奥本 隆行

Superior orbital fissure syndrome (SOFS) is a rare complication of craniofacial fracture, caused by damage to cranial nerves Ⅲ, Ⅳ, Ⅴ, and Ⅵ, which typically is associated with ophthalmoplegia, blepharoptosis, pupil dilatation and fixation, and upper eyelid and forehead hypesthesia. However, we here describe a very unusual case of craniofacial fracture with SOFS in the absence of pupil symptoms, involving a patient who was injured when he fell while riding his bicycle. Upon medical examination, we observed mild blepharoptosis and ophthalmoplegia of the right eye without pupillary symptoms. Computed tomography (CT) revealed basal skull and zygomatic fractures. After the patient had been treated conservatively for his skull base fracture, facial bone reduction was performed at our hospital. Because ophthalmoplegia and blepharoptosis remained after the surgery, we checked the preoperative CT images again and discovered stenosis of the superior orbital fissure. Postoperative CT revealed a widening of the superior orbital fissure after the facial bone reduction, and therefore, the patient was given steroid treatment without additional surgery. At 6 months postoperatively, the cranial nerves had completely recovered. Our finding emphasizes that, in contrast to common theory, trauma-induced SOFS can result in pupil-sparing oculomotor nerve palsy.

OBJECTIVES: Until 1999 at our hospital, primary cleft lip repair was performed by the straight-line method and external rhinoplasty was performed by the inverted trapezoidal suture method with bilateral reverse-U incisions for children with cleft lip and palate. Subsequently, repeated surgical corrections of the external nasal morphology became necessary during the growth period, often with unsatisfactory results because repeated external rhinoplasty results in a stronger scar contracture. From 2000 to 2004, we performed external rhinoplasty after patients had stopped growing; however, delaying surgery created a psychological burden for patients. Therefore, since 2005, we have focused on improving alar base ptosis and forming the nostril sill during the primary surgery. This study was performed to subjectively and objectively evaluate whether the current surgical method or the earlier technique produces a better treatment outcome. METHODS: We subjectively and objectively evaluated alar base asymmetry after primary cleft lip repair but before bone grafting for alveolar cleft repair. For the objective evaluation, we measured the angle of alar base ptosis in frontal view photographs taken at the age of 6 or 7 years in patients who underwent repair before 1999 (Group A) and after 2005 (Group B). RESULTS: The median angle was 2.75° in Group A and 1.50° in Group B, demonstrating a significant difference (P=0.04). CONCLUSIONS: The current surgical method, which reflects our focus on improving alar base ptosis and forming the nostril sill, subjectively and objectively improved the external nasal morphology.

OBJECTIVES: Breast reconstruction using synthetic materials has increased rapidly in Japan since July 2013, when national health insurance began covering the procedure. Although synthetic material-based reconstruction of other body parts has not resulted in wounds with complications, this significant advantage is overshadowed by a risk of complications, including infection, following breast reconstruction. We therefore reviewed breast-reconstruction patients who experienced infection after implantation of synthetic materials and the countermeasures we used to address the problem. METHODS: From July 2013 through December 2019, our department performed primary breast reconstructions using tissue expanders (TEs) in 106 patients and secondary breast reconstructions in 39 patients. We retrospectively reviewed these 145 patients in terms of their age, body mass index, timing of the reconstruction, presence/absence of both chemotherapy and radiation therapy before and after surgery, presence/absence of postoperative wound complications, and presence/absence of atopic dermatitis. We then evaluated whether these factors put patients at risk for postoperative TE infection. RESULTS: Among the 145 patients who underwent reconstruction with TE, 3 (2.0%) were diagnosed with a postoperative TE infection. Our review revealed that necrosis of the skin around the surgical wound (P=0.004) and atopic dermatitis (P=0.041) were risk factors for TE infection. CONCLUSIONS: Infection following breast reconstruction with synthetic materials is a serious complication. Thus, patients requiring this surgery deserve optimal perioperative management. For those with known risk factors, a more appropriate surgical approach-e.g., using autologous tissue instead of a synthetic material-could be considered.

Craniofrontonasal syndrome (CFNS) is a very rare genetic disorder, the common physical malformations of which include coronal synostosis, widely spaced eyes, clefting of the nasal tip, and various skeletal anomalies. Mutations of EFNB1, which encodes a member of the ephrin family of transmembrane ligands for Eph receptor tyrosine kinases, is the cause of CFNS. Although familial CFNS cases have been reported, no studies in the literature describe familial cases of CFNS expressing bilateral cleft lip and palate. Here, we describe a Japanese family with three cases of CFNS expressing bilateral cleft lip and palate.

Enophthalmos is caused by an increase of orbital volume after blowout fracture and is one of the most critical complications of such fractures, but is often masked by swelling soon after injury. If surgery is performed after swelling resolves, it becomes more difficult to treat enophthalmos because of atrophy and fibrosis. Accordingly, it is important to estimate the severity of enophthalmos soon after injury. We developed a new criterion for determining whether orbital fractures are indicated for surgery in Asian patients using analysis of orbital volume. We retrospectively calculated the orbital volume of patients treated surgically or conservatively and analyzed the correlation between changes of orbital volume and the severity of enophthalmos. Regression analysis of the correlation between enophthalmos and increased orbital volume (y = 0.8x + 0.2; correlation coefficient: 0.92) showed that enophthalmos of 2.0 mm corresponded to an increase in orbital volume of 2.25 cm3. This result is similar to data reported previously for Caucasian patients - enophthalmos of 2.0 mm is a common surgical indication worldwide. Our results suggest that an increase of orbital volume of >2.25 cm3 could be a new criterion for surgical treatment of blowout fractures in Asians.

<p>Background: Pedicled periosteal flaps are commonly used for tissue defects between the base of the skull and the midfacial area. This study aimed to clarify the 3-dimensional vascular distribution of temporal region flaps. Methods: Ten fresh cadavers were used. Full-thickness cranial flaps were elevated from the cranial bone and each layer was detached separately. Contrast enhancement of the full thickness of the scalp, macroscopic evaluation, and histologic analyses were performed. Radiographs were obtained and image analysis was performed using a 3-dimensional monitor. Results: The mean number of deep vessels extending from the parietal branch of the superficial temporal artery was 68.7, including 14.2 and 54.5 vessels on the proximal and distal sides, respectively. The mean number of deep vessels extending from the frontal branch of the superficial temporal artery was 71.6, including 17.6 and 54.0 vessels on the proximal and distal sides, respectively. There were significantly more perforating branches in the distal area than in the proximal area of both the frontal and parietal branches (P = 0.005). There was no significant difference in the number of perforating branches be