrects these deformities. The procedure uses the latissimus dorsi island flap. The inserted muscle is moved anteriorly and sutured between the deltoid and the biceps. Then the muscle flap is twisted between its origin and where it is inserted. The muscle fibers act like a pivot and the thickness of the flap is increased, which enables us to achieve a round anterior axillary fold. The muscle flap fills the infraclavicular region and softens the deep hollow area.

The role of psychiatry in aesthetic surgery

Twenty-five patients seeking aesthetic surgery were investigated and treated with the cooperation of the plastic surgeon and a psychiatrist. Three-fourths of the patients revealed psychiatric problems in their backgrounds. On the recommendation of the psychiatrist, eight cases underwent operations, in spite of psychiatric problems, and were satisfied with the treatment. Patients not operated on had been persuaded to abandon their operation after psychiatric therapy. In conclusion, the cooperation of the psychiatrist was found to be very effective in the treatment of those seeking aesthetic surgery.

Special surgical techniques for relief of phimosis

Almost one-half of the population of adolescent and adult Japanese males suffers from some degree of phimosis, i.e., the condition in which the prepuce is too long or too tightly covers the glans penis and causes complications. This condition makes local hygiene difficult, promotes secondary infection and purulence, retards maturation of the penis, and leads to sexual dysfunction that is psychologically and maritally distressing. Circumcision shortly after birth is not ordinarily praticed in Japan, and when relief of phimosis and its complications is attempted later in life by the conventional technique of circumcision or by limited operations like dorsal slit of the prepuce or incision of the frenulum of the prepuce, the condition and its related problems are not readily or always satisfactorily corrected. Consequently, new surgical techniques have been devised and are practiced at the Ohjimi Clinic for the relief of phimosis, especially for the sexual dysfunction that results from it.