Effect of Relaxin Expression from an Alginate Gel-Encapsulated Adenovirus on Scar Remodeling in a Pig Model.

PURPOSE: Relaxin (RLX) is a transforming growth factor-ß1 (TGF-ß1) antagonist that is believed to function as a potent collagen re-arranger and a major suppressor of extracellular matrix components. Adenoviruses (Ads) are accepted vectors for cancer gene therapy. However, repeated treatments of Ad are limited by short-term biological activity in vivo. The efficacy of sustained RLX expression to scar remodeling was assessed using an injectable alginate gel-matrix system. MATERIALS AND METHODS: Pig scar tissue was treated with relaxin-expressing Ad loaded in alginate gel (gel/Ad-RLX). Surface areas, color, and pliability of scars were compared, and various factors influencing scar formation and collagen arrangement were analyzed. RESULTS: Gel/Ad-RLX decreased scar size, color index, and pliability. Immunohistochemistry showed decreased levels of major extracellular matrix proteins in the gel/Ad-RLX-treated group. Furthermore, treatment with gel/Ad-RLX reduced expression of tissue inhibitor of metalloproteinase-1 and alpha-smooth muscle actin and markedly increased expression of matrix metalloproteinase-1 in pig scar tissues. Gel/Ad-RLX also significantly downregulated TGF-ß1 and upregulated TGF-ß3 mRNAs in pig scar tissues. CONCLUSION: These results support a prominent role for RLX in scar remodeling and suggest that gel/Ad-RLX may have therapeutic effects on scar formation.

Effect of Relaxin Expressing Adenovirus on Scar Remodeling: A Preliminary Study.

BACKGROUND: Relaxin is a transforming growth factor ß1 antagonist. To determine the effects of relaxin on scar reduction, we investigated the scar remodeling process by injecting relaxin-expressing adenoviruses using a pig scar model. METHODS: Scars with full thickness were generated on the backs of Yorkshire pigs. Scars were divided into two groups (relaxin [RLX] and Control). Adenoviruses were injected into the RLX (expressing relaxin) and Control (not expressing relaxin) groups. Changes in the surface areas, color index and pliability of scars were compared. RESULTS: Fifty days after treatment, the surface areas of scars decreased, the color of scars was normalized, and the pliability of scars increased in RLX group. CONCLUSION: Relaxin-expressing adenoviruses improved the surface area, color, and pliability of scars. The mechanism of therapeutic effects on scar formation should be further investigated.

Effect of Platelet-Rich Plasma on Ischemia-Reperfusion Injury in a Skin Flap Mouse Model.

Background: Ischemia-reperfusion (I/R) injury is a leading cause of surgical skin flap compromise and organ dysfunction. Platelet-rich plasma (PRP) is an abundant reserve of various growth factors. Activated platelets play a role in endothelial damage during I/R injury; however, exogenous PRP could inhibit the production of reactive oxygen species. The goal of this study was to investigate the effect of PRP on I/R injury. Methods: Four groups (n=30) of C57BL/6N mice with lateral thoracic artery island flaps were used. Group A, the control group, received flap elevation and repositioning. Group B received PRP and repositioning. Group C had 4 hours of ischemia and then were reperfused. Group D received PRP, had 4 hours of ischemia, and then were reperfused. The survival area of flap tissue and blood perfusion were assessed. Histological evaluation included neutrophil counts. Reactive oxygen species and proinflammatory cytokines were measured to evaluate I/R injury. Protein expression of phosphorylated apoptosis signaling regulating kinase-1 (pASK-1), p38MAPK, and pNF-κB was measured by western blot. Results: PRP treatment enhanced the survival area and perfusion of the flap, reduced neutrophil accumulation in mice subjected to I/R injury. PRP treatment also showed a protective effect, with decreases in nitric oxide, myeloperoxidase, malondialdehyde concentrations. Additionally, PRP suppresses monocyte chemotactic protein-1, TNF-α, IL-1ß, and IL-6. Finally, PRP decreased ASK-1 and NF-κB expression in tissues with I/R injury. Conclusion: PRP acts as a protective factor during flap I/R injury by reducing reactive oxygen species level and proinflammatory cytokines via decreased expression of pASK-1 and pNF-κB.

The Effect of Red Ginseng Extract Intake on Ischemic Flaps.

Red ginseng is well known for its angiogenic effects and its effect of increasing expression of vascular endothelial growth factors (VEGFs), but little experimental evidence has been published. In this study, we examined the effect of red ginseng using an ischemic flap model. Twenty male Sprague-Dawley rats were divided into two groups of 10. One group drank red ginseng solution from 7 days prior to surgery to 7 days after, whereas the other group drank distilled water. We created a local flap on the back of each rat. We analyzed the surviving area of the flap for 10 days after surgery and measured the blood flow of the flap. Ten days after the operation, CD31-positive vessels and VEGF expression were examined by immunohistochemistry. The percentages of surviving areas of the flap were 76 ± 3% for the experimental group and 39 ± 5% for the control group (P = 0.0002). Blood flow in the experimental group increased for 10 days after the surgery. The number of newly generated capillaries in the experimental group was 14.0 ± 3.5, which was significantly higher than 5.7 ± 1.9 in the control group. The expression of VEGF in the experimental group was significantly higher than in the control group (p = 0.0003). Administration of red ginseng extract increases the survival of ischemic flaps via angiogenesis and elevated blood flow. Further clinical studies are warranted to apply the effect shown in this current investigation to various ischemic conditions.

Successful eradication of helical rim keloids with surgical excision followed by pressure therapy using a combination of magnets and silicone gel sheeting.

Extremely limited data are available for the treatment of helical rim keloids. The purpose of the present study was to demonstrate the successful treatment of helical rim keloids using surgical exicison followed by a newly designed pressure therapy device. We treated 40 pure helical rim keloids in 36 patients with surgical excisions followed by pressure therapy using a combination of magnets and silicone gel sheeting for 12 hours over a period of 2 years, from May 2012 to February 2014, at tertiary medical centre. The follow-up period was 18 months. Primary outcome was recurrence of keloids. Secondary outcome was patient satisfaction as assessed by the Patient Observer Scar Assessment Scale (POSAS). The overall recurrence-free rate was 95·0% after a follow-up period of 18 months. Scores obtained from the POSAS showed that most items were reported to be improved. This adjuvant therapy protocol resulted in excellent outcomes in cases of helical rim keloids compared to previously published protocols.

Surgical Management of Gynecomastia: Subcutaneous Mastectomy and Liposuction.

BACKGROUND: The treatment of gynecomastia depends on multiple factors, and the best modality is controversial. In this study, we aimed to determine the best management approach by comparing outcomes of two groups of patients with gynecomastia who received subcutaneous mastectomy combined with liposuction and liposuction only. METHODS: We conducted a retrospective analysis of 64 patients who underwent surgery for gynecomastia. We divided the patients into two groups: group A, patients who underwent liposuction only; and group B, patients who underwent liposuction and subcutaneous mastectomy. The serial photographs of all patients were clinically evaluated with respect to size, shape, scarring, and overall outcome by three plastic surgeons, and patient satisfaction was surveyed with regard to palpable lumps, size, shape, scarring, and overall outcome. RESULTS: Of the 64 subjects, 16 received liposuction only, and 48 received the combination procedure. A total of 125 breasts were involved. The doctors' scores for size and overall outcome were significantly better in the combination group, whereas scarring was better in the liposuction-only group. Similarly, patient satisfaction regarding size was significantly higher in the combination group, and satisfaction regarding scarring was significantly higher in the liposuction-only group. The scores for scarring in the combination treatment group were acceptable. CONCLUSION: Our study shows that combination treatment with liposuction and subcutaneous mastectomy results in satisfactory outcomes, including the extent of scarring. We conclude that this combination treatment should be recommended as the standard surgical treatment for gynecomastia and can provide excellent results in cases where glandular tissue needs to be removed. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modulation of heat shock protein 90 affects TGF-ß-induced collagen synthesis in human dermal fibroblast cells.

Heat shock protein 90 is a chaperone molecule that aids in proper folding of target proteins. Recently, heat shock protein 90 was found to play a role in would healing through regulation of fibroblast functions. The aim of the present study was to investigate the role of heat shock protein 90 in collagen synthesis in human dermal fibroblasts. The effects of transforming growth factor-ß, 17-N-allylamino-17-demethoxygeldanamycin, and transfection of heat shock protein 90 were evaluated by real-time PCR, western blot, and immunofluorescence assays. The Smad 2/3 and Akt pathways were evaluated to identify the signaling pathways involved in collagen synthesis. Heat shock protein 90 and collagen levels were compared in keloid and control tissues by immunohistochemical analysis. The expression of collagen was significantly increased after treatment with transforming growth factor-ß, while 17-N-allylamino-17-demethoxygeldanamycin inhibited transforming growth factor-ß-induced collagen synthesis. Overexpression of heat shock protein 90 itself with or without transforming growth factor-ß increased collagen synthesis. These effects were dependent on Smad 2/3 pathway signaling. Finally, expression of heat shock protein 90 was increased in keloid tissue compared with control tissues. Taken together, these results demonstrate that modulation of heat shock protein 90 influences transforming growth factor-ß-induced collagen synthesis via regulation of Smad 2/3 phosphorylation.

Establishment of Patient-Derived Keloid Xenograft Model.

Recent advances on preclinical model based on patient-derived tumor xenografts have new insight into many clinical fields. According to our literature review, many authors believe that immunodeficient animals such as athymic rats and mice should be used to prevent tissue loss caused by acute rejection to establish patient-derived tumor xenografts models.However, recent advances showed that the microenvironment has gained attention as an important factor responsible for disease progression. Additionally, researchers attempt to come up with novel findings in chemotherapy drugs and immune modulator to control development of keloid. For these reasons, establishment of reliable animal model of keloids is very important.In this new model using an immunocompetent animal as a humanized-xenografts model, human keloid scar has been maintained for as long as 4 months. Results of migration assay have demonstrated that typical morphology of keloid fibroblast was preserved based on multiple time point observations despite its aging change. Quantitative real time polymerase chain reaction findings suggested that after implantation, there has been significant increase of vascular endothelial growth factor, CD34, and transforming growth factor beta 1 expression despite insignificant changes of hypoxia inducible factor 1 an matrix metallopeptidase 1, and matrix metallopeptidase 9 gene expression. These findings suggested that implantation of keloids within the immunocompetent animals yields is very useful experimental model in terms of fibrosis.In summary, the authors have successfully established and propagated patient-derived keloid model using the immunocompetent animals. This model could be used to test novel materials as well as combination therapies and is superior to the conventional cell line experiment models. In addition, the biology of the keloids can easily be assessed to identify predictive markers for responses to treatment regimens that are currently actively under research in various centers.

Pretarsal Augmented Lower Blepharoplasty.

BACKGROUND: Narrow and chubby pretarsal fullness is a characteristic of attractiveness and youthfulness, and pretarsal augmentation has gained popularity in Asia. Conventional lower blepharoplasty has focused on correcting the aged appearance of the lower eyelids by repositioning fat and removing excess skin. However, this technique can create flat lower eyelids and provide an indication that cosmetic surgery was performed. Therefore, our pretarsal augmented lower blepharoplasty technique focuses on restoring pretarsal fullness and creating a three-dimensional lower eyelid-cheek complex. The authors present the results of this technique, which demonstrate that it simultaneously enhances lower eyelid support and restores pretarsal fullness. METHODS: This retrospective chart review evaluated 659 consecutive patients who underwent pretarsal augmented lower blepharoplasty between 2011 and 2014. All procedures were performed by a single surgeon (H.L.C.). The outcomes and complications were assessed by evaluating the patients' preoperative and postoperative digital photographs and medical records. RESULTS: There were no permanent major complications, such as retrobulbar hemorrhage, diplopia, or hypertrophic scarring. Chemosis occurred in 90 patients (13.7 percent), 10 patients (1.5 percent) underwent minor revision because of an undercorrected nasojugal groove or loosened orbicularis oculi muscle suspension suture, and three patients (0.46 percent) experienced mild ectropion that resolved spontaneously. Approximately 98 percent of the patients were satisfied. Our technique provided a natural and younger appearance with pretarsal fullness, rather than the flattened appearance that is associated with conventional blepharoplasty. CONCLUSIONS: Pretarsal augmented lower blepharoplasty uses simple methods to restore pretarsal fullness. This technique improves periorbital contouring, rejuvenates the pretarsal roll, and provides excellent aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Rejuvenation of the deep superior sulcus in the eyelid.

BACKGROUND: Nowadays, a number of patients seeking cosmetic surgery for their sunken upper eyelid are increasing. The aim of this study was to provide an overview of the various treatment options for sunken superior sulcus with reported complications and to discuss effective methods for treatment. METHODS: In a PubMed search, studies involving patients undergoing correction of sunken superior sulcus with various treatment options were included. RESULTS: A systematic search revealed twelve articles representing 680 cases that satisfied inclusion criteria. All were case series, and no randomized controlled studies were found. Five reported on augmentation of the deformity with surgery, while hyaluronic acid filler was used in four reports. There was a report attempting to correct the deformity by the microautologous fat grafting. The combined surgical approaches including ptosis correction with upper blepharoplasty and appropriate fat grafting were used in two reports. About 7.2% of patients (49/680) experienced complications, with 4.3% requiring re-operation, while no severe complications were observed. CONCLUSIONS: By careful identification of the clinical features and proper classification of the types of sunken superior sulcus, the treatment plan can be specified.

Botulinum Toxin A Upregulates Rac1, Cdc42, and RhoA Gene Expression in a Dose-Dependent Manner: In Vivo and in Vitro Study.

UNLABELLED: Angiogenesis is the development of new capillaries from existing blood vessels and is a prerequisite for the wound-healing process. Many lines of scientific evidences have shown that complicated roles of small guanosine triphosphatases (GTPases) (ras-related C3 botulinum toxin substrate 1 [Rac1], cell division control protein 42 [Cdc42], and ras homolog gene family, member A [RhoA]) in regulation of signal transduction pathways exist to transmit distinct cellular effects on the modulation of actin cytoskeleton remodeling such as cell cycle progression, cell survival, and cell motility. In addition, these small GTPases activate mitogen-activated protein kinase kinase kinases (MAP3Ks) leading to activated mitogen-activated protein kinase kinases (MAPKK), mitogen-activated protein kinase (MAPK), and various transcription factors such as vascular endothelial growth factor with involvement of MAPK signaling pathways.In this study, the authors hypothesized that botulinum toxin A increases angiogenesis via the expression of small GTPases in vivo and in vitro studies.In vivo experiment, 24 Sprague-Dawley rats were randomly divided into 2 groups: a control group and a botulinum toxin A group. Five days prior to superiorly based transverse rectus abdominis myocutaneous flap elevation, the botulinum toxin A (BoTA) group was pretreated with BoTA, while the control group was pretreated with normal saline. quantitative real-time polymerase chain reaction was performed to evaluate the expression of Rac1, RhoA, and Cdc42.The angiogenic effects of botulinum toxin A on human dermal fibroblasts were measured in vitro experiment. To understand the mechanism of botulinum toxin A on small GTPases production of fibroblasts, Rac1, Cdc42, and RhoA were measured using qRT-PCR.The relative messenger ribonucleic acid expression of Rac1, RhoA, and Cdc42 was significantly higher in the BoTA group than in the control group, in every zone and pedicle muscle, on postoperative days 1, 3, and 5. Levels of these molecules increased significantly in human dermal fibroblasts grown in the presence of BoTA compared with control group over 5 IU.Our in vivo and in vitro studies suggest that administration of BoTA upregulates the expression of RhoA, Rac1, and Cdc42 in a dose-dependent manner. MAPK signaling pathway might be involved in BoTA-induced angiogenesis mechanism. LEVEL OF EVIDENCE: N/A.

Comparing the Effect of Nonactivated Platelet-Rich Plasma, Activated Platelet-Rich Plasma, and Bone Morphogenetic Protein-2 on Calvarial Bone Regeneration.

Although platelet-rich plasma (PRP) is widely used to enhance bone graft survival, the effect of PRP itself on bone regeneration is unclear. Because activated PRP releases many growth factors in a bolus, there are controversies regarding the effect of activation of the PRP on bone regeneration. Thus, we studied the effect of activated versus nonactivated PRP on bone regeneration and compared the effect with that of recombinant human bone morphogenetic protein-2 (rhBMP-2) in a critical-sized cranial defect model. Forty New Zealand white rabbits were randomly divided into 4 groups. Defect sizing 15 × 15 mm(2) was created on the cranium of each rabbit, and then a collagen sponge soaked with normal saline, rhBMP-2, nonactivated PRP, or PRP activated with CaCl2 solution was immediately placed on the defect. After 16 weeks, using three-dimensional computed tomography and digital photography, the volume and new bone surface area were measured. The newly created bone was histologically analyzed. The experimental groups showed a significantly increased volume and surface area of new bone compared with the control group (P < 0.05), but no significant differences were found among the experimental groups. Histologic examination in the experimental groups showed newly created bone that had emerged in the center as well as the margin of the defect. Overall, these results indicate that PRP enhanced bony regeneration regardless of activation with an effect that was comparable to that of rhBMP-2. Thus, PRP has therapeutic effects on bone regeneration and may replace rhBMP-2, which is costly.

Foreign body reactions may not influence the keloid recurrence.

PURPOSE: The foreign body reactions are comprised of macrophages and foreign body giant cells and are considered possible risk factors for recurrence in several conditions. The purpose of this study was to determine the effect of pathologically proven foreign body reactions on the recurrence of the auricular keloids. METHODS: This study was carried out in 76 cases in 70 patients reaching the pathologic diagnosis of auricular keloids from March 2006 to February 2012. Patients with auricular keloids were included in the study according to the following criteria: The keloid scar was caused by ear piercing and confirmed pathologically; surgical excision with primary closure was performed; and female patients who have not underwent any previous treatments. To compare any differences of recurrence rate between categorical variables (the presence/absence of foreign body reactions), Fisher's exact tests were used. All patients completed the treatment protocol with a follow-up interval of 18 months. RESULTS: Of these patients, 90.9% (69 keloids) had successful irradication of their auricular keloids, whereas 9.2% (seven keloids) had recurrences. Of the seven recurrent cases, two exhibited foreign body reactions at pathology, while five revealed no foreign body reactions (28.6% vs. 71.4%, P = 0.092). CONCLUSIONS: Detection of foreign body reactions in keloid tissue may not predict recurrence in auricular keloids.

Quantitative Mandibular Angle Ostectomy Facilitated by Oscillating-Blade Saw With Scalable Guide.

BACKGROUND: Although various techniques of mandibular angle ostectomy have been devised to correct overly prominent bony contours, none have incorporated methods to delineate the surgical line with precision. Herein, the authors describe one means of marking an ostectomy line more easily, using a specially designed oscillating-blade saw. METHODS: Between July 2013 and June 2014, a total of 75 patients underwent quantitative mandibular angle ostectomy using a custom oscillating-blade saw equipped with a scalable guide. Corticectomy, also done routinely to improve frontal appearance, called for a reciprocating saw only. Aesthetic outcomes gauged subjectively by the questionnaire about satisfaction and symmetry after postoperative 6 months. RESULTS: Satisfaction score was 4.9 and symmetric score was 4.7. No major complications, such as persistent nerve injury or fracture, were encountered. CONCLUSIONS: Use of an oscillating-blade saw equipped with a scalable guide facilitated quantitative mandibular angle ostectomy, enabling precise, and reproducible surgery with satisfactory outcomes with less complications.

Bilirubin provides perforator flap protection from ischaemia-reperfusion injury in a rat model: a preliminary result.

The use of bilirubin, a well-known and powerful antioxidant, has gained popularity in recent years because of its role in the prevention of ischaemic heart disease in patients with Gilbert's syndrome. We investigate the effects of bilirubin on ischaemia-reperfusion (I/R) injury using a rat perforator flap model. Forty-eight rats were randomly divided into two groups: experimental (bilirubin) group (n = 24) and control group (n = 24). In each group, elevated bilateral deep inferior epigastric perforator (DIEP) flaps were created. The right (no ischaemia side) and left (ischaemia side) DIEP flaps were separated according to the presence of ischaemia induction. Ischaemia was induced in anaesthetised rats by perforator clamping for 15 or 30 minutes. After surgery, the flap survival was assessed daily on postoperative days 0 to 5, and overall histological changes of DIEP flaps above the perforator were analysed at postoperative day 5. The flap survival rate in the bilirubin group was significantly higher than that in the control group at the ischaemia side following perforator clamping for 15 or 30 minutes (93·42 ± 4·48% versus 89·63 ± 3·98%, P = 0·002; and 83·96 ± 4·23% versus 36·46 ± 6·38%, P < 0·001, respectively). The difference in flap survival between the two groups was the most prominent on the ischaemic side following 30 minutes of perforator clamping. From a morphologic perspective, pre-treatment with bilirubin was found to alleviate perforator flap necrosis caused by I/R injury in this experimental rat model.

Presurgical Botulinum Toxin A Treatment Increases Angiogenesis by Hypoxia-Inducible Factor-1α/Vascular Endothelial Growth Factor and Subsequent Superiorly Based Transverse Rectus Abdominis Myocutaneous Flap Survival in a Rat Model.

To date, there have been several experimental studies to assess tissue viability of transverse rectus abdominis myocutaneous (TRAM) flaps. Botulinum toxin A (BoTA) has gained popularity in many clinical fields, for a variety of therapeutic and aesthetic purposes. In addition, there have been reports regarding the positive effect of BoTA on flap survival by various mechanisms. In this study, we hypothesized that pretreatment with BoTA could augment the survival of TRAM flaps via increased hypoxia-inducible factor (HIF)1α/vascular endothelial growth factor (VEGF)-dependent angiogenesis.Twenty-four Sprague-Dawley rats were randomly divided into 2 groups: a control group and a BoTA group. Five days before superiorly based TRAM flap elevation, the BoTA group was pretreated with BoTA, whereas the control group was pretreated with normal saline. Gross flap survival rates were assessed, and quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) and Western blotting were performed for the evaluation of angiogenesis-related factors (CD34, HIF-1α, and VEGF).In the BoTA group, the gross flap survival rate was significantly higher than that in the control group on both ipsilateral (92.78.3 ± 5.05% vs 86.8 ± 3.88%, P = 0.009) and contralateral (91.57 ± 5.79% vs 74.28 ± 11.83%, P < 0.001) sides.The relative mRNA expression of CD34 and VEGF was significantly higher in the BoTA group than that in the control group in every zone, whereas the relative mRNA expression of HIF-1α was significantly higher in the BoTA group than that in the control group on contralateral sides. The relative protein expression of CD34, VEGF, and HIF-1α was significantly higher in the BoTA group than that in the control group in every zone.In conclusion, we demonstrate that presurgical BoTA treatment might increase angiogenesis by HIF-1α/VEGF, subsequently increase superiorly based TRAM flap survival in a rat model.

Hepatocyte growth factor-expressing adenovirus upregulates matrix metalloproteinase-1 expression in keloid fibroblasts.

BACKGROUND: Keloids are marked by an overabundance of extracellular matrix. The antifibrotic effect of hepatocyte growth factor (HGF) is achieved by increasing the expression of matrix metalloproteinases (MMPs) that drive extracellular matrix catabolism. As such, we cultivated an RGD-modified HGF-expressing adenovirus (dE1-RGD/lacZ/HGF) for introduction into keloid fibroblasts (KFs), looking at the subsequent impact on MMP-1 expression. METHODS: KFs infected with either test virus as experimental group (dE1-RGD/lacZ/HGF) or its counterpart (dE1-RGD/lacZ) as control group were examined for HGF protein expression using an enzyme-linked immunosorbent assay (ELISA). Collagen (types I and III) and MMP-1 mRNA levels were also determined by reverse transcriptase-polymerase chain reaction, and ELISA was used to monitor MMP-1 protein expression. RESULTS: In KFs harboring the test virus, high levels of HGF were induced at a multiplicity of infection ratio of 50 (3260.6 ± 162.7 pg/ml) after 72 hours of incubation. Furthermore, reverse transcriptase-polymerase chain reaction and ELISA confirmed that MMP-1 mRNA and protein expression rose significantly in KFs after transduction by the test virus (P < 0.05). However, mRNA levels of collagen were unaffected by the experimental group. CONCLUSION: These results suggest that an HGF-expressing adenovirus may be therapeutic for keloids by increasing MMP-1 expression.

The Protective Effects of Botulinum Toxin A Against Flap Necrosis After Perforator Twisting and Its Underlying Molecular Mechanism in a Rat Model.

PURPOSE: The purpose of this study was to examine our hypotheses that botulinum toxin A (BoTA) protect necrosis of perforator flap from perforator twisting. METHODS: Twenty-four rats were randomly divided into 2 groups. Twelve International Units of BoTA versus 1.2 mL normal saline was injected subdermally 3 days before flap elevation. In each group, bilateral before deep inferior epigastric perforator (DIEP) flaps, 5 × 3 cm in size, were created. The right and left (180 and 360 degrees of perforator twisting) DIEP flaps were separated. At 1 and 3 days postoperatively, skin above the perforator of the DIEP flaps was harvested to examine the degrees of gene expressions. Final survival percentage of flap and histology were assessed at postoperative day 5. RESULTS: The survival percentage of flap was significantly higher in the BoTA group than in the control group at both DIEP flaps after 180 and 360 degrees of perforator twisting at postoperative day 5 (95.23 ± 2.85% vs 91.00 ± 3.77%; P = 0.021 and 91.59 ± 2.87% vs 30.03 ± 6.91%; P < 0.001, respectively).Higher fibroblast density, enhanced epithelial necrosis, and inflammation were noted in the control group than in the BoTA group. In 180 degrees of perforator twisting group, BoTA may augment angiogenesis possibly via nuclear factor-κB-induced destabilization and the nuclear factor-κB/hypoxia-inducible factor 1-α/vascular endothelial growth factor pathway, whereas in the 360 degrees of perforator twisting group, the mechanistic target of rapamycin/hypoxia-inducible factor 1-α/vascular endothelial growth factor pathway may participate in BoTA-induced effective angiogenesis. CONCLUSIONS: We demonstrated that pretreatment with BoTA protects perforator flap caused by perforator at the pathological and molecular level using an experimental rat model.

Functional Outcomes of Multiple Sural Nerve Grafts for Facial Nerve Defects after Tumor-Ablative Surgery.

BACKGROUND: Functional restoration of the facial expression is necessary after facial nerve resection to treat head and neck tumors. This study was conducted to evaluate the functional outcomes of patients who underwent facial nerve cable grafting immediately after tumor resection. METHODS: Patients who underwent cable grafting from April 2007 to August 2011 were reviewed, in which a harvested branch of the sural nerve was grafted onto each facial nerve division. Twelve patients underwent facial nerve cable grafting after radical parotidectomy, total parotidectomy, or schwannoma resection, and the functional facial expression of each patient was evaluated using the Facial Nerve Grading Scale 2.0. The results were analyzed according to patient age, follow-up duration, and the use of postoperative radiation therapy. RESULTS: Among the 12 patients who were evaluated, the mean follow-up duration was 21.8 months, the mean age at the time of surgery was 42.8 years, and the mean facial expression score was 14.6 points, indicating moderate dysfunction. Facial expression scores were not influenced by age at the time of surgery, follow-up duration, or the use of postoperative radiation therapy. CONCLUSIONS: The results of this study indicate that facial nerve cable grafting using the sural nerve can restore facial expression. Although patients were provided with appropriate treatment, the survival rate for salivary gland cancer was poor. We conclude that immediate facial nerve reconstruction is a worthwhile procedure that improves quality of life by allowing the recovery of facial expression, even in patients who are older or may require radiation therapy.

Heat Shock Protein 90 Inhibitor (17-AAG) Induces Apoptosis and Decreases Cell Migration/Motility of Keloid Fibroblasts.

BACKGROUND: The regulation of apoptosis, proliferation, and migration of fibroblasts is altered in keloids. The 90-kDa heat shock protein (heat shock protein 90) is known to play a key role in such regulation. Therefore, the authors investigated whether the inhibition of heat shock protein 90 in keloid fibroblasts could induce apoptosis and attenuate keloid fibroblast proliferation and migration. METHODS: The authors evaluated heat shock protein 90 expression in keloid tissues with immunohistochemistry. The authors used cell viability [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assays and annexin V/propidium iodide staining for apoptosis, a wound healing model and cell tracking system to assess cell migration, and Akt Western blotting analysis in keloid fibroblasts after inhibition of heat shock protein 90 with 17-allylaminodemethoxygeldanamycin (17-AAG). RESULTS: The expression of heat shock protein 90 in keloid tissues was significantly increased compared with normal tissues. The 17-AAG-treated keloid fibroblasts showed significantly decreased proliferation, promotion of apoptosis, and decreased expression of Akt. Furthermore, a dose-dependent decrease in cell migration was noted after 17-AAG treatment of keloid fibroblasts. The 17-AAG-treated keloid fibroblasts had less directionality to the wound center and migrated a shorter distance. CONCLUSIONS: The authors confirmed that the inhibition of heat shock protein 90 in keloid fibroblasts could promote apoptosis and attenuate proliferation and migration of keloid fibroblasts. Therefore, the authors think that the inhibition of heat shock protein 90 is a key factor in the regulation of biological processes in keloids. With further preclinical study, the authors will be able to apply these results clinically for keloid treatment.