A Case of Cochlear Implant Replacement Requiring Full-Thickness Skin Grafting.

Cochlear implants improve the quality of life of patients with bilateral severe sensorineural hearing loss. Normally, patients with cochlear implants can continue to use the devices for years without any complications. However, equipment failure or infection at the implant site could develop in some patients, and this might often necessitate implant replacement. Although cochlear implant replacement surgery itself is not a major risk in most cases, extensive tissue resection will be required in cases involving infection, and the insertion site of the temporal bone implant will need to be changed. We encountered a case of skin necrosis at the temporal bone implant site caused by constant external irritation from the temple of an eyeglass frame. The patient underwent cochlear implant replacement surgery involving full-thickness skin grafting from the abdomen. Thereafter, the patient's condition improved. Full-thickness skin grafting can be useful in cases of extensive skin defects encountered during cochlear implant replacement.

A fascia bow traction method for the treatment of unilateral marginal mandibular nerve paralysis after mandibulectomy for head and neck cancer.

Background: Unilateral paralysis of the marginal mandibular nerve (UPMMN) after head and neck cancer surgery is a relatively common condition that causes deformity and an asymmetric appearance of the lower lip and impairs the quality of life of patients. We developed a novel fascia grafting method to improve the appearance of the lower lip in patients with UPMMN. Methods: Two fascia strips and a small fascia loop connecting the two strips are used: one is fixed horizontally to pull the lower lip toward the paralyzed side, and the other is fixed in a bow shape at rest to avoid approaching the lateral mandibular margin. When patients smile or open their mouths, the bow-shaped graft straightens, pulling the paralyzed lower lip laterally downward through the small connecting loop. We used this method to treat four patients with UPMMN who had undergone head and neck cancer ablation. The symmetry and movement of the lower lip were assessed using preoperative and postoperative photographs of three poses (at rest, smiling, and opening the mouth). Results: The fascia grafting procedure restored the symmetry of the lower lip at rest and greatly improved symmetrical lower lip movement when smiling and opening the mouth. According to photographic evaluation scores, all patients had poor lower lip symmetry in the three poses before the procedure, whereas after the procedure, three had excellent lower lip symmetry, and one had good lower lip symmetry. There was a significant difference between the scores before and after the surgery. Conclusions: Fascia grafting is easy and minimally invasive, allows patients to generate an almost symmetrical smile, and consequently improves their QOL. This method may be particularly useful when the lateral mandibular bone is resected during cancer surgery, and the defect is reconstructed with metal plates/soft tissue, as the method does not require approaching the lateral mandibular region.

A Case of Traumatic Nasal Valve Stenosis Successfully Treated with Open Rhinoplasty and Z-Plasty.

External nasal deformity is common and can be treated surgically. It often occurs in conjunction with the development of the nasal septal cartilage, vomer, and vertical plate of the ethmoid bone but may be caused by trauma. Here, we present a case of external nasal deformity caused by trauma. A woman presented with nasal obstruction due to dysfunction of the nasal valve area and was referred to our department for treatment. No chronic rhinosinusitis or nasal septal deviation that causes nasal obstruction was noted at the initial examination. However, trauma-related scarring was observed in the nasal valve area, and a Cottle test yielded positive results. The patient underwent combined rhino- and Z-plasty surgery and is currently undergoing follow-up at an outpatient clinic.Although otolaryngologists generally use an endonasal approach to treat nasal obstruction, it is important to perform an appropriate evaluation of the external nose and to collaborate with a plastic surgeon, as necessary.

[A Case of Palliative Abdominoperineal Resection and Perineal Reconstruction by Gluteus Maximus Flap following Regrowth of Primary Anal Canal Cancer with the Perianal Skin Infiltration after CRT].

An 85-year-old woman who visited the hospital with sores on the perianal skin was diagnosed with squamous cell carcinoma of the anal canal(cT3N1aM0, cStage ⅢC). She received chemoradiotherapy(radiation total 54 Gy/30 Fr, mitomycin C/capecitabine). The tumor initially shrank, but regrowth of the primary lesion, extensive perianal skin infiltration, and the appearance of para aortic lymph node metastases was observed 6 months later. Laparoscopic abdominoperineal resection was performed to mitigate strong local symptoms. The perineal defect was repaired with bilateral gluteus maximus flap(V- Y flap). The operation prevented anal pain and improved ADL. The patient is currently undergoing chemotherapy 7 months after surgery. We report the case with a review of the literature in which ADL was improved by salvage surgery for tumor regrowth with severe local symptoms and distant metastases after chemoradiotherapy for squamous cell carcinoma of the anal canal.

A modified method for upper eyelid reconstruction with innervated orbicularis oculi myocutaneous flaps and lower lip mucosal grafts.

BACKGROUND: Numerous reports have described methods for repairing full-thickness upper eyelid defects using lower eyelid tissue. To avoid sacrificing the lower eyelid and thereby prevent lower eyelid sagging or dysfunction, we used innervated orbicularis oculi myocutaneous flaps harvested from the upper eyelid for upper eyelid reconstruction. METHODS: We modified a method reported by Moschella and Cordova for repairing full-thickness upper eyelid defects using innervated bipedicled orbicularis oculi myocutaneous flaps mobilized from the upper eyelid and labial mucosal grafts. First, we avoided the use of a Fricke flap, which is used in the original method to repair the myocutaneous flap donor site, since it can cause asymmetry of the eyebrows on both sides. Second, reconstruction of the double-fold eyelid was performed with buried sutures in the myocutaneous flap in secondary surgery, since the double eyelid fold of the original method is not necessary or is too wide for Asian people. Functional and cosmetic outcomes were assessed by six evaluators using postoperative photographs. RESULTS: Six patients with malignant upper eyelid tumours underwent repair of upper eyelid defects by our modified method. Donor sites of the myocutaneous flaps were repaired with a medial forehead flap in one patient with Merkel cell carcinoma, a lateral orbital flap in one patient with sebaceous carcinoma, and a two-stage skin graft in two patients with sebaceous carcinoma and basal cell carcinoma, respectively. The two remaining patients (one with sebaceous carcinoma and the other with basal cell carcinoma) required no donor site repair. Functional and cosmetic outcomes were good or excellent in most cases. CONCLUSION: Our modified method for repairing full-thickness upper eyelid defects using innervated orbicularis oculi myocutaneous flaps resulted in optimal eyelid function and support, with morphologically satisfactory results including bilateral symmetry. This method provides a useful alternative to conventional methods of upper eyelid reconstruction.

[A Case of Anal Canal Cancer with Skin Invasion to Which Abdominoperineal Resection and Perineum Reconstruction Were Performed after Neoadjuvant Chemoradiotherapy].

A 74-year-old man visited our hospital with an awareness of anal mass and bleeding. He was diagnosed as adenocarcino- ma of anal canal with wide spreading skin invasion. After neoadjuvant chemoradiotherapy(radiationtotal 45 Gy/25 Fr; cape- citabine 825mg/m2)was performed to reduce the mass volume, laparoscopic abdominoperineal resection with large perineum skin resection and lateral lymph node dissection was carried out. The perineal defect was repaired with a rectus abdominis musculocutaneous flap. Six days after surgery, the rectus abdominis musculocutaneous flap necrotized, and second perineum reconstruction by the bilateral gracilis musculocutaneous flaps was performed after debridement of necrotic tissue. We reported a case of radical resection of local advanced anal canal cancer with skin invasion by performing combined modality therapy and perineum reconstruction.

Transformation of keloids is determined by stress occurrence patterns on peri-keloid regions in response to body movement.

Keloids gradually change their shapes as they grow. We hypothesize that the change of keloid morphology reflects the incremental change of the stress patterns occurring in peri-keloid regions due to movement of the keloid-carrying body part. To examine the validity of this hypothesis, we used three-dimensional finite element analysis to calculate the stresses occurring in the peri-keloid regions of keloids on the chest in response to respiratory movement. The stresses concentrate at the peri-keloid regions close to the bilateral ends of the keloids. By reviewing this result in reference to our hypothesis, we can explain why keloids on the chest are likely to present crab or butterfly shapes. Although we know that keloids grow in response to mechanical stresses, our hypothesis differs from existing ones in that it focuses on morphological transformation. Our hypothesis is helpful for physicians in performing treatment for keloids, because they can predict what part of a keloid is likely to grow and perform preventive treatment in reference to the hypothesis.

Human Decidua-Derived Mesenchymal Cells Are a Promising Source for the Generation and Cell Banking of Human Induced Pluripotent Stem Cells.

Placental tissue is a biomaterial with remarkable potential for use in regenerative medicine. It has a three-layer structure derived from the fetus (amnion and chorion) and the mother (decidua), and it contains huge numbers of cells. Moreover, placental tissue can be collected without any physical danger to the donor and can be matched with a variety of HLA types. The decidua-derived mesenchymal cells (DMCs) are highly proliferative fibroblast-like cells that express a similar pattern of CD antigens as bone marrow-derived mesenchymal cells (BM-MSCs). Here we demonstrated that induced pluripotent stem (iPS) cells could be efficiently generated from DMCs by retroviral transfer of reprogramming factor genes. DMC-hiPS cells showed equivalent characteristics to human embryonic stem cells (hESCs) in colony morphology, global gene expression profile (including human pluripotent stem cell markers), DNA methylation status of the OCT3/4 and NANOG promoters, and ability to differentiate into components of the three germ layers in vitro and in vivo. The RNA expression of XIST and the methylation status of its promoter region suggested that DMC-iPSCs, when maintained undifferentiated and pluripotent, had three distinct states: (1) complete X-chromosome reactivation, (2) one inactive X-chromosome, or (3) an epigenetic aberration. Because DMCs are derived from the maternal portion of the placenta, they can be collected with the full consent of the adult donor and have considerable ethical advantages for cell banking and the subsequent generation of human iPS cells for regenerative applications.

[A case of total pelvic exenteration and reconstruction of perianal skin defect using a VY advancement of bilateral gluteus maximus musculocutaneous flaps for anal canal cancer associated with anal fistula].

A 53-year-old man, who was diagnosed as having an anal canal cancer associated with anal fistula, was introduced to our hospital. By CT and MRI examination, fluid collections were detected in the perirectal space and fistula was connected to bladder. Total pelvic exenteration was performed under the consideration of keeping the margin for the large skin defect. We reconstructed the perianal skin defect using a VY advancement of bilateral gluteus maximus musculocutaneous flaps. After the surgery, no sign of recurrence has been observed in 1 year and 4 months. This constructive technique was effective for anal defects.

Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis.

BACKGROUND: Keloids have been treated by using radiation for over a century, and it is currently suggested that keloids are best treated by a combination of surgery and postoperative radiation therapy, although randomized controlled trials testing this are still lacking. However, plastic surgeons tend to avoid radiation therapy for keloids for fear of inducing malignant tumors. Thus, the authors searched for previous reports of associations between carcinogenesis and keloid radiation therapy, and examined the evidence-based opinions of radiation oncologists regarding the acceptability of using radiation to treat keloids. METHODS: A computerized literature search was carried out using PubMed that included citations from MEDLINE and PubMed Central between 1901 and March of 2009. The following search terms were used: "keloid(s)," "hypertrophic scar(s)," "radiation," "radiation therapy," "radiotherapy," "carcinogenesis," "carcinoma," "cancer," "complications," and "side effects." Moreover, the references for each report were also retrieved. RESULTS: The authors located five cases of carcinogenesis (i.e., fibrosarcoma, basal cell carcinoma, thyroid carcinoma, and breast carcinoma) that were associated with radiation therapy for keloids. However, it was unclear whether an appropriate dose of radiation was used and whether sufficient protection of surrounding tissues was provided. Moreover, a questionnaire study of radiation oncologists around the world revealed that approximately 80 percent considered radiation to be acceptable for treating keloids. CONCLUSIONS: The authors conclude that the risk of carcinogenesis attributable to keloid radiation therapy is very low when surrounding tissues, including the thyroid and mammary glands, especially in children and infants, are adequately protected, and that radiation therapy is acceptable as a keloid treatment modality.

Muscle flap mass preservation by sensory reinnervation with end-to-side neurorrhaphy: an experimental study in rats.

The purpose of this study was to determine whether sensory reinnervation with end-to-side neurorrhaphy preserves muscle mass in pedicled muscle flaps. A new muscle flap model innervated by the common peroneal nerve (CPN) was tested in rats. Animals were divided into group 1 (CPN transected without repair), group 2 (CPN transected and immediately repaired by end-to-end neurorrhaphy), and groups 3A and 3B (CPN transected and repaired with the sural nerve, by end-to-end and end-to-side neurorrhaphy, respectively). We evaluated the muscle-preserving effect by measuring muscle weight and performed histological and morphometric analyses 3 months after the procedure. Sensory reinnervation significantly preserved the muscle mass, although less than motor reinnervation. There was no significant difference between the end-to-end and end-to-side procedures. Results of morphometric analysis in each group paralleled those of mean muscle weight. Sensory reinnervation with end-to-side neurorrhaphy appears to be useful in the preservation of muscle flap mass.