First Impressions: Setting the Stage for Better Relationships

Background:

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

Methods:

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

Results:

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

Conclusion:

The authors’ risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan

BACKGROUND

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

METHODS

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

RESULTS

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

CONCLUSION

The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Short ramus reconstruction for hemi-mandibulectomy defect: Case reports

Reconstruction of the mandible following hemimandibulectomy is difficult and complex.

The appropriate approach to condylar reconstruction remains controversial. In this report, the authors propose the concept of “short ramus reconstruction” after hemimandibulectomy. In this technique, a neocondyle is constructed around the base of the condyle to avoid trismus and ankylosis. Four patients underwent short condylar reconstruction using fibula free flaps. Post-surgery, no patient developed trismus or ankylosis. Centric occlusion, good masticatory function, and favourable aesthetic outcomes were achieved in all cases. “Short ramus reconstruction” is a simple and convenient method to reconstruct the mandible following hemimandibulectomy.

A modified preauricular and transmandibular approach for surgical management of osteosarcoma of the mandibular condyle within the masticator space and infratemporal fossa: a case report

Background

Osteosarcomas of the head and neck region are rare entities that comprise < 10% of all osteosarcomas. Multimodality treatment of patients with osteosarcoma is well-established for osteosarcoma in long bones, and the benefits of chemotherapy in long bones are clearly known. However, there is no consensus regarding the effects of chemotherapy in cases of head and neck osteosarcoma. The prognostic factor for head and neck osteosarcoma is complete tumor resection with negative margin, which is a radical surgery. However, a clear margin may be difficult to achieve in the head and neck region.

Case presentation

We present a case of a 69-year-old Japanese woman who developed osteosarcoma of the condyle within the masticator space and infratemporal fossa, which was treated with radical surgery using a modified preauricular and transmandibular approach. Although we recommended adjuvant treatment after surgery, the patient refused this treatment. There was no evidence of local recurrence or distant metastasis through 30 months of follow-up.

Conclusions

Our modified preauricular and transmandibular approach allowed access to the masticator space and infratemporal fossa, thereby increasing complete resection of the tumor and resulting in minimal functional and cosmetic deficits.

Evaluation of postoperative changes in vascularized iliac bone grafts used for mandibular reconstruction

Vascularized iliac bone grafts are used for mandibular reconstruction, but the factors affecting graft maintenance are unknown. This study explored the postsurgical changes in vascularized iliac bone grafts in patients who had undergone mandibular reconstruction after segmental resection. The study involved 24 patients (16 men and eight women) with oral tumours or osteoradionecrosis. Thirteen patients required bare bone grafting (BBG) and 11 patients required reconstruction with soft tissue coverage (six with a skin paddle and five with direct closure). The bone graft maintenance rate (with regard to the height of the centre of the graft) was calculated immediately after surgery and at 3, 6, 12, 24, and 36months after surgery. The maintenance rate was significantly lower in the BBG group than in the soft tissue coverage group at 3, 6, 12, 24, and 36months, and in those who were fitted with dentures compared to those who were not at 6, 12, 24, and 36months. Local infection also influenced the maintenance rate, but not significantly so. These findings indicate that the reconstruction technique and denture use can affect the bone graft maintenance rate after mandibular reconstruction with vascularized iliac bone grafts.

Growth curves for intracranial volume in normal Asian children fortify management of craniosynostosis

BACKGROUND

Although the charting of normal intracranial volume (ICV) is fundamental for managing craniosynostosis, Asian norms in this regard are unknown. The purpose of this study was to establish a growth curve for ICVs in a large series of normal Asian children, providing reference values to guide corrective surgery.

METHODS

A total of 124 normal children (male, 63; female, 61) and 41 children diagnosed with craniosynostoses were analyzed. Patients aged 0-8 years presenting to the emergency room and subjected to computed tomography (CT) for head trauma served as the reference cohort. Axial CT head scan data were obtained from radiographic archives at Jichi Medical University. Imaging was done on a Siemens CT scanner (5-mm slice thickness), using a DICOM viewer to measure ICVs.

RESULTS

ICVs were plotted against age, and best-fit logarithmic curves for normal subjects were generated, without and with gender stratification. Male and female growth curves were similar in shape but diverged past the age of 1 year (male > female). ICVs of patients with craniosynostoses were plotted to male and female growth curves by disease subset, revealing the following: sagittal synostosis, near normal (or marginally larger); metopic synostosis, below normal; other non-syndromic synostoses (unilateral, bilateral, and lambdoidal) and Crouzon syndrome, near normal; Apert syndrome, above normal; and Pfeiffer syndrome, variable.

CONCLUSION

ICVs of early childhood were investigated in Asian subjects, creating growth curves that set criteria for timing, planning and goalsetting in surgical correction of craniosynostosis.

Sutureless microvascular anastomosis assisted by an expandable shape-memory alloy stent

Vascular anastomosis is the highlight of cardiovascular, transplant, and reconstructive surgery, which has long been performed by hand using a needle and suture. However, anastomotic thrombosis occurs in approximately 0.5-10% of cases, which can cause serious complications. To improve the surgical outcomes, attempts to develop devices for vascular anastomosis have been made, but they have had limitations in handling, cost, patency rate, and strength at the anastomotic site. Recently, indwelling metal stents have been greatly improved with precise laser metalwork through programming technology. In the present study, we designed a bare metal stent, Microstent, that was constructed by laser machining of a shape-memory alloy, NiTi. An end-to-end microvascular anastomosis was performed in SD rats by placing the Microstent at the anastomotic site and gluing the junction. The operation time for the anastomosis was significantly shortened using Microstent. Thrombus formation, patency rate, and blood vessel strength in the Microstent anastomosis were superior or comparable to hand-sewn anastomosis. The results demonstrated the safety and effectiveness, as well as the operability, of the new method, suggesting its great benefit for surgeons by simplifying the technique for microvascular anastomosis.

[Submental tracheal intubation for a panfacial fracture patient]

Panfacial fractures represent a unique challenge to the surgical and anesthetic team. Often nasal and oral intubations interfere with surgical procedure, while tracheotomies include a number of potential complications as well as the formation of poor scarring in a highly visible area. Tracheal intubation through the floor of the mouth, mentioned as submental tracheal intubation, is a simple quick and effective alternative to oral and nasal tracheal intubation or tracheostomy in the surgical management of selected patients with panfacial fractures. In this case report, with successful submental tracheal intubation, the potential complications associated with a tracheotomy were avoided.

Current reconstructive techniques following head and neck cancer resection using microvascular surgery

Various techniques have been developed to reconstruct head and neck defects following surgery to restore function and cosmetics. Free tissue transfer using microvascular anastomosis has transformed surgical outcomes and the quality of life for head and neck cancer patients because this technique has made it possible for surgeons to perform more aggressive ablative surgery, but there is room for improvement to achieve a satisfactory survival rate. Reconstruction using the free tissue transfer technique is closely related to cardiovascular surgery because the anastomosis techniques used by head and neck surgeons are based on those of cardiovascular surgeons; thus, suggestions from cardiovascular surgeons might lead to further development of this field. The aim of this article is to present the recent general concepts of reconstruction procedures and our experiences of reconstructive surgeries of the oral cavity, mandible, maxilla, oropharynx and hypopharynx to help cardiovascular surgeons understand the reconstructions and share knowledge among themselves and with neck surgeons to develop future directions in head and neck reconstruction.

Clinical evaluation and morbidity of 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984–2003

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.

Esophagectomy and gastric pull-up in patients with previous free jejunal transfer

Several options exist for reconstruction after total esophagectomy in patients with esophageal carcinoma. However, the options for a major resection after previous head and neck surgery in these patients are extremely limited. The procedure performed in 2 patients requiring esophagectomy after resection for previous head and neck malignancies is described. Both patients underwent previous chemoradiation therapy and free jejunal transfer for hypopharyngeal squamous cell carcinoma. Esophagectomy and reconstruction with a cervical gastrojejunal anastomosis combined with deltopectoral flaps were performed after the diagnosis of esophageal disease. Soft tissue defects were closed with a modified deltopectoral flap using de-epithelization. The deltopectoral flap is effective not only for cutaneous resurfacing, but also to promote delayed wound healing after radiation therapy. This report demonstrates a useful multidisciplinary approach for resection and reconstruction in patients after a previous free jejunal transfer.

Case of subcutaneous sparganosis: Use of imaging in definitive preoperative diagnosis

Herein, we report a rare case of subcutaneous sparganosis in a 60-year-old Japanese woman. She had a 2 cm x 2 cm elastic-hard, subcutaneous nodule, which was the larva of a tapeworm, and a surrounding granuloma in her internal thigh. It was thought that she became infected by drinking water contaminated with the worm. She was definitively diagnosed by enzyme-linked immunosorbent assay (ELISA). After excision of the lesion, the titer of ELISA showed clear decline; therefore, we could conclude that she had been completely freed from sparganosis. The magnetic resonance imaging (MRI) and ultrasound sonography of her subcutaneous nodule demonstrated the characteristic signs: a band-like structure in the MRI and a coiled linear hypoechoic body in a clear, oval mass in the ultrasound sonography.

Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer

BACKGROUND

Few authors have reported the subsequent treatment for patients in whom free tissue transfers in the head and neck have failed as a result of vascular thrombosis.

METHODS

Between 1993 and May of 2005, 502 free flaps were transferred after head and neck cancer ablation in the authors' hospital, 19 of which resulted in total necrosis caused by vascular thrombosis. The authors categorized these 19 cases into four groups and analyzed the salvage treatment.

RESULTS

For failed free jejunal transfer, early initiation of oral intake was obtained when another free jejunum was transferred. For failed free soft-tissue transfer for intraoral defects, reconstruction with common free (first choice) or pedicled flaps was used: a voluminous musculocutaneous flap for extensive defects, forearm flap or pedicled pectoralis major flap for intermediate defects, and direct closure for small defects of the oral floor. For failed secondary soft-tissue transfer to improve a certain function, salvage flap transfer was not chosen in the acute setting. For failed secondary maxillary reconstruction, simple reconstruction using the rectus abdominis musculocutaneous flap combined with costal cartilage achieved stable results. The overall success rate of the repeated free flap was 89 percent (eight of nine patients).

CONCLUSIONS

When a free flap is judged unsalvageable, surgeons should determine subsequent treatments, considering the success rate as one of the most important factors. The authors believe that simple reconstruction using a common free flap is the first choice in most cases. When regional or general conditions do not permit further free flap transfer or when defects are comparatively small, reconstruction with a pedicled flap or direct closure of the defect may be considered.

Reconstruction with Rectus Abdominis Myocutaneous Flap for Total Glossectomy with Laryngectomy

From October 1999 to July 2005, defects after total glossectomy with laryngectomy (TGL) for cancer of the tongue or middle pharynx were reconstructed with rectus abdominis myocutaneous (RAMC) flaps in nine patients. The skin flaps were designed larger in width than the original defect to create a funnel-shaped oropharynx and prevent stricture. Six patients had uneventful postoperative courses and began to eat perorally 8 to 15 days postoperatively. One patient suffered flap necrosis due to arterial thrombosis and two patients had leakage. Eventually, eight patients could eat soft foods or gruel, except one patient who had ingested food through a gastrostomy preoperatively. When TGL was performed without mandibulectomy, the blood supply for the remnant mucosa of the backside of the mandible is generally not good, for which the reconstruction with the overlapping deepithelialized flap and muscle is useful for prevention of the fistula formation. We considered that the RAMC flap is a good option for reconstruction after TGL.

Immediate maxillary reconstruction after malignant tumor extirpation

AIMS

Immediate maxillary reconstruction after malignant tumor extirpation differs from other types of maxillary reconstruction. Our reconstruction algorithm is described in this article.

METHODS

One hundred ninety-four patients who had undergone maxillectomy for malignant tumors were reviewed, and maxillectomy defects were classified with the method of Cordeiro and Santamaria.

RESULTS

Mean total blood loss was 848 ml, and 71 patients died within 2 years after surgery. For type IIIa defects of the orbital floor, titanium mesh or vascularized bone or cartilage was used for reconstruction, but the rate of postoperative complications did not differ between titanium and autografts. Therefore, to reconstruct orbital floor defects we have recently used only titanium mesh. For type I or II defects, we use autografts for only selected cases.

CONCLUSIONS

We strive to perform less-invasive reconstructive surgery after resection for maxillary malignancy.

Free jejunal transfer for patients with a history of esophagectomy and gastric pull-up

Some patients who undergo pharyngolaryngoesophagectomy with free jejunal transfer reconstruction have a history of esophagectomy and gastric pull-up. We retrospectively reviewed a series of 12 patients to examine the characteristic problems in free jejunal transfer for patients with a history of esophagectomy and gastric pull-up. There was no postoperative thrombosis. No anastomotic leakage or fistula was found. Five of 12 patients presented postoperatively with dysphagia. Two of the 5 patients showed stricture at the distal anastomosis. Three of the 5 patients showed no stricture. However, their reconstructed tracts were tortuous around the distal anastomosis, which could be a cause of dysphagia. Even in patients with a history of esophagectomy and gastric pull-up, free jejunal transfer can be performed safely, although the functional outcome of swallowing is not always satisfactory.

A new flap design for reconstruction of full-thickness defects of the lower lip: The extended upper lip island (EULI) flap

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.

Aesthetic Upper Lip Reconstruction With Vermilion Submucosal-Pedicle Cross-Lip Flap

The localized cutaneous amyloidosis occurring on the upper lip of a 48-year-old man was surgically treated and aesthetically reconstructed with vermilion submucosal pedicle partial-thickness cross-lip flap. The reconstruction of the upper lip following the tumor resection or trauma with Abbe flap or its modified methods may not be always satisfactory because it leaves parallel scars extending to the free vermilion margin and trapdoor deformity. We considered that the replacement of free margin of the upper vermilion with that of the lower vermilion might be responsible for it. When significant vermilion is lost, some surgeons may discard its free margin additionally or convert this defect to a through-and-through defect for easier repair. We believe that surgeon should preserve a continuity of the free margin of upper-lip if possible. Our modified Abbe flap can be applied for a various defects of the upper lip so far as the free margin of the vermilion can be preserved.

Volumetric Changes in the Transferred Flap after Anterior Craniofacial Reconstruction

The goal of craniofacial reconstruction is not only life-saving but also facial aesthetics. From this viewpoint the authors evaluated the facial symmetry of patients after craniofacial reconstruction. The subjects were seven patients reconstructed after craniofacial resections. Their CT or MR images were evaluated just after surgery, 1 month after surgery, and 6 months after surgery. Based on these images, the proportion of simple area (PSA) and the proportion of overlapped area (POA) were calculated. The PSA is the proportion of the reconstructed quarter to the contralateral one, and the POA is the proportion of the overlapped area in the reconstructed quarter to the normal one. These values were assessed in two groups: five patients without and two with split calvarial bone grafts. Results demonstrated that the volumetric change of the reconstructed face with the bone graft was relatively stable.

Ectopic hamartomatous thymoma growing in the sternocleidomastoid muscle masquerading as sarcoma

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.

Standardization of Free Jejunum Transfer After Total Pharyngolaryngoesophagectomy

OBJECTIVE

Our latest free jejunum transfer procedure was reviewed and compared with previous procedures to standardize the operation.

METHODS

This was a retrospective study of 269 patients who had undergone total pharyngolaryngoesophagectomy and free jejunum transfer from 1992 through 2004. The patients were divided into two groups: a late group, in which surgery was performed with our latest standard procedure from 2000 through 2004, and an early group, in which various procedures had been used from 1992 through 1999. Surgical times, postoperative progress, and complications were evaluated.

RESULTS

The mean surgical time was shortened from 3 hours 25 minutes in the early group to 3 hours 9 minutes in the late group, and ischemic time was shortened from 2 hours 44 minutes to 2 hours 20 minutes. For recipient vessels, branches of the external carotid artery and the internal jugular vein were more often used in the late group. Length of hospitalization decreased from 31.7 days in the early group to 24.4 days in the late group, although the start of drinking was similar (15.4 days versus 12.1 days). The rates of complications were significantly reduced in the late group, particularly those associated with the enteric anastomosis such as minor leakage (18.2-5.2%) and stenosis (17.6-3.0%).

CONCLUSION

Our latest method of free jejunum transfer reconstruction has become reliable and expeditious through simple and stable minor revisions of procedures.

Subcranial facial bipartition osteotomy with glabellar reverse V-shaped and temporal approaches instead of the bicoronal approach

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.

Availability of End-to-Side Arterial Anastomosis to the External Carotid Artery Using Short-Thread Double-Needle Microsuture in Free-Flap Transfer for Head and Neck Reconstruction

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.

Hepatic artery reconstruction with double-needle microsuture in living-donor liver transplantation

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.

A Revised Method for Pharyngoesophageal Reconstruction Using Free Jejunal Transfer

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.

A patient with congenital defect of nasal cartilaginous septal and vomeral bone reconstructed with costal cartilaginous graft

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.

Cephalometric long-term follow-up of nasal augmentation using iliac bone graft

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.