Extra-oral fistula caused by a dental implant.

Dental implantation has become an important procedure for both dental treatment and head and neck reconstructive surgery. However, this useful technique sometimes results in peri-implantitis. We describe a rare complication of peri-implantitis in the maxilla which extended to the soft tissue and caused an extra-oral fistula above the alar region. The patient underwent the placement of dental implants in the maxilla 8 years earlier. Radiography showed osteolysis of the maxilla and implant exposure. After the implants were removed, the patient was fitted with a conventional fixed partial denture. Such unfavorable outcomes are caused by failed endodontic and apicoectomy procedures.

Basic fibroblast growth factor is beneficial for postoperative color uniformity in split-thickness skin grafting.

Color changes of visible and exposed body surfaces, such as the face and extremities, after burn injury or surgery, such as skin grafting, flap, or sclerotherapy for vascular malformations, are sometimes a concern. The consequences reduce the satisfaction of both patients and physicians. An easy and reproducible method has not yet been established for an objective analysis of color changes; therefore, we tested a hand-held color analyzer (NF-333; Nippon Denshoku Co. Ltd) with data transport to a computer database and analysis software for posttreatment skin color change. The parameters included L, a, and b, which measure clarity, red, and yellow, respectively. Two groups were prospectively divided with 20 (11 females and nine males) patients per group. One group received skin grafting plus basic fibroblast growth factor (bFGF) spray daily and the other group received only skin grafting. The patients were randomized by the date of their first visit to our hospital. Patients were treated with bFGF on odd days, while patients who came on even days were included in the non-bFGF-treated group. The donor site for skin grafting was the lateral thighs and the thickness was similar in both groups. The results were compared at 1-year posttreatment follow-up. Clinical and objective assessments of the scars were performed 1 to years after complete healing. Color change differentials in comparison with the surrounding skin were lower with bFGF treatment in all parameters (p<0.01), along with clinical assessment with the Vancouver Scar Scale; therefore, the treatment contribute to a better color match with skin grafting postoperatively.

Palliative surgery for advanced fungating skin cancers.

Advanced skin cancers sometimes develop complex wounds with associated pain, infection, malodor, massive discharge, and bleeding, which distresses patients and decreases his or her quality of life (QoL). The following cases presented large fungating skin ulcers that were treated with palliative abrasion along with wound resurfacing using free skin grafting. Palliative surgery allowed the patients to lead a more comfortable daily life at home with family. Simple palliative surgery can improve the QoL of terminal patients by reducing wound secretion, odors, and the risk of infection, and consequently, can improve nutritional status and their overall health condition.

Unusual Cheek and Upper Extremity Pressure Ulcers Resulting from Head-on-Hand and Arm Napping.

 Pressure ulcers commonly occur on the sacrum, ischium, lateral trochanter, and heel where pressure or shearing forces continuously affect bony prominences. The following describes three cases of unusual pressure ulcers of the cheek and upper extremity. Patients developed the wounds as a result of lying face downward on the hand for a prolonged period. All facial wounds were treated conservatively and eventually healed, but the damage to the hands was irreversible due to severe complications related to muscle contraction. The authors suggest that the risk factors for these unusual ulcers are living alone, and the combination of sleep aid medication and alcohol consumption..

Cervical osteomyelitis and epidural abscess treated with a pectoralis major muscle flap.

BACKGROUND: Spinal osteomyelitis and epidural abscess are uncommon but have a potentially disastrous outcome, although the surgical techniques and antimicrobial therapy have advanced. CASE DESCRIPTION: We present a case of cervical osteomyelitis and epidural abscess resulting from pharyngeal squamous cell carcinoma ablation, which were treated with a pectoralis major muscle flap successfully. CONCLUSION: Muscle flap insertion to the cervical contaminated wound enables radical removal of the contaminated tissue, and the muscle flaps for dead-space obliteration and neovasculation were obligatory for successful management of the infected complex wound. Furthermore, the inserted pectoralis major muscle flap can divide vertebrae and epidural canal from these origins of infection. We believe that this technique is simple, can be performed in a one-stage management, has minimal associated morbidity, and thus, is advocated as a desirable treatment option in the treatment of cervical osteomyelitis and epidural abscess.

Complex wounds tend to develop more rapidly in patients receiving hemodialysis because of diabetes mellitus.

The number of patients requiring dialysis because of diabetes mellitus is increasing and such patients often have complex chronic wounds, which are difficult to heal. However, there are few retrospective studies of wounds requiring surgical treatment. We evaluated 14 patients receiving hemodialysis (HD) (8 because of diabetes and 6 because of other diseases) who had extremity wounds and underwent surgical treatment in our unit from 2004 through 2007. We investigated differences in the cause of wounds, and in the interval between the start of HD and wound development. Wounds in patients undergoing HD because of diabetes originated due to ischemia in 2 cases (25%), trauma in 2 cases (25%), and infection in 4 cases (50%). Seven of 8 wounds developed infection with methicillin-resistant Staphylococcus aureus (MRSA). Wounds in patients undergoing HD because of other diseases developed due to ischemia in 2 cases (33%) and trauma in 4 cases (67%). Three of 6 wounds developed infection and MRSA were isolated from 2 wounds. The interval between the start of HD and wound development was significantly shorter in patients with diabetes than in patients without diabetes. All patients with infectious wounds required immediate debridement. We conclude that patients receiving HD because of diabetes are likely to have more severe and rapidly developing wounds due to infections. Thus, they usually require immediate debridement before blood access shunt infection occurs.

Evaluation of Nutrition in the Healing of Pressure Ulcers: Are the EPUAP Nutritional Guidelines Sufficient To Heal Wounds?

 Malnutrition is a significant factor in the development of pressure ulcers and many nutritional guidelines for preventing pressure ulcers have been published. However, few clinical investigations have examined the energy required to heal pressure ulcers. The aim of the present study was to investigate the relationship between nutritional intake and improvement of pressure ulcers. Total calories, which were supplied by mouth through a feeding tube and via venous alimentation were examined for 40 hospitalized bedridden inpatients who had pressure ulcers. Of these patients, 21 whose wounds improved or healed and 19 whose wounds became worse or did not improve were eligible for this retrospective study. Pressure ulcers in patients who received more than 30 kcal/kg per day improved or healed, while those of patients who received less than 20 kcal/kg per day worsened or failed to improve. Furthermore, intake of 30 kcal/kg per day enabled serum albumin levels to improve. Energy intake of 30 kcal/kg per day is comparable to the predicted total energy expenditure and is thought to be essential for improving pressure ulcers in bedridden patients .

Human mesenchymal stem cells may be involved in keloid pathogenesis.

BACKGROUND: The pathogenesis of keloid is poorly understood. Although vigorous investigations have attempted to elucidate the mechanisms or causative factors of keloid, there are little data on why keloids are very intractable and recur easily in each patient. METHODS: In an attempt to analyze the possible interaction between human mesenchymal stem cells and keloid-derived fibroblasts, the dual-chamber cell-migration assay, cell proliferation, ultrastructural morphology, and Western blot analysis were used to investigate the production of the extracellular matrices of the coculture. RESULTS: Cell proliferation was not significantly different between keloid-derived fibroblasts and normal dermal fibroblasts during a 4-day observation period. There was a significant cell migration of human mesenchymal stem cells when keloid-derived fibroblasts were placed in the bottom chamber, compared to when normal dermal fibroblasts were placed in the same way in 8-microm diameter pore membranes (190.6 +/- 51.45 and 32.0 +/- 6.20 cells/field, respectively, P < 0.01). With 3-microm diameter pores, the human mesenchymal stem cells migrated in the pores only when the keloid-derived fibroblasts were placed in the bottom chambers (6.4 +/- 3.84 cells/field). Monolayer coculture of human mesenchymal stem cells and keloid-derived fibroblasts demonstrated further functional differentiation, such as collagen secretion and abundant rough endoplasmic reticulum. Western blot analysis of the cells in the modified dual-chamber culture demonstrated most significantly abundant fibronectin expression when the human mesenchymal stem cells contained keloid fibroblasts. CONCLUSION: The results of this study may indicate that human mesenchymal stem cells participate and recruit in keloid pathogenesis by differentiating themselves toward keloid recalcitrant formation and progression.

Reconstruction of velopharyngeal competence for composite palatomaxillary defect with a fibula osteocutaneous free flap.

Velopharyngeal competence reconstruction is indispensable for acquiring the fine speech and ingesting function. However, the maxillary prosthesis becomes unstable in some patients who have undergone extensive palatomaxillary. We present a case of total palatomaxillary defect resulting from squamous cell carcinoma ablation of the palate, which was reconstructed using a fibula-free osteocutaneous flap. Velopharyngeal competence was reconstructed owing to the flap so that the patient could ingest a soft diet and speak without hypernasality 2 weeks after surgery.

Combined surgical excision and radiation therapy for keloid treatment.

Various methods have been attempted for the treatment and management of keloids; however, there is little satisfactory clinical evidence in long-term follow ups. Also, there is a preference for occurrence and recurrence in anatomic location. Usually anatomic locations with higher regional tension and more sebaceous glands are inclined toward pathogenesis. Thirty-eight keloids treated with combined surgical excision and postoperative irradiation, using electron beams with only a 10-mm opening by lead shielding, were investigated at a mean follow up of 4.4 +/- 2.5 years (range, 1-9 years) at a single institute. Ten locations such as the ear (n = 6), neck (n = 3), and upper lip (n = 1) were among the craniofacial locations. The hardness of the keloids and posttreatment scars was clinically and objectively tested with the Vancouver scar scale and a durometer, which is often used for the industrial measurement of thread balls and rubber. At a mean of 4.4 +/- 2.5 years of follow up, the clinical characteristics of the scars were significantly better posttreatment as 2.6 +/- 0.5 versus 1.0 +/- 0.6, 3.7 +/- 0.7 versus 1.7 +/- 0.7, 2.9 +/- 0.4 versus 1.3 +/- 0.5, and 2.7 +/- 0.5 versus 1.3 +/- 0.5 (keloid scars versus posttreatment scars: pigmentation, pliability, height and vascularity, respectively, P < 0.01). The durometer readings were significantly lower posttreatment, 15.2 +/- 3.9 versus 7.7 +/- 2.9 (keloid scars versus posttreatment scars, P < 0.01). The recurrence rate was 21.2% overall with none in craniofacial locations. Therefore, the combined treatment of surgical excision and postoperative electron beam irradiation is effective for scar quality and reducing the recurrence rate in long-term follow up.

Cavernous nerve graft reconstruction using an autologous nerve guide to restore potency.

OBJECTIVE: To present our experience of cavernous nerve graft reconstruction, using an autologous nerve vein-guide technique, to restore potency. PATIENTS AND METHODS: Prostate cancers frequently require radical resection involving one or both cavernous nerves that usually results in erectile dysfunction; nerve grafting has been used to restore erectile function, but clinical results are unsatisfactory owing to inadequate surgical techniques. In all, eight patients with prostate cancer who required radical resection involving one cavernous nerve had sural nerve grafting, with two or three sutures using the autologous vein-guide technique, in our unit between 2004 and 2005. Because of the difficulty of performing microsurgical manoeuvres deep within the pelvic cavity, the nerve anastomosis might be unsatisfactory. RESULTS: Seven of the eight patients had spontaneous erectile activity after grafting and six of these patients were able to have intercourse. CONCLUSION: Sural nerve grafting using the autologous vein-guide technique is simple, has minimal morbidity, and yields good outcomes.

Both nasal cerebral heterotopia and encephalocele in the same patient.

UNLABELLED: OBJECTIVE AND PATIENT: Both nasal cerebral heterotopia and encephalocele are rare congenital benign masses of neurogenic origin caused by an embryonic developmental abnormality. It is generally accepted that nasal heterotopia is a sequelae to encephalocele. This report presents an unusual case of nasal cerebral heterotopia and encephalocele arising in the same patient. The patient had a firm, solid mass measuring 1.5 x 1.0 cm on the bridge of the nose covered with normal skin and another mass in the nasal cavity obstructing the right nasal cavity. Computed tomography (CT) demonstrated that the nasal bone separated these masses. CT also showed a bony defect at the skull base. Surgery consisted of dividing the encephalocele and closure of the skull base fistulae, along with nasal subcutaneous mass enucleation. RESULTS: Intraoperative examination indicated the existence of a pit on the nasal bone where the pedicle of the nasal subcutaneous mass connected. Microscopic examination of the nasal cavity mass demonstrated meningoencephalocele, and examination of the nasal subcutaneous mass demonstrated nasal cerebral heterotopia, which was confirmed by immunohistochemical staining. After 10 months, complete removal of the subcutaneous nasal mass was recognized and there was no evidence of recurrence. CONCLUSION: Findings in this case suggest that the nasal cerebral heterotopias will result from encephalocele.