Utility of skin perfusion pressure values with the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification system.

OBJECTIVE: The addition of skin perfusion pressure (SPP) might enhance the predictive value of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system. The purpose of the present study was to evaluate the SPP for each WIfI classification stage among patients with foot wounds by cross-referencing the results of prospectively monitored limb outcomes and to derive the SPP criteria that could be combined with other measurements to grade ischemia for the WIfI classification. METHODS: From July 2015 to June 2017, patients with foot wounds that met the WIfI classification criteria were prospectively enrolled. We assessed the limbs using the WIfI ischemia grade without measuring the transcutaneous oxygen pressure but measured the SPP. After monitoring for 1 year, the predictability of the WIfI stages was analyzed according to whether the limbs had not healed (unchanged or worsened wounds, minor or major amputation, all-cause death) or had healed (improved or healed wounds) by comparing stages 1 and 2 with stages 3 and 4. We also statistically analyzed the SPP values that could be the boundary values between each ischemia grade and reevaluated the predictability of the WIfI stages with the boundary SPP values. RESULTS: We enrolled a total of 91 limbs for 76 patients (mean age, 70.5 ± 12.0 years). The mean SPP values stratified by ischemia grade 0 to 3 were 52.1, 41.1, 27.1, and 18.8 mm Hg, respectively (an SPP of <30 mm Hg indicates severe ischemia). After monitoring for 1 year, 19 of 48 limbs in stage 1 and 2 and 35 of 43 in stage 3 and 4 were in the nonhealed group and 29 limbs in stage 1 and 2 and 8 limbs in stage 3 and 4 were in the healed group. The SPP boundary values between each ischemia (I) grade were calculated as 45 mm Hg for I-0/I-1, 35 for I-1/I-2, and 25 for I-2/I-3. When jointly using the boundary SPP values, the ischemia grade changed for 23 limbs, altering the distribution of the WIfI stages and limb outcomes: 11 of 38 limbs in stage 1 and 2 and 43 of 53 in stage 3 and 4 were transferred to the nonhealed group. The sensitivity, efficiency, and negative predictive value of WIfI staging improved when staging with SPP: from 65% to 80%, 70% to 77%, and 60% to 71%, respectively. CONCLUSIONS: The SPP boundary values that could be used with ischemia grade in the WIfI classification were identified as 45, 35, and 25 mm Hg. The addition of SPP could improve the accuracy of the evaluation.

Collagen XVIII Deposition in the Basement Membrane Zone beneath the Newly Forming Epidermis during Wound Healing in Mice.

The basement membrane (BM) is composed of various extracellular molecules and regulates tissue regeneration and maintenance. Here, we demonstrate that collagen XVIII was spatiotemporally expressed in the BM during skin wound healing in a mouse excisional wound-splinting model. Re-epithelialization was detected at days 3 and 6 post-wounding. The ultrastructure of epidermal BM was discontinuous at day 3, whereas on day 6 a continuous BM was observed in the region proximal to the wound edge. Immunohistochemistry demonstrated that collagen XVIII was deposited in the BM zone beneath newly forming epidermis in day 3 and 6 wounds. Laminin-332, known to be the earliest BM component appearing in wounds, was colocalized with collagen XVIII in the epidermal BM zone at days 3 and 6. The deposition of α1(IV) collagen and nidogen-1 in the epidermal BM zone occurred later than that of collagen XVIII. We also observed the short isoform of collagen XVIII in the epidermal BM zone at day 3 post-wounding. Collectively, our results suggested that collagen XVIII plays a role in the formation of the dermal-epidermal junction during re-epithelialization, and that it is the short isoform that is involved in the early phase of re-epithelialization.

Usefulness of a Skin Graft Obtained from the Bilateral Nasolabial Folds for a Skin Defect following Resection of a Malignant Tumor at the Nasal Tip.

The cosmetic appeal of the nose is very important, as it is a structure located at the center of the face. Hence, the removal of nasal tumors requires matching aesthetic subunits for the ensuing reconstruction. This procedure often creates large defects that require skin grafts or local flaps for repair. If a large skin graft is required, harvesting of flaps from the head and neck region might have some limitations. Although flaps from the forehead can cover a wide range of facial defects, the skin properties of the forehead differ from those of the rest of the face. Moreover, early postoperative flap deformation may be due to the flap volume and the need for multiple surgeries, leading to vertical forehead scarring. Particularly, vertical forehead scars are more noticeable in Asians than in Westerners. Previously, grafts have been harvested from a unilateral nasolabial fold, but these grafts were small and resulted in asymmetry. Herein, we describe the case of a 67-year-old man with a basal cell carcinoma of the nasal tip, in which closure of the large defect was achieved through excision matching of the aesthetic unit by using skin harvested from bilateral nasolabial folds.

Unilateral Breast Inflation Caused by Breastfeeding after Polyacrylamide Hydrogel Injection.

Polyacrylamide hydrogel (PAAG) has been widely used in Russia and China as an injection material for cosmetic surgery. We report the case of a 36-year-old woman who noted breast enlargement subsequent to breastfeeding, after a PAAG injection. In 2016, a PAAG injection was administered to her under both mammary glands at a nearby cosmetic surgery clinic for breast augmentation. After she started breastfeeding following delivery in 2020, she was admitted to our hospital because of a rapid left breast enlargement and unbearable pain. Contrast-enhanced chest computed tomography revealed marked fluid retention in the left breast, and the mammary gland tissue had been pushed outward. A skin incision revealed a significant amount of yellowish-white odorless fluid accumulation. On surgery, a foreign body remained around the pectoralis major muscle, but complete removal was impossible. Currently, 3 months have passed since the operation; however, the patient has not experienced any further pain. There have been many reports on complications caused by PAAG injection. In our case, commencing breast feeding after receiving PAAG injections resulted in a rapid unilateral breast enlargement, and there is no similar report from Japan. In this case, suppressing lactation and rapid removal of the foreign body is the most important measure. It is difficult to completely remove PAAG once it has been injected. PAAG injections for breast augmentation should be avoided in all patients.

Anatomical Study of the Descending Branch of the Lateral Femoral Circumflex Artery and Veins in Vascular Grafting in Japanese Cadavers.

In microsurgery development, autologous vein grafting is necessary when there are no suitable blood vessels for anastomosis around the flap recipient site or when the vascular pedicle of the flap is short. The descending branches of the lateral femoral circumflex artery (LFCA) and vein have been used as a vascular bundle instead of vein grafts, but to our knowledge, there have been no reports on the relationship between thigh length and vessel length. In this study, we performed a macroscopic examination of the LFCA descending branch length required for grafting. METHODS: The length of the LFCA descending branches and veins as well as thigh length were measured in 16 preserved cadaveric legs. RESULTS: The average length of the thigh was 42.6 cm. It was possible to harvest a mean length of 14.2 cm of the descending branches of the lateral femoral circumflex vessels. Descending branches of the LFCA and veins were identified in all cases. It was estimated that the length of the LFCA descending branch and veins could be collected in 20% of the thigh length in 98% of cases. CONCLUSION: When preparing a preoperative plan, it is important to thoroughly consider the required length of blood vessels for grafting and whether it is possible to harvest vessels with sufficient length.

Analysis of Vascular Anatomy in Inferiorly Based Gastrocnemius Muscle Flaps in Japanese Individuals Using a Cadaver Study.

Inferiorly based gastrocnemius muscle flaps have been successfully used to cover soft tissue defects of the middle third of the leg. This is done especially in older patients or patients with major complications where operative time should be limited. We aimed to determine the gastrocnemius muscle length that can be safely used for preparing inferiorly based muscle flaps. METHODS: We performed angiographies and dissection to investigate the numbers and distribution of the communicating arterial branches between the medial and lateral heads of the gastrocnemius muscle, and the perforating arterial branches of the medial sural artery from the soleus to the gastrocnemius muscles on 18 legs of preserved cadavers. RESULTS: The lengths of the gastrocnemius heads were approximately 10 cm, and the communicating arterial branches of the gastrocnemius muscle also were located at approximately 10 cm from the gastrocnemius head. The perforating arterial branches from the soleus muscle to the gastrocnemius muscle were also located at approximately 10 cm from the gastrocnemius head. CONCLUSIONS: Communicating arterial branches of the gastrocnemius muscle were found in all cadavers. To the best of our knowledge, no other study has focused on investigating the perforating arterial branches that supply the gastrocnemius from the soleus muscle. Our study indicates that the entire gastrocnemius muscle can be safely used in reconstruction surgeries.

ADAMTS9 activation by interleukin 1 beta via NFATc1 in OUMS-27 chondrosarcoma cells and in human chondrocytes.

ADAMTS9 is a member of the disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) genes, with aggrecan-degrading activity. It has also been characterized to be reactive and highly activated ADAMTS by IL-1 beta in both chondrosarcoma cells and human chondrocytes (Demircan et al. Arthritis Rheum 52:1451-1460, 2005). In order to understand the regulation of ADAMTS9 gene expression a functional 3.0 kb human ADAMTS9 promoter has been cloned and characterized. A sequence analysis of the promoter revealed the presence of putative binding sites for Nuclear Factor of Activated T cells (NFAT), which is commonly found in the ADAMTS4 and ADAMTS5 promoters. NFATc1 was up-regulated in an activated form by IL-1 beta in human chondrocytes. The IL-1 beta inducible ADAMTS9 expression was inhibited by NFAT inhibitors, FK506 and 11Arg (11R)-VIVIT. Furthermore, direct binding of NFATc1 on distal and proximal promoters of ADAMTS9 was demonstrated by a chromatin immunoprecipitation assay. Promoter-reporter assays supported those results. These findings may provide a better understanding of the regulation of ADAMTS9 expression induced by inflammatory cytokines.

Mixed Tumor of the Nasal Root.

We reported the case of a 53-year-old man who presented with over 25-year history of a soft tissue on the nasal root. The tumor with a diameter of 4 cm was observed on the nasal root, the mass was soft, freely mobile, and painless on palpation. No adhesion with the nasal bone was observed. Magnetic resonance imaging revealed multiple nodular solid tumor masses. There was a region with low contrast in the tumor, and adipose tissue was confirmed. We performed total excision. Histopathological examination revealed that the tumor had multiple nodular lesions, and epithelial component had glandular features and a myxoid stromal component. So, we diagnosed mixed tumor of the skin. To the best of our knowledge, it seems to be the largest in the mixed tumor of the skin that occurred in the nasal root in the previous reports.

Spindle Cell Lipoma of the Thumb.

We report the case of a 34-year-old man who presented with a 4-year history of a soft tissue on the palmar aspect of the thumb. Magnetic resonance imaging demonstrated the presence of a mass with heterogeneous high intensities on T1-weighted images and high intensities on T2-weighted images. We performed excisional biopsy. Histologically, the tumor was composed of mature adipocytes and spindle cells in a collagen background. Immunohistochemically, the tumor cells showed strong expression of CD34. Therefore, we diagnosed it as spindle cell lipoma. To the best of our knowledge, only 2 cases of spindle cell lipoma of the thumb have previously been reported.

Anatomical Analysis of Cutaneous Perforator Distribution in the Forearm.

BACKGROUND: Few reports describe the distribution of cutaneous perforators from the radial and ulnar arteries in the forearm. This study aimed to map the location of the cutaneous perforators that arise directly from the radial and ulnar arteries in cadavers. METHODS: Twenty-nine human cadaveric forearms were dissected. All radial and ulnar arteries cutaneous perforators were analyzed for total number and distribution. To define the distribution of each cutaneous perforator, the forearm was divided into 10 sections, with the sections labeled as 10%, 20%, 30%, and so on, beginning at the wrist. RESULTS: From the radial artery, there were a total of 262 skin perforators with an average of 9.03 ± 2.28 (mean ± SD) per limb, whereas the total was 159 from the ulnar artery, with an average of 5.48 ± 1.49 per limb. Additionally, 128 (49%) radial artery cutaneous perforators and 75 (47%) from the ulnar artery were concentrated in the 0-30% section of the forearm. Both the radial and ulnar arteries had many cutaneous perforators in the forearm section labeled 70%, with 32 of 262 (12%) cutaneous perforators of the radial artery and 27 of 159 (17%) cutaneous perforators of the ulnar artery located here. CONCLUSIONS: There were more cutaneous perforators from the radial artery than from the ulnar artery, and both were concentrated in the distal one-third of the forearm and in the forearm section labeled 70%. This information could be helpful when harvesting forearm flaps.

Lymphangiography and subsequent sclerotherapy can be easily applied by cannulation of the lymph duct with a catheter for the neonatal central vein.

Therapeutic lipiodol lymphangiography for postoperative chyle leakage due to lymph duct damage has recently been attracting attention. Lymph duct puncture is technically complex and difficult. Lymphangiography and sclerotherapy can be easily applied by cannulation with a catheter for the neonatal central vein to the lymph duct under a microscope.

Photoletter to the editor: Pigmented dermatofibrosarcoma protuberans in a 4-year-old girl and ultrasonographic findings.

Dermatofibrosarcoma protuberans (DFSP) in children is often clinically misdiagnosed as hemangioma or vascular malformation. Ultrasonography and color Doppler imaging are useful noninvasive tools for the diagnosis of skin tumors and may help distinguish DFSP from other vascular skin lesions in children.

Free vascularized nail grafts for onychogryphosis of bilateral thumbnails after burn injury.

Free vascularized grafts of the toenails were used to repair bilateral onychogryphosis occurring after burn injury.

Superficial circumflex iliac artery perforator flap for reconstruction of limb defects.

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.

Risk factors for complications after reconstructive surgery for sternal wound infection.

BACKGROUND: Although the utility of flaps for the treatment of sternal wound infections following median sternotomy has been reported for 30 years, there have been few reports on the risk factors for complications after reconstruction. The objective of this investigation was to identify factors related to complications after the reconstruction of sternal wound infections. METHODS: A retrospective analysis of 74 patients with reconstructive surgery after sternal wound infection over a 5-year period was performed. Clinical data including age, sex, body mass index (BMI), comorbidities, bacterial culture, previous cardiac surgery, wound depth, mortality rate, type of reconstructive procedure, and complication rate were collected. RESULTS: The patients' BMI ranged from 15.2 to 33.6 kg/m(2) (mean, 23.1±3.74 kg/m(2)). Wound closure complications after reconstructive surgery were observed in 36.5% of the cases. The mortality rate was 2.7%. Diabetes mellitus significantly affected the rate of wound closure complications (P=0.041). A significant difference in the number of complications was seen between Staphylococcus aureus (S. aureus) and coagulase-negative Staphylococci (P=0.011). There was a correlation between harvesting of the internal thoracic artery and postoperative complications (P=0.048). The complication rates of the pectoralis major flap, rectus abdominis flap, omentum flap, a combination of pectoralis major flap and rectus abdominis flap, and direct closure were 23.3%, 33.3%, 100%, 37.5%, and 35.7%, respectively. CONCLUSIONS: Diabetes mellitus, S. aureus, harvesting of the internal thoracic artery, and omentum flap were significant factors for complications after reconstruction. The omentum flap volume may be related to the complications associated with the omentum flap transfer in the present study.

Transvascular accumulation of Sialyl Lewis X conjugated liposome in inflamed joints of collagen antibody-induced arthritic (CAIA) mice.

The aim of the current study was to investigate the specific accumulation of the Sialyl Lewis X (SLX) liposome in inflammation in the collagen-antibody induced arthritic (CAIA) model mice. The SLX-liposome encapsulating fluorescent substance (Cy5.5 or Cy3) was prepared for this study. The SLX-liposome was administered intravenously via the mouse caudal vein. After 1 to 24 h, the accumulation of SLX-liposome was observed using in vivo fluorescent imaging equipment (eXplore Optix), or the knee joints were removed for histological analysis. The in vivo fluorescent imaging showed that the signal was confined to the inflammatory site in the CAIA mice in an inflammatory dependent manner. The signal intensity was stronger at 24 h than at 1 h after injection. In the histological sections, the fluorescent signals were detected in the periarticular soft-tissue, especially in the hyperplastic synovium, including a pannus invasion with inflammatory cells in the CAIA. Intense signals were observed in vessel-like structures 1 h after injection; these were co-labeled with the vascular endothelial cell marker (CD31) and E-selectin, a ligand of the SLX-liposome expressed on activated endothelial cells. The diffused signals from the vessels increased time-dependently at 6 to 24 h after injection. This is the first report to examine the exact localization of the SLXliposome by encapsulated fluorescence in hyperplastic synovial tissue of CAIA mice. These results suggest the feasibility and potential use of SLX-liposome as a vehicle for the active targeting of drug delivery to inflammatory tissue.