Early enteral nutrition and mobilization following head and neck surgery with free flap reconstruction.

BACKGROUND: Perioperative management methods that reduce surgery-associated invasiveness and improve the quality of postoperative recovery are being promoted as enhanced recovery after surgery programs in various areas. Early enteral nutrition and mobilization are essential elements for enhanced recovery after surgery; however, their safety and feasibility are unclear in head and neck surgery with free tissue transfer reconstruction. This study aimed to clarify these uncertainties. METHODS: This is a retrospective before-after study. From 2018 to 2022, 187 and 173 patients received conventional management on or before April 2020 and early management on or after May 2020, respectively. The conventional management and early management groups received enteral nutrition and mobilization on postoperative days 2 and 1, respectively. The primary outcome for safety assessment was the incidence of complications. The secondary outcome was the compliance rate of conventional management or early management for feasibility assessment and the length of hospital stay. RESULTS: The clinical tumour-node-metastasis stage and American Society of Anesthesiologists physical status showed significant differences between the groups. In multivariable analysis, the early management group demonstrated a significantly lower incidence of treatment-required complication classified Clavien-Dindo Grade 2 and above (odds ratio = 0.57; 95% confidence interval = 0.31-0.92) and lower wound infection (odds ratio = 0.53; 95% confidence interval = 0.31-0.92). The early management group had lower compliance rate than the conventional management group; however, no statistically significant difference was observed (79.8% vs. 85.0%, P = 0.21). CONCLUSION: Early management is safe and feasible following head and neck surgery with free tissue transfer reconstruction. It could reduce the complication rate and is considered a useful postoperative management method.

Pectoralis Major Muscle Flap Utilization in Salvage Esophagectomy Including Great Vessel Resection Reconstructed by Prosthetic Grafts.

BACKGROUND: Salvage surgery is a therapeutic option for recurrent or residual esophageal cancer after definitive chemoradiation therapy. This report aimed to describe the procedure of reconstruction after salvage esophagectomy involving great vessel resection using prosthetic grafts, a pectoralis major muscle (PM) flap, and free jejunal transfer, if required. To the best of our knowledge, no previous report has described the reconstruction of the defect after combined esophageal and great vessel resection. PATIENTS AND METHODS: From January 2017 to December 2022, 4 patients underwent salvage esophagectomy with excision of the great vessels and reconstruction with prosthetic grafts, as well as a PM flap placement in a single center. We retrospectively investigated the patients' clinical data. The patients were all men, with a median age of 70 (range, 67-77) years. Regarding neoadjuvant therapy, 2 patients received chemoradiation therapy, 1 patient received radiotherapy only due to drug-induced pneumonia, and 1 patient received chemotherapy with adjuvant radiotherapy. RESULTS: Alimentary tract reconstruction was performed by free jejunal transfer in 2 cases, direct suture in 1 case, and stomach roll in 1 case. In all cases, a vascular bypass was established before tumor resection. We created mediastinal tracheostoma in 2 cases. A PM flap was inserted to cover the prosthetic grafts and approximate the tracheal mucosa. With regard to major complications, leakage from the jejunal esophageal anastomotic site was observed in 2 cases. The leakage improved with conservative treatment without graft removal or replacement in both cases. CONCLUSIONS: In cases of locally recurrent or residual tumors after definitive chemoradiation therapy, salvage esophagectomy along with great vessel resection, followed by reconstruction using prosthetic grafts, PM flaps, and free jejunal transfer, if necessary, is a useful option.

Reconstruction techniques using free jejunal transfer for total pharyngolaryngectomy with total glossectomy.

BACKGROUND: Total pharyngolaryngectomy is sometimes combined with total glossectomy for advanced hypopharyngeal or cervical esophageal cancers involving the tongue base. The optimal reconstruction method for total pharyngolaryngectomy with total glossectomy has not been established due to a considerable diameter mismatch between the floor of mouth and the esophageal stump. This report describes two reconstruction methods using free jejunal transfer. METHODS: Five consecutive patients who underwent total pharyngolaryngectomy with total glossectomy were included, with a mean age of 67.0 (range 55-75) years. Primary tumors included tongue, hypopharyngeal, cervical esophagus, and laryngeal cancers. The mean defect size was 17.0 (16-19) × 6.8 (6-7) cm. Surgical techniques involved either a simple incision or a two-segment method to address the size mismatch between the jejunum and the floor of mouth. In the simple incision method, a longitudinal cut was made to the antimesenteric or paramesenteric border of a jejunum wall to expand the orifice. In the two-segment method, a jejunal graft was separated into two segments to reconstruct the floor of mouth and the cervical esophagus, and these segments were connected with a longitudinal incision to the cervical esophageal segment to form a funnel-shaped conduit. RESULTS: Of the five patients, three underwent the simple incision method and two the two-segment method. Postoperative pharyngoesophagography showed a smooth passage for all patients. Postoperative courses were uneventful except for one flap loss due to arterial thrombosis. Four patients achieved oral feeding, while one became gastric-tube dependent. At a mean follow-up of 22.1 (4-39) months, one patient required tube feeding, two tolerated full liquid, and two consumed a soft diet. CONCLUSIONS: Both the simple incision and two-segment methods achieved satisfactory swallowing function. The choice between these reconstruction methods may depend on the extent of resection of the posterior pharyngeal wall.

The Ischemic Tolerance up to Four Hours of Free Jejunum Flap: A Retrospective Cohort Study.

BACKGROUND: While free jejunum transfer (FJT) following total pharyngo-laryngo-esophagectomy (TPLE) is a reliable reconstruction technique, the jejunum flap is viewed as more susceptible to ischemia than a standard free flap. Animal studies have indicated that the jejunum can tolerate ischemia for as little as 2 to 3 hours. Clinical studies also reported increased complications after the FJT with more than 3 hours of ischemia. Traditionally, our institution has carried out FJT with an initial intestinal anastomosis, followed by a vascular anastomosis, which often results in extended jejunal ischemia time. In this study, we retrospectively examined the actual tolerance of the jejunum to ischemia, considering perioperative complications and postoperative dysphagia. METHODS: We retrospectively studied 402 consecutive cases involving TPLE + FJT. Patients were divided into five groups based on jejunum ischemia time (∼119 minutes, 120∼149 minutes, 150∼179 minutes, 180∼209 minutes, 210 minutes∼), with each variable and result item compared between the groups. Univariate and multivariate analyses were conducted to identify independent factors influencing the four results: three perioperative complications (pedicle thrombosis, anastomotic leak, surgical site infection) and dysphagia at 6 months postoperatively. RESULTS: The mean jejunal ischemia time was 164.6 ± 28.4 (90-259) minutes. When comparing groups divided by jejunal ischemia time, we found no significant differences in overall outcomes or complications. Our multivariate analyses indicated that jejunal ischemia time did not impact the three perioperative complications and postoperative dysphagia. CONCLUSION: In TPLE + FJT, a jejunal ischemia time of up to 4 hours had no effect on perioperative complications or postoperative dysphagia. The TPLE + FJT technique, involving a jejunal anastomosis first followed by vascular anastomosis, benefits from an easier jejunal anastomosis but suffers from a longer jejunal ischemia time. However, we found that ischemia time does not pose significant problems, although we have not evaluated the effects of jejunal ischemia extending beyond 4 hours.

Surgical Outcome of Pharyngocutaneous Fistula After Total Laryngectomy: A Retrospective Study.

BACKGROUND: The management of pharyngocutaneous fistula is challenging. We typically treat postlaryngectomy pharyngocutaneous fistulas with a pedicled pectoralis major flap transfer. This study analyzed the outcomes of our surgical treatments for pharyngocutaneous fistula to propose considerations for surgical strategies. METHODS: This retrospective review included all patients who underwent surgical repair of a postlaryngectomy pharyngocutaneous fistula at the National Cancer Center Hospital East in Kashiwa, Japan, from January 2005 to December 2019. RESULTS: The final analysis included 33 cases (median age, 71 years). Twenty-two cases had a history of radiotherapy to the head and neck region. Wound closures were performed with a pedicled pectoralis major musculocutaneous flap (n = 26) or pedicled pectoralis major muscle flap (n = 7). In 1 case, a deltopectoral flap was combined with the pectoralis major musculocutaneous flap. The median total operation time was 236 minutes, the median blood loss during surgery was 144 mL, and the median hospital stay after the reconstructive surgery was 39 days. Minor leakage occurred in 19 cases, and major leakage occurred in 2 cases. The fistula was finally cured successfully in 31 cases. We compared the outcomes in patients with leakage after surgical repair to those in patients without leakage after surgical repair to determine the risk factors for leakage after surgical repair of a pharyngocutaneous fistula. Five patients in the nonleakage group and 17 in the leakage group had a history of preoperative radiation (P = 0.052). The median preoperative blood values in the nonleakage and leakage groups were as follows: albumin, 3.6 and 3.2 g/dL (P = 0.061), and C-reactive protein, 2.36 and 6.77 mg/dL (P = 0.031), respectively. The time between the occurrence of the fistula and reconstructive surgery was 32 and 9 days in the nonleakage and leakage groups, respectively (P = 0.009). CONCLUSIONS: Our surgical treatment for postlaryngectomy pharyngocutaneous fistula succeeded in 31 of 33 cases (94%). This study demonstrated that pedicled pectoralis major flap transfer is useful for the treatment of postlaryngectomy pharyngocutaneous fistula.

Treatment results of 99 patients undergoing open partial hypopharyngectomy with larynx preservation.

OBJECTIVE: Hypopharyngeal cancers frequently go undetected until advanced stages. However, recent advances in endoscopic technology have enabled earlier detection of hypopharyngeal cancer. We evaluated the effectiveness of larynx-preserving surgery for hypopharyngeal cancer. METHODS: We retrospectively analyzed 99 patients with hypopharyngeal squamous cell carcinoma who underwent partial hypopharyngectomy with larynx preservation between September 1992 and December 2009 at the National Cancer Center Hospital East. Of these, 91 patients underwent larynx-preserving surgery as initial treatment; eight patients underwent salvage surgery for recurrent disease after previous radiotherapy. Also, 9 of our patients had undergone previous radiotherapy in the head and neck for a different cancer. Before surgery, the TNM stage and tumor location was recorded. Free-flap reconstruction was performed in 60 patients, while the hypopharyngeal mucosa was closed without a free flap in 39 patients. RESULTS: The 5-year overall survival rate in our cohort was 66.9%, and 59 patients are currently alive without recurrence. Thirty-three patients died due to primary recurrence (n = 5), regional recurrence (n = 10), distant metastasis (n = 9), postoperative death (n = 1), and unrelated disease (n = 8). Laryngeal function could not be preserved in 19 patients, 2 of whom had undergone previous radiotherapy, and 7 of whom had undergone both previous radiotherapy and other salvage surgeries. CONCLUSION: Partial hypopharyngectomy can preserve laryngeal function in patients with pharyngeal cancer with careful patient selection.

Mandibular reconstruction in elderly patients.

BACKGROUND AND OBJECTIVES: The choice of reconstructive technique for a segmental mandibular defect in elderly patients is controversial. The aim of this study was to establish an algorithm for selecting a method of mandibular reconstruction in elderly patients. METHODS: We retrospectively evaluated 121 patients aged ≥65 years who underwent immediate microvascular mandibular reconstruction after oncologic resection. Patients were divided into three groups based on method of reconstruction: vascularized bone graft (n = 49), mandibular reconstruction plate and soft tissue flap (n = 22), and soft-tissue flap (n = 50). We compared perioperative outcomes among groups and investigated factors affecting the choice of reconstructive technique. RESULTS: Rates of postoperative complications did not differ significantly among groups. Mandibular reconstruction plate was indicated only for anterior mandibular defects. Soft-tissue flap was indicated for posterior mandibular defects in patients aged ≥75 years or with a poor postoperative Eichner index. CONCLUSIONS: Mandibular reconstruction plate and soft-tissue flap can be good alternatives to vascularized bone graft in the elderly. Our algorithm uses defect type, patient age, and postoperative Eichner index to determine reconstructive technique.

Comparison of Donor Site Drainage Duration and Seroma Rate Between Latissimus Dorsi Musculocutaneous Flaps and Thoracodorsal Artery Perforator Flaps.

INTRODUCTION: Donor site seroma formation and prolonged drainage duration are common complications of using latissimus dorsi musculocutaneous (LDMC) flaps. The present retrospective study aimed to investigate the effect of types of back flap harvest on drainage duration and seroma formation rates. METHODS: Adult patients (n = 155) who underwent reconstruction with a latissimus dorsi flap from January 2010 to October 2015 were included in the study, of which 54 patients underwent breast reconstruction with a pedicled LDMC flap (LD breast group), 80 patients underwent an LDMC flap transfer for purposes other than breast reconstruction (LD nonbreast group), and 21 patients underwent soft tissue reconstruction with a thoracodorsal artery perforator (TAP) flap (TAP group). Flap size, drainage durations, and seroma formation rates at donor sites were compared among the 3 groups. RESULTS: Flap sizes significantly differed between the LD nonbreast group (median value, 185.5 cm) and the other 2 groups (119 cm in the LD breast group. 127.5 cm in the TAP group), with no significant difference observed between the LD breast and TAP groups. The mean drainage duration was 11.6 days for the LD breast group. 9.82 days for the LD nonbreast group, and 4.81 days for the TAP group. Drainage durations significantly differed among the groups. Seroma formation rate of the LD breast group (42.6%) was significantly higher than those of the other groups. CONCLUSIONS: The type of back flap harvest used significantly affected drainage duration and seroma formation rate in the present study. Lumbar fat extension with the use of a LDMC flap for breast reconstruction may lead to seroma formation. Thoracodorsal artery perforator flaps are associated with minimal risks of seroma formation and significantly shortened drainage duration compared with LDMC flaps.

Analysis of functional outcomes in patients with mandible reconstruction using vascularized fibular grafts.

BACKGROUNDS: Although a vascularized fibular graft (VFG) is the favored method for mandible reconstruction, only few functional reports have been published. In this study, surgical outcomes and functional results after mandible reconstruction were analyzed. PATIENTS AND METHODS: From 1999 through 2010, oromandibular defects after segmental mandibulectomy were reconstructed with VFG in 101 patients. Operative outcomes and subjective functional evaluation was performed. Of these, 44 patients could be evaluated for functional outcomes, and bite force was measured with an occlusal force meter in 24 patients. RESULTS: Major surgical complications required secondary revisional surgery developed in four patients. A normal diet was possible in 37 patients (84.1%), and a soft diet was possible in 7 patients (15.9%). Conversational ability was rated as excellent in 42 patients (95.5%). The mean bite force on the nonaffected side of the mandible was 187.7 N, and bite force decreased as the number of osteotomies in the VFG increased. Furthermore, bite force was significantly lower (P = 0.001) on the affected side (58.2 N), compared to nonaffected side (191.9 N). CONCLUSIONS: Although masticatory force decreases as the number of osteotomies increases, oral function after mandible reconstruction is satisfactory in most cases. Transfer of a VFG is a safe and reliable method for functional mandible reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery 37:101-104, 2017.

A spindle cell hemangioendothelioma on the head resembling an arteriovenous malformation.

A spindle cell hemangioendothelioma is a relatively uncommon lesion, especially on the head and neck. Recurrence occurs after local excision of 50% to 60% of these lesions; therefore, it is important to recognize this unusual neoplasm and avoid misdiagnosis. Here, we report a rare case of a spindle cell hemangioendothelioma of the head. A 37-year-old woman presented with a soft subcutaneous mass, 2.5 cm in size, on her right occipital region. The mass pulsated strongly and a thrill was present. Magnetic resonance imaging showed that some dilated feeding arteries flowed into the mass and that a flow-void sign was present. The lesion looked like an arteriovenous malformation, and a marginal resection was performed. Histologically, there was a mix of cavernous vascular cavities and Kaposi sarcomalike spindle cell vascular zones, which is compatible with a spindle cell hemangioendothelioma.

Combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury.

Early detection and intervention of deep tissue injury are important to lead good outcome. Although the efficiency of ultrasonographic assessment of deep tissue injury has been reported previously, it requires a certain level of skill for accurate assessment. In this study, we present an investigation of the combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury. We retrospectively reviewed 28 early-stage pressure ulcers (21 patients) presenting at the University of Tokyo Hospital between April 2009 and February 2010, surveying the associated thermographic and ultrasonographic findings. The wound temperature patterns were divided into low, even and high compared with the surrounding skin. Ultrasonographic findings were classified into unclear layer structure, hypoechoic lesion, discontinuous fascia and heterogeneous hypoechoic area. All 13 ulcers that were associated with low temperature showed good outcome; three ulcers had even temperatures and 12 ulcers showed high temperature on thermographic assessment. The two deep tissue injuries were rated high on thermographic assessment and showed heterogeneous hypoechoic area findings on ultrasonographic assessment. No non-deep tissue injury lesion was associated with these two findings simultaneously. The combination of thermographic and ultrasonographic assessments is expected to increase the accuracy of the early detection of deep tissue injuries.

Machine learning approach to predict tracheal necrosis after total pharyngolaryngectomy.

BACKGROUND: Tracheal necrosis is a potentially severe complication of total pharyngolarynjectomy (TPL), sometimes combined with total esophagectomy. The risk factors for tracheal necrosis after TPL without total esophagectomy remain unknown. METHODS: We retrospectively reviewed data of 395 patients who underwent TPL without total esophagectomy. Relevant factors associated with tracheal necrosis were evaluated using random forest machine learning and traditional multivariable logistic regression models. RESULTS: Tracheal necrosis occurred in 25 (6.3%) patients. Both the models identified almost the same factors relevant to tracheal necrosis. History of radiotherapy was the most important predicting and significant risk factor in both models. Paratracheal lymph node dissection and total thyroidectomy with TPL were also relevant. Random forest model was able to predict tracheal necrosis with an accuracy of 0.927. CONCLUSIONS: Random forest is useful in predicting tracheal necrosis. Countermeasures should be considered when creating a tracheostoma, particularly in patients with identified risk factors.

Second free jejunum transfer after flap loss does not affect oral intake: A retrospective case-control study.

PURPOSE: Free jejunum transfer is one of the standard procedures for restoring oral intake after total pharyngo-laryngo-esophagectomy. Flap loss leading to a second free jejunum transfer rarely occurs. This study investigated the impact of a second free jejunum transfer on post-operative oral intake. METHODS: A retrospective review was conducted on patients who underwent a first free jejunum transfer between July 1998 and December 2019. A total of 367 patients were included in the study. Among them, 17 patients who underwent a second free jejunum transfer because necrosis constituted the second free jejunum transfer group, whereas 350 patients who did not require a second free jejunum transfer formed the first free jejunum transfer group. The incidence of dysphagia requiring tube feeding and post-operative complications was compared between the two groups. Moreover, risk factors for dysphagia and complications were estimated. RESULTS: There were no statistically significant differences in the incidence of dysphagia post-operation between the two groups. A second free jejunum transfer was a statistically significant factor for complications at 2- and 6-months post-operation; however, there were no significant differences in complication rates at the 12-month follow-up. Furthermore, there were no significant differences in the incidence of severe complications between the two groups. CONCLUSION: Although a second free jejunum transfer increases early complications, it is not associated with major complications and does not negatively impact oral intake. These findings support the conclusion that free jejunum transfer is safe and helps maintain post-operative quality of life.

Evaluation of aesthetic outcomes of mandibular reconstruction using artificial intelligence.

BACKGROUND: Although vascularized bone graft (VBG) transfer is the current standard for mandibular reconstruction, reconstruction with a mandibular reconstruction plate (MRP) and with a soft-tissue flap (STF) alone remain crucial options for patients with poor general conditions. However, objective aesthetic outcome evaluations for these methods are limited. METHODS: In a retrospective analysis of 65 patients (VBG, 33; MRP, 19; and STF, 13), mandibular asymmetry value was calculated for each patient's photograph using facial recognition AI, with a higher value indicating worse asymmetry. RESULTS: The MRP group had a value comparable to the VBG group regardless of mandibular defect types. The STF group had a significantly higher value than the VBG group. CONCLUSIONS: Regarding cosmesis, STF was inferior to VBG, whereas MRP was comparable to VBG, even for anterior defects for which rigid reconstruction is mandatory. However, MRP's risks of plate-related complications limit its use to cases where VBG is contraindicated or with poor prognosis.

Zygomatico-orbital artery as a recipient vessel for microsurgical head and neck reconstruction.

The selection of recipient vessels in head and neck reconstruction is one of the key factors influencing its difficulty and outcome. We report a case of a microsurgical scalp reconstruction using the zygomatico-orbital artery as a recipient vessel.A 71-year-old woman had intractable skin ulcers on her head after neurosurgeries. Computed tomography angiography findings showed that the superficial temporal artery was obstructed and that the zygomatico-orbital artery ran forward and upward. She underwent scalp reconstruction using a free anterior lateral thigh flap. The zygomatico-orbital artery was dissected distally, cut, and turned over cranially. The diameter of the zygomatico-orbital artery was 1.2 mm. The blood flow through the zygomatico-orbital artery was sufficient. The thinned scalp area was excised, and some of the titanium devices and infectious tissues were removed. An anterior lateral thigh flap measuring 20 × 9 cm was harvested and transferred to the defect in the head. The discrepancy in calibers was within double, and the zygomatico-orbital artery fit the descending branch of the lateral circumflex femoral artery. The flap was transferred successfully.The zygomatico-orbital artery is one of the branches from the external carotid artery and supports the suprazygomatic territory. The zygomatico-orbital artery is present in 78% to 92% of people and originates from the superficial temporal artery and sometimes from the frontal branch of superficial temporal artery. The mean diameter of the zygomatico-orbital artery at origin is reported to be 1.20 mm. The zygomatico-orbital artery is another option as a recipient vessel in head and neck reconstruction.

Human papillomavirus-related multiphenotypic sinonasal carcinoma.

Human papillomavirus-related multiphenotypic sinonasal carcinoma (HMSC) is a rare primary tumor of the sinonasal tract that has been reported recently. It is reportedly associated with human papillomavirus infection. The tumor presents with glandular cyst-like histology, but some cases exhibit squamous epithelialization and are positive on p16 immunohistochemical staining. The clinical picture and treatment of this disease have not been established. However, this report describes a recurrent case of this disease treated with salvage surgery. The patient was a 61-year-old woman who presented to the previous doctor with a chief complaint of nasal obstruction. A localized tumor was found in the left nasal cavity and was resected under endoscopic guidance. The postoperative pathological diagnosis was HMSC. Twenty-one months after the surgery, local recurrence was observed, and the patient was referred to our hospital. Since the recurrent lesion had widely infiltrated outside the nasal cavity, extensive resection and reconstructive surgery were performed. Postoperative radiotherapy was performed as an additional treatment. Notably, 13 months have passed since the salvage surgery, and no recurrence has been observed to date.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan.

BACKGROUND: There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction. METHODS: This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence. RESULTS: Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15. CONCLUSION: The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Adipose injury-associated factors mitigate hypoxia in ischemic tissues through activation of adipose-derived stem/progenitor/stromal cells and induction of angiogenesis.

Based on the analysis of exudates from injured adipose tissue, we prepared a mixture containing the injury-associated growth factors at the same proportion as the exudates, named adipose injury cocktail (AIC). We hypothesized that AIC induces a series of regenerating and angiogenic processes without actual wounding. The purpose of this study is to elucidate the therapeutic potentials of AIC. AIC preferentially activated adipose-derived stem/progenitor/stromal cells (ASCs) to proliferate, migrate, and form networks compared with vascular endothelial cells, whereas vascular endothelial growth factor did not induce mitogenesis or chemotaxis in human ASCs. Each component growth factor of AIC was differently responsible for the ASC activation. AIC-treated ASCs tended to differentiate into adipocytes or vessel-constituting cells rather than into other cell types. In ischemic adipose tissues of mice, induced by either a surgical intervention or diabetes, AIC administration enhanced proliferation, especially of CD31(-)/CD34(+) ASCs, and mitigated tissue hypoxia by increasing capillary density and reducing fibrogenesis. These results suggest that AIC may have therapeutic potentials for various ischemic/hypoxic conditions by inducing adipose remodeling and neovascularization through activation of ASCs and other cells. Treatment with AIC has many advantages over cell-based therapies regarding morbidity, cost, and physical risks and may be used as an alternative therapy for improving tissue oxygen.

Clinical assessment of early mobilization after head and neck free flap reconstruction: A retrospective case-control study.

PURPOSE: We examined whether there were any differences in perioperative complications between patients who mobilized on the first postoperative day (early mobilization) and those who mobilized on the second postoperative day after head and neck reconstruction using free tissue transfer. METHODS: In the control group (n = 74), patients were instructed to mobilize on the second postoperative day (April 2019-March 2020), while in the early mobilization group (n = 101), patients were instructed to mobilize on the first postoperative day (April 2020-March 2021). Mobilization was defined as maintaining a standing position or walking. Clinical data were collected from medical records and retrospectively analyzed. RESULTS: There were no significant differences in clinical background factors, with the exception of intraoperative blood loss volume. The proportion of patients who successfully mobilized on the day of instruction was significantly lower in the early mobilization group (89.1% vs. 98.7%). One case of total flap loss and four cases of partial flap loss occurred in the control group, and three cases of partial flap loss occurred in the early mobilization group. There was no significant difference in partial or total flap loss between the two groups. There were no significant differences in other perioperative complications (wound infection, postoperative bleeding, and delirium) between the two groups. The median postoperative hospital stay was 24.5 and 25.0 days in the control and early mobilization groups, respectively. CONCLUSION: In this study, early mobilization on the first day after head and neck free flap reconstruction was safe and feasible.

A prospective randomized controlled study of oral tranexamic acid for preventing postinflammatory hyperpigmentation after Q-switched ruby laser.

BACKGROUND: Postinflammatory hyperpigmentation (PIH) is the most common skin complication in Asians after invasive cosmetic treatments. OBJECTIVE: To determine whether oral tranexamic acid (TA) reduces the incidence of PIH after Q-switched ruby laser (QSRL) treatment. METHODS AND MATERIALS: Thirty-two Japanese women underwent QSRL treatment for senile lentigines on the face. They were randomly divided into two groups that did (n=15) and did not (n=17) receive oral TA treatment (750 mg/d) for the first 4 weeks after QSRL treatment. Nineteen participants had melasma-like maculae at baseline. Clinical and colorimetric assessments were performed at baseline and 2 and 4 weeks later. RESULTS: Pigmentation was effectively treated using QSRL at 2 weeks, but PIH was frequently seen at 4 weeks. There was no significant difference in the incidence of PIH between participants who received oral TA and those who did not. The presence of melasma did not influence the effectiveness of the treatment. CONCLUSION: Although oral TA has been reported to have depigmentation effects, it may not be effective for preventing PIH after QSRL. Considering the dosage and duration of treatment, an optimal protocol may be needed to induce the efficacy of this treatment to achieve the PIH-preventing effect of oral TA.