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Takuya Fujimoto, Keisuke Imai, Makoto Takahashi, Takaharu Hatano, Motoki Tamai, Tomoaki Nakano, Hiroaki Sakamoto, and Kenji Ohata


In 1997 the authors presented the case of a 3-year-old girl who underwent complete resection of a huge tumor via a new technique using a dismasking flap. Since that report, 14 patients have undergone surgery using this technique. There have been few reports on long-term follow-up after a craniofacial surgical approach and reconstruction of a huge tissue defect. The authors report details of this procedure based on these cases, including long-term follow-up in the original case.


The dismasking flap is a cranioorbitofacial degloving method that uses a circumpalpebral approach with or without piriform margin incisions and presents a wide surgical field under direct vision. Fourteen patients have undergone surgery using the dismasking flap technique. These patients had multiple craniofacial bone fractures (3 cases) and malignant or premalignant craniofacial tumors (11 cases). Patients ranged in age from 3 to 62 years old. The longest follow-up period was 15 years. The results of these cases are reported regarding changes in the facial bones and soft tissues with growth, the various pathologies involved, and complications.


Complications using this approach were lagophthalmos with ectropion of the lower eyelid, disturbance of the superior orbital nerve, disturbance of the inferior orbital nerve, maxillary hypoplasia, and blepharoptosis. In all affected patients these complications were almost always temporary. In 2 of the 14 cases, a repair operation for lagophthalmos was necessary, while others showed spontaneous improvement approximately 6 months to a year after the procedure. In the case with the longest follow-up duration, the patient's nose is asymmetrical, especially the alar portion, due to hypoplasia of the grafted bone and/or the fixation with titanium miniplates.


This flap is very useful for en bloc resection of huge skull base tumors, multiple craniofacial bone fractures, and as a lateral approach to a deep portion of the middle cranial base. Careful attention is necessary, however, because one may encounter unexpected complications if one does not ensure adequate protection of the perioperative flap. Meticulous postoperative management is also essential.

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Hidetoshi Matsukawa, Hiroyasu Kamiyama, Yu Kinoshita, Norihiro Saito, Yuto Hatano, Takanori Miyazaki, Nakao Ota, Kosumo Noda, Takaharu Shonai, Osamu Takahashi, Sadahisa Tokuda, and Rokuya Tanikawa


It is well known that larger aneurysm size is a risk factor for poor outcome after surgical treatment of unruptured saccular intracranial aneurysms (USIAs). However, the authors have occasionally observed poor outcome in the surgical treatment of small USIAs and hypothesized that size ratio has a negative impact on outcome. The aim of this paper was to investigate the influence of size ratio on outcome in the surgical treatment of USIAs.


Prospectively collected clinical and radiological data of 683 consecutive patients harboring 683 surgically treated USIAs were evaluated. Dome-to-neck ratio was defined as the ratio of the maximum width of the aneurysm to the average neck diameter. The aspect ratio was defined as the ratio of the maximum perpendicular height of the aneurysm to the average neck diameter of the aneurysm. The size ratio was calculated by dividing the maximum aneurysm diameter (height or width, mm) by the average parent artery diameter (mm). Neurological worsening was defined as an increase in modified Rankin Scale score of 1 or more points at 12 months. Clinical and radiological variables were compared between patients with and without neurological worsening.


The median patient age was 64 years (IQR 56–71 years), and 528 (77%) patients were female. The median maximum size, dome-to-neck ratio, aspect ratio, and size ratio were 4.7 mm (IQR 3.6–6.7 mm), 1.2 (IQR 1.0–1.4), 1.0 (IQR 0.76–1.3), and 1.9 (IQR 1.4–2.8), respectively. The size ratio was significantly correlated with maximum size (r = 0.83, p < 0.0001), dome-to-neck ratio (r = 0.69, p < 0.0001), and aspect ratio (r = 0.74, p < 0.0001). Multivariate logistic regression analysis showed that the specific USIA location (paraclinoid segment of the internal carotid artery: OR 6.2, 95% CI 2.6–15, p < 0.0001; and basilar artery: OR 8.4, 95% CI 2.8–25, p < 0.0001), size ratio (OR 1.3, 95% CI 1.1–1.6, p = 0.021), and postoperative ischemic lesion (OR 9.4, 95% CI 4.4–19, p < 0.0001) were associated with neurological worsening (n = 52, 7.6%), and other characteristics showed no significant differences.


The present study showed that size ratio, and not other morphological parameters, was a risk factor for 12-month neurological worsening in surgically treated patients with USIAs. The size ratio should be further studied in a large, prospective observational cohort to predict neurological worsening in the surgical treatment of USIAs.