Successful management for repeated bar displacements after Nuss method by two bars connected by a stabilizer.

The Nuss method has become the standard surgery for the treatment of funnel chest, and good therapeutic results have been reported. Among the complications of the Nuss method, displacement of the bar is the most frequent, and there are cases in which reoperation is necessary. In this case report, we have devised a new stabilizer that connects and fixes two bars as bar displacement occurred following each of the two prior Nuss procedures, and the outcome of our procedure was evaluated.

Effect of Mature Adipocyte-Derived Dedifferentiated Fat Cells on Formation of Basement Membrane after Cultured Epithelial Autograft on Artificial Dermis.

BACKGROUND: Artificial dermis is an important option for preparing full-thickness wounds for cultured epithelial autografting. Long-term fragility after cultured epithelial autografting remains a problem, probably because of the lack of basement membrane proteins. The authors hypothesized that treating artificial dermis with mesenchymal stem cells would promote basement membrane protein production. The authors tested this using dedifferentiated fat cells in a porcine experimental model. METHODS: This study used four male crossbred (Landrace, Large White, and Duroc) swine. Cultured epithelium and dedifferentiated fat cells were prepared from skin and subcutaneous fat tissue harvested from the cervical region. Full-thickness open dorsal wounds were created and treated with artificial dermis to prepare a graft bed for cultured epithelial autograft. Two groups were established: the control group (artificial dermis treated with 0.5 ml of normal saline solution applied to the wounds) and the dedifferentiated fat group (artificial dermis treated with 0.5 × 10 dedifferentiated fat cells suspended in 0.5 ml of normal saline solution sprayed onto the wounds). On postoperative day 10, the prepared cultured epithelium was grafted onto the generated dermis-like tissue. Fourteen days later, tissue specimens were harvested and evaluated histologically. RESULTS: Light microscopy of hematoxylin and eosin-stained sections revealed the beginning of rete ridge formation in the dedifferentiated fat group. Synthesis of both collagen IV and laminin-5 was significantly enhanced in the dedifferentiated fat group. Transmission electron microscopy revealed a nearly mature basement membrane, including anchoring fibrils in the dedifferentiated fat group. CONCLUSION: Combined use of artificial dermis and dedifferentiated fat cells promotes post-cultured epithelial autograft production and deposition of basement membrane proteins at the dermal-epidermal junction and basement membrane development, including anchoring fibrils.

Stability of Orbital Floor Fracture Fixation After Endoscope-Assisted Balloon Placement.

In recent years, endoscope-assisted balloon fixation using transantral and endonasal approaches has gained popularity as a minimally invasive treatment for orbital floor fractures. However, the optimal duration for balloon placement and the efficacy of the method have not been fully evaluated. The authors report their assessment of this method using postoperative and chronological measurements of the maxillary sinus volume.Fourteen patients with blowout fracture of the orbital floor who underwent reduction using endoscopic transantral and endonasal approaches followed by 6-week fixation with a balloon were evaluated. The volume of the maxillary sinus was measured for comparison using computed tomography at the time of balloon removal and 6 months after the surgery.The ratio of change in the maxillary sinus volume (maxillary sinus volume 6 months after surgery/maxillary sinus volume at balloon removal) for all subjects was 0.90 to 1.04 (0.96 ±â€Š0.44, mean ±â€ŠSD). No postoperative reduction in volume was detected, indicating satisfactory fixation. Postoperative computed tomography showed bone regeneration in the orbital floor in all patients in whom the fractured bone fragments were removed. No subjects had remaining enophthalmos greater than 2 mm.The postoperative change in the maxillary sinus volume was small, confirming the efficacy of 6-week balloon placement. This method was effective even in patients in whom fractured bone fragments were removed. Therefore, it is advisable to remove the fractured bone fragments if there is concern that the fragments will stray into the orbit due to inflation of the balloon.

Endoscopic Endonasal Repair of Isolated Medial Orbital Wall Fracture With Balloon Technique.

Endonasal endoscopic repair of medial orbital wall fractures is minimally invasive and benefits the patients. The authors describe the authors' modified balloon technique, which allows longer support of the orbital wall. From October 2010 through January 2016, the author repaired 9 isolated medial wall fractures by this method. Five patients were diagnosed as having enophthalmos of greater than 2 mm, and 6 patients had persistent diplopia before the operation. The herniated orbital contents that filled the anterior ethmoidal sinus were gently reduced with a 4-mm-diameter 0° sinus endoscope. Then a posterior nasal cavity balloon (Type B # 32014, KOKEN Co, Japan) was inserted into the ethmoidal sinus and filled with normal saline. The inflation tube of the balloon was sutured to the nasal cavity wall with absorbable sutures. After checking the status of the balloon, the inflation tube was ligated and cut so that it could be hidden inside the nasal cavity. The balloon was removed on an outpatient basis 6 to 7 weeks after the surgery. In this series, the mean inflation volume of the balloon was 1.6 mL, the mean period of leaving the balloon in place was 5.7 weeks, and the mean operative time was 38.6 minutes.Resolution of the preoperative diplopia and enophthalmos was achieved in all 9 patients, and there was no recurrence of prolapse of the orbital contents. This method allows leaving the balloon in place for a long period of time without interfering with daily life, which reduces the risk of rebulging of the orbital contents.

The Effect of Mature Adipocyte-Derived Dedifferentiated Fat (DFAT) Cells on a Dorsal Skin Flap Model.

BACKGROUND: Dedifferentiated fat (DFAT) cells, isolated from mature adipose cell, have high proliferative potential and pluripotency. We report on the expansion of flap survival areas on the back of rats administrating DFAT cells. MATERIALS AND METHODS: Intraperitoneal adipose tissue was collected from a male Sprague-Dawley (SD) rat. The mature fat cells were cultured on the ceiling surface of culture flask to isolate DFAT cells. On day 7 of the culture, the flask was inverted to allow normal adherent culture. A dorsal caudal-based random pattern flap measuring 2 × 9 cm was raised on each SD rat. We prepared a control group (n = 10) and a flap base injection group in which DFAT cells were injected 2 cm from the flap base (n = 10) and a flap center DFAT injection group (n = 10). In which DFAT cells at 1 × 106 cells/0.1 ml were injected beneath the skin muscle layers of the flap. The flap survival areas were assessed on day 14 after surgery. RESULTS: The mean flap survival rates of the control group, flap center injection group and flap base injection group were 53.6 ± 6.1%, 50.6 ± 6.4% and 65.8 ± 2.4%, respectively. The flap survival areas significantly expanded in the flap base injection group (p < .05). In H-E staining beneath the skin muscle layer connective tissue thickened in the flap base injection group. In the India ink staining, abundant neovascularization was observed inside the thickened parts. CONCLUSION: The injection of DFAT cells into the flap base promoted the expansion of survival areas.

Effects of combination therapy using basic fibroblast growth factor and mature adipocyte-derived dedifferentiated fat (DFAT) cells on skin graft revascularisation.

BACKGROUND: Although the benefits of basic fibroblast growth factor (bFGF) for wound healing and angiogenesis are well known, its effects on the process of skin graft revascularisation have not been clarified. It was hypothesised that bFGF would be beneficial to promote taking of skin grafts, but that the effect might be limited in the case of bFGF monotherapy. Therefore, this study investigated the efficacy of combination therapy using bFGF and dedifferentiated fat (DFAT) cells. DFAT cells have multilineage differentiation potential, including into endothelial cells, similar to the case of mesenchymal stem cells (MSC). METHODS: Commercially available human recombinant bFGF was used. DFAT cells were prepared from SD strain rats as an adipocyte progenitor cell line from mature adipocytes. Full-thickness skin was lifted from the back of SD strain rats and then grafted back to the original wound site. Four groups were established prior to skin grafting: control group (skin graft alone), bFGF group (treated with bFGF), DFAT group (treated with DFAT cells), and combination group (treated with both bFGF and DFAT cells). Tissue specimens for histological examination were harvested 48 hours after grafting. RESULTS: The histological findings for the bFGF group showed vascular augmentation in the grafted dermis compared with the control group. However, the difference in the number of revascularised vessels per unit area did not reach statistical significance against the control group. In contrast, in the combination group, skin graft revascularisation was significantly promoted, especially in the upper dermis. CONCLUSION: The results suggest that replacement of the existing graft vessels was markedly promoted by the combination therapy using bFGF and DFAT cells, which may facilitate skin graft taking.

Effects of mature adipocyte-derived dedifferentiated fat (DFAT) cells on generation and vascularisation of dermis-like tissue after artificial dermis grafting.

Although artificial dermis (AD) is effective for skin reconstruction, it requires two separate procedures, because the AD must be vascularised before skin grafts. To shorten the period of the dermis-like tissue generation before the secondary skin grafting must be beneficial. Dedifferentiated fat (DFAT) cells are isolated from mature adipose cell suspensions and have potential to differentiate into multiple cell types including endothelial cells. This study aimed to investigate effects of DFAT cells on dermal regeneration after AD grafts in rats. The effects of combination use of DFAT cells and basic fibroblast growth factor (bFGF) were also tested to mimic clinical situations. DFAT cells were isolated from SD rats. Full-thickness wounds were created on the back of rats followed by AD grafting. Five groups were established; Group I: control, Group II: treated with DFAT cells, Group III: treated with bFGF, Group IV: treated with both of DFAT cells and bFGF, and Group V: treated with Green fluorescent protein (GFP)-labelled DFAT cells and bFGF. Histological evaluation was serially performed. Group IV showed markedly promoted vascularisation of dermis-like tissue. In particular, capillary infiltration into the dermis was obtained within 2 days. Immunohistochemical examination revealed that the transplanted DFAT cells had differentiated into endothelial cells and participated in angiogenesis. Group IV also showed a marked increase in the thickness of the dermis like tissue. The present results suggest that the use of DFAT cells under bFGF treatment could be beneficial to shorten the period required for dermal regeneration and vascularisation and contribute to use AD more effectively and safely.

Successful management of the cervicothoracic esophagus reconstruction by expanded skin flap.

The limited availability of reconstruction materials can often make it difficult to treat defects in the esophagus caused by necrosis of the transplanted intestinal tissue after cervicothoracic esophagus reconstruction. We were forced to perform flap reconstruction on a patient who suffered necrosis due to impeded blood flow of the transplanted intestinal tract after twice conducting cervicothoracic esophagus reconstruction with an intestinal tract flap. The procedure we performed was esophagus reconstruction using a pectoralis major myocutaneous flap that had been expanded with a tissue expander due to the small volume of tissue available to perform the reconstruction. This case suggested that esophagus reconstruction with a skin flap using a tissue expander should be considered as a possible treatment choice when performing reconstruction of the cervicothoracic esophagus, which requires stable blood flow and a large amount of tissue.

Endoscopic transmaxillary repair of orbital floor fractures: a minimally invasive treatment.

Although endoscopic transmaxillary repair of orbital floor fractures is a minimally invasive treatment, controversy remains regarding the method for supporting the orbital floor after elevation of the orbital contents. To date, a urethral balloon catheter has been widely used. However, it can be difficult to leave the catheter in place for a long time period due to the inconvenience, and prolapse of the orbital contents may recur in the case of its premature removal. This study described the techniques for endoscopic reduction and use of a balloon for orbital floor fractures. From June 2006 through November 2011, 30 of 52 patients (57.7%) with an isolated orbital floor fracture underwent endoscopic transmaxillary repair. A maxillary sinus balloon (#3007, Koken Co., Japan) was inserted into the maxillary sinus to support the orbital floor after endoscopic transmaxillary reduction, and the connecting tube of the balloon was pulled into the nasal cavity through the maxillary ostium. After confirmation of accurate reduction by postoperative CT, the connecting tube was shortened and hidden in the nasal cavity. The balloon was left in place for 4-8 weeks, and then removed via the maxillary ostium on an outpatient basis. Complete resolution of the preoperative diplopia was achieved in 93%, and no late-developing enophthalmos was seen in 97% of the patients. There were no significant complications. This technique is safe and permits prolonged retention of the balloon, without interfering with daily life.

Wound dressing material containing lyophilized allogeneic cultured cells.

Although topical application of a single growth factor is known to accelerate wound healing, treatment with allogeneic cultured cells is more efficient and physiological, because they release various mediators that interact and regulate the wound healing mechanism. However, in clinics, the cells must be cryopreserved until use. To overcome this inconvenience, we designed novel wound dressing materials containing lyophilized allogeneic cultured epithelial cells and/or fibroblasts. This study aimed to confirm growth factor release from those lyophilized products. The results revealed that the cultured cells retained their morphology even after lyophilization and released growth factors. When fibroblasts were used alone, they released growth factors in significantly higher concentrations after lyophilization than after cryopreservation. In particular, bFGF release was almost a hundredfold higher in the lyophilized group compared to the cryopreserved group. When epithelial cells and fibroblasts were co-cultured, both bFGF and VEGF were released in higher concentrations by the cryopreserved dressing material than by the lyophilized dressing material. The growth factors' release was probably regulated by interaction between epithelial cells and fibroblasts. We speculate that repeated application may be necessary for treating difficult wounds with the lyophilized product, because the lyophilized cells release the mediators in a single, transient burst.

False-negative monitoring flap in free jejunal transfer.

We treated a case that exhibited dissociation between blood flow in the transferred jejunum and the monitoring flap. The monitoring flap showed a false-negative, indicating blood flow to be favorable despite blood congestion in the transferred jejunum. The patient was a 69-year-old man. After tumor resection, reconstruction was performed with free jejunal transfer. Vascular anastomosis was performed on the jejunal artery and transverse cervical artery and on the jejunal vein (V1) and external jugular vein. After esophagus anastomosis, blood congestion was noted in the transferred jejunum. An engorged arcade vein (V2) was observed in the mesenterium on the transferred jejunum side. Therefore, it was anastomosed to the external jugular vein bifurcation. The first postoperative day, thrombus had formed in the vein (V2). The transferred jejunum side vein (V2) was re-anastomosed to the external jugular vein, and improved blood flow was observed in the transferred jejunum. Monitoring transferred jejunum blood flow with monitoring flap exteriorization appears to be a simple and highly reliable method. However, because the monitoring flap cannot directly evaluate transferred jejunum blood flow, blood flow obstruction can occur between the transferred jejunum and the true situation may not be reflected.

The estimation of tissue loss during tangential hydrosurgical debridement.

The preservation of healthy tissue during surgical debridement is desirable as this may improve clinical outcomes. This study has estimated for the first time the amount of tissue lost during debridement using the VERSAJET system of tangential hydrosurgery. A multicenter, prospective case series was carried out on 47 patients with mixed wound types: 21 (45%) burns, 13 (28%) chronic wounds, and 13 (28%) acute wounds. Overall, 44 (94%) of 47 patients achieved appropriate debridement after a single debridement procedure as verified by an independent photographic assessment. The percentage of necrotic tissue reduced from a median of 50% to 0% (P < 0.001). Median wound area and depth increased by only 0.3 cm (6.8%) and 0.5 mm (25%), respectively. Notably, 43 (91%) of 47 wounds did not progress into a deeper compartment, indicating a high degree of tissue preservation.

Administration of a peroxynitrite decomposition catalyst into the bronchial artery attenuates pulmonary dysfunction after smoke inhalation and burn injury in sheep.

Reactive nitrogen species such as peroxynitrite play a significant role in burn and smoke inhalation injury. The bronchial circulation increases more than 10-fold in response to this combination injury. We hypothesized that direct delivery of low-dose WW-85, a peroxynitrite decomposition catalyst, into the bronchial artery would attenuate burn- and smoke inhalation-induced acute lung injury. In adult female sheep (n = 17), the bronchial artery was cannulated in preparation surgery. After a 5- to 7-day recovery period, sheep were subjected to a burn (40% total body surface area, third degree) and inhalation injury (48 breaths of cotton smoke, <40°C). The animals were divided into three groups following the injury: (i) WW-85 group: 1 h after injury, WW-85 (0.002 mg/kg per hour) was continuously infused into the bronchial artery, n = 5; (ii) control group: 1 h after injury, an equivalent amount of saline was injected into the bronchial artery, n = 6; (iii) sham group: no injury, no treatment, same operation and anesthesia, n = 6. All animals were mechanically ventilated and fluid resuscitated equally. In the control group, the injury induced a severe deterioration of pulmonary oxygenation and shunting and an increase in pulmonary microvascular permeability toward sham. The injury was further associated with an increase in reactive nitrogen species in lung tissues of the control group. All these alterations were significantly attenuated in the WW-85 group. We demonstrated that a low dosage of WW-85 directly administered into the bronchial artery attenuated pulmonary dysfunction to the same extent as higher systemically administered doses in previous experiments. Our data strongly suggest that local airway production of peroxynitrite contributes to pulmonary dysfunction following smoke inhalation and burn injury.

Administration of poly(ADP-ribose) polymerase inhibitor into bronchial artery attenuates pulmonary pathophysiology after smoke inhalation and burn in an ovine model.

Poly(ADP-ribose) polymerase (PARP) is well known to be an enzyme that repairs damaged DNA and also induces cell death when overactivated. It has been reported that PARP plays a significant role in burn and smoke inhalation injury, and the pathophysiology is thought to be localized in the airway during early stages of activation. Therefore, we hypothesized that local inhibition of PARP in the airway by direct delivery of low dose PJ-34 [poly(ADP-ribose) polymerase inhibitor] into the bronchial artery would attenuate burn and smoke-induced acute lung injury. The bronchial artery in sheep was cannulated in preparation for surgery. After a 5-7 day recovery period, sheep were administered a burn and inhalation injury. Adult female sheep (n=19) were divided into four groups following the injury: (1) PJ-34 group A: 1h post-injury, PJ-34 (0.003mg/kg/h, 2mL/h) was continuously injected into the bronchial artery, n=5; (2) PJ-34 group B: 1h post-injury, PJ-34 (0.03mg/kg/h, 2mL/h) was continuously injected into bronchial artery, n=4; (3) CONTROL GROUP: 1h post-injury, an equivalent amount of saline was injected into the bronchial artery, n=5; (4) Sham group: no injury, no treatment, same operation and anesthesia, n=5. After injury, all animals were placed on a ventilator and fluid resuscitated equally. Pulmonary function as evaluated by measurement of blood gas analysis, pulmonary mechanics, and pulmonary transvascular fluid flux was severely deteriorated in the control group. However, the above changes were markedly attenuated by PJ-34 infusion into the bronchial artery (P/F ratio at 24h: PJ-34 group A 398±40*, PJ-34 group B 438±41*†‡, Control 365±58*, Sham 547±47; * vs. sham [p<0.05], † vs. control [p<0.05], ‡ vs. PJ-34 group A [p<0.05]). Our data strongly suggest that local airway production of poly(ADP-ribose) polymerase contributes to pulmonary dysfunction following smoke inhalation and burn.

Preliminary report of novel technique for cryopreservation--vacuum-assisted cryoprotectant infiltration.

To date, cryopreservation of large soft tissues has not been successfully achieved because of limitation of cryoprotective agent (CPA) infiltration into the tissue. This study aimed to investigate the effects of a vacuum on the tissue-infiltration of a CPA. An instant pickle-maker was modified for use as a vacuum apparatus, and glycerol was selected as the CPA. Twenty-six rats were used, and their thighs were divided into three treatment groups. Group 1: fresh control; Group 2: cryopreserved control, i.e., immersed in the CPA for 1h under atmospheric pressure and cryopreserved; Group 3: vacuum-assisted CPA infiltration, i.e., immersed in the CPA under negative pressure (20, 40 and 60 cmHg, for durations of 10, 20 and 30 min at each) and cryopreserved. The Groups 2 and 3 specimens were thawed after 3 weeks of cryopreservation at -80 °C and histologically examined, in comparison with Group 1. Skin: in Groups 2 and 3, the skin was well preserved. Muscle: in Group 2, both extracellular and intracellular ice crystal formation was widely distributed throughout the muscle tissue. In Group 3, under an adequate vacuum, the muscle tissue was well preserved, with no ice crystal formation. However, when the treatment was conducted under excessive vacuum conditions, the muscle tissue showed focal necrosis. Blood vessels: in Group 3, both the arteries and veins were well preserved up to the tunica intima. The method described in this paper may be a useful technique for achieving cryopreservation of large soft tissues.

Usefulness of radial recurrent artery in transplant of radial forearm flap: an anatomical and clinical study.

Because of its long and stable pedicle, the radial forearm flap is very useful for salvage operations in which there are few choices of recipient vessels. However, pedicle length deficiency and size discrepancy of anastomotic vessels still exist. In such cases, the radial recurrent artery that bifurcates from the radial artery can be used as an anastomotic vessel. Anatomical variations of the recurrent radial artery were studied in 18 cadavers. The branch types were classified as branch from radial artery (Type A), branch from radial artery root (Type B), branch from brachial artery (Type C), and branch from ulnar artery (Type D). Radial artery and radial recurrent artery diameters were measured. The radial recurrent artery was used as an anastomotic vessel in four salvage operations. Branching type variations were Type A: 61.1%, Type B: 33.3%, Type C: 0%, and Type D: 5.6%. Radial recurrent artery diameter was 1.84 ± 0.59 mm at the 20 mm point from bifurcation. In clinical cases, all flaps survived without any anastomotic difficulties. Thus, anastomosis using radial recurrent artery vessels is recommended as a strategy in free radial forearm transplantation for salvage operations.

Successful management of a thick transverse vaginal septum with a vesicovaginal fistula by vaginal expansion and surgery.

We present a case of a thick transverse vaginal septum with a vesicovaginal fistula treated with vaginal expansion using dilators, followed by surgery. A 27-year-old woman was admitted to our hospital with vaginal atresia and cyclical hematuria. Urethroscopy and cystography showed a vesicovaginal fistula between the proximal vagina and bladder. The vaginal septum was 4 cm thick. Over a 6-month period, the distal vagina was expanded with the use of dilators and the septum was sufficiently thinned. Reconstruction using a transvaginal and transabdominal approach created a direct anastomosis between the proximal and distal vagina. No vaginal strictures or contractures in the anastomotic region have been observed during the 12 months following surgery. The combination of expansion and subsequent reconstructive surgery for the treatment of a thick transverse vaginal septum with a vesicovaginal fistula was less invasive than alternative surgical approaches and provided the desired outcome.

Granular cell tumor of the suprasternal space.

A case of granular cell tumor (GCT) was reported. We encountered a 33-year-old woman with a painless, elastic, hard mass in the soft tissue of the suprasternal space. The tumor was excised with several millimeters margin of normal tissue above the deep cervical fascia and the wound was closed primarily. Histological examination on hematoxylin-eosin stain showed a tumor growth in the mid- to deep dermis and eosinophilic small granules that were consistent with granular cell tumors. Immunohistochemical studies showed positive staining for S-100 protein. We experienced a case of a granular cell tumor occurring in the suprasternal space and report the importance of including it in the differential diagnosis of subcutaneous soft tissue tumors.

Treatment of mesh skin grafted scars using a plasma skin regeneration system.

Objectives. Several modalities have been advocated to treat traumatic scars, including surgical techniques and laser resurfacing. Recently, a plasma skin regeneration (PSR) system has been investigated. There are no reports on plasma treatment of mesh skin grafted scars. The objective of our study is to evaluate the effectiveness and complications of plasma treatment of mesh skin grafted scars in Asian patients. Materials and Methods. Four Asian patients with mesh skin grafted scars were enrolled in the study. The plasma treatments were performed at monthly intervals with PSR, using energy settings of 3 to 4 J. Improvement was determined by patient questionnaires and physician evaluation of digital photographs taken prior to treatment and at 3 months post treatment. The patients were also evaluated for any side effects from the treatment. Results. All patients showed more than 50% improvement. The average pain score on a 10-point scale was 6.9 +/- 1.2 SD and all patients tolerated the treatments. Temporary, localized hypopigmentation was observed in two patients. Hyperpigmentation and worsening of scarring were not observed. Conclusions. Plasma treatment is clinically effective and is associated with minimal complications when used to treat mesh skin grafted scars in Asian patients.