- Email: [email protected]
Refinement of straight line repair of unilateral complete cleft lip: Bow-shaped excision method
Correspondence and communications
Mean platelet volume: A critical factor relative to thrombosis in microsurgery
With technical and patient-selection advances, microvascular free-flap techniques have improved over the past two decades. Despite greater experience, improved technology, and development of anastomotic devices, some components of free-flap failure might be attributable to undiagnosed patient factors, among which thrombogenesis in anastomotic blood vessels is one of the primary contributing events. Central to this process is platelet activation and subsequent platelet-endothelial adhesion, platelet-platelet aggregation, activation of the coagulation cascade and the formation of a platelet-fibrin plug.1 It is traditionally recognised that thrombogenesis correlated with the total platelet count, that is, an elevated number of platelets leads to a hypercoagulable state. Thus, most surgeons recognise the total platelet count as a critical index in the perioperative period of free-flap surgery with microvascular anastomosis. Similar to total platelet count, platelet volume is also a marker of platelet function and activation, which is readily measured as the mean platelet volume (MPV) by clinical haematology analysers that use sodium citrate as the anticoagulant.2 Although MPV has been included for decades in routine complete blood-counting measurements, it has not been routinely involved as a clinical monitoring index in patients undergoing free-flap surgery. Established as a technique nearly 30 years ago, MPV quantification has only recently been fully appreciated as a biomarker of cardiovascular (CV) disease,3 and there are strong links between an elevated MPV and increased coronary artery disease (CAD) risk. Increasing evidence demonstrates that MPV is likely an indicator of platelet activation and elevated in acute coronary syndromes.4,5 Potential reasons for this finding might be that MPV correlates with platelet function, as well as the fact that larger platelets have greater mass and are both metabolically and enzymatically more active than smaller platelets. Hence, increased MPV likely leads to a hypercoagulable state, which is an important risk factor for CAD. The abovementioned data relevant to MPV from the field of cardiology could bring novel inspirations to microvascular surgery: MPV might be a more important clinical index reflecting blood coagulability than total platelet count, which is traditionally emphasised in patients scheduled for free-flap surgery. However, limited data clarify the relationship between thrombogenesis and MPV after microvascular anastomotic surgeries. Moreover, it is still unknown whether the patients with elevated MPV should receive prophylactic applications of anticoagulant during the perioperative period rather than the postoperative period. To date there are no unified standards for the indication of anticoagulant therapy among patients who need free-flap surgery. Furthermore, different hospitals e even various surgeons in the same department e may have divergent opinions. On the basis of these abovementioned studies, we hypothesise that MPV and its dynamic variation during the operative period may be a more efficient
1749 criterion compared to total platelet count when attempting to characterise blood coagulability. It is necessary to monitor the MPV value in each patient scheduled to undergo free-flap surgery with vascular anastomosis. It is also necessary to include ‘high MPV’ as an indication for anticoagulant therapy not only before but also after microvascular operations. Further clinical research efforts are needed to test this hypothesis.
Conflicts of interest The authors declare that they have no competing interests.
References 1. Davison SP, Kessler CM, Al-Attar A. Microvascular free flap failure caused by unrecognized hypercoagulability. Plast Reconstr Surg 2009;124:496e9. 2. Jagroop IA, Tsiara S, Mikhailidis DP. Mean platelet volume as an indicator of platelet activation: methodological issues. Platelets 2003;14:335e6. 3. Boos CJ, Lip GY. Assessment of mean platelet volume in coronary artery disease e what does it mean? Thromb Res 2007;120: 11e3. 4. Lippi G, Filippozzi L, Salvagno GL, et al. Increased mean platelet volume in patients with acute coronary syndromes. Arch Pathol Lab Med 2009;133:1441e3. 5. Varol E, Akcay S, Ozaydin M, et al. Mean platelet volume in patients with coronary artery ectasia. Blood Coagul Fibrinolysis 2009;20:321e4.
Kai Huang Qiao-feng Guo Xiao-wen Zhang Chun Zhang Li-feng Shen Department of Orthopaedics, Tongde Hospital of Zhejiang Province, Health Bureau of Zhejiang Province, 234 GuCui Road, Hangzhou, Zhejiang 310012, PR China E-mail addresses: [email protected], [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.03.016
Refinement of straight line repair of unilateral complete cleft lip: Bow-shaped excision method Dear Sir, Previously, we reported a small semi-circular flap method above the white skin roll instead of the triangular flap.1 However, the result with the semi-circular flap was sometimes conspicuous, because the closure line was not precisely along the philtral ridge. Therefore, we present
1750
Correspondence and communications
Figure 1
a further modification: the bow-shaped excision method. In this, crescent-shaped skin defects are marked above the white skin roll, and closed to each other. With this manipulation, lip elongation and straight closure line can be obtained. In the white skin roll of both sides, 1.5 mm straight line parts perpendicular to the vermillion border are marked to reconstruct the continuity of white skin roll (Figure 1a). On the non-cleft side, 1.5 1.0 mm wavy line is marked above this part. On the cleft side, first incision is marked straight. Flap X is designed on the white lip tissue between the alar base and the alveolus.2 This flap is inserted into the tail of the medial crural footplate to create the nostril floor. Flaps A and B are used for the lining of nostril floor. After muscle closure, the cleft side bow-shaped excision is performed (Figure 1b). The size of excision must equal that on the opposite side for the closure line to be straight.
After the lip closure, a modified reverse-U incision is applied for nasal repair.3,4 Pre- and post-operatively, palatal plates are applied for the correction of alveolar position. Cases are shown at 2 years (Figure 2a) and at 22 months after surgery (Figure 2b). From December of 2007 to November of 2008, this method was applied by one surgeon to 18 cases of unilateral complete cleft lip and 17 cases of unilateral incomplete cleft lip. Post-operative scars of 15 complete cases were evaluated by three surgeons with photos. 10 cases were excellent and had inconspicuous scars along the philtral ridges. Three cases were evaluated as good because the scars were not along the philtral ridges. Two cases were evaluated as poor because of widened scars. Rotation-Advancement method is most widely used for the cleft lip repair. However, the transverse scar is sometimes conspicuous. From the 1980s, we applied
Figure 2
Correspondence and communications modifications to avoid transverse scars. The resulting method is very simple because it requires no manipulation of flaps. Tight stitches are essential for prevention of scar widening, however, if that should occur then later correction is facilitated by the straight line of closure. Further follow-up is necessary, however the initial scar contracture is minimal in comparison with other conventional methods after more than one year follow-up.
Conflict of interest None.
Funding None.
References 1. Nakajima T, Tamada I, Miyamoto J, et al. Straight line repair of unilateral cleft lip: new operative method based on 25 years experience. J Plast Reconstr Aesthet Surg 2008;61: 870e8. 2. Nakajima T, Yoshimura Y. Early repair of unilateral cleft lip employing a small triangular flap method and primary nasal correction. Br J Plast Surg 1993;46:616e8. 3. Nakajima T, Yoshimura Y, Kami T. Refinement of the “reverse-U” incision for the repair of cleft lip nose deformity. Br J Plast Surg 1986;39:345e51. 4. Miyamoto J, Nakajima T. Anthropometric evaluation of complete unilateral cleft lip nose with cone beam CT in early childhood. J Plast Reconstr Aesthet Surg 2010;63:9e14.
Tatsuo Nakajima Junpei Miyamoto Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan E-mail address: [email protected] Ikkei Tamada Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Children’s Hospital, Japan ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.03.002
Mandibular reconstruction with vascularised fibular osteocutaneous flaps using prefabricated stereolithographic mandibular model Mandibular reconstruction using vascularised osteocutaneous flaps is necessary to improve functional outcomes, such as jaw movement and mastication, and aesthetics
1751 after the wide resection of the mandible. For successful mandibular reconstruction, it is important for the continuity lost in the mandibular bone due to mandibulectomy to be precisely restored, and for donor bone shaping to complement the mandibular defect. The vascularised fibula first reported by Hidalgo1 has been a preferred donor site because of its length and versatility. We have also mainly used vascularised fibular osteocutaneous flaps for mandibular reconstruction. When fibular osteotomy is required for a mandibular defect, mandibular reproduction at the time of reconstruction is difficult, the operation time is long, and the manipulation requires high-level proficiency. In an attempt to overcome these problems, we have performed surgical planning (model-based surgery) using a prefabricated stereolithographic mandibular model (SLMM) preoperatively in 23 patients. This model clarifies the form and state of diseases, shortens the operation time, and reduces operative blood loss.2 We present a procedure for mandibular reconstruction using the SLMM and a device during the preoperation and operation. In the preoperative state, a prefabricated stereolithographic mandibular model (SLMM) constructed preoperatively by 3D-CT was employed in order to accurately and promptly perform mandibulectomy and fibular osteotomies. Replicas of the mandible and fibula (acrylic plastic) were also made preoperatively for model-based surgery (Figure 1a). Surgical guides were also prefabricated to decide on the line of mandibular resection (Figure 1b). A precisely simulated postreconstructive mandibular model with fibular replacement was also made employing modelbased surgery. (Figure 1c), and the number and lengths of harvested fibula could be planned. During the operation, in order to avoid malocclusion and displacement of the condylar head after mandibulectomy, a 3-dimensional adjustable fixation device was applied to fix the parts of the mandible to be preserved, and, then, the surgical guide was matched to the mandibular bone by setting preoperatively (Figure 2a). Segmental mandibulectomy was performed according to the planned line of resection with the surgical guide. Segmental mandibulectomy and fibular harvesting were performed simultaneously by maxillofacial and orthopaedic microsurgical teams. After mandibulectomy, the harvested fibula was shaped with several osteotomies to fit the mandibular defect using a prefabricated reconstruction model (Figure 2b), and fixed to the remaining mandibular bone with a titanium mini plate (Figure 2c). Next, the graft was anastomosed to the recipient site vessels after fixing the grafted bone. In this way, mandibular reconstruction was performed with this procedure using the SLMM in our clinic. The utility of the SLMM has been reported.3,4 Using it, we can perform model-based surgery to simulate the resection range and fibular osteotomies, and facilitate accurate and prompt mandibulectomy and fibular osteotomy during the operation. In addition, the prefabricated reconstructed model is helpful for recreating the symmetry of the mandible postoperatively. It is important to maintain the symmetry of the mandible on reconstruction. Therefore, in order to avoid displacement of the remaining mandibular bone after mandibulectomy, although, we performed
Mean platelet volume: A critical factor relative to thrombosis in microsurgery
With technical and patient-selection advances, microvascular free-flap techniques have improved over the past two decades. Despite greater experience, improved technology, and development of anastomotic devices, some components of free-flap failure might be attributable to undiagnosed patient factors, among which thrombogenesis in anastomotic blood vessels is one of the primary contributing events. Central to this process is platelet activation and subsequent platelet-endothelial adhesion, platelet-platelet aggregation, activation of the coagulation cascade and the formation of a platelet-fibrin plug.1 It is traditionally recognised that thrombogenesis correlated with the total platelet count, that is, an elevated number of platelets leads to a hypercoagulable state. Thus, most surgeons recognise the total platelet count as a critical index in the perioperative period of free-flap surgery with microvascular anastomosis. Similar to total platelet count, platelet volume is also a marker of platelet function and activation, which is readily measured as the mean platelet volume (MPV) by clinical haematology analysers that use sodium citrate as the anticoagulant.2 Although MPV has been included for decades in routine complete blood-counting measurements, it has not been routinely involved as a clinical monitoring index in patients undergoing free-flap surgery. Established as a technique nearly 30 years ago, MPV quantification has only recently been fully appreciated as a biomarker of cardiovascular (CV) disease,3 and there are strong links between an elevated MPV and increased coronary artery disease (CAD) risk. Increasing evidence demonstrates that MPV is likely an indicator of platelet activation and elevated in acute coronary syndromes.4,5 Potential reasons for this finding might be that MPV correlates with platelet function, as well as the fact that larger platelets have greater mass and are both metabolically and enzymatically more active than smaller platelets. Hence, increased MPV likely leads to a hypercoagulable state, which is an important risk factor for CAD. The abovementioned data relevant to MPV from the field of cardiology could bring novel inspirations to microvascular surgery: MPV might be a more important clinical index reflecting blood coagulability than total platelet count, which is traditionally emphasised in patients scheduled for free-flap surgery. However, limited data clarify the relationship between thrombogenesis and MPV after microvascular anastomotic surgeries. Moreover, it is still unknown whether the patients with elevated MPV should receive prophylactic applications of anticoagulant during the perioperative period rather than the postoperative period. To date there are no unified standards for the indication of anticoagulant therapy among patients who need free-flap surgery. Furthermore, different hospitals e even various surgeons in the same department e may have divergent opinions. On the basis of these abovementioned studies, we hypothesise that MPV and its dynamic variation during the operative period may be a more efficient
1749 criterion compared to total platelet count when attempting to characterise blood coagulability. It is necessary to monitor the MPV value in each patient scheduled to undergo free-flap surgery with vascular anastomosis. It is also necessary to include ‘high MPV’ as an indication for anticoagulant therapy not only before but also after microvascular operations. Further clinical research efforts are needed to test this hypothesis.
Conflicts of interest The authors declare that they have no competing interests.
References 1. Davison SP, Kessler CM, Al-Attar A. Microvascular free flap failure caused by unrecognized hypercoagulability. Plast Reconstr Surg 2009;124:496e9. 2. Jagroop IA, Tsiara S, Mikhailidis DP. Mean platelet volume as an indicator of platelet activation: methodological issues. Platelets 2003;14:335e6. 3. Boos CJ, Lip GY. Assessment of mean platelet volume in coronary artery disease e what does it mean? Thromb Res 2007;120: 11e3. 4. Lippi G, Filippozzi L, Salvagno GL, et al. Increased mean platelet volume in patients with acute coronary syndromes. Arch Pathol Lab Med 2009;133:1441e3. 5. Varol E, Akcay S, Ozaydin M, et al. Mean platelet volume in patients with coronary artery ectasia. Blood Coagul Fibrinolysis 2009;20:321e4.
Kai Huang Qiao-feng Guo Xiao-wen Zhang Chun Zhang Li-feng Shen Department of Orthopaedics, Tongde Hospital of Zhejiang Province, Health Bureau of Zhejiang Province, 234 GuCui Road, Hangzhou, Zhejiang 310012, PR China E-mail addresses: [email protected], [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.03.016
Refinement of straight line repair of unilateral complete cleft lip: Bow-shaped excision method Dear Sir, Previously, we reported a small semi-circular flap method above the white skin roll instead of the triangular flap.1 However, the result with the semi-circular flap was sometimes conspicuous, because the closure line was not precisely along the philtral ridge. Therefore, we present
1750
Correspondence and communications
Figure 1
a further modification: the bow-shaped excision method. In this, crescent-shaped skin defects are marked above the white skin roll, and closed to each other. With this manipulation, lip elongation and straight closure line can be obtained. In the white skin roll of both sides, 1.5 mm straight line parts perpendicular to the vermillion border are marked to reconstruct the continuity of white skin roll (Figure 1a). On the non-cleft side, 1.5 1.0 mm wavy line is marked above this part. On the cleft side, first incision is marked straight. Flap X is designed on the white lip tissue between the alar base and the alveolus.2 This flap is inserted into the tail of the medial crural footplate to create the nostril floor. Flaps A and B are used for the lining of nostril floor. After muscle closure, the cleft side bow-shaped excision is performed (Figure 1b). The size of excision must equal that on the opposite side for the closure line to be straight.
After the lip closure, a modified reverse-U incision is applied for nasal repair.3,4 Pre- and post-operatively, palatal plates are applied for the correction of alveolar position. Cases are shown at 2 years (Figure 2a) and at 22 months after surgery (Figure 2b). From December of 2007 to November of 2008, this method was applied by one surgeon to 18 cases of unilateral complete cleft lip and 17 cases of unilateral incomplete cleft lip. Post-operative scars of 15 complete cases were evaluated by three surgeons with photos. 10 cases were excellent and had inconspicuous scars along the philtral ridges. Three cases were evaluated as good because the scars were not along the philtral ridges. Two cases were evaluated as poor because of widened scars. Rotation-Advancement method is most widely used for the cleft lip repair. However, the transverse scar is sometimes conspicuous. From the 1980s, we applied
Figure 2
Correspondence and communications modifications to avoid transverse scars. The resulting method is very simple because it requires no manipulation of flaps. Tight stitches are essential for prevention of scar widening, however, if that should occur then later correction is facilitated by the straight line of closure. Further follow-up is necessary, however the initial scar contracture is minimal in comparison with other conventional methods after more than one year follow-up.
Conflict of interest None.
Funding None.
References 1. Nakajima T, Tamada I, Miyamoto J, et al. Straight line repair of unilateral cleft lip: new operative method based on 25 years experience. J Plast Reconstr Aesthet Surg 2008;61: 870e8. 2. Nakajima T, Yoshimura Y. Early repair of unilateral cleft lip employing a small triangular flap method and primary nasal correction. Br J Plast Surg 1993;46:616e8. 3. Nakajima T, Yoshimura Y, Kami T. Refinement of the “reverse-U” incision for the repair of cleft lip nose deformity. Br J Plast Surg 1986;39:345e51. 4. Miyamoto J, Nakajima T. Anthropometric evaluation of complete unilateral cleft lip nose with cone beam CT in early childhood. J Plast Reconstr Aesthet Surg 2010;63:9e14.
Tatsuo Nakajima Junpei Miyamoto Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan E-mail address: [email protected] Ikkei Tamada Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Children’s Hospital, Japan ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.03.002
Mandibular reconstruction with vascularised fibular osteocutaneous flaps using prefabricated stereolithographic mandibular model Mandibular reconstruction using vascularised osteocutaneous flaps is necessary to improve functional outcomes, such as jaw movement and mastication, and aesthetics
1751 after the wide resection of the mandible. For successful mandibular reconstruction, it is important for the continuity lost in the mandibular bone due to mandibulectomy to be precisely restored, and for donor bone shaping to complement the mandibular defect. The vascularised fibula first reported by Hidalgo1 has been a preferred donor site because of its length and versatility. We have also mainly used vascularised fibular osteocutaneous flaps for mandibular reconstruction. When fibular osteotomy is required for a mandibular defect, mandibular reproduction at the time of reconstruction is difficult, the operation time is long, and the manipulation requires high-level proficiency. In an attempt to overcome these problems, we have performed surgical planning (model-based surgery) using a prefabricated stereolithographic mandibular model (SLMM) preoperatively in 23 patients. This model clarifies the form and state of diseases, shortens the operation time, and reduces operative blood loss.2 We present a procedure for mandibular reconstruction using the SLMM and a device during the preoperation and operation. In the preoperative state, a prefabricated stereolithographic mandibular model (SLMM) constructed preoperatively by 3D-CT was employed in order to accurately and promptly perform mandibulectomy and fibular osteotomies. Replicas of the mandible and fibula (acrylic plastic) were also made preoperatively for model-based surgery (Figure 1a). Surgical guides were also prefabricated to decide on the line of mandibular resection (Figure 1b). A precisely simulated postreconstructive mandibular model with fibular replacement was also made employing modelbased surgery. (Figure 1c), and the number and lengths of harvested fibula could be planned. During the operation, in order to avoid malocclusion and displacement of the condylar head after mandibulectomy, a 3-dimensional adjustable fixation device was applied to fix the parts of the mandible to be preserved, and, then, the surgical guide was matched to the mandibular bone by setting preoperatively (Figure 2a). Segmental mandibulectomy was performed according to the planned line of resection with the surgical guide. Segmental mandibulectomy and fibular harvesting were performed simultaneously by maxillofacial and orthopaedic microsurgical teams. After mandibulectomy, the harvested fibula was shaped with several osteotomies to fit the mandibular defect using a prefabricated reconstruction model (Figure 2b), and fixed to the remaining mandibular bone with a titanium mini plate (Figure 2c). Next, the graft was anastomosed to the recipient site vessels after fixing the grafted bone. In this way, mandibular reconstruction was performed with this procedure using the SLMM in our clinic. The utility of the SLMM has been reported.3,4 Using it, we can perform model-based surgery to simulate the resection range and fibular osteotomies, and facilitate accurate and prompt mandibulectomy and fibular osteotomy during the operation. In addition, the prefabricated reconstructed model is helpful for recreating the symmetry of the mandible postoperatively. It is important to maintain the symmetry of the mandible on reconstruction. Therefore, in order to avoid displacement of the remaining mandibular bone after mandibulectomy, although, we performed