Flexible Curved V-Y Subcutaneous Flap for Facial Skin Defects.

UNLABELLED: We devised an improved type of the V-Y subcutaneous pedicle flap with the elements of both advancement and rotation flaps. This flexible curved V-Y subcutaneous flap was used for facial skin defect reconstruction in 15 patients. Curved flaps were designed according to the elasticity of the surrounding skin and the postoperative scar direction. RESULTS: In all the 15 patients, the flap survived without circulatory impairment, and follow-up for more than 1 year indicated an inconspicuous scar and good course. CONCLUSIONS: With elements of both advancement and rotation flaps, transfer and wound closure of the flexible curved V-Y subcutaneous flap are easy. In addition, the postoperative scar can be positioned along natural wrinkle lines and relaxed skin tension lines. This may be a useful local flap for facial and general plastic surgery.

Conchal Cartilage Graft for Correction of Bilateral Cleft Lip Nasal Deformities during Childhood.

BACKGROUND: Various methods for primary repair of bilateral cleft lip have been developed, but they often produce inadequate results, such as an upturned nose or a short columella. We perform primary lip repair with muscle reconstruction to correct depression of the nasal floor and inferoposterior displacement of the alar base. Then, open rhinoplasty to project the nasal tip is performed during childhood. This article describes the methods and results of open rhinoplasty for bilateral cleft lip patients. METHODS: Open rhinoplasty with a modified forked flap is performed. The harvested conchal cartilage is grafted as a strut to strengthen and extend the septum. The lower lateral cartilages are sutured to the grafted cartilage and fixed in the correct position. Before skin closure, the tips of the 2 V flaps of the forked flap and the reverse V-flap between the forked flap are trimmed. Three trapezoidal flaps are sutured to the base of the columella. Thirty patients with bilateral cleft lip nasal deformities have undergone surgery. The operative results of 15 of 30 patients were evaluated photogrammetrically. RESULTS: The nose was refined and more projected. The nasolabial angle and the nasal tip projection were improved. The reformed configuration was well maintained for many years. Photogrammetric analysis demonstrated increases in both the nasal height-to-width ratio and the nostril height-to-width ratio and a decrease in the nasolabial angle. CONCLUSIONS: Open rhinoplasty during childhood using 3 trapezoidal flaps and conchal cartilage graft improves bilateral cleft lip nasal deformities effectively.

A retrospective analysis on the proper size of tissue expanders to treat scalp lesions.

BACKGROUND: Tissue expanders have become established instruments for scalp reconstruction. However, selection of the size of the expander has not been investigated systematically, and it generally depends on the experience of the surgeon. METHODS: We retrospectively analyzed 21 patients who had undergone treatment for scalp lesions using tissue expanders without any complications and measured 2 variables: the volume of the expanders per area of the excised lesions and the hypothetical stretched functional skin width relative to the width of the excised lesions. We also sought to evaluate the relationship between these 2 variables and the need for revision surgery during the postoperative course. RESULTS: The need for revision surgery was statistically higher in patients with a volume of 7 ml/cm(2) lesion or less and width of functional skin of less than 2.5 cm/cm lesion (P < 0.05). For scar repairs, the required size and volume of the expanders tended to be larger than those required for any other lesions. CONCLUSIONS: Expanders that generate functional skin at least more than 2.5 times the width of the lesion and have a volume more than 7 ml/cm(2) lesion are necessary to cover scalp lesions without complications.

Tissue augmentation by white blood cell-containing platelet-rich plasma.

Platelet-rich plasma (PRP) is a matrix of fibrin and platelets that releases cytokines that are important in wound healing. PRP is produced from the patient's blood and therefore has less risk of allergic reaction and infection. We have obtained PRP with an enhanced white blood cell component (W-PRP) by optimizing the centrifugal separation of PRP from plasma. Here we show that injection of W-PRP into the auricle of nude mice gave greater tissue augmentation compared to PRP. Further augmentation occurred when bFGF was added to W-PRP, and there was a significant increase in the number of α-smooth muscle actin-positive cells in mice treated with W-PRP+bFGF. Our results suggest that W-PRP may have value in cosmetic surgery aimed at rejuvenation of wrinkled and sagging skin. W-PRP injection constitutes a new concept in cell transplantation, in which cells required for tissue regeneration are induced by cytokines released from the transplanted cells.

Adipose tissue-specific regulation of angiotensinogen in obese humans and mice: impact of nutritional status and adipocyte hypertrophy.

BACKGROUND: The adipose tissue renin-angiotensin system (RAS) has been implicated in the pathophysiology of obesity and dysfunction of adipose tissue. However, neither regulation of angiotensinogen (AGT) expression in adipose tissue nor secretion of adipose tissue-derived AGT has been fully elucidated in humans. METHODS: Human subcutaneous abdominal adipose tissue (SAT) biopsies were performed for 46 subjects with a wide range of body mass index (BMI). Considering the mRNA level of AGT and indices of body fat mass, the amount of adipose tissue-derived AGT secretion (A-AGT-S) was estimated. Using a mouse model of obesity and weight reduction, plasma AGT levels were measured with a newly developed enzyme-linked immunosorbent assay (ELISA), and the contribution of A-AGT-S to plasma AGT levels was assessed. RESULTS: A-AGT-S was substantially increased in obese humans and the value was correlated with the plasma AGT level in mice. A-AGT-S and plasma AGT were higher in obese mice, whereas lower in mice with weight reduction. However, the AGT mRNA levels in the liver, kidney, and aorta were not altered in the mouse models. In both humans and mice, the AGT mRNA levels in mature adipocytes (MAs) were comparable to those in stromal-vascular cells. Coulter Multisizer analyses revealed that AGT mRNA levels in the MAs were inversely correlated with the average size of mature adipocytes. CONCLUSIONS: This study demonstrates that adipose tissue-derived AGT is substantially augmented in obese humans, which may contribute considerably to elevated levels of circulating AGT. Adipose tissue-specific regulation of AGT provides a novel insight into the clinical implications of adipose tissue RAS in human obesity.

Long-term preservation of rat skin tissue by epigallocatechin-3-o-gallate.

Skin grafts can be preserved by cryopreservation and refrigerated storage at 4 degrees C. Epigallocatechin-3-O-gallate (EGCG) enhances the viability of stored skin grafts and also extends the storage time up to 7 weeks at 4 degrees C. EGCG, the major polyphenolic constituent present in green tea, has potent antioxidant, antimicrobial, antiproliferative, and free radical scavenging effects. This study examined the effects of EGCG on skin cryopreservation. Skin sample biopsy specimens from GFP rats were previously treated with/without EGCG then moved to -196 degrees C. Skin samples were transplanted to nude mice after 2, 8, and 24 weeks of preservation. Glucose consumption was measured after thawing to assess the metabolic activity. Two weeks later the transplanted skin grafts were excised and histologically analyzed. Histological examinations revealed the degeneration of the epidermal and dermal layers in all groups. In the EGCG groups, the grafts showed higher integrity in the epidermal layer and dermal matrix. The present findings suggest the future clinical usefulness of EGCG for skin preservation; however, the mechanism by which EGCG promotes skin preservation still remains unclear.

Green tea polyphenols affect skin preservation in rats and improve the rate of skin grafts.

Green tea polyphenols have been recently reported to promote the preservation of tissues, such as blood vessels, corneas, nerves, islet cells, articular cartilage, and myocardium, at room temperature. These findings indicate the possibility of a new method of tissue banking without freezing. A main active ingredient of green tea, epigallocatechin-3-gallate (EGCG), is a polyphenol that possesses antioxidant, antimicrobial, antiproliferative, and free radical scavenging effects. This study examined the effects of EGCG regarding skin preservation. Skin sample biopsy specimens measuring 1 x 1 cm from GFP rats were held in sterile containers with 50 ml preserving solution at 4 degrees C and 37 degrees C for up to about 8 weeks. Periodically, some of the preserved skin specimens were directly examined histologically and others were transplanted into nude mice. Histological examinations of skin preserved at 4 degrees C revealed a degeneration of the epidermal and dermal layers from 5 weeks in all groups. In the groups preserved at 37 degrees C, degeneration and flakiness of the epidermal layer were demonstrated starting at 2 weeks preservation regardless of addition of EGCG. After 2-7 weeks of preservation the rat skin grafted to nude mice in the EGCG groups stored at 4 degrees C showed successful engraftment. However, grafts preserved at 4 degrees C without EGCG and at 37 degrees C did not demonstrate GFP-positive keratinocyte or fibroblasts. In conclusion, the present findings suggest the future clinical usefulness of EGCG for skin preservation without freezing; however, the mechanism by which EGCG promotes skin preservation still remains unclear.

Enhanced wound healing by an epigallocatechin gallate-incorporated collagen sponge in diabetic mice.

Epigallocatechin-3-O-gallate (EGCG), the major polyphenolic compound present in green tea, has potent anti-oxidant and free radical-scavenging activities. In this study, various concentrations (10, 100, and 1,000 ppm) of EGCG were incorporated into a collagen sponge (CS) in order to investigate its healing effects on full-thickness wounds created in type 2 diabetic mice. After 14 days, the residual wound size of the mice treated with 10 ppm EGCG-incorporated collagen sponge (E-CS) decreased significantly faster than that of the other mice. Moreover, significant increases in the degree of reepithelialization, the thickness of the granulation tissue, and the density of the capillaries were also histologically observed in the wound sites exposed to 10 ppm E-CS in comparison with the others. Furthermore, 10 ppm E-CS resulted in significant increases in the immunoreactivity of Ki-67 (reepithelialization at the wound site), CD31 (formation of blood vessels), and alpha-smooth muscle actin (the induction of myofibroblasts across the dermis). These results suggest that a CS incorporated with EGCG at low concentrations can enhance wound healing in diabetic mice by accelerating reepithelialization and angiogenesis as well as improving the cellular reorganization of granulation tissue by triggering the activity of myofibroblasts.

Nicotine at a low concentration promotes wound healing.

BACKGROUND: The adverse effects of smoking on wound healing of the skin are known clinically. Recently, an endogenous cholinergic pathway for angiogenesis mediated by endothelial nicotinic acetylcholine receptors was discovered. The objective of this study was to investigate the appropriate concentration of nicotine at which angiogenesis and wound healing are accelerated in a murine excisional wound model. MATERIALS AND METHODS: Full-thickness skin defects (8 mm) were created on the dorsum of C57BL mice and a silicone sheet (8 mm) was sutured. PBS (10 microL), bFGF (1 microg), nicotine (10(-1) M, 10(-3) M, 10(-4) M, 10(-7) M, and 10(-10)M), and both bFGF and 10(-4) M nicotine were topically injected for 7 days. Mice were sacrificed on day 8, and the wound area, the neoepithelium length, and the area of newly formed capillaries were assessed. RESULTS: The wound area was significantly decreased in the wound treated with bFGF, with 10(-4) M nicotine, and with both bFGF and 10(-4) M nicotine. The length of the epithelium was significantly longer and the area of capillaries was also increased significantly in these three groups. The wound area, the length of the epithelium, and the area of capillaries in the group treated with both bFGF and 10(-4) M nicotine were significantly different from those in the 10(-4) M nicotine-treated group. CONCLUSIONS: In this study, nicotine at a low concentration accelerated angiogenesis and promoted wound healing; these effects of nicotine were synergistic with bFGF.

In vivo culturing of a bilayered dermal substitute with adipo-stromal cells.

BACKGROUND: Skin grafting is an important procedure to cover skin defects. Recently, cultured epidermal sheets and bilayered cultured skin have been used clinically, but they lack subcutaneous tissue. The objective of this study was to produce a bilayered dermal substitute with adipose tissue simultaneously in vivo. MATERIALS AND METHODS: We disseminated adipo-stromal cells on one side of a collagen sponge at a density of 1,0 x 10(5)cells/cm(2) and incubated overnight. Then, we turned over the sponge and disseminated dermal fibroblasts and keratinocytes at a density of 1,0 x 10(6)cells/cm(2) on the other side of the sponge. Finally, we cultured this for 1 wk and implanted it on the backs of severe combined immunodeficiency mice with or without basic FGF. RESULTS: Six weeks after implantation, specimens were harvested. Macroscopically, the formed tissue in the bFGF-administered group was thick, and the epidermal component, the dermal component, and adipose tissue were formed in the cross section. The thickness of newly formed tissue in bFGF-administered group was significantly greater than that in the group without bFGF administration. The area of the newly formed capillaries in the bFGF-administered group was significantly larger than that in the group without bFGF administration. CONCLUSIONS: We could produce a thick composite tissue in vivo, combining three kinds of human cells, collagen scaffold, and bFGF. This composite graft was thicker than the bilayered dermal substitute and could be a substitute for a skin flap.

Incorporation of basic fibroblast growth factor into preconfluent cultured skin substitute to accelerate neovascularisation and skin reconstruction after transplantation.

Cultured skin substitutes (CSS) with both epidermal and dermal components seem to be ideal, but they have not been widely used clinically, partly because it takes several weeks to produce them. Decreasing the number of seeding cells may reduce the period required for production, but it still takes a long time before the cells become confluent and neovascularisation is completed in CSS after grafting. As we have already succeeded in reducing the number of seeded keratinocytes in this study, we first attempted to reduce the number of seeded fibroblasts. Consequently, preconfluent CSS with 10 x 10(3) cells/cm2 of fibroblasts combined with 100 x 10(3) cells/cm2 of keratinocytes could be successfully grafted on to full-thickness wounds. bFGF-impregnated gelatin microspheres were then added to the preconfluent CSS before grafting. Incorporation of bFGF significantly accelerated neovascularisation and increased epidermal thickness, cellular components, and thickness of the dermis. The incorporation of bFGF makes CSS a potential therapeutic approach for management of skin wounds.

Effects of bFGF incorporated into a gelatin sheet on wound healing.

Basic fibroblast growth factor (bFGF) is well known to promote the proliferation of almost all cells associated with wound healing. However, as the activation duration of bFGF is very short in vivo, we incorporated bFGF into an acidic gelatin hydrogel and studied the sustained release of bFGF in vivo. In addition, we investigated the effects of the acidic gelatin sheet containing bFGF on wound healing. To distinguish wound contraction from neoepithelialization, we measured both the wound area and neoepithelium length. Other histological parameters such as thickness of granulation tissue and number of capillaries were also determined as indices of wound healing. Fibrous tissue was assessed using an Elastica van Gieson and Azan stain. A skin defect (1.5 x 1.5 cm) of full thickness was created on the back of each test mouse and the wound was covered with an acidic gelatin hydrogel, referred to as a gelatin sheet in this study (2 x 2 cm), with bFGF (100 microg/site) (A) or without bFGF (B). 1, 2, 3, 5, 7 and 14 days after covering, mice were killed and an enzyme-linked immunosorbent assay (ELISA) was performed to estimate the concentration of bFGF in the plasma. In another experiment, each wound was covered with (A), (B) or a hydrogel dressing (control group, C) and the wound area was measured 1 or 2 weeks postoperatively with a computer planimeter. The histological parameters, as mentioned above, were assessed using a light microscope. Sustained release of bFGF from the gelatin sheet was observed and the gelatin sheet containing bFGF promoted neoepithelialization, granulation, neovascularization and wound closure. This gelatin sheet containing bFGF was concluded to be effective for wound healing and promising for clinical use.

Evaluation of the donor site in patients who underwent reconstruction with a free radial forearm flap.

A major disadvantage of free radial forearm flaps is the conspicuous donor site. However, there have been few studies on donor scars. The authors evaluated the donor site in patients who underwent oral-floor reconstruction with a free radial forearm flap. The subjects were 23 patients (19 males and four females) who underwent reconstruction with a free radial forearm flap following resection of a malignant oral tumor, and were followed for 1 year or longer. The fasciocutaneous flap collection site was closed by full-thickness skin graft (FTSG) from the groin with tie-over dressing. All grafts took perfectly. At the scar at the donor site, five items (pigmentation, scar width, depression, wrist mobility, and sensory abnormalities) were evaluated. Depression and pigmentation were often observed, but patient dissatisfaction was slight. While their main postoperative concern was the oral reconstruction site, after about 1 year, the donor site became more important to patients. However, the results were good. A 100 percent take of the FTSG at the donor site should produce good results. Surgeons should pay adequate attention not only to the outcome at the reconstruction site, but also to the closure of the donor site.

Surgery without skin resection for eyelid entropion.

The previously reported surgical methods for eyelid entropion are basically manipulations of the skin or the conjunctival surface. When entropion is marked, manipulations also involve the tarsus. In the most widely used method, the eyelashes are directed outward by horizontal wedge resection of an appropriate amount of the excessive skin in the ciliary vestibule. This method is simple and effective but sometimes causes recurrences, conspicuous scars due to tension of the resection site, or lagophthalmos due to excessive resection. We speculated that partial swelling of the orbicularis muscle at the front of the tarsus is one of the main causes of pediatric eyelid entropion and found that correction of entropion is possible by partial resection of this muscle without skin resection. Eight patients with congenital entropion were treated by this method, and good results were obtained.

Usefulness of palatal mucoperiosteal grafts for artificial eye socket contracture.

The authors performed palatal mucoperiosteal grafting for contracture of the artificial eye socket in 4 patients. Mucoperiosteal grafts were collected from the paramedian area of the hard palate. After release of contracture, the grafts were sutured with absorbable thread to the defective areas on the conjunctival side of the artificial eye socket after release of contracture. All patients showed mucoperiosteal graft survival without problems, no recurrence of contracture, and good courses of artificial eye wear. The mucoperiosteal donor areas showed closed healing after 3 to 4 weeks. Palatal mucoperiosteal grafts can be collected en bloc and are relatively rigid, which allows the simultaneous reconstruction of the conjunctival side and supportive tissue of the eyelid. Although the size of graft collection is limited, grafts with adequate size for partial reconstruction can be collected. Mucoperiosteal grafts are a good reconstruction material for contracture of the artificial eye socket.