Longitudinal physiological remoulding of lower limb skin as a cause of diabetic foot ulcer: a histopathological examination.

OBJECTIVE: Diabetic foot ulcer (DFU) is recognised as a severe complication in patients with type 2 diabetes. With the increasing incidence of diabetes, it represents a major medical challenge. Several models have been proposed to explain its aetiology; however, they have never been assessed by longitudinal histopathological examination, which this study aims to address. METHOD: Multiplex-immunofluorescence analysis was carried out with lengthwise serial skin specimens obtained from the medial thigh, lower leg, ankle, dorsum of foot and acrotarsium close to the DFU region of a patient with type 2 diabetes receiving above the knee amputation. RESULTS: Proximal-to-distal gradual loss of peripheral nerve was demonstrated, accompanied by compromised capillaries in the superficial papillary plexus and distended CD31-positive capillaries in the dorsum of foot. Neural fibres and capillaries were also significantly compromised in the sweat gland acinus in the ankle and dorsum of foot. Injuries in the superficial papillary plexus, sweat gland acinus, and sweat gland-associated adipose tissues were accompanied by significant infiltration of macrophages. These results indicated that longitudinal impairment of local blood circulation could be the cause of peripheral neuropathy, which initiated ulcer formation. Resultant chronic inflammation, involving sweat gland-associated adipose tissue, gave rise to impairment of wound healing, and thus DFU formation. CONCLUSION: Longitudinal histopathological examination demonstrated that impairment of local microvascular circulation (rather than the systemic complication caused by type 2 diabetes) was considered the primary cause of peripheral neuropathy, which initiated ulceration. Together with chronic inflammation in the superficial papillary plexus and sweat gland-associated adipose tissue, it resulted in the development of a DFU. Although this is a study of just one individual's limb, our study provided a unique observation, contributing mechanistic insights into developing novel intervening strategies to prevent and treat DFUs.

Rotation Advancement Distraction Osteogenesis Technique is Attributed to Unilateral Lambdoid Synostosis and is Used to Correct Posterior Plagiocephaly.

Unilateral lambdoid synostosis is the rarest form of craniosynostosis. Surgical correction is technically challenging from a morphological standpoint and is used to decompress intracranial pressure. Herein, the authors present a "rotational advancement bone flap" technique for the repair of posterior plagiocephaly. A bicoronal skin incision was performed, to expose the occipital region. The rotational advancement bone flap was designed to hinge off the nonsynostotic side, and it was set up to include an occipital protrusion on the normal side. On the premature side, an advancement bone flap was set up to include the flattened and deformed occipital bone. A titanium cranial distractor, which was attached between the bone flap and the anterior bone. An absorbable plate, which would later become a hinge due to the movement of the bone flap, was attached to the area for reinforcement. The authors technique was able to decompress intracranial pressure with satisfactory esthetic outcomes.

Intraoperative obturator nerve injury reconstructed using a PGA-collagen tube: Three case reports.

We herein report three cases of obturator nerve injury, which is rare in gynecological surgery. In all cases, it was difficult to suture both nerve ends without tension. Therefore, we used a PGA-collagen tube to interpose the nerve defect. After follow-ups of at least seven months, all three patients were able to adduct the hip joint and medial thigh sensations also improved. These results suggest the potential of a PGA-collagen tube in the treatment of obturator nerve injury.

Scarring Caused by the Percutaneous Approach to Fractures of the Orbit and Orbital Rim.

ABSTRACT: Percutaneous and transconjunctival approaches are commonly used for fractures of the orbit and orbital rim. However, it leaves visible scarring on the face. Although previous studies reported scarring from the percutaneous approach, few reported the degree of such scarring. The authors examined the degree of scarring associated with percutaneous approaches to fractures of the orbit and orbital rim in the Japanese population. The authors reviewed photographs of patients who were treated surgically for fractures of the orbital floor, medial orbital wall, or zygomatic bone via percutaneous approaches to examine the presence of scarring and deformation. In 36% of all patients, the observers were unable to determine the side on which the surgery was performed. Furthermore, the site of scarring was identified accurately in only 20.6% of the cases in which observers were able to identify the surgical side. The authors' study demonstrated that the subciliary approach left minimal scarring under the eyelashes. On the other hand, the medial canthal approach left depressed and wide scarring, whereas pigmentation was apparent in patients who underwent surgery via the lateral eyebrow approach. Similarly, pigmentation under the eyelashes and at the site of secondary incision was common after the subciliary approach.

Examination of Postoperative Outcomes Using Morphological and X-Ray Classifications and Selection of the Toe to Be Excised in Postaxial Polydactyly of the Foot.

The treatment of postaxial polydactyly requires excision of the medial fifth or lateral sixth toe, and separation of the adjacent fourth/fifth toes if the adjacent toes exhibit skin syndactyly. Morphological changes in the retained toes and reoperation are common problems after such surgery. This study examined the effects of preoperative classifications and selecting the medial fifth or lateral sixth toe for excision on the postoperative outcomes of surgery for postaxial polydactyly. From April 2006 to March 2019, surgery for postaxial polydactyly was performed on 55 feet in 49 patients. The patients' mean age at surgery was 28.8 months. Postoperative esthetic and bone alignment scores, the reoperation rate, and postoperative dysfunction were examined. The postoperative esthetic and bone alignment evaluations were performed by examining postoperative photograph and X-ray images using original scoring systems. The surgical procedure was chosen by the surgeon-in-charge during a preoperative conference after considering the toe growth and bone alignment. In the postoperative esthetic evaluation, excising the lateral sixth toe produced significantly better outcomes than excising the medial fifth toe. The morphological classification also indicated that excising the lateral sixth toe produced better outcomes, as it resulted in the bifurcated toes being clearly independent. Interestingly, the postoperative X-ray-based bone alignment score was not correlated with the esthetic score. The reoperation rate tended to be high after medial fifth toe excision. There were no postoperative functional complications. Lateral sixth toe excision for postaxial polydactyly of the foot produces good postoperative esthetic outcomes.

Paracrine Effects of Adipose-Derived Stem Cells Promote Lymphangiogenesis in Irradiated Lymphatic Endothelial Cells.

BACKGROUND: There is currently no reliable treatment for secondary lymphedema caused by lymph node dissection or radiotherapy; however, stem cell-based regenerative medicine is emerging as a promising remedy for such complications. The purpose of this study was to examine the effects of adipose-derived stem cells on lymphangiogenesis involving human dermal lymphatic endothelial cells exposed to ionizing radiation. METHODS: Proliferation, migration, and tube formation were analyzed in human dermal lymphatic endothelial cells that were co-cultured with adipose-derived stem cells or cultured in adipose-derived stem cell-conditioned medium. The levels of lymphangiogenic factors secreted from adipose-derived stem cells were analyzed by enzyme-linked immunosorbent assays and Western blotting. RESULTS: Co-culturing with adipose-derived stem cells and the use of adipose-derived stem cell-conditioned medium both significantly promoted proliferation, migration, and tube formation in nonirradiated human dermal lymphatic endothelial cells. The authors also found that irradiated adipose-derived stem cells had similar alleviative effects on irradiated human dermal lymphatic endothelial cells. Enzyme-linked immunosorbent assays and Western blotting analysis revealed that irradiating adipose-derived stem cells increased their secretion of basic fibroblast growth factor in a dose-dependent manner, whereas it caused no detectable change in their secretion of vascular endothelial growth factor A or C, or hepatocyte growth factor. CONCLUSIONS: These results demonstrated that factors secreted by adipose-derived stem cells contribute to the promotion of lymphangiogenesis in irradiated human dermal lymphatic endothelial cells. The authors' findings also suggest that radiation potentiates the paracrine effects of adipose-derived stem cells by stimulating basic fibroblast growth factor protein expression.

Fatty tissue atrophy of free flap used for head and neck reconstruction.

BACKGROUND: Many investigators have reported that microsurgical transplanted muscle shows a reduction in volume; however, changes in the size of transplanted fatty tissue have not been studied. The purpose of this study was to describe the degree of fatty tissue atrophy of microsurgical flaps. METHODS: Nineteen patients who underwent head and neck reconstruction using free flaps between 2003 and 2008 were available for this study. They were divided into an irradiated (8 patients) and nonirradiated (11 patients) group. The free flaps used for reconstruction were rectus abdominal musculocutaneous, anterolateral thigh fasciocutaneous, and forearm flaps. This retrospective study utilized radiographs of magnetic resonance imaging or computed tomography, which were taken two to three and after six months postoperatively. The fatty tissue thickness of free flaps in each magnetic resonance imaging or computed tomography slice was measured. The transplanted fatty tissue thickness of the flap after more than six months was compared with the change in the normal fat thickness of the same slice, to avoid any bias caused by a change in diet due to the general postoperative condition. RESULTS: The thickness of transplanted fatty tissue tends to decrease over period of 6-10 months after surgery. In the nonirradiated group, the mean postoperative fatty tissue thickness change in the free flaps was decreased by 15.9% (range, 0.3-31.4%). In the irradiated group, this change in the free flaps was decreased by 20.9% (range, 2.3-39.4%). CONCLUSIONS: Fatty tissue in free flaps shows atrophy over a period of six to nine months after surgery, and irradiation is more likely to result in severer fatty tissue atrophy.