Breast reconstruction is a cosmetically critical procedure for women and it must be undertaken to balance the shape, size, and position of the breast with the other breast. Since the first introduction of the free abdominoplasty flap in 1979, the transverse rectus abdominis musculocutaneous (TRAM) flap technique has been a widely accepted method of breast reconstruction after mastectomy. In breast reconstruction with a free flap, the selection of suitable recipient vessels is the critical decision to be made by the surgeon. The most common recipient vessel for free flap breast reconstruction is the axillary system. However, when used as a recipient, the axillary system may limit flap movement and flexibility in breast shaping. The use of the internal mammary vessels as a recipient site attains ideal breast symmetry. However, the technique requires partial rib resection and eliminates the opportunity for a potential coronary artery bypass graft, which requires the internal mammary artery. Based on these considerations, the selection of suitable recipient vessels constitutes an important requirement for successful free tissue transfer. The authors have performed breast reconstruction with the TRAM flap anastomosed to the internal mammary perforator vessel and conclude that these perforators could be useful as recipient vessels, especially in the case of immediate breast reconstruction with the free TRAM flap.

The purpose of the treatment of mandibular fractures is to restore proper dental occlusion and stable temporomandibular joint movement, as well as the reduction of the displaced fracture. Consideration must be given to the selection of the most appropriate surgical and rehabilitation methods in such patients. Typical surgical methods for the treatment of mandibular fractures include the arch bar method or plating at the location of the fracture combined with fixing the mandible to the maxilla using the arch bar method. However arch bars and circumdental wires, which require teeth for fixation, damage teeth and periodontal tissue, and tend to be uncomfortable for patients during the fixation period. Moreover, daily maintenance of oral hygiene is difficult for patients with an arch bar. Surgeons are also exposed to the risk of blood-transmitted diseases through skin punctures by wires when affixing these devices. For these reasons, we chose to study the potential of the MMFS method, which is thought to lessen all of the following problems: tissue damage, operating time, patient discomfort, and possible exposure to percutaneous infectious disease due to puncture of gloves and skin by the wires. We demonstrated the utility of the MMFS method in the present study.T he restoration of proper dental occlusion is important in the treatment of a mandibular fracture. The arch bar method is generally used to treat such fractures at present. However, both teeth and periodontal tissue are damaged by penetration of and ligation with the more than 10 wires required by this procedure. The operating team is also placed at considerable risk due to the potential for the ends of the wires to puncture gloves and/or fingers. We analyzed the potential for use of a treatment in which screws are inserted into the maxilla and mandible, and are then ligated with wires to fix both the maxilla and mandible in place and avoid the aforementi1d problems. Fifteen patients with mandibular fractures were treated with maxillomandibular fixation screws (the MMFS method) at the Izunagaoka Hospital of Juntendo University from April, 2000 to December, 2001. Proper dental occlusion was achieved in all patients treated using the MMFS method, and normal temporomandibular joint function was restored after rehabilitation. However, paresthesia occurred around the symphysis menti of the mandible in 33.3% of the patients. The MMFS method proved to be a reliable surgical method for the treatment of mandibular fractures. It not only restores proper dental occlusion and natural temporomandibular joint function, but it also offers the advantages of increased ease of oral and dental hygienic maintenance as well as decreased dental damage, operating time and risk of puncturing gloves and skin. PATIENTS AND METHODSA retrospective chart review was conducted on 15 patients with mandibular fractures treated by the MMFS method at the Izunagaoka Hospital of Juntendo University from April, 2000 to December, 2001. The mean age of the 15 patients was 23.3 years. T...

Background: The currently employed technique of distraction osteogenesis (DO) for the surgical treatment of craniosynostosis (CS) is commonly performed due to advantages such as shorter operation time, less bleeding and thus less need for transfusions and a lower risk of infections. Several surgical techniques for the various types of CS have been reported, but a uniform surgical method is as yet unavailable. Methods: We compared 23 patients who underwent rotating DO (RDO) with 15 patients who received conventional craniotomy and remodeling (CR). RDO consisted of suturectomy of the pathologic suture and resection of the bone flap to allow wide suture separation for distraction and open-door rotation. Results: The mean operation duration in the RDO group was 255.9 ± 97.8 min, which was significantly shorter than the 414.0 ± 106.9 min for the CR group (p = 0.0001). Perioperative complications in the RDO group consisted of 2 cases of distractor breakage and 2 cases of minimal pus discharge, while in the CR patients there was 1 case of postoperative epidural hematoma and 1 case of spontaneous bone fracture. Conclusion: We suggest that RDO may be a valid and efficient method for treating children with CS by DO by expanding the intracranial volume and correcting abnormal skull contour shapes.

Background: Secondary craniosynostosis rarely develops within several months in infants or children after shunt operations in early infancy. However, conventional operations (CO) such as fronto-orbital advancement and total skull reshaping have not been efficient enough to expand the intracranial volume in children with secondary craniosynostosis. Recently, distraction osteogenesis (DO) was reported to be effective in treating most craniosynostosis cases. Methods: We compared 9 children treated with DO and 3 children treated with CO who developed secondary craniosynostosis after shunt operation in early infancy. We measured the preoperative and follow-up head sizes with regard to head circumference, cephalometric intracranial volume, and intracranial volume estimated from the 3-dimensional computed tomogram. Results: The mean intracranial volumes expanded by 10.5% in the DO group 1 month after surgery and by 13.1% in the CO group on the immediate postoperative day. Further expansion was observed 6 months postoperatively, i.e. 10.3 and 4.7% in the DO and CO groups, respectively. Operation time and anesthesia time were significantly shorter in DO compared to CO patients, and the volumes of the blood transfusions were also less for DO patients. Conclusion: We suggest that DO is probably more efficient and safer than CO in expanding the intracranial volume in children with secondary craniosynostosis.

Cranial distraction osteogenesis has been applied as a mode of therapy to patients with various types of craniosynostosis. Several minor complications during distraction have been reported in the previous literature, including infection, device exposure, and dislocation and distortion of the device. To our knowledge, this is the first report of 2 cases of spontaneous device breakage during cranial distraction osteogenesis. Two infant patients were diagnosed with shunt-induced microcephalies. The ages of the 2 patients were 8 and 12 months. Their head circumferences were 3 percentiles below that of normal children of the same age. Distraction osteogenesis advancement to the frontal skull and the orbital bar was performed with two distractors. We distracted a total of 7.0 and 14.4 mm at a rate of 0.6–1.5 mm per day before device breakage occurred 7 and 25 days after the distraction activation, respectively. Both patients underwent reoperation to exchange the broken device for further distraction. To prevent further device breakage, we suggest increasing the rate of distraction, placing stronger or more devices, or relieving the scalp retraction pressure probably by extensive dissection of the subcutaneous layers or multiple incisions into the galeal layers.