Effects of platelet-rich plasma on tissue-engineered vascularized flaps in an in vivo chamber.

AIMS: We investigated the reproducibility of creating a vascularized tissue flap in an in vivo tissue engineering chamber by incubating a vascular pedicle imbedded in a collagen sponge with activated platelet-rich plasma (aPRP) and basic fibroblast growth factor (bFGF). METHODS: Collagen sponge soaked with saline (control group), bFGF (Group 1), aPRP (Group 2), and aPRP/controlled release bFGF (Group 3) was implanted with a saphenous arteriovenous pedicle into a tissue engineering chamber, located subcutaneously in the groin of rabbits. After 4 weeks of implantation, the contents in the chamber were harvested for volumetric and histological analyses. RESULTS: The total volume of generated tissue in Group 3 was the largest among the Groups (control group vs. Group 3, p < 0.01). The volume of the pedicle vascular bundle/adipose tissue component was larger in Groups 1 and 3 than that in the control group (p < 0.05 and p < 0.01, respectively). The inflammatory tissue volume was larger in Groups 2 and 3 (control group vs. Group 3, p < 0.05). In a smaller long-term study, inflammatory tissue at 4 weeks was gradually replaced by the adipose tissue within 8 weeks. CONCLUSION: PRP-induced inflammatory reactions were considered to be necessary to stimulate cell migration into the chamber, leading to more tissue regeneration with abundant cell components. We conclude that PRP contributes to the reproducibility of preparing vascularized flaps in an in vivo chamber.

Normobaric oxygen therapy increases cartilage survival ratio in auricular composite grafting in rat models.

PURPOSE: This study aims to clarify whether normobaric oxygen therapy improves the survival of auricular composite grafts in rats. METHODS: For 10 male SD rats, 1.5 cm2 composite grafts were harvested from bilateral ear regions including whole auricles. The harvested grafts were transferred caudally and sutured there. The 10 rats were randomly divided into two groups and kept for 21 days in two different circumstances. The first group (Control group: five rats carrying 10 grafts) was kept in room air (20% oxygen) throughout the 21 days, and the second group-named NBO (normobaric oxygen) group (five rats carrying 10 grafts)-was kept in normobaric 60% oxygen for 3 days and then in room air for 18 days. All the 10 rats were sacrificed on the 21st day. Surviving areas of the grafts and the height of the surviving auricular cartilage were examined for statistical comparison of the two groups. Furthermore, the conditions of chondrogenesis occurring around the perichondrium were compared between the two groups. RESULTS: Surviving areas did not present statistically significant differences between the two groups. The height of surviving cartilage was significantly greater for the NBO group (2610 ± 170 SD µm) than that for the Control group (1720 ± 190 SD µm). Chondrogenesis occurred at positions more distant from the recipient bed in the NBO group than that in the Control group. CONCLUSION: Normobaric oxygen therapy increases the thickness of surviving cartilage in auricular composite grafting in rats, thus suggesting that NBO therapy may also be effective in composite grafting for humans.

Thoracic outlet syndrome after the Nuss procedure for pectus excavatum: Is it a rare complication?

OBJECTIVE: The present study aims to elucidate the frequency of thoracic outlet syndrome after the Nuss procedure for pectus excavatum and the conditions in which thoracic outlet syndrome is likely to develop. METHODS: A retrospective study including 85 pectus excavatum patients (58 males and 27 females) was conducted. Thoracic outlet syndrome was defined as a condition in which the patient has numbness, lassitude, or pain of the upper limbs at rest or during motion of the upper limbs. The frequency of the thus-defined thoracic outlet syndrome was evaluated in 85 patients. Age, sex, Haller indices, and the positions of the correction bars were compared between the patients who developed thoracic outlet syndrome and those who did not. RESULTS: Preadolescent patients (18 out of 85) did not develop postoperative thoracic outlet syndrome. In total, 15.2% of adult male patients (7 out of 46) and 33% of adult female patients (7 out of 21) developed postoperative thoracic outlet syndrome. For both male and female groups, Haller indices were significantly greater for patients who had postoperative thoracic outlet syndrome than for those who did not. Correction bars were generally placed at higher intercostal spaces in patients who developed postoperative thoracic outlet syndrome than in those who did not. CONCLUSION: A considerable percentage of adult patients develop thoracic outlet syndrome after the Nuss procedure for pectus excavatum. Maturity of the thoracic wall, femininity, severity of the deformity (represented by greater Haller indices), and placement of correction bars at superior intercostal spaces are risk factors for postoperative thoracic outlet syndrome.

Preservation of deep-layer fat of lateral zones prevents postoperative seroma after TRAM-flap harvesting for breast reconstruction: a retrospective study.

OBJECTIVE: The present study elucidates whether or not preserving fat tissues deeper than the Scarpa's fascia in zone 3 and zone 4 reduces postoperative fluid collection after harvesting the transverse rectus-abdominis muscle (TRAM) flap. METHODS: Thirty-one patients for whom breast reconstruction with free TRAM flaps had been performed were included in the study. Fat tissues deeper than the Scarpa's fascia in zone 3 and zone 4 were addressed in two ways. With 17 patients, these tissues were preserved on the abdominal wall; with 14 patients, these fat tissues were harvested as part of the TRAM flap. The former and latter groups were named the Preservation Group and Non-Preservation Group, respectively. Drainage tubes were placed at the donor site until daily drainage became less than 20 ml, at which time the tubes were removed. The total amount of postoperative fluid drained from the donor site and the days required before tube removal were compared between the two groups. RESULTS: The total volume of drained fluid was significantly greater for the Non-Preservation Group (444 ± 48.2 ml) than for the Preservation Group (230 ± 21.9 ml); the period before removal of drainage tubes was significantly longer for the Non-Preservation Group (12.4 ± 0.84 days) than for the Preservation Group (7.6 ± 0.55 days). CONCLUSION: Preservation of deep-fat tissues in zone 3 and zone 4 reduces postoperative fluid exuded from the donor site, and enables earlier removal of drainage tubes. For cases where optimal breast shape can be achieved without these fat tissues, the fat tissues should be preserved.

Utilization of a sero-muscular patch for safe wound closure after free jejunum transfer for a skin-esophageal fistula.

This paper introduces our original technique of free jejunum transfer, in which a sero-muscular patch is used to cover the jejunum. Our results demonstrate its effectiveness for touch-up surgery after esophageal leakage.

Scoring of Deformed Costal Cartilages Reduces Postoperative Pain after Nuss Procedure for Pectus Excavatum.

OBJECTIVE: The present study aims to elucidate whether or not scoring deformed cartilages reduces postoperative pain after the Nuss procedure for pectus excavatum patients. METHODS: A total of 46 pectus excavatum patients for whom the Nuss procedure was conducted were included in the study. The patients were categorized into two groups, depending on whether or not the supplementary maneuver of scoring deformed cartilages was performed in addition to the Nuss procedure. Patients for whom deformed costal cartilages were scored were categorized as the Scoring Group (n = 24); those who received no such scoring were categorized as the Non-Scoring Group (n = 22). After evaluating the maximum stresses occurring on the thoraces by means of dynamic simulation using finite element analyses, intergroup comparison of the maximum von-Mises stress values was performed. Furthermore, after quantifying postoperative pain as the frequency with which patients injected anesthetics through an epidural pain-control system within 2 postoperative days, the degree of pain was compared between the two groups. RESULTS: The maximum stresses occurring on the thorax were significantly greater for the Non-Scoring Group than for the Scoring Group; injection frequency was also greater for the Non-Scoring Group (average 4.9 times for 2 days) than for the Scoring Group (average 2.5 times for 2 days). CONCLUSION: High stresses occur due to the performance of the Nuss procedure, causing postoperative pain. The stresses can be reduced by performing supplementary scoring on deformed cartilages. Accordingly, postoperative pain is reduced.

Correction of secondary deformity after Nuss procedure for pectus excavatum by means of cultured autologous cartilage cell injection.

INTRODUCTION: For some cases of pectus excavatum, ideal chest shape cannot be achieved solely by performing the Nuss procedure. This manuscript presents a case where the residual deformity following Nuss was corrected using injection-transplantation of cultured autologous chondrocytes. PRESENTATION OF CASE: The treatment was performed for an 18-year-old male, who sought improvement of his chest shape after previously undergoing the Nuss procedure. A 1cm(2) auricular cartilage piece was harvested from his ear. Chondrocytes were isolated from the cartilage piece and were cultured. The cultured chondrocytes were processed into gel form and were injection-transplanted to the deformed region of the patient's chest. The grafted chondrocytes consolidated in one month, presenting elasticity equivalent to ordinary costal cartilage. The patient's chest remains in an optimal shape after a one-year postoperative follow up. DISCUSSION: Secondary correction of the chest deformity after previous operation for pectus excavatum is often tricky, because of the possible adhesion of the lungs or pericardium with the thoracic wall. Transplantation of cultured autologous chondrocytes does not require intra-thoracic maneuvers, and so is less invasive than other surgical interventions. Hence, priority can be placed, in some cases, on the chondrocyte transplantation rather than the re-correction of the thorax with the Nuss procedure or Ravitch procedure. CONCLUSION: Transplantation of cultured autologous chondrocytes is recommended as a useful option for secondary correction of chest deformity after the Nuss procedure.

Rotation arc of pedicled anterolateral thigh flap for abdominal wall reconstruction: How far can it reach?

PURPOSE: The aim of this study was to elucidate the extent to which pedicled anterolateral thigh (ALT) flaps can reach in reconstruction of abdominal wall defects. METHODS: A total of 60 pedicled ALT flaps were raised from cadavers and were experimentally transferred to the abdominal region. The distance between the umbilicus and the most cranial point of the flap after transfer was defined as cranially reachable distance (CRD). Three issues were evaluated: (1) the difference in the CRD when the flap pedicle was positioned superficial or deep into the rectus femoris (RF) and sartorius (SA) muscles; (2) the difference in the CRD in those cases where the main artery of RF arises from the descending branch of the lateral femoral circumflex artery, and is preserved or severed; and (3) maximum values of CRD. RESULTS: (1) CRD was significantly greater when the pedicle was passed deep into the muscles (-2.5 ± 3.8 SD cm) compared with superficial (-5.8 ± 3.3 SD cm), indicating placement of pedicles beneath the two muscles enables additional extension. (2) CRD was significantly greater for the severed condition (-0.3 ± 4.0 SD cm) than for the preserved condition (-3.3 ± 4.1 SD cm), indicating severing the main artery of RF allows additional extension. (3) Out of the 60 specimens, the CRD was cranial to the umbilicus in 17 flaps, indicating pedicled ALT flaps can reach the umbilicus in less than one-third (17/60) of cases. CONCLUSION: Pedicled ALT flaps can reliably reach regions inferior to the umbilicus. However, for defects superior to the umbilicus, other reconstructive options should be considered.

The "Sea" should not be operated on in scar revision for "Island-Like" scars.

Scars developing on body surfaces not only restrict body movement, but are also problematic from a cosmetic standpoint. Hence, revision is conducted by removing the scar and re-suturing the resultant defects. In performing scar revision, care should be taken to prevent the re-sutured wounds from developing hypertrophy again. Scars often present a pattern where hard, red parts are separated by soft parts in between. As the hard and soft parts may be analogized as islands and seas respectively, we call this the "Island-Like" scar. Two strategies can be taken to treat scars of this type. The first is to remove the entire scar-including both hard and soft parts; the second is to remove only the hard parts and leave the soft parts untouched. The authors conducted a biomechanical study using finite element analyses and found that as a body moves, greater stresses occur in the peri-wound regions with the first strategy than with the second strategy. A wound's likelihood to develop hypertrophy increases as the stresses working on it increase. Hence, it is hypothesized that the second strategy carries less risk of the operated wounds developing re-hypertrophy than the first strategy. Based on this logic, in performing scar revision for scars consisting of hard and soft parts, it is recommended only to remove only hard parts and not to operate on soft parts in between.

Optimal technique for microvascular anastomosis of very small vessels: Comparative study of three techniques in a rat superficial inferior epigastric arterial flap model.

OBJECTIVE: The anastomosis of very small vessels (external diameter: < or = 0.5mm) is challenging and requires high microsurgical skill. This study aims to investigate the optimal technique for the anastomosis of very small vessels. We compared three anastomotic techniques on the basis of success rate and anastomosis time in a superficial inferior epigastric arterial flap model in rats. METHODS: Forty-five Sprague-Dawley rats were divided into three groups of 15 rats. The superficial inferior epigastric artery flap was elevated, and only the artery was cut and anastomosed under magnification. The anastomosis was performed with the conventional technique, with the intravascular stenting technique or with the open guide suture technique. Flap survival was assessed on postoperative day 5, and the success rates of the groups were compared. In addition, the time required for anastomosis was compared between the groups. RESULTS: All flaps survived, and success rates did not differ significantly between the groups. The average anastomosis times with the conventional technique (770.0s) and the intravascular stenting technique (822.8s) did not differ significantly but were significantly greater than that with the open guide suture technique (699.2s). CONCLUSION: The open guide suture technique simplifies anastomosis and can be recommended as a new standard technique for the anastomosis of very small vessels. Furthermore, the benefit of the intravascular stenting technique is minimal for either skilled or unskilled microsurgeons.

Nonmicrosurgical replantation using a subcutaneous pocket for salvage of the amputated fingertip.

PURPOSE: The pocket principle suggested by Brent in 1979 is an alternative method for use when microsurgical replantation is not feasible. The application and the amputation level for which the method is available, however, have not been well examined. METHODS: Between 1999 and 2003 we treated 6 patients (7 fingers) by nonmicrosurgical replantation using a subcutaneous pocket (the Brent technique). All patients had sustained complete fingertip amputations across or proximal to the lunula in digits other than the thumb. In every case the amputation was a crush or avulsion-type injury and microsurgical replantation was not feasible; however, cosmetic symmetry was desired strongly by the patient. RESULTS: Of the 7 fingers only one survived completely but became atrophic after 4 months. One finger developed necrosis involving less than half of the replant but a hooked nail deformity developed. Two fingers developed partial necrosis involving more than half of the replant but both fingers were missing the fingernail and the cosmetic results were not acceptable. Three fingers developed total necrosis. In addition a slight flexion contracture not improved with therapy in the digits was noted in 4 patients. CONCLUSIONS: The Brent technique should be performed scrupulously for fingertip amputation across or proximal to the lunula because of the poor survival rate and the possibility of contracture in the digits or other proximal joints.

Rubinstein-Taybi syndrome (RTS) with postaxial polydactyly of the foot: 4-year follow-up until improvement of dysbasia.

Rubinstein-Taybi syndrome (RTS), also known as 'broad thumbs syndrome' or 'broad thumb-hallux syndrome', is a malformation syndrome characterized by the triad of broad thumbs or first toes, a peculiar facial expression called 'comical face' and mental retardation. Although various malformations are combined with the triad, polydactyly is rare. We treated a male patient with RTS complicated by postaxial polydactyly of the foot. His clinical course was different from typical patients with polydactyly, especially in the aspect of walking development. Osteoplasty-combined surgery, which was ideal for anatomical reconstruction, was performed on the patient at 2 years and 11 months of age. A 4-year follow-up period was required until there was an improvement of dysbasia.