Techniques in Lower Extremity Reconstruction with Supermicrosurgery

PURPOSE: The concept and development of perforator free flaps have led to significant advances in microsurgery. Ongoing developments in perforator free flap surgery are aimed at reducing complications and improving surgical outcomes. The aim of this study was to evaluate the effectiveness and application of supermicrosurgery in free flap surgery. MATERIALS AND METHODS: A total of 267 patients with soft tissue defects of the lower extremity due to various etiologies from January, 2007 to January, 2013. The patients received either an anterolateral thigh free flap (n=83), a superficial circumflex iliac artery free flap (n=152), an upper medial thigh free flap (n=19), or a superior gluteal artery perforator free flap (n=13). Microanastomosis was performed using a perforator-to-perforator technique, either end-to-end or end-to-side. RESULTS: The mean postoperative follow up period was eight months (range: one to 16 months) and flap loss occurred in 11 cases out of 267. All cases of flap loss occurred within two weeks of surgery due to either arterial insufficiency (n=5) or venous congestion (n=6). CONCLUSION: Supermicrosurgery enables the selection of the most efficient perforator for microanastomosis at the defect site. It also reduces the time required for dissection of recipient vessels, and reduces the possibility of injury to major vessels. Microsurgery using a vessel of less than 1 mm has been reported to increase the risk of flap failure; however, using the most advanced surgical tools and developing experience in the technique can produce success rates similar to those found in the literature.

Management of Velopharyngeal Insufficiency Using Double Opposing Z-Plasty in Patients Undergoing Primary Two-Flap Palatoplasty

BACKGROUND: Velopharyngeal insufficiency (VPI) may persist after primary repair of the cleft palate, and surgical correction is necessary in many cases. The purpose of this study is to evaluate the effect of double opposing Z-plasty (DOZ) in cleft palate patients suffering from VPI after primary two-flap palatoplasty. METHODS: Between March 1999 and August 2005, we identified 82 patients who underwent two-flap palatoplasty for cleft palate repair. After excluding the patients with congenital syndrome and mental retardation, 13 patients were included in the final study group. The average age of the patients who underwent DOZ at was 5 years and 1 month. Resonance, nasal emission, and articulation were evaluated by a speech pathologist. The velopharyngeal gaps were measured before and after surgery. RESULTS: Six patients attained normal speech capabilities after DOZ. The hypernasality grade was significantly improved after surgery in all of the patients (P=0.0015). Whereas nasal emission disappeared in 8 patients (61.5%), it was diminished but still persisted in the remaining 5 patients. Articulation was improved in all of the cases. In two cases, the velopharyngeal gap was measured using a ruler. The gap decreased from 11.5 to 7 mm in one case, and from 12.5 to 8 mm in the second case. CONCLUSIONS: The use of DOZ as a surgical option to correct VPI has many advantages compared with other procedures. These include short surgery time, few troublesome complications, and no harmful effects on the dynamic physiological functioning of the pharynx. This study shows that DOZ can be another option for surgical treatment of patients with VPI after two-flap palatoplasty.

Atypical Patterns of Deep Inferior Epigastric Artery: Clinical Implication of Preoperative CT Angiography

PURPOSE: The free deep inferior epigastric artery perforator (DIEP) flap is a popular option for autologous breast reconstruction. However, the anatomy of the deep inferior epigastric artery(DIEA) may vary from one individual to another. Unexpected vascular anomaly can confuse the surgeon and affects on the safety of the free DIEP flap. MATERIALS AND METHODS: Thirty five consecutive patients who underwent free DIEP/TRAM flap for immediate breast reconstruction between Mar. 2010 and Oct. 2010 were enrolled in this study. Computed tomography angiography (CT angiography) of abdomen was evaluated part of our standard preoperative assessment: atypical patterns of DIEA/DIEP were evaluated by preoperative CT angiography and compared with intraoperative finding. RESULTS: Atypical patterns of DIEA/DIEP which may affect preoperative planning were noted as the following: Circummusclar/subfascial DIEA (n=1), DIEA running underneath rectus muscle (n=8), septocutaneous perforator (n=3), peritoneo-cutaneous perforator (n=1), a large branch going into peritoneum (n=1), and very early division and muscle penetration of DIEA (n=1). CONCLUSION: Atypical DIEA/DIEP that might change the operation plan is not rare, so the individualized planning based on the preoperative CT angiography is recommended. Preoperative CT angiography could help to select reliable and easy-to-dissect perforator in free DIEP/TRAM breast reconstruction.

Modified Design of Anterolateral Thigh Free Flap for Hypopharyngeal Reconstruction

PURPOSE: Defect after ablation of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Since neo-hypopharynx is totally buried, various methods have been suggested for monitoring. We propose a modified design of anterolateral thigh (ALT) free flap for reconstruction of pharyngolaryngectomy defect, which has an exteriorized part for clinical monitoring and allows for primary closure. MATERIALS AND METHODS: Three consecutive patients with hypopharyngeal cancer were reconstructed with ALT flap with modified design: 1) distal part of flap was elongated into fusiform shape and used as exteriorized monitoring segment with a deepithelized bridge and 2) proximal part was designed as curve so the maximum width of the flap was reduced to less than 10 cm. RESULTS: Patient 1, 2 had uneventful postoperative course with healthy skin color and fresh pin prick bleeding. In patient 3, defect after cancer ablation was shorter than usual and deepithelized bridge was longer. When the general hemodynamic status of the patient was aggravated in postoperative course, the color of monitoring skin was changed. Viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks and repair was necessary. In all patients the donor sites were closed primarily. CONCLUSION: By the modified design of ALT flap, clinical monitoring can be possible by examining exteriorized monitoring flap and also donor site can be closed primarily. However possibility of false positive exists and technical caution and patient selection is needed because of danger of leakage.

A Case of Lithium Toxicity in a Patient Treated with Maintenance Dose of Lithium / 대한정신약물학회지

Lithium is widely used in the treatment of various psychiatric disorders, including bipolar disorder. Lithium has been known to have a narrow therapeutic range inducing severe toxic effects with overdose. Many clinical guidelines recommended clinicians to check serum levels and renal panels regularly during lithium administration. In this case report, we report a case of 60 years old man with severe lithium toxicity, who was taking daily dose of lithium 900 mg through an year. The serum lithium level checked 4 months before admission was 0.4 mEq/L. He restarted his habitual drinking a few months before admission, and soon after acute confusional symptoms were occurred to bring him to emergency room of the Dongguk University International Hospital. During hospitalization the highest serum lithium level was found to be 3.55 mEq/L. He was treated with hemodialysis and recovered without any prominent sequela. Acute renal failure associated with dehydration, alcohol drinking, and nephrotoxic effects by lithium were thought to be risk factors of lithium toxicity.

xCITED2 Induces Neural Genes in Animal Cap Explants of Xenopus Embryos

Neural tissue is arisen from presumptive ectoderm via inhibition of bone morphogenetic protein (BMP) signaling during Xenopus early development. Previous studies demonstrate that ectopic expression of dominant negative BMP4 receptor (DNBR) produces neural tissue in animal cap explants (AC) and also increases the expression level of various genes involved in neurogenesis. To investigate detail mechanism of neurogenesis in transcriptional level, we analyzed RNAs increased by DNBR using total RNA sequencing analysis and identified several candidate genes. Among them, xCITED2 (Xenopus CBP/p300-interacting transcription activator) was induced 4.6 fold by DNBR and preferentially expressed in neural tissues at tadpole stage. Ectopic expression of xCITED2 induced anterior neural genes without mesoderm induction and reduced BMP downstream genes, an eye specific marker and posterior neural marker. Taken together, these results suggest that xCITED2 may have a role in the differentiation of anterior neural tissue during Xenopus early development.

Human telomerase catalytic subunit (hTERT) suppresses p53-mediated anti-apoptotic response via induction of basic fibroblast growth factor

Although human telomerase catalytic subunit (TERT) has several cellular functions including telomere homeostasis, genomic stability, cell proliferation, and tumorigenesis, the molecular mechanism underlying anti-apoptosis regulated by TERT remains to be elucidated. Here, we show that ectopic expression of TERT in spontaneously immortalized human fetal fibroblast (HFFS) cells, which are a telomerase- and p53-positive, leads to increases of cell proliferation and transformation, as well as a resistance to DNA damage response and inactivation of p53 function. We found that TERT and a mutant TERT (no telomerase activity) induce expression of basic fibroblast growth factor (bFGF), and ectopic expression of bFGF also allows cells to be resistant to DNA-damaging response and to suppress activation of p53 function under DNA-damaging induction. Furthermore, loss of TERT or bFGF markedly increases a p53 activity and DNA-damage sensitivity in HFFS, HeLa and U87MG cells. Therefore, our findings indicate that a novel TERT-bFGF axis accelerates the inactivation of p53 and consequent increase of resistance to DNA-damage response.

Nitric Oxide Is an Essential Mediator for Neuronal Differentiation of Rat Primary Cortical Neuron Cells

Nitric oxide (NO) regulates proliferation, differentiation and survival of neurons. Although NO is reported to involve in NGF-induced differentiation of PC12 cells, the role of NO has not been characterized in primary neuron cells. Therefore, we investigated the role of NO in neuronal differentiation of primary cortical neuron cells. Primary cortical neuron cells were prepared from rat embryos of embryonic day 18 and treated with NMMA (NOS inhibitor) or PTIO (NO scavenger). Neurite outgrowth of neuron cells was counted and the mRNA levels of p21, p27, c-jun and c-myc were measured by RT-PCR. Neurite outgrowth of primary cortical neuron cells was inhibited a little by NOS inhibitor and completely by NO scavenger. The mRNA levels of p21 and p27, differentiation-induced growth arrest genes were increased during differentiation, but they were decreased by NOS inhibitor or NO scavenger. On the other hand, the level of c-jun mRNA was not changed and the level of c-myc mRNA was increased during differentiation differently from previously reported. The levels of these mRNA were reversed in NOS inhibitor- or NO scavenger-treated cells. The level of nNOS protein was not changed but NOS activity was inhibited largely by NOS inhibitor or NO scavenger. These results suggest that NO is an essential mediator for neuronal differentiation of primary cortical neuron cells.

p190RhoGAP and Rap-dependent RhoGAP (ARAP3) inactivate RhoA in response to nerve growth factor leading to neurite outgrowth from PC12 cells

Rat pheochromocytoma (PC12) cells have been used to investigate neurite outgrowth. Nerve growth factor (NGF) has been well known to induce neurite outgrowth from PC12 cells. RhoA belongs to Ras-related small GTP-binding proteins, which regulate a variety of cellular processes, including cell morphology alteration, actin dynamics, and cell migration. NGF suppressed GTP-RhoA levels after 12 h in PC12 cells and was consistently required for a long time to induce neurite outgrowth. Constitutively active (CA)-RhoA suppressed neurite outgrowth from PC12 cells in response to NGF, whereas dominant-negative (DN)-RhoA stimulated it, suggesting that RhoA inactivation is essential for neurite outgrowth. Here, we investigated the mechanism of RhoA inactivation. DN-p190RhoGAP abrogated neurite outgrowth, whereas wild-type (WT)-p190RhoGAP and WT-Src synergistically stimulated it along with accelerating RhoA inactivation, suggesting that p190RhoGAP, which can be activated by Src, is a major component in inhibiting RhoA in response to NGF in PC12 cells. Contrary to RhoA, Rap1 was activated by NGF, and DN-Rap1 suppressed neurite outgrowth, suggesting that Rap1 is also essential for neurite outgrowth. RhoA was co-immunoprecipitated with Rap1, suggesting that Rap1 interacts with RhoA. Furthermore, a DN-Rap-dependent RhoGAP (ARAP3) prevented RhoA inactivation, abolishing neurite formation from PC12 cells in response to NGF. These results suggest that NGF activates Rap1, which, in turn, up-regulates ARAP3 leading to RhoA inactivation and neurite outgrowth from PC12 cells. Taken together, p190RhoGAP and ARAP3 seem to be two main factors inhibiting RhoA activity during neurite outgrowth in PC12 cells in response to NGF.

Isolation of Early Neurogenesis Genes with Xenopus cDNA Microarray / 한국실험동물학회지

Neurogenesis is the process that develops neuroectoderm from ectoderm. Bone morphogenetic protein (BMP) inhibition in ectodermal cells is necessary and sufficient for neurogenesis in Xenopus embryos. To isolate genes involved in early neurogenesis, Xenous Affymetrix gene chips representing 14,400 genes were analyzed in early stage of neuroectodermal cells that were produced by inhibition of BMP signaling with overexpression of a dominant-negative receptor. We identified 265 candidate genes including 107 ESTs which were newly expressed during the early neurogenesis by blocking BMP signaling. The candidates of 10 ESTs were selected and examined for upregulation in neuroectoderm. Five EST genes were confirmed to be upregulated in neuroectoderm and examined for time-dependent expression patterns in intact embryos. Two EST genes were cloned and identified as a homology of CYP26c (Xl.1946.1.A1_at) and Kielin containing VWC domain (Xl.15853.1.A1_at). One of them, CYP26c, was further characterized for its transcriptional regulation and role of anterior-posterior patterning during neurogenesis. Taken together, we analyzed and characterized genes expressed in early neurogenesis. The results suggest that neurogenesis by inhibition of BMP provides useful system to isolate genes involved in early events of neurogenesis during early vertebrate embryogenesis.

Ascorbic acid extends replicative life span of human embryonic fibroblast by reducing DNA and mitochondrial damages

Ascorbic acid has been reported to extend replicative life span of human embryonic fibroblast (HEF). Since the detailed molecular mechanism of this phenomenon has not been investigated, we attempted to elucidate. Continuous treatment of HEF cells with ascorbic acid (at 200 micrometer) from 40 population doubling (PD) increased maximum PD numbers by 18% and lowered SA-beta-gal positive staining, an aging marker, by 2.3 folds, indicating that ascorbic acid extends replicative life span of HEF cells. Ascorbic acid treatment lowered DCFH by about 7 folds and Rho123 by about 70%, suggesting that ascorbic acid dramatically decreased ROS formation. Ascorbic acid also increased aconitase activity, a marker of mitochondrial aging, by 41%, indicating that ascorbic acid treatment restores age-related decline of mitochondrial function. Cell cycle analysis by flow cytometry revealed that ascorbic acid treatment decreased G1 population up to 12%. Further western blot analysis showed that ascorbic acid treatment decreased levels of p53, phospho-p53 at ser 15, and p21, indicating that ascorbic acid relieved senescence-related G1 arrest. Analysis of AP (apurinic/apyrimidinic) sites showed that ascorbic acid treatment decreased AP site formation by 35%. We also tested the effect of hydrogen peroxide treatment, as an additional oxidative stress. Continuous treatment of 20 micrometer of hydrogen peroxide from PD 40 of HEF cells resulted in premature senescence due to increased ROS level, and increased AP sites. Taken together, the results suggest that ascorbic acid extends replicative life span of HEF cells by reducing mitochondrial and DNA damages through lowering cellular ROS.

Cellular characteristics of primary and immortal canine embryonic fibroblast cells

Using normal canine embryonic fibroblasts (CaEF) that were shown to be senescent at passages 7th-9th, we established two spontaneously immortalized CaEF cell lines (designated CGFR-Ca-1 and -2) from normal senescent CaEF cells, and an immortal CaEF cell line by exogenous introduction of a catalytic telomerase subunit (designated CGFR-Ca-3). Immortal CGFR- Ca-1, -2 and -3 cell lines grew faster than primary CaEF counterpart in the presence of either 0.1% or 10% FBS. Cell cycle analysis demonstrated that all three immortal CaEF cell lines contained a significantly high proportion of S-phase cells compared to primary CaEF cells. CGFR-Ca-1 and -3 cell lines showed a loss of p53 mRNA and protein expression leading to inactivation of p53 regulatory function, while the CGFR-Ca-2 cell line was found to have the inactive mutant p53. Unlike the CGFR-Ca-3 cell line that down-regulated p16INK4a mRNA due to its promoter methylation but had an intact p16INK4a regulatory function, CGFR-Ca-1 and -2 cell lines expressed p16INK4a mRNA but had a functionally inactive p16INK4a regulatory pathway as judged by the lack of obvious differences in cell growth and phenotype when reconstituted with wild-type p16INK4a. All CGFR-Ca-1, -2 and -3 cell lines were shown to be untransformed but immortal as determined by anchorage-dependent assay, while these cell lines were fully transformed when overexpressed oncogenic H-rasG12V. Taken together, similar to the nature of murine embryo fibroblasts, the present study suggests that normal primary CaEF cells have relatively short in vitro lifespans and should be spontaneously immortalized at high frequency.

The clinical study of the temporal bone fractures / 대한이비인후과학회지

No abstract available.

The role of the neck on the control of body posture in bilateral labyrinthectomized rabbits / 대한이비인후과학회지

No abstract available.

Total Hip Arthroplasty for Ankylosed Hip / 대한정형외과학회잡지

The conversion of the ankylosed hip to a total hip arthroplasty may be indicated if a fused hip causes low back pain, pain in the ispilateral knee, or a fibrous ankylosis is painful. Fifteen hips converted to total hip arthroplasty between Aug., 1982 and Jul., 1988 have been reviewed one to seven years after operation and the results are as follows:1. Among the 15 hips, 8 cases confirmed as fibrous ankylosis and 7 cases confirmed as bony ankylosis. 2. The causes of ankylosis is as follow tuberculous arthritis(4 cases), secondary osteoarthritis due to pyogenic hip(4 cases), rheumatoid arthritis(4 cases), post-traumatic arthritis secondary to central fracture-dislocation of hip(2 cases), and ankylosing spondylitis(1 cases). 3. The duration of immobility of the involved hip ranged from two to twenty-five years. 4. In the 14 patients, three complained of low back pain, five of ipsilateral knee pain and six of ipsilateral hip pain. 5. The lower back pain due to malposition was relieved in all cases except ankylosing spondylitis, and the pain in ipsilateral knee was also relived in all cases after hip arthroplasty. 6. The average Harris score of the fifteen hips before arthroplasty and after was 50.1 and 88.1.