Use of non-enhanced angiography to assist the second toetip flap transfer for reconstruction of the fingertip defect.

Toetip flap transfer is a useful reconstructive method for fingertip defect, but elevation of a toetip flap is technically demanding because of difficulty to dissect a pedicle vein of the flap. Recently, nonenhanced angiography (NEA) has been reported to be useful for preoperative visualization of the digital vessels without contrast enhancement or invasiveness. We report a case in which preoperative NEA visualized a vein suitable for a venous pedicle of a second toetip flap and facilitated successful toetip flap transfer for reconstruction of a fingertip defect. A 27-year-old male suffered from the right middle fingertip crush amputation in Tamai zone 1. The fingertip was reconstructed using a second toetip flap with preoperative NEA guidance. A pedicle vein was easily found and dissected exactly where NEA visualized. Nine months after the toetip flap transfer, the reconstructed right middle finger was functionally and aesthetically pleasing, and the toe nail at the donor site was preserved without any morbidity. NEA may help a surgeon to find drainage veins for a toetip flap, which leads to easier and more secure toetip flap transfer.

Wound blotting: a convenient biochemical assessment tool for protein components in exudate of chronic wounds.

Because wound exudate includes secreted proteins that affect wound healing, its biochemical analysis is useful for objective assessment of chronic wounds. Wound blotting allows for collection of fresh exudate by attaching a nitrocellulose membrane onto the wound surface. To determine its applicability for several analysis methods and its executability in clinical wound assessment, this study comprised an animal experiment and clinical case reports. In the animal experiment, full-thickness wounds were created on the dorsal skin of mice, and exudate samples were collected daily by a conventional method and by wound blotting. Extremely small but adequate volumes of exudate were collected by wound blotting for subsequent analysis in the animal experiments. Immunostaining showed the concentration and distribution of tumor necrosis factor (TNF) α. The activity of alkaline phosphatase was visualized by reaction with chemiluminescent substrate. The TNF distribution analysis indicated three different patterns: wound edge distribution, wound bed distribution, and a mostly negative pattern in both the animal and clinical studies, suggesting association between the TNF distribution pattern and wound healing. Our results indicate that wound blotting is a convenient method for biochemical analysis of exudate and a candidate tool with which to predict the healing/deterioration of chronic ulcers.

Using indocyanine green fluorescent lymphography and lymphatic-venous anastomosis for cancer-related lymphedema.

Advances in cancer therapy have increased the importance of improvement of quality of life after cancer survival. Cancer-related lymphedema or secondary lymphedema that occurs after lymph node dissection in resection of tumors of abdominal visceral organs can impair quality of life. However, standard curative treatment for secondary lymphedema has not been established. This may be due to the lack of a method for early diagnosis of lymphedema, and because of selection of conservative treatment such as compression therapy to delay edema progression in many cases. To develop a curative approach, we have performed definite diagnosis of early-stage lymphedema using magnetic resonance imaging and an indocyanine green fluorescent lymphography, followed by surgical treatment with lymphatic-venous anastomosis using supermicrosurgery. Herein, we report the first case of secondary lymphedema in which we performed early diagnosis and surgery using these techniques and achieved an almost complete cure of lymphedema. We suggest that early diagnostic imaging and early microsurgery is the key of lymphedema treatment.

Reconstruction of the larynx and aryepiglottic fold using a free radial forearm tendocutaneous flap after partial laryngopharyngectomy: a case report.

The patient was a 62-year-old man with chief complaints of pharyngeal pain and dysphagia. He was diagnosed with pyriform sinus poorly differentiated squamous cell carcinoma T3N0M0 (Stage II) and underwent partial laryngopharyngectomy, lymphadenectomy in the right neck, tracheostomy, and reconstruction of the larynx and aryepiglottic fold with a free radial forearm flap and the associated vascularized palmaris longus tendon. No particular problems occurred after surgery, and swallowing and articulation functions were successfully recovered. A free jejunum transfer is the first choice for reconstruction of a defect after partial hypopharyngectomy, but reconstruction of the supracricoid complex structure of the larynx using a free jejunum transfer after partial laryngopharyngectomy may lead to aspiration of intestinal fluids. In this case, we performed functional reconstruction of the laryngopharyngeal defect using a free radial forearm flap including a vascularized tendon of the palmaris longus, and satisfactory postoperative function was achieved. We believe that the key to successful functional recovery after partial laryngopharyngectomy is establishment of the three-dimensional complex structure of the arytenoid and aryepiglottic fold.

Lymphaticovenous anastomosis for facial lymphoedema after multiple courses of therapy for head-and-neck cancer.

Lymphaticovenous anastomosis (LVA) is a treatment for lymphoedema that can improve lymph circulation by the anastomosis of lymph vessels and veins. A therapeutic effect of LVA for lymphoedema has been shown in limbs, but efficacy for other regions has not been shown. Lymphoedema in the head-and-neck region following cancer resection and radiotherapy is mainly treated with manual lymphatic drainage. However, there is no alternative when this treatment is ineffective because application of compression treatment using a bandage is difficult in this region. We used LVA for lymphoedema in the head-and-neck region and achieved a good outcome. Functional and dilating lymph vessels were identified using pre- and intra-operative fluorescent lymphography, and a lymph vessel with a diameter of about 0.2-1.0 mm was anastomosed with a vein using supermicrosurgery. The outcome of this case suggests that LVA is applicable for treatment of lymphoedema in the head-and-neck region.

Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema.

Measurement of the circumference is the most commonly used method for evaluating extremity lymphedema. However, comparison between different patients is difficult with this measurement. To resolve this problem, we have formulated a new index, lower extremity lymphedema (LEL) index, which can be easily obtained from measurements of the body. We evaluated correlation between lower LEL index and clinical stage in patients with LEL. The LEL indices were significantly correlated with clinical stages and could be used as a severity scale. The LEL index makes objective assessment of the severity of lymphedema through a numerical rating, regardless of the body type. This numerical rating makes the index useful for evaluation of lymphedema severities between different cases.

Prophylactic cross-face nerve flap for muscle protection prior to facial palsy.

The facial muscles of a 28-year-old woman with left acoustic neuroma were successfully protected with a vascularised cross-face nerve flap using a vascularised lateral femoral cutaneous nerve along with a perforator of the lateral circumflex femoral system. It was transferred as a vascularised cross-face nerve flap to bridge a 15-cm-long defect between the bilateral buccal branches. Three months after the nerve flap transfer, the total tumour including the facial nerve was resected. Postoperatively, rapid nerve sprouting through the nerve flap and excellent facial reanimation were obtained 3-6 months after resection. This method is a one-stage reconstruction procedure, has minimal donor-site morbidity and results in strong postoperative muscle contraction. To our knowledge, this is the first report on a prophylactic cross-face nerve flap technique for the protection of facial muscles before facial nerve transection, and also the usefulness of vascularised lateral femoral cutaneous nerve flap.

Combination of Ultrasonographic and Thermographic Assessments for Predicting Partial-thickness Pressure Ulcer Healing .

UNLABELLED: The ability to predict the prognosis of a pressure ulcer is re- quired to establish appropriate management in the early phase. The present study reports the usefulness of a combined assessment tech- nique using ultrasonography and thermography for predicting delayed wound healing. METHODS: This retrospective cohort study included 37 patients with Stage I or II pressure ulcers. The patients were followed up for at least 3 weeks. The ultrasonographic and thermographic as- sessments were conducted at the initial multidisciplinary team round. The presence of four ultrasonographic features (unclear layered struc- ture, hypoechoic lesion, discontinuous fascia, and heterogeneous hy- poechoic area) and one thermographic feature (increased temperature) were determined from within the wound bed. Wound healing was re- assessed after 2 weeks and the rate of area reduction was calculated to determine whether the pressure ulcer was healing properly. A mul- tivariate logistic analysis was used to assess the predictive values of the possible assessment features. RESULTS: A comprehensive review of the ultrasonographic and thermographic assessments of the pressure ulcers found that the combination of unclear layered structure and increased temperature was beneficial for predicting wound healing. When a pressure ulcer presented with an unclear layered structure and increased temperature in the wound bed, the risk of delayed wound healing or wound deterioration was 6.85 times higher compared with a pressure ulcer that did not have these manifestations. CONCLUSION: The combination of ultrasonographic and thermographic assessments facilitates precise prediction of pressure ulcer outcomes.

Fascicular turnover flap for nerve gaps.

BACKGROUND: It is well known that free vascularised nerve grafts have a potential for rapid axonal sprouting. However, they are not very popular as the surgical techniques are complicated. With the recent development of supramicrosurgical techniques and microanatomy of nerve trunks, a new method, 'fascicular turnover method', using vascularised fascicular flap was used for repairing nerve gaps. METHODSAND RESULTS: Arterial embalming method, using rat sciatic nerves, was employed to observe fascicular micro-vascularisation. Rich vascular network systems were observed within and outside the rat island nerve flaps. Four cases with digital and facial nerves gaps were repaired with fascicular turnover flap without a nerve graft. Three patients had digital nerve gaps (10-20mm in length) and one had a 3-cm facial nerve gap. The results of sensory recovery of digital nerve gap were 3.22-3.66 (Semmes-Weinstein values) and 6-12mm (moving two-point discriminations) at 6 and -16 months after surgery, respectively. CONCLUSION: The advantages of this method are: retention of the normal donor nerve, a shorter operation time and repair of the digital nerve gaps under local anaesthesia. Fascicular flap is a vascularised nerve flap with fast and accurate nerve sprouting in comparison to a non-vascularised graft. Excellent nerve regeneration can be expected even in cases with longer nerve gap and scarred recipient bed. It is a simple and quick surgery compared to free vascularised nerve flaps. In addition, there is no functional loss because of the sacrificed fascicle in the operated area. The only disadvantage is the need to employ superficial palmar branch of radial artery (SPRA)-microsurgical techniques using a 50-micron needle.

New thoracodorsal artery perforator (TAPcp) flap with capillary perforators for reconstruction of upper limb.

BACKGROUND: Thoracodorsal artery perforator (TAP) flap is not yet popularised because the dominant large muscle perforators are often absent. Even in those cases, small capillary perforators exist around the proximal portion of the lateral border of the latissimus dorsi muscle, and they have a potential of a large skin territory. To overcome the weakness of thoracodorsal artery muscle perforator (TAP-MCp) and septocutaneous perforator (TAP-SCp) flaps, we present a new TAP flap with capillary perforators (TAPcp) flap. METHODS AND RESULTS: A total of 14 patients with upper-limb defects were repaired with free TAPcp flap. Among them were three combined TAP flaps with vascularised scapula bone flap and eight flow-through flaps. Recipient sites were one axilla, three upper arms, one elbow, two forearms and seven hands. The only postoperative complication was a partial necrosis of the flaps. CONCLUSION: A new TAP flap with capillary perforators is very useful for the reconstruction of upper limb. The advantage is easier elevation within short time (does not require intramuscular dissection) with long or short vascular pedicle. The flap can be elevated in a supine position, and even lateral descending branch can be a pedicle vessel. The flap can be a flow-through flap and is less invasive, because the remaining muscle can be preserved along with the motor nerve.

Cross-face nerve transfer for established trigeminal branch II palsy.

Reconstruction for trigeminal nerve II palsy is challenging. Cross-face nerve transfer from the contralateral trigeminal nerve facilitates this reconstruction. However, the microanatomy and techniques required for nerve sutures cause problems for many surgeons. Following the recent development of supramicrosurgical techniques appropriate for the microanatomy of peripheral nerves, a new method of intraoral "cross-face nerve transfer" was successfully used for repairing trigeminal nerve II palsy. Two cases of trigeminal nerve II palsy were repaired with contralateral trigeminal nerve transfer without any nerve graft. Affected upper labial sensory recovery was 1.65 to 2.44 (Semmes-Weinstein values) and 15 to 30 mm (moving 2-point discriminations) at 1 to 1 1/2 years after surgery. The advantages of this method are excellent nerve regeneration and the lack of donor site morbidity. It is a brief and simple operation in comparison to free nerve grafts. The disadvantage is a need for a supramicrosurgical technique, using a needle less than 80 microm wide.

Short pedicle thoracodorsal artery perforator (TAP) adiposal flap for three-dimensional reconstruction of contracted orbital cavity.

SUMMARY BACKGROUND: Eye socket reconstruction for orbital contracture after removal of retinoblastoma remains challenging, because it is often accompanied by atrophy of facial soft tissue, malar bone and temporal muscle. CASE DESCRIPTION: A 45-year-old woman with a contracted eye socket underwent reconstructive surgery with a trilobed thoracodorsal artery perforator (TAP) adiposal flap with skin island. The flap was successfully transferred to expand the eye socket and augument hypoplastic facial tissue. A short pedicle TAP adiposal flap through the mid-axillary line was obtained with the patient in a supine position. The T portion of the lateral intramuscular branch was transected as a pedicle vessel and flow-through vascular anastomosis was carried out. CONCLUSION: TAP adiposal flap obtained with the patient supine is very useful for reconstruction of the eye socket, eyelid, temporal muscle, and malar tissue. The advantages of the short pedicle TAP flap are that it is minimally invasive, can be transferred with only a lateral muscular branch of the thoracodorsal system, and preserves the main trunk of the thoracodorsal artery and nerve and the branch to the serratus anterior. Flow-through vascular anastomosis is possible and the flap can be harvested without the need for secondary debulking.

Intravascular stenting (IVaS) for safe and precise supermicrosurgery.

The diameter of very small vessels (about 0.5 mm or less) causes difficulties in placing forceps into the lumen and in completing anastomosis without inadvertently catching the back wall during supermicrosurgery. The insertion of nylon monofilaments into small vessels has overcome this problem. We implanted superficial inferior epigastric arterial (SIEA) flaps in 10 rats and also performed supermicroanastomosis (diameter, 0.15 mm) using SIEA flaps in mice. The back wall was never inadvertently caught using the intravascular stenting (IVaS) method, and the immediate patency rate was 100%. An advantage of using nylon for IVaS is that various sizes can be selected. We successfully anastomosed vessels with a minimum diameter of 0.15 mm. Even smaller vessels can be precisely and safely anastomosed using the IVaS method.

Epidermal hyperpigmentation in non-syndromic solitary cafe-au-lait macules may be associated with increased secretion of endothelin-1 by lesional keratinocytes.

To clarify the mechanism of accentuated melanisation in non-syndromic solitary cafe-au-lait macules we used an enzyme-linked immunosorbent assay (ELISA) to measure the concentration of melanogenic cytokines secreted by cultured keratinocytes and fibroblasts derived from the skins of the macules and compared them with those derived from normal people. Endothelin-1 (ET-1) was significantly increased in cultured keratinocytes in the macules compared with the normals. In contrast, the secretion of other cytokines secreted by keratinocytes or fibroblasts did not differ between the groups. It may be that the increased secretion of ET-1 by epidermal keratinocytes has a role in the accentuated epidermal melanisation seen in non-syndromic macules.

Topical negative pressure using a drainage pouch without foam dressing for the treatment of undermined pressure ulcers.

UNLABELLED: Topical negative pressure is gaining popularity as an acute and chronic wound management technique. In general, foam dressing is applied to the wound surface to maintain negative pressure. Due to the potential for clogging by the foam dressing, topical negative pressure cannot be used when there is a high volume of necrotic tissue or massive infection present. In this study, topical negative pressure was applied using a drainage pouch without any dressing. Topical negative pressure was applied to 8 patients with 9 pressure ulcers complicated by undermining. This approach was effective in the treatment of all 9 ulcers and allowed the wounds to be visualized while maintaining negative pressure. Since this technique can be performed without foam dressing, it can be used to treat early-stage infectious pressure ulcers in which there is a lot of necrotic tissue. CONCLUSION: Topical negative pressure without dressing is an extremely effective treatment of pressure ulcers complicated by undermining.

Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for acquired dermal melanocytosis.

BACKGROUND AND OBJECTIVE: Acquired dermal melanocytosis (ADM; acquired bilateral nevus of Ota-like macules) is known for its recalcitrance compared with Nevus of Ota, and we assume that one of the reasons is a higher rate and degree of postinflammatory hyperpigmentation (PIH) seen after laser treatments. METHODS: Topical bleaching treatment with 0.1% tretinoin aqueous gel and 5% hydroquinone ointment containing 7% lactic acid was initially performed (4 to 6 weeks) to discharge epidermal melanin. Subsequently, Q-switched ruby (QSR) laser was irradiated to eliminate dermal pigmentation. Both steps were repeated two to three times until patient satisfaction was obtained (usually at a 2-month interval for laser sessions). This treatment was performed in 19 patients with ADM. Skin biopsy was performed in six cases at baseline, after the bleaching pretreatment, and at the end of treatment. RESULTS: All patients showed good to excellent clearing after two to three sessions of QSR laser treatments. The total treatment period ranged from 3 to 13 (mean of 8.3) months. PIH was observed in 10.5% of the cases. Histologically, epidermal hyperpigmentation was observed in all specimens and was dramatically improved by the topical bleaching pretreatment. CONCLUSION: QSR laser combined with the topical bleaching pretreatment appeared to treat ADM consistently with a low occurrence rate of PIH and lessen the number of laser sessions and total treatment period and may also be applied to any other lesions with both epidermal and dermal pigmentation.

Differential expression of heparin-binding EGF-like growth factor (HB-EGF) mRNA in normal human keratinocytes induced by a variety of natural and synthetic retinoids.

It was recently revealed that epidermal growth following topical treatment with all-trans retinoic acid (atRA) was at least partly induced by heparin-binding epidermal growth factor-like growth factor (HB-EGF) released from suprabasal keratinocytes. Since proliferation of keratinocytes appears to be one of the critical roles of atRA in depigmentation treatment and promotion of wound healing, HB-EGF is considered suitable for assessing the therapeutic value of topical retinoids. In this study, HB-EGF mRNA expression in normal human keratinocytes after atRA treatment was examined, and the effects of a variety of natural and synthetic retinoids were compared. The results of reverse transcription polymerase chain reaction (RT-PCR) suggested that induction of differentiation increased HB-EGF mRNA expression in cultured keratinocytes. Real-time PCR analyses revealed that HB-EGF mRNA expression was elevated dose-dependently with atRA, peaking at 12 h. This elevation was more prominent in confluent keratinocytes than in subconfluent cells, suggesting that differentiated keratinocytes are more subject to stimulation of HB-EGF expression by atRA than proliferating keratinocytes. HB-EGF mRNA was upregulated in differentiation-induced keratinocytes by all retinoids used in this study at 1 micromol/l, and marked upregulation was seen when treated with three isotypes of retinoic acid (atRA, and 9-cis and 13-cis retinoic acid). RARalpha-selective agonists (Am80, Am580, ER-38925, and TAC-101) and a panagonist of RARs (Re80) caused relatively low elevation of HB-EGF transcripts, as did all-trans retinol (Rol) and all-trans retinal (Ral). Although another panagonist (Ch55) showed the highest elevation of HB-EGF mRNA, it was relatively cytotoxic at the concentration employed. Ral and Rol were found to upregulate HB-EGF when used at 100 micromol/l to 1 mmol/l, to a similar extent of atRA at 1-10 micromol/l. The capacity of retinoids to upregulate HB-EGF may be an important index for investigation and development of an ideal synthetic retinoid, which has maximum benefits and minimum side-effects

Tretinoin reverses upregulation of matrix metalloproteinase-13 in human keloid-derived fibroblasts.

Keloids are skin abnormalities that are characterized by excessive deposition of collagen bundles in the dermis. Patients with keloids complain not only about their cosmetic appearance, but also about continuous itching and/or tenderness associated with chronic inflammation. Degradation of extracellular matrix (ECM) may be upregulated, associated with the expansion of keloids into circumferential skin, and high metabolic activity of keloid tissues may be due to increased matrix metalloproteinase (MMP) activity. Based on these hypotheses, we examined differences in expression of MMP-1, MMP-8, and MMP-13 between keloid-derived and normal dermal fibroblasts. Since retinoids are potent inhibitors of MMPs in the treatment of photoaged skin and cancers, we also examined whether or not tretinoin affects MMP expression of keloid-derived fibroblasts. The results of real-time polymerase chain reaction and ELISA demonstrated significant upregulation of MMP-13 and significant downregulation of MMP-1 and MMP-8 in keloid-derived fibroblasts, at both mRNA and protein levels. MMP-1 mRNA expression in the control group was significantly upregulated after the addition of tretinoin, whereas no significant change was observed in the keloid group. MMP-8 mRNA expression in the control group was significantly upregulated by tretinoin, with the peak at 12 h, while no significant change was observed in the keloid-derived fibroblasts. In contrast, the remarkably elevated MMP-13 mRNA expression in the keloid group was significantly suppressed, with the peak suppression at 12 h after addition of tretinoin, while MMP-13 mRNA expression in the control group was not significantly changed. The decrease in MMP-1 and MMP-8 may contribute to accumulation of type I and type III collagen in keloid tissues, and this mechanism may be modulated by molecular interaction with MMP-13. Tretinoin appeared to reverse the abnormal expression profile of MMPs in keloid-derived fibroblasts, such as markedly elevated expression of MMP-13, partly through inactivation of AP-1 pathway. The present results suggest that tretinoin may be clinically useful to improve the chronic inflammation seen in keloids and prevent expansion of keloid tissues into circumferential normal skin.

Elevated expression of hepatocyte and keratinocyte growth factor in cultured buccal-mucosa-derived fibroblasts compared with normal-skin-derived fibroblasts.

Oral mucosa heals faster with less scar formation than skin and a hypertrophic scar is very rare in the oral cavity, but its mechanism has not been elucidated enough. To elucidate whether or not there are differences in growth factor expression between fibroblasts derived from buccal mucosal and normal skin, we investigated the expression of hepatocyte growth factor (HGF), keratinocyte growth factor (KGF) and stem cell factor (SCF) by cultured fibroblasts. The semiquantitative RT-PCR revealed that the expression of HGF and KGF transcripts by buccal mucosal fibroblasts was significantly elevated compared with that by dermal fibroblasts. In parallel, ELISA revealed the significant increase of HGF production by buccal mucosal fibroblasts. The level of production of SCF protein did not differ significantly. Our study suggests that increased expression of HGF and KGF by buccal mucosal fibroblasts may partly be responsible for the faster wound healing with less scar formation in the oral cavity compared with normal skin.