A novel intervention for wound bed preparation in severe extremity trauma: Highly concentrated carbon dioxide bathing.

Introduction: In severe extremity trauma involving large tissue defects, early closure (e.g., free-flap surgery) of the defects is an essential step for good functional reconstruction; however, in some cases, early closure may be difficult. Highly concentrated carbon dioxide bathing, used to improve blood flow in ischemic limbs and skin ulcers, can also be applied in wound bed preparation for severe limb trauma. Patients and Methods: The three cases in this study required an average of 13 weeks of highly concentrated carbonated bathing, which led to significantly better wound bed preparation, even in the exposed bone and tendon regions. Results: We successfully achieved good functional limb reconstruction in patients with deep burns and severe open fractures by reducing wound infection and facilitating good wound bed preparation. Conclusions: Highly concentrated carbon dioxide bathing was sufficient to prevent frequent wound infections, even in severe extremity trauma involving large soft-tissue defects such as deep crush burns and Gustilo Anderson classification ≥3b open fractures of the extremities. To our knowledge, such interventions have not been reported in the past and are valuable as new procedures for wound bed preparation in severe extremity trauma from both cost and wound infection control perspectives.

En bloc resection of a large bilateral vulvar lipoma through a caesarean scar: A case report.

Large bilateral symmetrical vulvar tumors are rare. A 30-year-old multiparous Asian woman presented with severe discomfort during urination and intercourse owing to a large bilateral symmetrical lipoma in the labia majora. En bloc resection through a pre-existing Caesarean scar achieved good cosmetic and symptomatic results. This alternative and unique approach may be helpful in similar rare cases.

Predominant control of PDGF/PDGF receptor signaling in the migration and proliferation of human adipose­derived stem cells under culture conditions with a combination of growth factors.

Human adipose-derived stem cells (hASCs) play important roles in regenerative medicine and tissue engineering. However, their clinical applications are limited because of their instability during cell culture. Platelet lysates (PLTs) contain large amounts of growth factors that are useful for manufacturing cellular products. Platelet-derived growth factor (PDGF) is a major growth factor in PLTs and a potent mitogen in hASCs. To optimize growth conditions, the effects of a combination of growth factors on the promotion of hASC proliferation were investigated. Moreover, PDGF-BB combined with vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) markedly enhanced the viability of hASCs compared with the effects of PDGF-BB alone. Neither VEGF nor HGF had any effect alone. All growth factor receptor inhibitors inhibited cell proliferation. Wound healing assays revealed that VEGF and HGF stimulated PDGF-dependent cell migration. The effects of these growth factors on the activation of their cognate receptors and signaling enzymes were assessed using immunoblotting. Phosphorylation of PDGF receptor (PDGFR)ß, VEGF receptor (VEGFR)2 and MET proto-oncogene and receptor tyrosine kinase was induced by PDGF-BB treatment, and was further increased by treatment with PDGF-BB/VEGF and PDGF-BB/HGF. The levels of phospho-ERK1/2 and phospho-p38MAPK were increased by these treatments in parallel. Furthermore, the expression levels of SRY-box transcription factor 2 and peroxisome proliferator-activated receptor g were increased in PDGF-BB-treated cells, and PDGF-BB played a dominant role in spheroid formation. The findings of the present study highlighted that PDGF/PDGFR signaling played a predominant role in the proliferation and migration of hASCs, and suggested that PDGF was responsible for the efficacy of other growth factors when hASCs were cultured with PLTs.

Activation of cell adhesion and migration is an early event of platelet-rich plasma (PRP)-dependent stimulation of human adipose-derived stem/stromal cells.

Stem cell therapy is a promising treatment in regenerative medicine. Human adipose-derived stem/stromal cells (hASCs), a type of mesenchymal stem cell, are easy to harvest. In plastic and aesthetic surgery, hASC may be applied in the treatment of fat grafting, wound healing, and scar remodeling. Platelet-rich plasma (PRP) contains various growth factors, including platelet-derived growth factor (PDGF), which accelerates wound healing. We previously reported that PRP promotes the proliferation of hASC via multiple signaling pathways, and we evaluated the effect of PRP on the stimulation of hASC adhesion and migration, leading to the proliferation of these cells. When hASCs were treated with PRP, AKT, ERK1/2, paxillin and RhoA were rapidly activated. PRP treatment led to the formation of F-actin stress fibers. Strong signals for integrin ß1, paxillin and RhoA at the cell periphery of RPR-treated cells indicated focal adhesion. PRP promoted cell adhesion and movement of hASC, compared with the control group. Imatinib, an inhibitor of the PDGF receptor tyrosine kinase, inhibited the promotion of PRP-dependent cell migration. PDGF treatment of hASCs also stimulated cell adhesion and migration but to a lesser extent than PRP treatment. PRP promoted the adhesion and the migration of hASC, mediated by the activation of AKT in the integrin signaling pathway. PRP treatment was more effective than PDGF treatment in enhancing cell migration. Thus, the ability of PRPs to promote migration of hASC to enhance cell growth is evident.

Ultrastructural changes of vascular smooth muscle cells and resistance to vasospasm treatment in femoral arteries of an arteriosclerotic rat model.

The objective of this study was to establish an animal model of arteriosclerosis for assessing vasospasm and to investigate the relationship between arteriosclerosis and vasospasm. Twelve-week-old male Sprague-Dawley rats were fed a diet supplemented with adenine and vitamin D (adenine/vitD). Body weight, blood, and femoral artery histopathology were assessed at 2, 4, and 6 weeks. Change in the femoral artery was examined by transmission electron microscope (TEM). Vasospasm was induced by administering epinephrine extravascularly into the femoral artery and released by the treatment with lidocaine as a vasodilator. During this period, the extravascular diameter and blood flow were measured. The rats in the adenine/vitD group developed renal dysfunction, uremia, hyperphosphatemia, and elevated serum alkaline phosphatase. Histological and TEM analyses of the femoral arteries in the treated rats revealed the degeneration of elastic fibers and extensive calcification of the tunica media and intima. Vascular smooth muscles were degenerated and osteoblasts were developed, resulting in calcified arteriosclerosis. Vasospasm in arteriosclerotic arteries was detected; however, vasodilation as well as an increase in the blood flow was not observed. This study revealed the development of vasospasm in the femoral arteries of the arteriosclerotic rats and, a conventional vasodilator did not release the vasospasm.

Functional and cosmetic reconstruction of palmar heat press injury following wound bed preparation combined with artificial highly concentrated carbon dioxide bathing: A case report.

Background: The effect of artificial highly concentrated carbon dioxide bathing on heat-press-injured wounds has been clinically observed. Case presentation: A 46-year-old male patient with a heat press injury of the right palmar region achieved complete necrotic tissue removal and sufficient granulation of the skin graft by continuous hand bathing in a solution containing highly concentrated carbon dioxide for four weeks. The patient successfully underwent a full-thickness skin graft from the plantar to the palmar region, and his right hand function improved to the extent that it did not interfere with daily life. Conclusions: Heat press injuries are often refractory to treatment owing to the synergistic effects of heat and crush injuries. Highly concentrated carbon dioxide bathing has long been known to increase skin and muscle blood flow, and its clinical applications in ischemic limbs, skin ulcers, and osteomyelitis have already been reported. In this case, the results suggest an effect of improved blood flow leading to maturation of the graft bed at the heat-press injury site. Lay Summary: Highly concentrated carbon dioxide bathing is not only clinically applicable to ischemic extremities, skin ulcers, and osteomyelitis, due to increased cutaneous and muscular blood flow, but also to the reliable debridement of heat press injury wounds and the granulation of graft beds. We successfully used this novel combination of procedures to establish a graft bed with a good blood flow despite the deep heat press injury occurring in the palmar region, leading to an excellent functional recovery. The cost per procedure is low, at about $1(USD), making it a wound care option that should be considered from a healthcare economic perspective.

Morpheaform basal cell carcinoma of the nasal ala associated with multiple familial trichoepithelioma reconstructed by anterolateral thigh flap: a case report.

The right nasal ala had been destroyed and was diagnosed as morpheaform basal cell carcinoma associated with multiple familial trichoepithelioma (Brooke-Spiegler syndrome). After extended resection, the right buccal and nasal ala defect was reconstructed with a flow-through type anterolateral thigh (ALT) flap, which achieved good functional and cosmetic results.

Twenty-minute harvesting of flow-through type vastus lateralis muscle flap significantly reduces the need for a temporary intravascular shunt in the treatment of severe upper extremity trauma in civilian patients.

For the reconstruction of severe upper extremity trauma involving arterial injury in civilian patients, it is generally recommended that the revascularization time be shortened using a temporary intravascular shunt (TIVS). However, if a flow-through type vastus lateralis muscle (VLm) flap can be harvested in 20 minutes and bypassed at the obstructed ischemic zone within 30 minutes, blood flow can be restored as quickly or more quickly than when using a TIVS, eliminating the need for a TIVS. This procedure was applied in the reconstruction of 3 cases of severe extremity trauma with vascular injury. The mean age was 69.7 years. Surgery was started an average of 2.93 hours from the onset. The average flap harvest time was 0.33 hours. The average time to revascularization from flap harvest was 1.33 hours, the average total operation time was 6.43 hours, and all upper extremities were salvaged. No cases showed ischemia-reperfusion injury or severe muscle contracture. The flow-through-type VLm flap can be applicable as a bypass graft for a 20 cm defect at any region distal to the elbow. In addition, harvesting the flap attached to blood-rich muscle not only controls the infection of contaminated wounds through the filling of dead space, but also has the potential to replace damaged muscle or tendon tissue. Even though TIVS placement is currently used extensively in this field of treatment, its role could be significantly reduced if a flow-through-type VLm flap can be harvested within 20 minutes.

Potent Micrografting Using the Meek Technique for Knee Joint Wound Reconstruction.

Background: Efficient treatment of extensive skin defects by using skin grafting is a significant challenge because the skin available to use is limited. A mesh graft is usually used; however, the expansion ratio is small (up to 1:6) and inaccurate. The Meek technique is a method of skin grafting that processes the skin into micrografts by cutting. The advantage of the Meek technique is its efficient use of available skin, expanding its area by up to 9 times. In 2020, Japanese insurance companies began to cover treatment using the Meek technique. This report aimed to show the usefulness of the Meek technique for treating left leg necrotizing fasciitis. Methods: A 55-year-old male was referred to our hospital for treating necrotizing fasciitis of the left leg. Debridement was performed, and antibiotics were administered immediately. After 1 month, Meek micrografts were applied to the left knee wound. The expansion ratio of the Meek micrografts was 1:9. Results: The skin was processed 9 times using the Meek technique, enabling effective use of a small amount of skin. Epithelialization of the Meek micrograft area was completed 1 month after skin grafting. The scar after Meek micrografting was soft and not reddish. The range of motion of the knee joint was >90 degrees. Conclusions: The Meek technique allows expansion of limited skin efficiently. Meek micrografts can cover a larger wound with smaller skin grafts than is possible with mesh grafts. After healing with Meek micrografts, the scar was soft, and the knee joint flexed smoothly. The Meek technique is useful for treating large wounds requiring skin grafts.

Beneficial Impact of "Supercharged" Pectoralis Major Musculocutaneous Flap With Indocyanine Green Angiography on Reconstruction in a Patient at High Risk for Necrosis.

Background: The pectoralis major musculocutaneous (PMMC) flap is a versatile and commonly used technique for reconstruction of the head and neck in patients at high risk in free tissue transfer procedures. In this report, a "supercharged" PMMC flap, in which the lateral thoracic artery was cut, preserved, and anastomosed to the cervical vessels, was developed to stabilize blood flow. Methods: The supercharged PMMC flap was introduced in a patient who was at high risk for partial necrosis of the flap and underwent surgery for reconstruction of the tongue. Intraoperative perfusion monitoring using laser-assisted indocyanine green angiography (ICGA) was also performed to verify the status of blood flow in the flap. Results: ICGA monitoring of blood flow in the flap revealed instability. Subsequently, a supercharged PMMC flap was applied, which prevented partial necrosis of the flap. Conclusions: Combined with ICGA, a supercharged PMMC flap contributed to successful reconstruction in a patient at high risk for necrosis of the flap region.

Functional and cosmetic reconstruction of ocular laceration complicated by extensive eyelid degloving injury: A case report.

A 22-year-old woman sustained ocular laceration complicated by extensive an eyelid degloving injury when she accidentally fell and the drinking glass in her hand broke and cut her in the right eye area. She immediately noticed significant vision loss; thus, early surgical intervention was performed in collaboration with ophthalmologists and plastic surgeons. At 16 months after the injury, a good visual prognosis was achieved (visual acuity >20/40: IOL) without eye movement disorder or eyelid opening disorder, and phthisis bulbi and the need for prosthetic eye wear were avoided. Functional and cosmetic reconstruction can be achieved with concurrent emergency surgical intervention by ophthalmologists and plastic surgeons, even in cases of ocular laceration complicated by extensive eyelid degloving injury, where blindness and phthisis bulbi are predicted.

Reduction and fixation of comminuted fractures of the midface by using a Hoffman-type external fixator: A case report.

Internal fixation using plates remains the gold standard for facial fracture fixation. External wound fixators are rarely used. In the present study, we successfully treated multiple comminuted facial fractures with midfacial depressions by using a Hoffman-type external fixator and achieved good functional and cosmetic results. Internal fixation using plates is sometimes problematic in comminuted facial fractures, such as those associated with high-energy trauma. Depending on the fracture pattern, a Hoffman-type external fixator, which is a single pillar type of external fixator, can be effective.

A case of occipital spindle cell lipoma: a case report.

Spindle cell lipoma (SCL) is a subtype of lipoma first defined by Enzinger; it accounts for ~1.5% of all fatty tumors. Most cases occur in the posterior neck and shoulders of middle-aged men and rarely in women or the occiput. A 41-year-old woman presented to us with complaints of a mass on her left occiput which had slowly grown in size over six years. We excised the tumor, and pathological findings confirmed the diagnosis of SCL. There was no recurrence one year after the surgery.

Long-Term Follow-up With Multispecialty Management of a Giant Lymphangioma of an Infant Tongue Contributed to Reduced Complications of the Disease: A Case Report of a 21-Year Follow-up.

Background. Lymphangiomas are benign tumors of abnormal lymphatic tissue. Approximately 6% of all lymphangiomas occur on the tongue. A lymphangioma of the tongue may present as a localized or a diffused growth, which may enlarge to cause macroglossia, impaired speech, and difficulty in mastication. This article reports a 21-year follow-up of a male infant who presented with a giant tongue lymphangioma. This long-term follow-up with multidisciplinary management including partial glossectomy, sclerotherapy, and orthodontic treatment to diminish complications of the disease in adulthood.

Accelerated Angiogenesis of Human Umbilical Vein Endothelial Cells Under Negative Pressure Was Associated With the Regulation of Gene Expression Involved in the Proliferation and Migration.

ABSTRACT: Negative pressure has been used as a preferred therapy for wound healing; however, the mechanisms by which negative pressure promotes tissue restoration remain unclear. In the present study, RNA-sequencing analysis was performed to identify differentially expressed genes in human umbilical vein endothelial cells (HUVECs) exposed to negative pressure. Cell viability and DNA synthesis were examined using the cell counting kit-8 assay and bromodeoxyuridine incorporation, respectively. Cell migration was assessed using tube formation, Transwell, and wound healing assays. Activity of the serine/threonine kinase (AKT) signaling pathway was also examined by measuring the levels of phospho-paxicillin, phospho-focal adhesion kinase (p-FAK), and p-AKT1. The exposure of HUVECs to negative pressure enhanced cell proliferation and DNA synthesis. Negative pressure enhanced the migration and invasion of HUVECs, which was accompanied by upregulation of genes involved in angiogenesis, extracellular matrix organization, and cytoskeletal organization. The mRNA levels of growth factors, including placental growth factor and platelet-derived growth factor B, also increased. In addition, phosphorylation of paxicillin, focal adhesion kinase, and AKT increased under negative pressure. Collectively, the findings of this study demonstrated that negative pressure stimulates the angiogenic activity of HUVECs by increasing their proliferation and migration via activation of the AKT signaling pathway.

Osteolytic metatarsal osteomyelitis regenerated by combined treatment of artificial carbon dioxide foot bathing and povidone-iodine sugar ointment: a case report.

BACKGROUND: In recent years, the number of patients with ischemic skin ulcers due to diabetes mellitus and arteriosclerosis obliterans are increasing. Accordingly, endovascular therapy, drugs, and various wound dressings have been developed and applied to diabetic foot ulcers, and negative-pressure wound therapy, which often requires expensive and burdensome procedures for medical personnel, has also become popular. So simple and minimal invasive home treatment by the patient or their caregiver is required. CASE PRESENTATION: The present patient (77 years old, male, Asian) had developed left sole ulcers with draining pus that were resistant to conventional treatment, and he suffered from gait disturbance. We report a case of metatarsal osteomyelitis in a patient with diabetes mellitus and arteriosclerosis obliterans, in whom artificial carbon dioxide foot bathing and povidone-iodine sugar ointment were used continuously to promote bone and joint regeneration, and skin ulcer healing. CONCLUSIONS: A simple therapeutic intervention with artificial carbon dioxide foot bathing and povidone-iodine sugar ointment can improve not only ischemic skin ulcers, but also the bone and joint regeneration of ischemic limbs. This therapy can lead to a reduction in healthcare costs for a huge number of diabetic patients.

A stylized two-stage debridement strategy using an electric dermatome and a Versajet™ hydrosurgery system for deep axillary burns.

Treatment of axillary contracture after extensive deep burns is a serious clinical challenge. Various surgical intervention for releasing contracture using skin grafts, flaps and artificial skin have been used, but no consensus on the optimal treatment has been obtained. A standardized two-stage debridement strategy using an electric dermatome (for eschar) and the Versajet™ hydrosurgery system (for slough) can be an appropriate debridement strategy that provides reliable wound bed preparation in cases of for axillary deep burns. Using this approach focus on management of acute axillary burns, it is possible to avoid engraftment failure and prevent contracture caused by prolonged infection. This treatment strategy can be standardized and can be performed easily, even by non-experts.

Reconstruction of an Extensive Full-Layer Defect of the Upper Eyelid.

What are the zones of the eyelid and the characteristics of this defect?What are the eyelid defect reconstruction options?What are the major potential complications of the eyelid defect reconstruction?How can the complications be avoided?

A solitary giant neurofibroma of the left thigh: a case report.

A neurofibroma not associated with neurofibromatosis type 1 is termed solitary neurofibroma. A solitary giant neurofibroma of the thigh is an extremely rare tumor. A 44-year-old woman presented to us with a well-defined swelling on her left thigh for 10 years. On the basis of magnetic resonance image finding, we diagnosed the tumor as a neurofibroma. We excised the tumor and the pathological findings established the diagnosis of neurofibroma. There was no recurrence 8-months after surgery.