VEGF secretion by adipose tissue-derived regenerative cells is impaired under hyperglycemic conditions via glucose transporter activation and ROS increase.

Transplantation of cultured adipose-derived regenerative cells (ADRCs) into ischemic tissues promotes neovascularization and blood perfusion recovery. These effects are attenuated in diabetes patients. We examined the effects of hyperglycemia on the angiogenic capacity of ADRCs derived from Wistar rats both in vivo and in vitro. Cultured ADRCs were predominantly composed of CD90 positive cells; prevalence of CD90 positive cells was not affected by hyperglycemia. mRNA and protein levels of vascular endothelial growth factor (VEGF) were significantly decreased in ADRCs under hyperglycemic conditions independent of osmolarity, whereas mRNA levels of hepatocyte growth factor and fibroblast growth factor were unaffected. Since ADRCs express glucose transporter proteins GLUT1, 3 and 4, we examined the effects of the glucose transporter inhibitor phloretin on reactive oxygen species (ROS) and angiogenic factors. Phloretin decreased the glucose uptake rate, reduced ROS, and increased VEGF mRNA in ADRCs exposed to a hyperglycemic condition. In vivo transplantation of ADRCs cultured under hyperglycemic conditions into mouse ischemic limbs resulted in significantly decreased blood perfusion and capillary density in ischemic regions compared with transplantation of ADRCs cultured under normoglycemic conditions. These results suggest that hyperglycemia impaired VEGF production in ADRCs via an increase of ROS, impairing the angiogenic capacity of ADRCs transplanted into ischemic limbs.

Ulcerative pigmented squamous cell carcinoma in a 101-year-old Japanese woman.

Pigmented squamous cell carcinoma is a rare variant of squamous cell carcinoma. We report a case of pigmented squamous cell carcinoma with dermoscopic examination probably arisen from actinic keratosis in a 101-year-old woman who was surgically treated under general anesthesia. In addition, we discuss indications of general anesthesia in elderly patients with skin cancer, differential diagnosis and dermoscopic features of pigmented squamous cell carcinoma.

A new design for free flap reconstruction of the tongue and oropharynx.

Radical resection of tongue and oropharyngeal carcinomas often results in complex defects that are challenging to reconstruct. Furthermore, remaining function should not be disturbed by the reconstruction. We introduce a new flap design and monitored swallowing and speech following reconstruction of complex oral defects. The new design consists of four lobes on a single pedicle. The first reconstructs the tongue, the second the tongue base, the third the oral floor, and the fourth the lateral wall. The records of cases performed between July 2002 and December 2006 were reviewed. Twenty-three patients (17 men and 6 women) with an average age of 60 years underwent immediate reconstruction using a free flap after radical resection of a malignant carcinoma of tongue or oropharynx using a free flap. Postoperative swallowing and speech were rated using a self-report questionnaire. Moreover, the functional outcome in patients with and without a tongue base defect was compared. All free flaps took entirely, and postoperative function was largely satisfactory. Swallowing in patients with and without a tongue base defect was similar, but speech was more impaired in patients who had a tongue base defect. Our new design is effective for reconstructing intraoral defects three-dimensionally. However, further refinement is required to preserve speech.

Combined fibular osteocutaneous and omental flaps.

BACKGROUND: The free vascularized fibular bone graft, first described in 1975, has become one of the most commonly used bone grafts. It is useful for reconstructing mandibular and traumatic long bone defects and defects following tumor resection. This flap, however, does not have a long pedicle and does not have very much volume. The authors report a solution to these problems through the use of an omental flap as a bridge. METHODS: Over a 3-year period, nine patients were treated by means of a free fibular osteocutaneous flap with an omental flap. These cases required bone reconstruction without suitable recipient vessels that existed near the defect. The nine patients had the following disorders: two femoral pseudoarthrosis, two tibial pseudoarthrosis, two malignant femoral tumors, one maxillary defect after tumor resection, and one femoral and tibial osteomyelitis. RESULTS: All flaps were transferred successfully. In one case, an additional skin graft was performed because of partial omental necrosis that occurred within 2 weeks. Fibular synostosis developed in eight cases, but amputation was performed in one case because of failed fibular synostosis. In one case, femoral amputation was performed because the femoral artery became obstructed 3 months postoperatively. CONCLUSIONS: An omental flap has a long pedicle for use as a bridge flap. It is useful as a vascular flap. A combined fibular osteocutaneous and omental flap is useful for bone reconstruction without satisfactory recipient vessels that exist near the defect. Furthermore, the flap is useful for infected wounds.

Analysis of salvage operation in head and neck microsurgical reconstruction.

In this study, we examined salvage operations after reexploration in head and neck reconstruction and analyzed ways to solve problems. Free flap reconstruction of the head and neck lesion was carried out for 513 cases in our hospital over the past 12 years. Twenty-one cases of reexploration were caused by postoperative thrombosis (4.1%). We could only salvage seven cases (33.3%) of 21 cases from flap thrombosis. All seven cases were included in the category of venous thrombosis, and they were undertaken within 3 days postoperatively. Our results have shown that once thrombosis occurs, there is little possibility of flap salvage, particularly 3 days after operation and in infectious cases. When no flow phenomena are observed and no flap salvage is deemed possible, aggressive treatment such as a second free flap or next pedicle flap should be chosen as soon as possible to avoid any delay in postoperative treatment.

Posterolateral cervical vein as a recipient vein in reconstructive microvascular surgery of the head and neck.

Free flaps are becoming the preferred method of choice for head and neck reconstruction. However, many patients who have undergone radiotherapy and radical neck dissection or who require treatment for recurrent tumor, often present difficulty in choosing recipient vessels. The authors have noted a potential recipient vein coursing vertically along the anterior ridge of the trapezius muscle. They used this vein as the recipient vein in two patients; the two free flaps were transferred successfully without complications. This vein, which they provisionally named the posterolateral cervical vein (PLCV), is considered an important option as a recipient vein in head and neck reconstruction when more commonly used recipient cervical veins are unavailable.

Autoperipheral blood mononuclear cell transplantation improved giant ulcers due to chronic arteriosclerosis obliterans.

We report the case of a 74-year-old man with Fontaine stage IV chronic arteriosclerosis obliterans who had been suffering from inveterate giant skin ulcers on the dorsum and heel of the right foot. As conventional medical treatments had not improved these ulcers and surgical treatment was considered unfeasible, amputation of the right lower limb below the knee appeared to represent the only option. The patient was admitted to Tottori University Hospital to attempt a new angiogenic therapy using auto-mononuclear cell transplantation to avoid amputation. On admission, neither right ankle blood pressure nor transcutaneous partial pressure of oxygen at the right toe were detectable. The patient had a history of multiple cerebral infarctions, and collection of mononuclear cells from bone marrow was considered too difficult, so collection of peripheral blood mononuclear cells was selected. Transcutaneous partial pressure of oxygen and skin temperature in the treated limb started to improve from 2 weeks after implantation. Ulcer size was recognizably reduced by 1 month after treatment. Partial auto-skin implantation on the right heel was performed 2 months after treatment, and the giant skin ulcer was finally completely covered. No adverse effects were noted during follow-up lasting 1 year. These results suggest that peripheral blood mononuclear cell implantation may offer a suitable alternative rescue therapy for patients with critical limb ischemia whose general condition is not good.

Successful upper alveolar reconstruction for gingival cancer using a fibular osteoadipofascial flap without osseointegrated implants.

An upper alveolar skeletal reconstruction with closure of the palatal fistula using an osteocutaneous free flap is considered an ideal reconstructive strategy after curative surgery for cancer of the lower maxilla. Although installation of osseointegrated implants into the bone has advantages for utilizing a dental prosthesis, it is often time and cost prohibitive. In the case of 1 patient, we reconstructed and fit the patient with a conventional denture, eliminating the need for installation of osseointegrated implants. The patient underwent upper alveolar reconstruction using a fibular osteoadipofascial flap, followed by a skin graft for creation of an alveololabial sulcus. It was then possible for the patient to wear a conventional denture without implants. One explanation for this success is that the regenerated mucosa on the adipofascial flap and skin graft was immobile, which allowed it to serve as a base for the dental prosthesis. The alveololabial sulcus that had been constructed kept the denture in place. This reconstruction confirmed that a fibular osteoadipofascial flap might be a useful choice in restoring a natural upper alveolar osseous and soft tissue structure.

Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy.

The surgical strategy for maxillary reconstruction after maxillectomy has yet to be standardized. The authors developed a technique using a three-dimensional orbitozygomatic skeletal model of a titanium mesh for skeletal reconstruction after maxillectomy. From May of 1996 to September of 2000, 18 patients underwent reconstruction using the titanium mesh model in conjunction with a soft-tissue free flap following total maxillectomy for a maxillary malignancy. The soft-tissue free flap was conventional and consisted of two skin paddles to the maxillary defect. One skin paddle became the lateral nasal wall and the other was used to close the palatal defect. After modeling, the titanium mesh plate was implanted between the orbital contents and the upper edge of the free flap to lie over the front of the flap. The model was fixed to the residual zygoma laterally and to the nasal or frontal bone medially. The palatal skin paddle was anchored by three or four dermal stitches to the bottom edge of the titanium mesh to create a concave neopalate that allowed the patient to wear a denture. Thirteen of 18 patients who underwent implantation had good facial appearance and oral function. This procedure prevented lagophthalmos, facial deformity, and sagging of the palatal skin paddle caused by gravitational force. Five patients (27.8 percent) developed exposure or infection of the implant and lost the benefit of having the prosthesis. However, treatment did not require total removal of the implant. Maintaining adequate tissue volume during soft-tissue transfer on either side of the mesh plate may minimize the complication rate. Titanium mesh implantation for skeletal reconstruction after maxillectomy avoids the need for bone grafting and may be especially beneficial in fragile or aged patients.

The gastrocnemius with soleus bi-muscle flap.

The gastrocnemius muscle flap is often insufficient in volume and arc of rotation for coverage of a large soft tissue defect of the knee and the upper third of the leg. Therefore we developed a new concept of the flap which combines soleus and gastrocnemius muscles, named the 'gastrocnemius with soleus bi-muscle flap'. In 16 cadavers we studied the location and number of perforators, which penetrate the gastrocnemius muscle through the soleus muscle. In all cases perforators were found in the distal half of the gastrocnemius muscle. Angiography in one fresh cadaver confirmed that the soleus muscle could receive the reversed flow from the gastrocnemius muscle perforators. We subsequently treated a patient with exposed proximal tibia with this flap. This flap is useful to cover a large soft tissue defect of the knee and the upper third of the leg.

Role of the anterolateral thigh flap in head and neck reconstruction: advantages of moderate skin and subcutaneous thickness.

Skin-flap thickness is an important consideration when choosing a free flap for head and neck reconstruction. The anterolateral thigh flap, the rectus abdominis flap, and the radial forearm flap, which included the epidermis, the dermal, and the subcutaneous layers, were measured using ultrasonography in 31 patients. The mean skin and subcutaneous thickness of the anterolateral thigh flap was 7.1 mm; the rectus abdominis flap was 13.7 mm; and the radial forearm flap was 2.1 mm. Further analysis revealed a statistically significant difference among the skin and subcutaneous thickness of the three flap groups. Of the 44 anterolateral thigh flap transfers done for head and neck reconstruction after cancer ablative surgery, 41 (93.2 percent) were transferred successfully. The anterolateral thigh flap creates a moderately thick skin flap, and is less variable in thickness across its area than is the rectus abdominis flap. The flap is adaptable for reconstruction of head and neck soft-tissue defects.

Usefulness of a first transferred free flap vascular pedicle for secondary microvascular reconstruction in the head and neck.

The authors found that a previously transferred free flap vascular pedicle, distal to the first microvascular anastomosis, can be used as a recipient vessel for an additional free flap transfer. Free flap transfers were performed by using the standard procedure in patients with head and neck cancer. The mean age of the patients was 62 years. Five patients were men and three were women. A second free flap was transferred for secondary primary head and neck cancer in two cases, facial deformity in two cases, osteomyelitis of the skull in two cases, recurrent cancer in one case, and exposure of a mandibular reconstruction plate in one case. The interval between the two operations was from 4 months to 12 years (median, 21 months). All secondary free flaps were performed successfully. In two cases, the external jugular vein proximal to the previously anastomosed site was used for venous drainage. In another case, additional venous anastomosis was performed for flap congestion. It became clear that a previously transferred free flap vascular pedicle could be used as a recipient vessel for microvascular anastomosis. This is an excellent procedure for additional free flap transfers.