Creating and Transferring an Innervated, Vascularized Muscle Flap Made from an Elastic, Cellularized Tissue Construct Developed In Situ.

Reanimating facial structures following paralysis and muscle loss is a surgical objective that would benefit from improved options for harvesting appropriately sized muscle flaps. The objective of this study is to apply electrohydrodynamic processing to generate a cellularized, elastic, biocomposite scaffold that could develop and mature as muscle in a prepared donor site in vivo, and then be transferred as a thin muscle flap with a vascular and neural pedicle. First, an effective extracellular matrix (ECM) gel type is selected for the biocomposite scaffold from three types of ECM combined with poly(ester urethane)urea microfibers and evaluated in rat abdominal wall defects. Next, two types of precursor cells (muscle-derived and adipose-derived) are compared in constructs placed in rat hind limb defects for muscle regeneration capacity. Finally, with a construct made from dermal ECM and muscle-derived stem cells, protoflaps are implanted in one hindlimb for development and then microsurgically transferred as a free flap to the contralateral limb where stimulated muscle function is confirmed. This construct generation and in vivo incubation procedure may allow the generation of small-scale muscle flaps appropriate for transfer to the face, offering a new strategy for facial reanimation.

Usefulness of intraoperative monitoring for mesenteric lymph node metastasis in transplanted free jejunum.

We herein report a rare case of a patient with hypopharyngeal squamous cell carcinoma (SCC) who presented with recurrent metastasis in the mesenteric lymph node of a transplanted jejunum. Removal of the metastatic lymph node required resection of the nutrient vessels which risked the current state of the transplanted jejunum. Importantly, although the nutrient vessels were resected, the jejunum did not become necrotic. This case and another similar case indicate that it may be possible to predict the viability of a transplanted jejunum where jejunal nutrient vessels must subsequently be resected. Key indicators for jejunal survival include determining jejunal blood flow by intraoperative indocyanine green fluorescence imaging, confirming good jejunal color and observation of peristaltic movement by intraoperative blood flow blockage of nutrient vessels. In conclusion, if intraoperative indocyanine green fluorescence imaging in the entire jejunum can be confirmed, there is a high possibility that the jejunum can be well preserved. The clinical presentation and clinical course are described with a proposed new schema of the resectable site of the transplanted jejunal mesentery.

Posterior ischemic optic neuropathy following postoperative bleeding and internal jugular vein compression.

Perioperative blindness, especially posterior ischemic optic neuropathy (PION), is an uncommon but potentially devastating complication. We report a case of a 65-year-old male patient who underwent laryngopharyngectomy, bilateral neck dissection, and free jejunum flap reconstruction, but then experienced PION in his right eye following postoperative bleeding and bilateral internal jugular veins (IJVs) compression. Despite systemic corticosteroid therapy, his visual recovery prognosis was poor. The specific mechanism responsible for PION remains unclear, and no therapy has been shown to improve this condition. As such, prevention of perioperative PION remains the only available strategy. Surgeons should be aware of this rare potential complication and its risk factors and strive to avoid it. As postoperative bleeding and IJV compression are one of important risk factors for PION, avoiding these are critical.

Intermediate Outcomes of Orbital Wall Reconstruction Using Different Alloplastic Materials: Which Is Ideal?

BACKGROUND: Despite the popularity and superiority of resorbable alloplastic materials in orbital fracture reconstruction, it is unclear whether the reconstructed wall is maintained after implant resorption. Unsintered hydroxyapatite/poly-L-lactide (u-HA/PLLA) is one such material, but it differs from conventional materials for the replacement of natural bones. This study investigated the intermediate-term safety and efficacy of u-HA/PLLA implants compared with those of implants made with other alloplastic materials. METHODS: The authors retrospectively analyzed 240 eligible patients who underwent orbital fracture reconstruction with one alloplastic material between January of 2006 and October of 2018. Materials used for treatment were as follows: u-HA/PLLA sheet in 101 patients, u-HA/PLLA mesh in 38 patients, poly-L-lactic acid/poly-glycolic acid mesh in 47 patients, silicone sheet in 35 patients, and titanium mesh in 19 patients. Intermediate-term follow-up was performed for a median duration of 48.2 months. A chart review was performed. Postoperative complications and factors affecting them were studied. Reconstructed area deformities were assessed using computed tomography. RESULTS: Postoperative complications occurred significantly more frequently in patients reconstructed with the silicone sheet than in those reconstructed with the u-HA/PLLA sheet. Deformities were found for the silicone sheet (28.6 percent) and poly-L-lactic acid/poly-glycolic acid mesh (31.9 percent). These deformity rates were significantly higher than those for the u-HA/PLLA sheet. CONCLUSIONS: Compared with other alloplastic materials, u-HA/PLLA has low rates of postoperative complications and reconstructed area deformities. Because of its complete absorption, clinicians should consider using u-HA/PLLA as an alloplastic material for orbital wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Genetic Panel Test of Double Cancer of Signet-Ring Cell/Histiocytoid Carcinoma of the Eyelid and Papillary Thyroid Carcinoma: Case Report and Literature Review.

Signet-ring cell/histiocytoid carcinoma (SRCHC) is a rare, aggressive neoplasm that often originates in the eyelid. We present a rare case of a 64-year-old male with SRCHC and papillary thyroid carcinoma (PTC) that underwent exome panel sequencing with next-generation sequencing (NGS). In addition, we reviewed reports of genetic mutations in SRCHC and compared them with our results. The imaging findings allowed us to recognize the differences in pathology between the left and right cervical nodes. For first-line treatment, an extended total maxillectomy with orbital exenteration and dissection of the left neck was performed. Two months later, total thyroidectomy and right neck dissection were performed. Two years after surgery, multiple bone metastases occurred. An exome panel sequence with NGS was used to determine the chemotherapy regimen. Notably, somatic mutations in cadherin 1 (CDH1), human epidermal growth factor receptor 2 (ERBB2), neurofibromin 1 (NF1), and tumor protein p53 (TP53) were detected. These mutations are rarely detected in PTC; therefore, cervical metastases are assumed to originate from SRCHC. To our knowledge, there have been no reports of simultaneous cancer of SRCHC and PTC. Somatic mutations in CDH1, ERBB2, NF1, and TP53 were detected in the exome panel sequence of the metastatic lymph nodes of SRCHC and correlated with previous reports of SRCHC.

Breast reconstruction using a tissue expander after enucleation of a giant fibroadenoma: A case report.

INTRODUCTION: Fibroadenomas are among the most common benign tumors in women. Juvenile giant fibroadenomas account for nearly 0.5% of all fibroadenomas. Due to its size, a giant juvenile fibroadenoma leaves a large defect or deformity after its resection. The optimal surgical management strategy for giant juvenile fibroadenomas remains unclear. Here, we report a case of successful breast reconstruction without residual deformity through gradual deflation of a saline-filled tissue expander after resection of a giant juvenile fibroadenoma. PRESENTATION OF CASE: A 14-year-old girl with a growing tumor in her left breast presented to a private clinic. Given that the tumor was 8 cm in size, phyllodes could not be ruled out. Consequently, she was referred to our hospital for further examination and treatment. Core needle biopsy confirmed the tumor to be a fibroadenoma. We resected the tumor and inserted a tissue expander filled with 120 mL of saline, matching the area of the large defect caused by tumor resection. We removed approximately 25 mL of saline every 3 weeks to aid normal mammary tissue enlargement. After completely draining saline from the tissue expander and confirming an acceptable enlargement of the residual mammary gland, we performed an operation to remove the tissue expander. Follow-up revealed that the symmetry and contour of the breast were excellent after the second operation. CONCLUSIONS: Our observations suggest that using a tissue expander to enlarge normal mammary tissue may help reconstruct large defects caused by excision of benign tumors.

Symptomatic cystic lesions as late post-operative complications of silicone implantation for orbital wall fracture reconstruction: A long-term follow-up study.

Although complications of silicone implants and development of new materials have led to a decline in the use of silicone implants for orbital wall fractures, their advantages are still reported. The overall incidence, risk factor and treatment of silicone implant complications, especially those caused by cystic lesions, remain unclear. We aimed to report our experiences of patients with orbital wall fractures that were reconstructed with silicone implants and followed up for a long period. We retrospectively analysed 56 patients who underwent surgical repair of the orbital wall fractures with a silicone implant from January 2006 to December 2017 and were followed up for more than 6 months. A chart review and the assessment of demographic and surgical factors, among others, were performed. There were 47 eligible patients in this study, and the mean post-operative follow-up period was 83.1 months. When comparing the results obtained 6 months post-operatively with those obtained at the final follow-up, the overall complication rate increased from 5/47 to 13/47, and the silicone implant removal rate increased from 0/47 to 10/47. The symptoms caused by the cystic lesions were managed through silicone implant removal. The immediate post-operative bleeding was significantly associated with silicone implant survival (p = 0.008). Silicone implants used for orbital wall fractures were never stabilised during the long-term study. Much attention should be paid during the follow-up of high-risk patients. Most late complications were caused by cystic lesions, and only silicone implant removal would be sufficient and considered safe as the initial intervention.

Burn on the buttocks caused by gel wheelchair cushion left on driver's seat of hand control car.

Context: Nowadays, people with paraplegia and quadriplegia have greater opportunities to venture into the general public. However, there is also an increased risk of associated hazards.Findings: This report describes a 42-year-old man with paraplegia, who was insensate below the T7 level and sustained burns from sitting on a gel wheelchair cushion that had been left on the driver-side seat of a hand control car on a sunny day. Physical examination revealed deep partial-thickness burns on both his buttocks. He underwent surgical debridement and received an autologous split-thickness skin graft, and healed well.Conclusion In modern times, the lives of people with paralysis are no longer restricted to the bed and wheelchair. Active people with spinal cord injuries inevitably diversify the use of wheelchair cushions in many ways; therefore, there is a greater possibility for the occurrence of associated hazards. This is a preventable issue, so both the user and manufacturers should recognize this potential hazard of gel wheelchair cushions.

Immediate and long-term results of unsintered hydroxyapatite and poly L-lactide composite sheets for orbital wall fracture reconstruction.

INTRODUCTION: Bone defect reconstruction in orbital wall fractures with absorbable alloplastic such as the unsintered hydroxyapatite and poly L-lactide composite (u-HA/PLLA) system is gaining popularity. The u-HA/PLLA material has osteoconductive and osteosynthetic properties. However, quantitative, long-term outcome data after the use of u-HA/PLLA for orbital wall fractures are lacking. PATIENTS AND METHODS: We retrospectively analyzed 115 patients who underwent surgical repair of orbital wall fractures with a u-HA/PLLA sheet from 2011 to 2016. A chart review was performed, and the time-dependent changes at fracture sites were assessed by imaging. The immediate postoperative and the latest follow-up bony orbital volumes of the affected side were compared. RESULTS: Seventy patients were eligible for this study (mean age, 44.6 ± 22.1 years; 48 men and 22 women; mean follow-up period, 29.7 ± 12.8 months). Except for one case of hematoma, there were no postoperative wound complications. Of the 70 patients, 10 had postoperative diplopia and 2 had enophthalmos; these conditions were presumably caused by the extension and severity of the fracture. Satisfactory reduction in the entire orbital wall, without pathological changes, was demonstrated. There were no significant differences in the mean bony orbital volumes of the affected side immediately after surgery (24.774 ± 3.092 cm3) and at the latest follow-up (24.749 ± 3.205 cm3) (p = 0.756). CONCLUSION: The u-HA/PLLA sheet is useful for orbital wall fracture reconstruction because of its desirable handling characteristics, initial mechanical strength, long-term maintenance of structural stability, radiopacity, and few associated complications. Future randomized controlled trials need to be performed to compare u-HA/PLLA with other conventional materials.

Selection of recipient vessels for free flap following intra-arterial chemoradiotherapy.

OBJECTIVE: This study aims at selecting recipient vessels for free flap following intra-arterial chemoradiotherapy. At present, many centers combine intra-arterial chemotherapy and concomitant radiotherapy for treating head and neck cancer with favorable results. However, some patients develop recurrent, residual disease/complications after completing treatment protocols and thus require free-flap surgery. The feasibility of microsurgery following intra-arterial chemoradiotherapy remains unclear. STUDY DESIGN AND METHODS: We retrospectively analyzed 730 patients who underwent free-flap surgery for managing treatment-related complications/defects following head and neck surgery from January 1999 to February 2012. All patients were categorized into two groups according to the presence (group A)/absence (group B) of a history of intra-arterial chemotherapy. Microvascular revision rates were compared between the groups. In group A, the correlation between catheterization sites and recipient vessels used for microsurgery was assessed. RESULTS: A total of 769 free flaps were created in 730 patients and comprised 36 and 733 flaps in groups A and B, respectively. Microvascular revision rates were 2.8% (1/36) and 4.2% (31/733) in groups A and B, respectively, with no significant difference observed between the groups. No statistically significant difference was observed when only cases of arterial thrombosis were included. Vessels used for recipient anastomoses were not directly exposed to intra-arterially injected agents. CONCLUSION: Preoperative intra-arterial chemoradiotherapy does not significantly increase the risk of microvascular revisions, particularly artery-related revisions, if vessels selectively catheterized and perfused with chemotherapeutic agents during intra-arterial chemotherapy are avoided as recipient vessels.

Salvage surgery and microsurgical reconstruction for recurrence of skull base osteosarcoma after carbon ion radiotherapy.

Carbon ion radiotherapy has recently emerged as an alternative choice of treatment for malignant tumors of the head and neck. However, it is still in the infant stages and its influence on subsequent salvage surgery remains unclear. Here we report the case of a 43-year-old woman who underwent salvage surgery for left frontal bone osteosarcoma recurrence following carbon ion radiotherapy. Tumor resection was performed with a wide margin including the tissue considered to have been damaged by carbon ion radiotherapy. The dural defect was reconstructed using a fascia lata graft and pedicled galeal pericranial flap. The soft tissue defect was reconstructed using an anterolateral thigh flap anastomosed to the ipsilateral neck interposed by the radial forearm flap. As the patient developed no postoperative wound complications, she was able to initiate adjuvant chemotherapy early. Carbon ion radiotherapy is useful for its focused distribution and strong biological effects. Although the affected field may be limited, its high potency may severely damage adjacent normal tissue and lead to serious postoperative complications. Despite these concerns, satisfactory results were achieved in this case.

Antitumor activity of an interleukin-2 monoclonal antibody in a murine osteosarcoma transplantation model.

BACKGROUND: Injection of monoclonal antibody to interleukin-2 (S4B6) into mice depletes regulatory T-cells (Tregs) and exhibits antitumor activities mediated through an autoimmune reaction. In this study, we demonstrate that administration of S4B6 suppresses the murine osteosarcoma cell line, LM8. MATERIALS AND METHODS: LM8 osteosarcoma cells were transplanted subcutaneously into C3H mice (n=58). C3H mice were injected intraperitoneally with S4B6 starting at 7 days before LM8 transplantation (pre-S4B6 group), 2 days after transplantation, or 5 days after transplantation. Control group mice were injected with normal rat IgG. Mice were sacrificed and examined 4 weeks later. RESULTS: The number of pulmonary metastatic colonies and the tumor size were significantly reduced in the pre-S4B6 group compared to the control group. In addition, pulmonary metastases were inhibited in mice injected with S4B6 2 days, but not 5 days, after tumor transplantation. CONCLUSION: S4B6 administration inhibited metastasis even when injected 2 days after LM8 transplantation. Our data suggest that treatment with S4B6 might be suitable in a postoperative clinical setting.

The tumor suppressive effect of angiotensin II type 1 receptor antagonist in a murine osteosarcoma model.

BACKGROUND: Angiogenesis is involved in the growth and metastasis of most solid tumors. Several reports have demonstrated that angiotensin II stimulates growth and migration of certain cancer cell lines and induces angiogenesis through up-regulation of vascular endothelial growth factor. This study examined whether an angiotensin II type 1 receptor (AT1R) antagonist (CV11974) inhibits osteosarcoma progression and distant metastasis. MATERIALS AND METHODS: Osteosarcoma (LM8) was transplanted into subcutaneous dorsal tissue of C3H mice. The mice were administered CV11974 daily by intraperitoneal injections at 0.1 mg/kg, 1 mg/kg, or 10 mg/kg, or saline for 28 days. RESULTS: Subcutaneous tumor size was smaller in the CV11974 treatment groups than in the control group. Lung and liver metastases were significantly reduced in the CV11974 treatment groups when compared with the control group. CONCLUSION: CV11974 is widely used to treat hypertension clinically and therefore may be a novel antiangiogenic therapy for osteosarcoma through blocking AT1R-mediated signaling.

Suppression of tumour metastasis in a murine osteosarcoma model with anti-CD25 monoclonal antibody treatment.

BACKGROUND: Mouse regulatory T cells (Treg) may be deleted by intraperitoneal injection of anti-CD25 monoclonal antibody (mAb) (PC61). When Treg populations are thus suppressed, the immune system attacks tumours in autoimmune reactions. MATERIALS AND METHODS: An osteosarcoma (LM8) was transplanted subcutaneously into C3H/He mice. Serial injections of PC61 were conducted from seven days before (pre-PC61 group) or from two days thereafter (post-PC61 group) and tumour growth and metastasis were examined four weeks later. A control group received PBS injections. RESULTS: Subcutaneous tumours were reduced in size and the numbers of lung and liver metastatic colonies were significantly decreased in both pre- and post-PC61 groups compared to the control group. CONCLUSION: Tumour suppression was effective even when injection of PC61 was performed two days after LM8 transplantation. These results indicate that such treatments might be suitable to be applied in the clinic after surgical operations.