Post-reconstruction Free Flap Complications After Oral Cancer Ablation.

Introduction: Microvascular free flap transfer is considered a standard reconstruction after the ablation of oral cancer. Although the success rate is high, flap complications occasionally occur. This study investigated the reasons for and local factors involved in complications of free flap transfer and explored how to salvage the flaps. Patients and Methods: The cases of 53 patients who underwent a free flap transfer [radial forearm flaps (n = 36), abdominis musculocutaneous flaps (n = 6), scapular osteocutaneous flaps (n = 10), and fibular osteocutaneous flap (n = 1)] were analyzed: flap complications were observed in five of the cases. Results: In the all five cases, a salvage operation was performed under general anesthesia. The flap complications occurred within 33 h after anastomosis. In the salvage operation, thrombotic occlusion in veins of flap feeders was observed in three of the five cases. The possible reasons for flap complications were a twisting of the anastomosed vein where two veins were united, pressure to the feeder due to subcutaneous hematoma, and edema of adjacent tissue and/or drain tube; the reason was not clear in one case. The flaps were successfully salvaged in four cases by thrombectomy in veins, release of pressure at the veins, and/or interposition of the vein graft. Conclusion: Surgeons should pay close attention to the pressure and/or twisting in the feeder as well as the hemostasis in the surgical field, and a salvage operation should be carried out immediately when a flap complication is identified.

A simple sandwich technique using buttons combined with a tie-over technique for an intraoral split-thickness skin graft.

A simple sandwich technique using buttons to compress grafted tissue combined with a tie-over technique for intraoral split-thickness skin grafts (STSGs) is introduced. This technique yielded an excellent engraftment rate (90.5%) and no instances of total graft failure were recorded. This simple sandwich technique for STSGs is readily applicable and inexpensive, and the present results show that it would be potentially useful for repair of defects in the oral cavity.

Functional evaluation of swallowing in patients with tongue cancer before and after surgery using high-speed continuous magnetic resonance imaging based on T2-weighted sequences.

OBJECTIVES: The aim of this study was to determine the usefulness of evaluating the function of swallowing before and after surgery in patients with tongue cancer by using T2-weighted sequences of high-speed continuous magnetic resonance imaging (HSCMRI). STUDY DESIGN: The imaging findings and related parameters on HSCMRI along with those on routine MRI examinations before and after surgery were examined in 19 patients with tongue cancer. In addition, changes in various parameters during 1 year after surgery were evaluated in 10 patients. RESULTS: In most patients examined, the direction of flow to the esophagus could be seen on HSCMRI before and after surgery. Significant correlations were observed among 4 parameters and in the responses to a dysphagia questionnaire. CONCLUSIONS: The results of the present study suggest that the dynamics of swallowing can be directly visualized on HSCMRI by using 4 parameters that permit the evaluation of changes before and after surgery, and this enables objective evaluation of patients' swallowing complaints.

Changes in the distributions of fluorine-18-labelled fluoro-2-deoxy-d-glucose accumulation into tongue-related muscles after dissection in patients with tongue cancer.

OBJECTIVES: To elucidate the changes in the distributions of fluorine-18-labelled fluoro-2-deoxy-d-glucose (18F-FDG) accumulation in the tongue muscles of patients following four kinds of surgical operations for tongue cancers. METHODS: The changes in the distributions of 18F-FDG accumulations in the tongue muscles on positron emission tomography (PET)-CT, in association with imaging findings on CT and MRI, were retrospectively analyzed before and after four kinds of surgical operations for 50 patients with tongue cancers. RESULTS: 18F-FDG-PET-positive areas appeared at the back of the intrinsic muscles of the tongue after invasive surgery for tongue cancers despite the absence of abnormal findings on CT and MRI. A correlation between the standardized uptake value maximum of 18F-FDG in the intrinsic muscles and the degree of invasiveness of the surgical procedures for tongue cancers (r = 0.539, p < 0.01) was found. CONCLUSIONS: It is important to pay attention to the changes in 18F-FDG distributions in the intrinsic muscles of the tongue before and after invasive surgery despite the absence of abnormal findings on CT and MRI when evaluating the tongue on 18F-FDG-PET.

Modified Lateral Surgical Approach to the Pterygopalatine Fossa.

Oral cancer, especially that originates in the maxillary tuberosity, buccal mucosa, and maxillary alveolus, is apt to invade the pterygopalatine fossa, where an intraoral approach is nearly impossible. There are 2 main types of extraoral approach to the pterygopalatine fossa; the anterior approach and the lateral approach. Although the lateral approach has an advantage compared with the anterior approach in terms of cosmetics, after the operation numbness of the lower lip occurs due to the sacrifice of the mental nerve. In the conventional lateral approach, a vertical incision is made in the center of the lower lip; a lateral flap is then elevated with the sacrifice of the mental nerve. The authors introduce here a new lateral approach to the pterygopalatine fossa with preservation of the mental nerve. In the present technique, a vertical incision was made in the corner of the mouth, and a lateral flap was then elevated with preservation of the mental nerve. This technique could also preserve the marginal mandibular branch of facial nerve in patients without a large metastasis in the submandibular lymph nodes. Additionally, expedient mandibular osteotomy, which is applied in the conventional lateral approach, could be omitted in the present technique, thus helping to prevent postoperative infection. The present approach was applied to 5 patients with oral cancer invading the pterygopalatine fossa. The postoperative numbness of the lower lip was estimated using the current perception threshold. The lesions were successfully resected with little numbness of the lower lip, and no postoperative infection occurred in any of the patients. This technique is available as an approach to the pterygopalatine fossa that preserves the mental nerve and can prevent postoperative infection.

Fluorescence-guided bone resection by using Visually Enhanced Lesion Scope in diffuse chronic sclerosingosteomyelitis of the mandible: Clinical and pathological evaluation.

UNLABELLED: Diffuse chronic sclerosingosteomyelitis (DCSO) is a refractory disease, becausethe etiology and pathogenesis remain poorly understood and to determine the border betweenunhealthy boneandhealthybone is difficult. However, progressive inflammation, clinical symptoms and a high recurrence rate of DCSO were the reasons for surgical treatment. We report a case of a 66-year old woman with DCSO of the right side of mandible who was treated with hemimandibulectomy and simultaneous reconstruction by vascularized free fibula flap. After preoperative administration of minocycline for 1 month, the bone fluorescence was successfully monitored by using a Visually Enhanced Lesion Scope (VELscope®). Intraoperatively, we could determine the resection boundaries. We investigated the clinical and histopathological findings. The fluorescence findings were well correlated with histopathological findings. Using a VELscope®was handy and useful to determine the border between DCSO lesion andhealthybone.The free fibula flap under the minocycline-derived bone fluorescence by using a VELscope®offered a good quality of mandibular bone and the successful management of an advanced and refractory DCSO. KEY WORDS: Fluorescence-guided bone resection, fibular free flap, osteomyelitis of the mandible, diffuse chronicosteomyelitis, VELscope®.

Emergency Cricothyroidotomy for Difficult Airway Management After Asynchronous Bilateral Neck Dissections: A Case Report and Literature Review.

PURPOSE: This report describes a case that required emergency cricothyroidotomy for an upper airway obstruction owing to laryngeal edema after asynchronous bilateral neck dissections. PATIENT AND METHODS: A 57-year-old man was diagnosed with multicentric squamous cell carcinoma of the tongue (T1 and 2N0M0), and partial glossectomy with primary closure was performed. Three months after surgery, secondary metastases in the right cervical lymph nodes were detected, and a right radical neck dissection was performed. Contrast-enhanced computed tomographic (CT) scan taken 2 weeks after the right neck dissection visualized a possible third metastasis in the left cervical lymph node. Four weeks after the right radical neck dissection, left supraomohyoid neck dissection was carried out. In this surgery, the left internal jugular vein (IJV) was preserved. Nine hours after surgery, severe swelling of the face and pharynx was recognized, resulting in a stoppage of respiration and then an emergency cricothyroidotomy. RESULTS: The patient's life was saved without any encephalopathy or airway trouble. Contrast-enhanced CT scan taken the next day confirmed the preserved left IJV patency. CONCLUSION: Oral and maxillofacial surgeons should be aware of the possibility of life-threatening laryngeal edema associated with bilateral neck dissections even if the unilateral IJV is preserved and should know the procedure for emergency cricothyroidotomy.

Combination of retrograde superselective intra-arterial chemotherapy and Seldinger method in locally advanced oral cancer.

The nonsurgical strategies for locally advanced oral cancer are desirable. Superselective intra-arterial infusion with radiotherapy was utilized for this purpose, and there are two types of superselective intra-arterial infusion methods: The Seldinger method and the retrograde superselective intra-arterial chemotherapy (HFT method). In one case, the HFT method was applied to locally advanced tongue cancer, and the Seldinger method was used for additional administration of cisplatin (CDDP) to compensate for a lack of drug flow in the HFT method. In another case, the HFT method was applied to locally advanced lower gingival cancer. The Seldinger method was applied to metastatic lymph nodes. In both cases, additional administration of CDDP using the Seldinger method resulted in a complete response. The combination of the HFT and Seldinger methods was useful to eradicate locally advanced oral cancer because each method compensated for the defects of the other.

UDP-D-galactose synthesis by UDP-glucose 4-epimerase 4 is required for organization of the trans-Golgi network/early endosome in Arabidopsis thaliana root epidermal cells.

Endomembrane organization is essential for cell physiology. We previously identified an Arabidopsis thaliana mutant in which a plasma membrane (PM) marker GFP-NIP5;1 and trans-Golgi network/early endosome (TGN/EE) markers were accumulated in intracellular aggregates in epidermal cells of the root elongation zone. The mutant was identified as an allele of UDP-glucose epimerase 4 (UGE4)/root hair defective 1/root epidermal bulgar 1, which was previously described as a mutant with swollen root epidermal cells and has an altered sugar composition in cell wall polysaccharides. Importantly, these defects including aggregate formation were restored by supplementation of D-galactose in the medium. These results suggested that UDP-D-galactose synthesis by UGE4 is important for endomembrane organization in addition to cell wall structure. Here, we further investigated the nature of the aggregates using various markers of endomembrane compartments and BOR1-GFP, which traffics from PM to vacuole in response to high-B supply. The markers of multi-vesicular bodies/late endosomes (MVB/LEs) and BOR1-GFP were strongly accumulated in the intracellular aggregates, while those of the endoplasmic reticulum (ER), the vacuolar membrane, and the Golgi were only slightly affected in the uge4 mutant. The abnormal localizations of these markers in the uge4 mutant differed from the effects of inhibitors of actin and microtubule polymerization, although they also affected endomembrane organization. Furthermore, electron microscopy analysis revealed accumulation of abnormal high-electron-density vesicles in elongating epidermal cells. The abnormal vesicles were often associated or interconnected with TGN/EEs and contained ADP-ribosylation factor 1, which is usually localized to the Golgi and the TGN/EEs. On the other hand, structures of the ER, Golgi apparatus, and MVB/LEs were apparently normal in uge4 cells. Together, our data indicate the importance of UDP-D-galactose synthesis by UGE4 for the organization and function of endomembranes, especially TGN/EEs, which are a sorting station of the secretory and vacuolar pathways.

A case of glandular odontogenic cyst in the mandible treated with the dredging method.

Glandular odontogenic cyst (GOC) is a rare odontogenic cyst derived from the odontogenic epithelium. GOC shows unpredictable and potentially aggressive behavior. Although enucleation and curettage are applied in most cases, the recurrence rate remains relatively high. Because a standard care procedure for GOC has not been established, we propose a new treatment procedure for GOC. In this case report, we describe a 62-year-old Japanese woman who suffered from GOC arising at the anterior region of her mandible and who was treated using the dredging method. She underwent enucleation and curettage twice using the dredging method with preservation of the teeth, which were involved with the lesion, but the lesion recurred 2 years later. In addition to enucleation and curettage, apicoectomy of the teeth was performed with a third dredging method procedure, and prognosis has been good with no recurrence for 18 months since the last treatment.

Predictability and accuracy of maxillary repositioning during bimaxillary surgery using a three-dimensional positioning technique.

OBJECTIVE: The purpose of this retrospective study was to evaluate the predictability and accuracy of maxillary repositioning during bimaxillary surgery using a three-dimensional positioning technique. STUDY DESIGN: Twenty-six adult patients who underwent bimaxillary surgery requiring high superior maxillary impactions were divided into 2 groups. In group A, a three-dimensional positioning technique during maxillary repositioning was used along with an intermediate occlusal splint. In group B, only an intermediate occlusal splint with internal reference points was used. Both groups had measurements from predictive tracings compared to postoperative cephalograms to assess the accuracy of horizontal and vertical movements of the maxilla. RESULTS: Group A showed excellent correlation between the planned and actual maxillary positions in vertical and horizontal dimensions. In group B, the maxilla tended to move anteriorly than planned. CONCLUSIONS: Use of the three-dimensional positioning technique offered a predictive and accurate method for maxillary repositioning.

Long-term follow-up after reimplantation of tumorous mandible bone treated with combination of decalcification and lyophilization.

Mandibular resection requires reconstruction, with often unsatisfactory morphofunctional results. Reimplantation of the resected mandible itself is one of ideal solutions to this problem. However, both devitalization of tumor cells involved in resected bone and preservation of osteoinductive activity are required for successful results. Lyophilization appears to enable devitalization of tumor cells, and decalcified bone implants are likely to have osteoinductive potential. Accordingly, we speculated that decalcification and lyophilization of resected bone would be an appropriate method for mandibular reconstruction. However, there is no study on the reimplantation of mandibles treated with these methods to date. The purpose of this study was to estimate the long-term follow-up of reimplanted mandibles treated with decalcification and lyophilization. Presented here are 2 patients of reimplanted mandibles treated by decalcification and lyophilization who were followed up for 8 and 9 years. We observed a good incorporation of the graft in 1 case, but severe absorption in the other. Our results suggest that treatment with decalcification and lyophilization is 1 strategy for reimplantation of the resected bone in mandibular reconstruction, but further study is needed to prevent absorption of the reimplanted bone over the long term.

Difference in cesium accumulation among rice cultivars grown in the paddy field in Fukushima Prefecture in 2011 and 2012.

After the accident of the Fukushima 1 Nuclear Power Plant in March 2011, radioactive cesium was released and paddy fields in a wide area including Fukushima Prefecture were contaminated. To estimate the levels of radioactive Cs accumulation in rice produced in Fukushima, it is crucial to obtain the actual data of Cs accumulation levels in rice plants grown in the actual paddy field in Fukushima City. We herein conducted a two-year survey in 2011 and 2012 of radioactive and non-radioactive Cs accumulation in rice using a number of rice cultivars grown in the paddy field in Fukushima City. Our study demonstrated a substantial variation in Cs accumulation levels among the cultivars of rice.

Identification and characterization of an Arabidopsis mutant with altered localization of NIP5;1, a plasma membrane boric acid channel, reveals the requirement for D-galactose in endomembrane organization.

Endomembrane organization is important for various aspects of cell physiology, including membrane protein trafficking. To explore the molecular mechanisms regulating the trafficking of plasma membrane-localized proteins in plants, we screened for Arabidopsis mutants with defective localization of green fluorescent protein (GFP)-nodulin 26-like intrinsic protein (NIP)5;1. Fluorescence imaging-based screening led to the isolation of a mutant which accumulated abnormal intracellular aggregates labeled by GFP-NIP5;1. The aggregates appeared in epidermal cells in the root elongation zone and included the trans-Golgi network/early endosomes. Rough mapping and whole-genome sequencing identified the mutant as an allele of UDP-glucose 4-epimerase 4 (uge4)/root hair defective 1 (rhd1) /root epidermal bulgar 1 (reb 1), which was originally defined as a cell wall mutant. The responsible gene encodes UDP-glucose 4-epimerase 4 (UGE4), which functions in the biosynthesis of d-galactose, especially for the synthesis of the cell wall polysaccharide xyloglucan and arabinogalactan proteins (AGPs). The endomembrane aggregates in the mutants were absent in the presence of d-galactose, indicative of a requirement for a d-galactose-containing component in endomembrane organization. Genetic and pharmacological analyses suggested that the aggregates were not caused by the disruption of cell wall polysaccharides or the cytoskeleton. Overall, our results suggest that UGE4 activity in d-galactose synthesis is required for the structure of cell wall polysaccharides and endomembrane organization.

Identification of peripheral vessels in oral and maxillofacial regions on magnetic resonance angiography obtained using a balanced steady-state free-precession sequence with a time-spatial labeling inversion pulse and using fresh blood imaging.

OBJECTIVE: To elucidate the characteristics of visualizing thin main peripheral vessels in oral and maxillofacial regions of 3-dimensional magnetic resonance angiography (MRA) using a balanced steady-state free-precession (SSFP) sequence with a time-spatial labeling inversion pulse (time-SLIP) and using fresh blood imaging (FBI). STUDY DESIGN: The conspicuity of blood vessels and the characteristics on MRA using SSFP with a time-SLIP was compared with those on MRA using FBI in 20 healthy participants. RESULTS: The conspicuity of the main peripheral arteries was significantly higher on MRA using SSFP with a time-SLIP than on MRA using FBI. MRA scans using SSFP were obtained in all participants, and scans using FBI were obtained in 16 of 20 participants. An electrocardiogram was unnecessary when using SSFP but was necessary when using FBI. CONCLUSIONS: MRA obtained using SSFP with a time-SLIP is a useful technique to visualize thin main peripheral arteries in the oral and maxillofacial regions without contrast medium.

GDFs promote tenogenic characteristics on human periodontal ligament-derived cells in culture at late passages.

Tendon/ligament injures are leading disabilities worldwide. The periodontal ligament (PDL) connects teeth to bone, and is comparable to a tendon/ligament-to-bone insertion. PDL-derived cells (PDLCs) express both osteo/cementogenesis and teno/ligamentogenesis genes. However, an efficient method to induce a tenogenic differentiation of PDLCs has not been thoroughly examined. Therefore, this study tested if growth/differentiation factors (GDFs) enhanced tenogenic characteristics of human PDLCs, as a potential cell source for tendon/ligament engineering. Results demonstrated recombinant GDF-5/GDF-7 inhibited alkaline phosphatase (ALP) activity of PDLCs from passage 3 to 6, while GDF-5 enhanced ALP in dental pulp-derived cells and mesenchymal stem cells. GDF-5 (particularly at 10 ng/ml concentration) induced high expression of both early (scleraxis) and mature (tenomodulin, aggrecan, collagen3) tenogenic genes in P4-6 PDLCs, while inhibiting expression of specific transcription-factors for osteogenic, chondrogenic and adipogenic differentiation. Exogenous GDFs might lead PDLCs being expanded in culture during several passages to highly useful cell source for tendon/ligament engineering.

Treatment outcome of Photofrin-based photodynamic therapy for T1 and T2 oral squamous cell carcinoma and dysplasia.

BACKGROUND: Photodynamic therapy (PDT) is a minimally invasive treatment modality for early and superficial malignancy or premalignancy in the head and neck regions. However, few studies have examined the use of Photofrin-mediated PDT to manage early carcinoma and dysplasia in the oral cavity. METHODS: Between January 2004 and November 2008, 25 T1 to T2 patients with N0 oral squamous cell carcinoma and mucosal dysplasia in the oral cavity were treated by Porfimer sodium (Photofrin(®))-mediated PDT at Nagasaki University Hospital. Clinical responses were evaluated according to the guidelines of the Response Evaluation Criteria in Solid Tumors (RECIST). After the PDT and a 2-year follow-up period, disease specific survival rates were then calculated. RESULTS: A total of 30 regions in 25 patients (18 with squamous cell carcinoma and 7 with epithelial dysplasia with hyperkeratosis in the oral cavity) were treated by PDT. Complete response was achieved in 24 of the 25 patients (96%), with a partial response found in the remaining patient. For the three patients who exhibited recurrence at 4, 5, and 15 months after PDT, salvage surgery or a second PDT was performed. Of these three patients, one died due to another disease, while one died due to local lymphatic metastasis that occurred during the follow-up period. Overall, the disease specific survival rate was 95.8%. Treatment-related edema and pain emerged within 24h after irradiation. Pain control using non-steroid anti-inflammatory drugs and opiates was required for 3-4 weeks in all patients. Complete healing was attained at 4-6 weeks after the treatment. No persistent problems related to functional or esthetic outcomes were noted.

Surgical approach to the pterygopalatine fossa-comparison between anterior approach and lateral approach.

The anterior and the lateral approach for resecting an invading tumor in the pterygopalatine fossa region were compared. An anterior approach was applied for resecting a malignancy that originated from the maxillary tuberosity, upper hard plate, and maxillary sinus, and a lateral approach was applied for resecting a malignancy that originated from the upper gingiva and buccal mucosa. The anterior approach was capable of exposing the whole maxilla, although it was difficult to achieve such exposure by the lateral approach. However, the submandibular incision technique used in the Dingman approach was useful for upper neck dissection as well as for exposure of the artery and vein to anastomose them for reconstruction. The anterior approach should be useful for resection of the pterygopalatine fossa concomitant with total maxillectomy. On the other hand, the lateral approach might have an advantage in terms of its cosmetic effects.

Synergic effect of photodynamic therapy using talaporfin sodium with conventional anticancer chemotherapy for the treatment of bile duct carcinoma.

BACKGROUND: Photodynamic therapy (PDT) is an effective laser treatment for locally treating advanced bile duct carcinoma (BDC). The study objective was to evaluate the synergic effect of PDT using a new photosensitizer, talaporfin sodium (Laserphyrin), in combination with conventional anticancer drug treatments. METHODS: The range of the necrotic area, the percentage of apoptosis-positive cells, the vascular endothelial growth factor expression quantification, and the proliferating cell nuclear antigen-labeling index, as treatment effects, were examined in the BDC cell line (NOZ) in vitro and in vivo (4-wk-old male BALB/c mice). RESULTS: Tumor viability was determined by an in vitro MTS assay. PDT with a single treatment of 5-fluorouracil, gemcitabine, oxaliplatin, and cis-diamminedichloroplatinum showed a significantly lower viability compared with the control or the PDT-alone group (P<0.05). Furthermore, administering PDT combined with two anticancer drugs showed a further decline in the tumor viability. A treatment of PDT combined with oxaliplatin and gemcitabine showed the least viability (P<0.05). Thus, this regimen was administered in the in vivo study. The tumor necrotic area, apoptosis positivity, and the vascular endothelial growth factor expression rate were higher in the PDT with anticancer drugs group compared with those of the other groups (P<0.05). The proliferating cell nuclear antigen-labeling index results in the PDT with the anticancer drugs group were significantly lower than those of the other groups (P<0.05). CONCLUSIONS: A treatment of PDT combined with gemcitabine and oxaliplatin showed the best synergic effect for necrosis, apoptosis, and cytostatic alterations for the treatment of BDC.

Reconstruction of the mandible bone by treatment of resected bone with pasteurization.

The results of long-term follow-up for reimplantation of the mandibular bone treated with pasteurization are reported. Mandibulectomy was performed for mandibular malignancy in 3 cases. The resected bones were subsequently reimplanted after treatment with pasteurization in 3 cases to eradicate tumor cells involved in the resected bone. Although postoperative infection was observed in 2 of 3 cases, reimplantation of the resected mandibular bone treated by pasteurization was finally successful. Ten to 22 years of follow-up was carried out. Pasteurization was able to devitalize tumor cells involved in the resected bone and to preserve bone-inductive activity. Reimplantation of pasteurization could be a useful strategy for reconstruction of the mandible in patients with mandibular malignancy.