Longitudinal physiological remoulding of lower limb skin as a cause of diabetic foot ulcer: a histopathological examination.

OBJECTIVE: Diabetic foot ulcer (DFU) is recognised as a severe complication in patients with type 2 diabetes. With the increasing incidence of diabetes, it represents a major medical challenge. Several models have been proposed to explain its aetiology; however, they have never been assessed by longitudinal histopathological examination, which this study aims to address. METHOD: Multiplex-immunofluorescence analysis was carried out with lengthwise serial skin specimens obtained from the medial thigh, lower leg, ankle, dorsum of foot and acrotarsium close to the DFU region of a patient with type 2 diabetes receiving above the knee amputation. RESULTS: Proximal-to-distal gradual loss of peripheral nerve was demonstrated, accompanied by compromised capillaries in the superficial papillary plexus and distended CD31-positive capillaries in the dorsum of foot. Neural fibres and capillaries were also significantly compromised in the sweat gland acinus in the ankle and dorsum of foot. Injuries in the superficial papillary plexus, sweat gland acinus, and sweat gland-associated adipose tissues were accompanied by significant infiltration of macrophages. These results indicated that longitudinal impairment of local blood circulation could be the cause of peripheral neuropathy, which initiated ulcer formation. Resultant chronic inflammation, involving sweat gland-associated adipose tissue, gave rise to impairment of wound healing, and thus DFU formation. CONCLUSION: Longitudinal histopathological examination demonstrated that impairment of local microvascular circulation (rather than the systemic complication caused by type 2 diabetes) was considered the primary cause of peripheral neuropathy, which initiated ulceration. Together with chronic inflammation in the superficial papillary plexus and sweat gland-associated adipose tissue, it resulted in the development of a DFU. Although this is a study of just one individual's limb, our study provided a unique observation, contributing mechanistic insights into developing novel intervening strategies to prevent and treat DFUs.

Examination of Postoperative Outcomes Using Morphological and X-Ray Classifications and Selection of the Toe to Be Excised in Postaxial Polydactyly of the Foot.

The treatment of postaxial polydactyly requires excision of the medial fifth or lateral sixth toe, and separation of the adjacent fourth/fifth toes if the adjacent toes exhibit skin syndactyly. Morphological changes in the retained toes and reoperation are common problems after such surgery. This study examined the effects of preoperative classifications and selecting the medial fifth or lateral sixth toe for excision on the postoperative outcomes of surgery for postaxial polydactyly. From April 2006 to March 2019, surgery for postaxial polydactyly was performed on 55 feet in 49 patients. The patients' mean age at surgery was 28.8 months. Postoperative esthetic and bone alignment scores, the reoperation rate, and postoperative dysfunction were examined. The postoperative esthetic and bone alignment evaluations were performed by examining postoperative photograph and X-ray images using original scoring systems. The surgical procedure was chosen by the surgeon-in-charge during a preoperative conference after considering the toe growth and bone alignment. In the postoperative esthetic evaluation, excising the lateral sixth toe produced significantly better outcomes than excising the medial fifth toe. The morphological classification also indicated that excising the lateral sixth toe produced better outcomes, as it resulted in the bifurcated toes being clearly independent. Interestingly, the postoperative X-ray-based bone alignment score was not correlated with the esthetic score. The reoperation rate tended to be high after medial fifth toe excision. There were no postoperative functional complications. Lateral sixth toe excision for postaxial polydactyly of the foot produces good postoperative esthetic outcomes.

Peroneal perforator-based peroneus longus tendon and sural neurofasciocutaneous composite flap transfer for a large soft-tissue defect of the forearm: A case report.

We describe the use of a composite flap composed of a sural neurofasciocutaneous flap and a vascularized peroneus longus tendon for the reconstruction of severe composite forearm tissue defects in a patient. A 43-year-old man had his left arm caught in a conveyor belt resulting in a large soft-tissue defect of 18 × 11 cm over the dorsum forearm. The extensor carpi radialis, superficial radial nerve, and radial artery were severely damaged. A free neurofasciocutaneous composite flap measuring 16 × 11 cm was outlined on the patient's left lower leg to allow simultaneous skin, tendon, nerve, and artery reconstruction. The flap, which included the peroneus longus tendon, was elevated on the subfascial plane. After the flap was transferred to the recipient site, the peroneal artery was anastomosed to the radial artery in a flow-through manner. The vascularized tendon graft with 15 cm in length was used to reconstruct the extensor carpi radialis longus tendon defect using an interlacing suture technique. As the skin paddle of the sural neurofasciocutaneous flap and the vascularized peroneus longus tendon graft were linked by the perforator and minimal fascial tissue, the skin paddle was able to rotate and slide with comparative ease. The flap survived completely without any complications. The length of follow-up was 12 months and was uneventful. Range of motion of his left wrist joint was slightly limited to 75 degrees. This novel composite flap may be useful for reconstructing long tendon defects associated with extensive forearm soft tissue defects.

Evaluation of the use of recombinant human basic fibroblast growth factor in combination with negative pressure wound therapy with instillation and dwell time in porcine full-thickness wound model.

NPWT with instillation and dwell time (NPWTi-d), which combines NPWT with wound irrigation, has been clinically applied as a more effective treatment than conventional NPWT. Commercially available recombinant human basic fibroblast growth factor (rh-bFGF) has been demonstrated to be beneficial for use over the wound beds. The objective of this study was to evaluate the effectiveness of combined treatment with NPWTi-d and rh-bFGF. Six pigs received 12 full-thickness excisional skin wounds and were treated with six different treatment groups for each pair. The treatment regimens were composed NPWTi-d, NPWT, or advanced wound care with or without rh-bFGF. On day 6, the minimum granulation tissue thickness and blood vessel number of the group of combined treatment with NPWTi-d and rh-bFGF spray were significantly greater than that of the control group. Combined treatment with NPWTi-d and rh-bFGF spray reads to good granulation tissue formation and vascularization for accelerating wound healing.

Effectiveness of basic fibroblast growth factor for pediatric hand burns.

AIM OF THE STUDY: Pediatric hand deep dermal and deep burns may lead to serious hand deformity with functional impairment and result in an esthetically unfavorable outcome. Since there is no guideline regarding the use of growth factors for pediatric hand burns, we sought to investigate the effectiveness of an angiogenic and regenerative growth factor, basic fibroblast growth factor (bFGF). METHODS: Consecutive series of second degree or third degree palmer burns at less than 3 years of age seen from January 2010 to June 2014 were included for evaluation at 6 months post-wound healing. The bFGF treatment started from just after injury and continued up to 21 days. Each patient had their scars scored using the Vancouver Scar Scale (VSS) at 6 months after wound healing. RESULTS: There were 34 children with 49 acute palmar burns. The mean healing period was 13.5 ± 4.3 days (7-44 days) and 43 wounds healed within 21 days. There was no need of additional surgery in the 43 wounds, healed within 21 days. In comparison to the wounds for which healing took more than 21 days, the wounds that healed within 21 days demonstrated significantly better pigmentation, pliability, and height according to the VSS (p < 0.05), as well as no scar contracture or hypertrophic scars. CONCLUSION: bFGF treatment was effective in cases that healed within 21 days, avoiding scar contractures and hypertrophic scars. Our methods using bFGF to complete wound healing are less invasive and produce better results in pediatric palmer burns.

Combined treatment with artificial dermis and basic fibroblast growth factor for cranial bone-exposing wounds.

AIM OF THE STUDY: Cranial bone-exposing wounds should be resurfaced as soon as possible using flaps. However, early one-stage wound closure is sometimes difficult due to the poor general condition of the patient or equipment shortages. Artificial dermis composed of atelocollagen sponge is useful for reconstructing bone-exposing wounds. In addition, the treatment of wounds with basic fibroblast growth factor helps more severe wounds to heal faster. We employed combined treatment with artificial dermis and basic fibroblast growth factor to treat cranial bone-exposing wounds in 2 cases, and we describe these cases here. MATERIALS AND METHODS: Case 1: A 56-year-old man suffered severe burns, which exposed the occipital bone and mandible, after attempting suicide. Case 2: A 79-year-old woman suffered a full-thickness skin defect on her forehead due to a fall, which resulted in her frontal bone being exposed. Both patients underwent combined treatment with artificial dermis and basic fibroblast growth factor, followed by free skin grafting. RESULTS: The combined treatment promoted the formation of granulation tissue, which acted as a wound bed for the subsequent skin grafting. The free skin grafting resulted in the complete resurfacing of the patients' wounds. CONCLUSION: Combined treatment with artificial dermis and bFGF is an easy, fast-acting, and effective way of preparing a favorable wound bed for skin grafting, and hence, is useful for the treatment of cranial bone-exposing wounds.

Combined serratus anterior and latissimus dorsi myocutaneous flap for obliteration of an irradiated pelvic exenteration defect and simultaneous site for colostomy revision.

BACKGROUND: Usually, several surgical methods are used, with re-suturing, free skin grafting and local flaps, for the reconstruction of wall defects after abdominoperineal resection. However, or larger defects, free flaps have been preferred because they can provide a large area of well-vascularized soft tissue, which is suitable for defect repair. We present the case of a large abdominal wall defect, which was treated with a free combined serratus anterior and latissimus dorsi myocutaneous flap, resulting in a successful outcome. CASE PRESENTATION: A 38-year-old female originally had squamous cell carcinoma of the cervix uteri, and had undergone radical hysterectomy and oophorectomy followed by radiotherapy. She had a recurrence of the cervical cancer after 13 years, and underwent pelvic exenteration. However, the mid-abdominal wound developed dehiscence and an abdominal full-thickness defect communicating with the pelvic cavity. Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis. During surgery, the empty pelvic cavity was filled with a combined serratus anterior and latissimus dorsi myocutaneous flap to prevent chronic peritonitis, to create a new stoma in the skin paddle of the flap for the necrotic colon, and to separate the pelvic cavity from the drained stools. The patient could walk in the absence of abdominal hernia formation and relapse of infection. CONCLUSIONS: A combined serratus anterior and latissimus dorsi myocutaneous free flap was applied to cover the raw surface and reinforce the abdominal wall and to fashion a new colostomy, as well as successfully filling the pelvic cavity with a large muscle body and long vascular pedicle. This is the optimal method for reconstructing severe abdominal wall defects that have many complications.

Fresh human amniotic membrane wrapping promotes peripheral nerve regeneration in PGA-collagen tubes.

BACKGROUND: An artificial nerve conduit can interpose the peripheral nerve defect without donor site morbidity. However, treatment outcomes are often unsatisfactory. Human amniotic membrane (HAM) wrapping has been reported to promote peripheral nerve regeneration. We evaluated the effects of a combined application of fresh HAM wrapping and a polyglycolic acid tube filled with collagen (PGA-c) in a rat sciatic nerve 8-mm defect model. METHODS: The rats were divided into three groups: (1) the PGA-c group (n = 5), in which the gap was interposed with the PGA-c; (2) the PGA-c/HAM group (n = 5), in which the gap was interposed with the PGA-c bridge, then HAM (14 × 7 mm) was wrapped around it; and (3) the Sham group (n = 5). Walking-Track recovery, electromyographic recovery, and histological recovery of the regenerated nerve were evaluated at 12 weeks postoperatively. RESULTS: Compared to the PGA-c group, the PGA-c/HAM group showed significantly better recovery in terminal latency (3.4 ± 0.31 ms vs. 6.6 ± 0.72 ms, p < 0.001), compound muscle action potential (0.19 ± 0.025 mV vs. 0.072 ± 0.027 mV, p < 0.01), myelinated axon perimeter (15 ± 1.3 µm vs. 8.7 ± 0.63 µm, p < 0.01), and g-ratio (0.69 ± 0.0089 vs. 0.78 ± 0.014, p < 0.001). CONCLUSION: This combined application highly promotes peripheral nerve regeneration and may be more useful than PGA-c alone.

Reconstruction with a free temporoparietal fascia flap for intractable flexor tenosynovitis of the wrist accompanied by a soft tissue defect: a case report.

We herein report a case of intractable flexor tenosynovitis. The inflamed synovium was debrided twice because of suspected infectious tenosynovitis. However, it relapsed and caused a soft tissue defect. Reconstruction with a free temporoparietal fascia (TPF) flap was performed. Recurrence has not been detected in the six years after surgery.

Foot reconstruction with the superficial circumflex iliac artery perforator flap under local anesthesia: Two case reports.

RATIONALE: The superficial circumflex iliac artery perforator (SCIP) free flap is a popular method used in foot reconstruction. Although the SCIP flap has a relatively short pedicle and does not require intramuscular dissection, general anesthesia is largely preferred for SCIP flap reconstruction. We report 2 cases with the free SCIP flap for skin and soft tissue reconstruction of the foot under local anesthesia. PATIENT CONCERNS: Case 1 was a 34-year-old man sustained a crush injury to the dorsal foot, resulting in a soft tissue defect with bone and tendon exposure. Case 2 was a 41-year-old man with type 2 diabetes was referred to our division for an intractable ankle wound after surgery for a calcaneal bone fracture. DIAGNOSIS: The diagnosis was intractable wounds on feet caused by trauma and surgery. Patients were unable to receive general anesthesia because of asthma or elevated liver enzymes. INTERVENTIONS: Two patients with tissue defects on their feet were treated with SCIP flaps under local anesthesia. Fifteen milliliter of 0.5% bupivacaine was injected for ankle block. SCIP flaps were harvested after injecting 10 to 15 mL of 1% lidocaine combined with epinephrine around the flap incisions. OUTCOMES: No complications related to the use of local anesthesia developed during the operation or postoperatively. Two flaps survived and fully took without complications. LESSONS: With proper local anesthesia, successful foot reconstruction with a free SCIP flap was possible. This method can be considered a sufficient option for foot reconstruction for patients unable to receive general anesthesia.

Paracrine Effects of Adipose-Derived Stem Cells Promote Lymphangiogenesis in Irradiated Lymphatic Endothelial Cells.

BACKGROUND: There is currently no reliable treatment for secondary lymphedema caused by lymph node dissection or radiotherapy; however, stem cell-based regenerative medicine is emerging as a promising remedy for such complications. The purpose of this study was to examine the effects of adipose-derived stem cells on lymphangiogenesis involving human dermal lymphatic endothelial cells exposed to ionizing radiation. METHODS: Proliferation, migration, and tube formation were analyzed in human dermal lymphatic endothelial cells that were co-cultured with adipose-derived stem cells or cultured in adipose-derived stem cell-conditioned medium. The levels of lymphangiogenic factors secreted from adipose-derived stem cells were analyzed by enzyme-linked immunosorbent assays and Western blotting. RESULTS: Co-culturing with adipose-derived stem cells and the use of adipose-derived stem cell-conditioned medium both significantly promoted proliferation, migration, and tube formation in nonirradiated human dermal lymphatic endothelial cells. The authors also found that irradiated adipose-derived stem cells had similar alleviative effects on irradiated human dermal lymphatic endothelial cells. Enzyme-linked immunosorbent assays and Western blotting analysis revealed that irradiating adipose-derived stem cells increased their secretion of basic fibroblast growth factor in a dose-dependent manner, whereas it caused no detectable change in their secretion of vascular endothelial growth factor A or C, or hepatocyte growth factor. CONCLUSIONS: These results demonstrated that factors secreted by adipose-derived stem cells contribute to the promotion of lymphangiogenesis in irradiated human dermal lymphatic endothelial cells. The authors' findings also suggest that radiation potentiates the paracrine effects of adipose-derived stem cells by stimulating basic fibroblast growth factor protein expression.

Successful reconstruction of congenital perineal skin defect using gluteal-fold bilobed perforator flap.

Perineovaginorectal defect usually requires surgical repair; however, direct closure often leads to dehiscence. We present two patients with a congenital perineal skin defect who were successfully treated using a gluteal-fold bilobed perforator flap. This flap facilitates esthetic restoration and a more natural perineovaginorectal appearance, using only a one-stage procedure. This technique may be a favorable option for perineal and genital repair.

Adipose-Derived Stem Cells and Vascularized Lymph Node Transfers Successfully Treat Mouse Hindlimb Secondary Lymphedema by Early Reconnection of the Lymphatic System and Lymphangiogenesis.

BACKGROUND: Secondary lymphedema is often observed in postmalignancy treatment of the breast and the gynecologic organs, but effective therapies have not been established in chronic cases even with advanced physiologic operations. Currently, reconstructive surgery with novel approaches has been attempted. METHODS: The hindlimbs of 10-week-old male C57BL/6J mice, after 30-Gy x-irradiation, surgical lymph node dissection, and 5-mm gap creation, were divided into four groups, with vascularized lymph node transfer abdominal flap and 1.0 × 10 adipose-derived stem cells. Lymphatic flow assessment, a water-displacement plethysmometer paw volumetry test, tissue quantification of lymphatic vessels, and functional analysis of lymphatic vessels and nodes were performed. RESULTS: Photodynamic Eye images, using indocyanine green fluorescence, demonstrated immediate staining in subiliac lymph nodes, and linear pattern imaging of the proximal region was observed with the combined treatment of adipose-derived stem cells and vascularized lymph node transfer. Both percentage improvement and percentage deterioration with the combined treatment of adipose-derived stem cells and vascularized lymph node transfer were significantly better than with other treatments (p < 0.05). The numbers of lymphatic vessels with LYVE-1 immunoreactivity significantly increased in mice treated with adipose-derived stem cells (p < 0.05), and B16 melanoma cells were metastasized in groups treated with vascularized lymph node transfers by day 28. CONCLUSIONS: Adipose-derived stem cells increase the number of lymphatic vessels and vascularized lymph node transfers induce the lymphatic flow drainage to the circulatory system. Combined adipose-derived stem cell and vascularized lymph node transfer treatment in secondary lymphedema may effectively decrease edema volume and restore lymphatic function by lymphangiogenesis and the lymphatic-to-venous circulation route.

Successful reconstruction after resection of malignant skin tumor on triangular fossa using anterior auricular bilobed flap.

Reconstruction of surgical defects is challenging, especially when they are localized in an anterior surface. The authors present two patients with a malignant skin neoplasm localized in the triangular fossa. Each tumor was removed and the cartilage-exposing wound was reconstructed using an anterior auricular bilobed flap. The donor site of the flap was primarily closed. The viability of the flap was favorable without complications and with excellent esthetic results. There are various surgical procedures for reconstruction of the anterior auricle. Among them, an anterior auricular bilobed flap can be performed quickly, has minimal associated morbidity and yields a favorable outcome. We believe that this technique is an effective option, especially for the triangular fossa skin defect resurfacing.

A retrospective comparison of perforator and rotation flaps for the closure of extensive Stage IV sacral pressure ulcers.

Wound coverage using a flap, most commonly a perforator or rotation flap, often is required for the closure of extensive sacral pressure ulcers. To assess the duration of wound healing and postsurgical complications following two types of surgical closure procedure, perforator and rotation flaps, a retrospective study was conducted among a convenience sample of 20 patients (10 men, 10 women) with Stage IV sacral pressure ulcers. All ulcers were repaired in 2011 and 2012 by the same surgical group and included nine perforator and 11 rotation flaps. Patient demographic and wound outcomes data were abstracted, and data were analyzed using Wilcoxon signed rank and chi-squared tests. No significant differences were noted in patient demographics between the two groups, although serum albumin level in the rotation flap group was significantly higher than in the perforator flap group (P = 0.01). The mean follow-up period was 18 (range 6-30) months. Mean time to healing was 34 ± 15.4 (range 10-58) days in patients with a perforator flap and 45.5 ± 24.0 (range 11-80) days in patients with a rotation flap (P = 0.03). Patients who underwent rotation flap surgery had a higher rate of postoperative complications and a significantly higher rate of postsurgical seroma (n = 9) compared to those who underwent perforator flap surgery (n= 2) (P = 0.05). The mean time to healing in both groups was 13.5 days in patients without and 48.5 days in patients who developed a seroma. (P <0.01). The results of this study show the proportion of patients who develop a seroma following surgical repair of a sacral pressure is lower following perforator than rotation flap surgery. Additional clinical studies are needed to confirm these findings.

Transcatheter arterial embolization for shock caused by intratumoral hemorrhaging in neurofibromatosis type 1: a report of two cases.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by café-au-lait spots and neurofibroma. Vascular NF-1 lesions are rare, but bleeding from such lesions can sometimes cause lethal complications because surgical hemostasis is difficult to achieve due to the fragile nature of the surrounding blood vessels and soft tissue. In recent years, some reports have suggested that transcatheter arterial embolization (TAE) is an effective treatment for vascular NF-1 lesions. We report the cases of 2 NF-1 patients who developed intratumoral hemorrhaging and were successfully treated with TAE.