Comparison of Conduits Fabricated by Fresh and Predegenerated Skeletal Muscles for Peripheral Nerve Repairing.

ABSTRACT: Reconstruction of peripheral nerve injury remains a challenge for clinical medicine. Previous reports have confirmed that external oblique muscle-fabricated nerve conduit (EMC) could effectively be used to promote peripheral nerve regeneration. In this study, we compared between conduits fabricated from fresh muscle and conduits fabricated from predegenerated muscle for the repair of peripheral nerve defects in a mouse sciatic nerve transection model. We found that the number, diameter, and myelin sheath thickness of the myelinated nerve fibers of the regenerative nerve in the EMC group were larger than those of the predegenerated-EMC (P-EMC) group eight weeks after surgery. The sciatic function index and gastrocnemius wet-weight mass ratio in the EMC group were higher than those in the P-EMC group. The Bcl-2/Bax ratio and the number of Schwann cell nucleus in the proximal nerve stumps in the EMC group were greater than those in the P-EMC group. In conclusion, our results confirmed that the use of fresh skeletal muscle nerve conduit increased the Bcl-2/Bax ratio and promoted the survival of Schwann cells of the proximal nerve stump compared with that of predegenerated skeletal muscle nerve conduits, thus achieving better functional recovery after sciatic nerve defect.

Effect of Dermabrasion and ReCell® on Large Superficial Facial Scars Caused by Burn, Trauma and Acnes△.

Objective To explore the effects of dermabrasion combined with ReCell® on large superficial facial scars caused by burn, trauma and acnes.Methods Nineteen patients with large superficial facial scars were treated by the same surgeon with dermabrasion combined with ReCell®. According to the etiology, patients were classified into post-burning group (n=5), post-traumatic group (n=7) and post-acne group (n=7). Fifteen patients completed the follow-ups, 5 patients in each group. Healing time, complication rate, the preoperative and 18-month-post-operative assessments using Patient Satisfaction Score (PSS), Vancouver Scar Scale (VSS), and Patient and Observer Scar Assessment Scale (POSAS) of each group were analyzed to compare the effect of the combined therapy on outcomes.Results The healing time of post-burning group (19.6±4.0 days), post-traumatic group (15.8±2.6 days), and post-acne group (11.4±3.1 days) varied remarkably (F=7.701, P=0.007). The complication rates were 60%, 20%, and 0 respectively. The post-operative POSAS improved significantly in all groups (P<0.05), where the most significant improvement was shown in the post-acne group (P<0.05). The post-operative PSS and VSS improved only in the post-traumatic group and post-acne group (all P<0.05), where the more significant improvement was also shown in the post-acne group (P<0.05).Conclusions The combined treatment of dermabrasion and ReCell® has remarkable effect on acne scars, moderate effect on traumatic scars and is not suggested for burn scars. POSAS should be applied to assess the therapeutic effects of treatments for large irregular scars.

Influence of partial masseter muscle resection along with reduction of mandibular angle.

UNLABELLED: The mandibular angle plays an important role in determining the Asian human facial attractiveness. Currently, mandibular angle osteotomy is often reported as the correction of square face appearance due to its prominence. However, no previous study has documented the long-term outcome of partial masseter muscle resection along with reduction of mandibular angle. OBJECTIVE: Our study aims to investigate the outcome and complications of partial masseter muscle resection along with reduction of mandibular angle in long-term follow-up. METHOD: One hundred fifty-one patients were subjected to the computed tomography scan before and 3 years after surgery. Morphometrical analysis was conducted on all parameters for clinical evaluation, so as to reveal the change of masseter muscle, the postsurgical result, and the complication. RESULTS: All patients were satisfied with the optimal outcome of the reduction of mandibular angle and masseter muscle. Morphometrical analysis indicated that the volume of masseter muscle changed statistically significantly before and after surgery (reduced 21.31 ± 7.64% on left, 20.77 ± 7.45% on right). Complications included swelling and low lip numbness, yet no patients reported infection or facial nerve injury. CONCLUSION: Partial masseter muscle resection along with reduction of mandibular angle can improve the appearance of the patients greatly, and only a few complications occurred.

Influence of the maxillary sinus exposure in reduction malarplasty with an L-shaped osteotomy.

BACKGROUND: The zygomatic bone forms the prominence of the midface and plays an important role in determining the human facial attractiveness. The Oriental face is mesocephalic, with a prominent zygomatic body and wide zygomatic arch. Nevertheless, as an oval face is considered ideal, reduction malarplasty is always requested by Oriental people. Currently, L-shaped zygomatic osteotomy is often reported in literature yet no previous study has documented the exact outcome of this approach after exposure of the maxillary sinus. The objective of the study was to investigate the outcome and complications of intraoral L-shaped zygomatic osteotomy with the opening of maxillary sinus. METHOD: All patients were subjected to computed tomography before and 12 months after surgery. All parameters were obtained with morphometric analysis for clinical evaluation, so as to reveal the change in maxillary sinus, postsurgical results, and complications. RESULTS: All patients were satisfied with the optimal outcome of reduction malarplasty. Morphometric analysis indicated that the volume and surface area of maxillary sinus statistically significantly changed before and after surgery. Complications included deeper nasolabial fold, infraorbital nerve injury, and so on, yet no patients reported infection or dental pulp necrosis. CONCLUSIONS: Intraoral L-shaped osteotomy of the zygoma can improve the appearance of the patients greatly, and the exposure of maxillary sinus caused only a few complications.

Skeletal muscle-derived cells repair peripheral nerve defects in mice.

Skeletal muscle-derived cells have strong secretory function, while skeletal muscle-derived stem cells, which are included in muscle-derived cells, can differentiate into Schwann cell-like cells and other cell types. However, the effect of muscle-derived cells on peripheral nerve defects has not been reported. In this study, 5-mm-long nerve defects were created in the right sciatic nerves of mice to construct a peripheral nerve defect model. Adult female C57BL/6 mice were randomly divided into four groups. For the muscle-derived cell group, muscle-derived cells were injected into the catheter after the cut nerve ends were bridged with a polyurethane catheter. For external oblique muscle-fabricated nerve conduit and polyurethane groups, an external oblique muscle-fabricated nerve conduit or polyurethane catheter was used to bridge the cut nerve ends, respectively. For the sham group, the sciatic nerves on the right side were separated but not excised. At 8 and 12 weeks post-surgery, distributions of axons and myelin sheaths were observed, and the nerve diameter was calculated using immunofluorescence staining. The number, diameter, and thickness of myelinated nerve fibers were detected by toluidine blue staining and transmission electron microscopy. Muscle fiber area ratios were calculated by Masson's trichrome staining of gastrocnemius muscle sections. Sciatic functional index was recorded using walking footprint analysis at 4, 8, and 12 weeks after operation. The results showed that, at 8 and 12 weeks after surgery, myelin sheaths and axons of regenerating nerves were evenly distributed in the muscle-derived cell group. The number, diameter, and myelin sheath thickness of myelinated nerve fibers, as well as gastrocnemius muscle wet weight and muscle area ratio, were significantly higher in the muscle-derived cell group compared with the polyurethane group. At 4, 8, and 12 weeks post-surgery, sciatic functional index was notably increased in the muscle-derived cell group compared with the polyurethane group. These criteria of the muscle-derived cell group were not significantly different from the external oblique muscle-fabricated nerve conduit group. Collectively, these data suggest that muscle-derived cells effectively accelerated peripheral nerve regeneration. This study was approved by the Animal Ethics Committee of Plastic Surgery Hospital, Chinese Academy of Medical Sciences (approval No. 040) on September 28, 2016.

Purification of Schwann cells from adult rats by differential detachment.

Differential detachment by collagenase treatment is a new and efficient method for Schwann cell (SC) purification. As its effect on adult animals remains unclear, we have investigated the possibility of SC purification from adult rats. To avoid any systematic bias, Schwann cell purity before and after purification were compared by morphology, immunostaining of P75(NTR) and S100 and flow cytometric analysis. The final SC purities reached 99% as confirmed by three independent analyses SC purity and the cell yields were above 10(6) cells after two rounds of purification. The method of differential detachment is also suitable for SC purification in adult rats and could be useful for research and clinical applications.

Segmental osteotomy in the treatment of obsolete orbitozygomatic fractures.

Different kinds of orbitozygomatic fractures lead to different levels of orbital structural destructions. Although the magnitude of the management of orbitozygomatic fractures varies considerably, an unsolved and important question remains regarding how to select the best surgical modality according to different kinds of fractures. Among 26 cases of unilateral noncomminuted orbitozygomatic fractures, a segmental osteotomy technique was used to repair the displaced orbitozygomatic complex. The fragment contributing to the orbital structure was mobilized and reduced, whereas the fragment without contribution to the orbital structure was not mobilized and left in situ. Next, the cuneate fragment was imbricated with the orbital osteotomy sites unilaterally or bilaterally. Miniplates and screws were used to span the osteotomy sites and provided fixation once the alignment of the orbit was achieved. The mean difference in volume between fractured orbits preoperatively and postoperatively was 2.47 mL. The mean difference in ocular globe projection was 2.76 mm. When postoperative results were compared with those of the preoperative site, statistically significant difference was noted. At follow-up 1 year postoperatively, the management of orbitozygomatic fractures using segmental osteotomy reduces complications and attains aesthetically satisfying results. Subjective assessment of the patients' globe position found that 88.5% of the patients were satisfied with the outcome, and 11.5% of the patients found it unacceptable. Compared with the traditional method, segmental osteotomy is a simple technique requiring less dissection and can reconstruct the orbital anatomic structure and restore globe position effectively.

Surgical outcome and patient satisfaction after Z-epicanthoplasty and blepharoplasty.

AIM: To evaluate surgical outcomes of modified Z-epicanthoplasty with blepharoplasty that we previously reported from the patient's perspective using patient-reported outcome measures (PROMs) and patient satisfaction scores. METHODS: A total of patients (n=180) who underwent the surgery between January 2013 and June 2016 were randomly selected. Standardized patient satisfaction forms (total score, 40) and validated PROMs questionnaires (total score, 12) were sent to patients for completion. PROMs assesses the severity of scarring, pain and asymmetry, as well as functional and appearance issues. RESULTS: All patients were female, ranging from 18 to 35 years old (mean=24). The response rate was 73.3% (n=132). The majority of patients reported good or excellent outcomes based on PROM analysis. Patients reported minimum or non-visible scarring at both the double eyelid surgical scar (85.6%) and the inner canthus (80.3%). Issues concerning function and appearance were minimal as 80.3% reported satisfaction with both domains. Notably, the majority of patients reported either a high or very high satisfaction rate to yield a mean score of 104 out of 120 (P<0.05). CONCLUSION: Integration of our modified Z-epicanthoplasty with blepharoplasty produces good outcomes based on PROM results, which shows a positive linear relationship with patient satisfaction scores.

[Role of urinary basic fibroblast growth factor in differentiating hemangiomas from vascular malformation].

OBJECTIVE: To investigate a novel method to differentiate hemangioma from vascular malformation, to stage hemangiomas and to monitor the efficacy of management for hemangioma. METHODS: The urinary basic fibroblast growth factor (bFGF) concentration of 144 cases (including 69 cases of proliferating hemangiomas, 41 cases of involuting hemangiomas, 23 cases of vascular malformations and 11 negative controls) was examined using enzyme linked immunosorbent assay (ELISA). RESULTS: The differences of urinary bFGF concentration among proliferating hemangiomas, involuting hemangiomas, vascular malformations and negative control were all significant, while the differences between the latter three groups were not significant. CONCLUSIONS: Our findings suggest that examination of urinary bFGF concentration using ELISA technique is helpful in differentiating hemangioma from vascular malformation, staging hemangiomas and dynamically monitoring the efficacy of treatment for hemangiomas. Our results probably shed new light on the potential pathogenesis of hemangiomas and vascular malformation.

Peripheral nerve repair with epimysium conduit.

Autologous tissues such as skeletal muscle have high biocampatibility and can effectively promote nerve regeneration compared to other biological and artificial materials; however, the reasonable and effective application of skeletal muscle requires further study. The purpose of this investigation was to assess the possibility of preparing a hollow nerve conduit, termed the epimysium conduit (EMC), using thin crimps of epimysium with skeletal muscle fibers and evaluate its effectiveness in repairing peripheral nerve defects. We prepared nerve conduits containing lumen with the external oblique muscle of the CAG-EFGP transgenic mice using microsurgical techniques for bridge repair of a 5-mm long sciatic nerve defect in wild-type mice. Systematic histological and functional assessments of the regenerated nerves were performed 8 and 12 weeks after surgery. EMC was found to effectively repair the sciatic nerve defect with significantly greater effectiveness than artificial conduits; however, the repair effect of EMC was lower than that of autologous nerve grafting for some parameters. In addition, our findings showed that some EMC-derived cell components migrated into the region of the regenerated nerves and contributed to reconstruction. Based on these findings, we conclude that a hollow conduit prepared with epimysium and a few skeletal muscle fibers is ideal for repairing peripheral nerve defects, and the cell components in the grafts contribute to nerve regeneration and structural remodeling, which provides an alternative option for the emergency primary repair of peripheral nerve defects in clinical practice.

[Zygomatic reduction with midface L-shaped osteotomy and its effect on the maxillary sinus].

OBJECTIVE: To investigate the result of zygomatic reduction with midface L-shaped osteotomy through intraoral approach. METHODS: From June 2006 to Aug. 2009, 67 cases received zygomatic reduction with midface L-shaped osteotomy through intraoral approach. 52 cases underwent CT scan before operation and 12 months after operation. The images were analyzed by software GE AW 4.1 for evaluation of clinical effect, maxillary sinus change and complication. SAS 6.12 software was applied for one-way ANOVA. RESULTS: Satisfactory results were achieved in all the patients. The volume of maxillary sinus at left and right side was (21233.96 +/- 4455.04) mm3, and (22020.64 +/- 3663.82) mm3, respectively before operation: (17840.91 +/- 4381.03) mm3 and (18511.85 +/- 3466.24) mm3 respectively 12 months after operation, showing a significant difference between them (P<0.05). No infection or dental pulp necrosis happened. CONCLUSIONS: Good results can be achieved with intraoral L-shaped osteotomy for zygomatic reduction. Exposure of maxillary sinus would not cause any complication.

[The morphological study on masseter muscle following mandibular angle osteotomy].

OBJECTIVE: To evaluate the morphological change of masseter after the mandibular angle osteotomy. METHODS: Computerized tomography (CT) examination was performed on 120 patients treated by mandibular angle osteotomy before operation and at 3, 6, 12 months after operation, respectively. The pre- and postoperative masseter muscle thickness and cross-sectional area were evaluated using 3D CT images observed from 3 selected slice planes, which were paralleled with Frankfurt horizontal plane. These CT images were stored and three-dimensional reconstruction were made for calculation of masseter muscle volume through software. RESULTS: After operation, the reduction of the masseter muscle volume and cross-sectional area was seen. The volume of the masseter at 3, 6, 12 months postoperatively decreased to 82.02%, 77.00% and 80.43% (P < 0.05). The cross-sectional area at 3, 6,12 months postoperatively decreased to 85.81%, 78.86% and 81.56% at A plane, 80.94%, 75.03% and 77.04% at B plane, and reached to 13.46%, 11.48% and 13.89% at C plane (P < 0.05, P < 0.05, P < 0.01). The masseter thickness after operation was significantly different from that before operation during the follow-up period, but not at 12 months after operation at A plane. CONCLUSIONS: The masseter atrophy happens spontaneously after mandibular angle osteotomy, especially at the region of mandibular angle. It should be considered during surgical design.

Repair of canine mandibular bone defects with bone marrow stromal cells and coral.

Tissue engineering has become a new approach for repairing bone defects. Previous studies indicated that coral scaffolds had been utilized with bone marrow stromal cells (BMSCs) in a variety of approaches for bony reconstruction. In these applications, the degradation rate of the material did not match the rate at which bone was regenerated. In this study, a previously established 30 mm long mandibular segmental defect was repaired with engineered bone using green fluorescent protein-labeled osteogenic BMSCs seeded on porous coral (n = 12). Defects treated with coral alone (n = 12) were used as an experimental control. In the BMSCs/coral group, new bone formation was observed from 4 weeks postoperation, and bony-union was achieved after 32 postoperative weeks. The residual coral volume of the BMSCs/coral grafts at 12 weeks (20-30%) was significantly higher than that at 32 weeks (10-15%, p < 0.05), which was detected by microcomputed tomography and histological examination. The engineered bone with BMSCs/coral achieved satisfactory biomechanical properties at 32 weeks postoperation, which was very close to that of the contralateral edentulous mandible. More importantly, immunostaining demonstrated that the implanted BMSCs differentiated into osteoblast-like cells. In contrast, minimal bone formation with almost solely fibrous connection was observed in the group treated with coral alone. Based on these results, we conclude that engineered bone from osteogenically induced BMSCs and biodegradable coral can successfully repair the critical-sized segmental mandibular defects in canines and the seeding cells could be used for bony restoration.

[Application of adipose-derived cells in reconstruction of tissue engineered cartilage in vitro].

OBJECTIVE: To explore the feasibility of application of adipose-derived cells (ADCs) in reconstruction of tissue engineered cartilage in vitro. METHODS: Adipose tissue were obtained from human liposuction aspirate (19 cases, 31.5 +/- 5.8 years old). ADCs were isolated by collagenase digestion from liposuction aspirates. 3rd passage cells were seeded into PLGA scaffolds. The copolymer constructs were cultured in conditioned or non-conditioned medium in vitro for 4 weeks. The constructs were evaluated though gross morphology, histology, and immunohistochemistry. RESULTS: The cell-polymer constructs kept its original shape in the induced group, but lost its original shape in the non-induced group. The scaffold group were collapsed. Histologically, the induced groups showed dense cellularity and lacunae-containing cells embedded in a basophilic matrix, while non-induced groups showed connective tissue-like morphology. Collagen and proteoglycan deposition was revealed by Massons's trichome and Safranin' O staining, and minor collagen II expression in the matrix was detected by immunohistochemistry staining in the induced group. They were all negative in the non-induced groups. CONCLUSIONS: Although ADCs included many kinds of cells, it is feasible to use ADCs as seeds cells for reconstruction of tissue engineered cartilage.

[Research and clinical application of computer-aided design of craniofacial prosthesis using mirror technique].

OBJECTIVE: To explore the feasibility of creating a 3D-CAD model of craniofacial prostheses through mirror technique to repair the unilateral craniofacial defects and restore craniofacial symmetry. METHODS: Patients with unilateral craniofacial defects underwent spiral CT scanning. CAD3-D image was reconstructed ad 3-D CAD model of craniofacial prosthesis was created with mirror technique, Boolean operation and rapid prototyping technique. Then the prosthesis made of bioactive artificial bone was made through plaster cavity block. RESULTS: 15 cases were treated with no complications. Good symmetry was achieved after operation. CONCLUSIONS: Designing the craniofacial prosthesis with mirror technique guarantees excellent functional and cosmetic results for repairing the unilateral craniofacial defects.

[Monobloc distraction osteogenesis and cranial vault remodeling in a pediatric patient with severe Crouzon's syndrome].

OBJECTIVE: To report the treatment of a case of severe Crouzon's syndrome using monobloc distraction osteogenesis and cranial vault remodeling. METHODS: Through intra-and extra-cranial approach, monobloc osteotomy was performed and external distractor was placed. Distraction began on the 7th postoperative day at a rate of 1 mm a day, two times a day. The distractor removed after consolidation for 4 months. RESULTS: The distraction distance attained 20 mm. The exophthalmos and cross bite were corrected completely. The severe obstructive apnea improved markedly. CONCLUSIONS: Monbloc distraction osteogenesis and cranial vault remodeling are effective and safe procedure for Crouzon's syndrome.

[The changes of the muscular fiber phynotype at different condition of nerve injury].

OBJECTIVE: To observe the change of the muscular fiber phynotype at different condition of nerve injury. METHODS: Rabbits were used as an animal model in this study. The trigeminus and facial nerves of the animal were simultaneously severed (group 1) or only the latter was severed (group 2). The morphologic change of the muscular fibers was observed with histochemical methods; the tension of contraction and the threshold value of electrical stimulation were observed with electrical physiological methods. RESULTS: Trigeminus nerve play an important role in delaying muscular atrophy after facial nerve was severed. The atrophy degree of type II a and II b muscular fibers was less in group 2 than that in group 1. The change of type 1 muscular fibers was not affected by trigeminus nerve. New muscular fibers emerged in group 2. The tension of contraction and the threshold value of electrical stimulation were better in group 2 than that of in group 1. CONCLUSIONS: Sensory nerve could delay muscle atrophy after denervation. Sensory nerve should be repaired simultaneously when the motor nerve was sutured. The results of this study would facilitate clinical treatment for facial palsy.

[Individual 3-D image prototyping models for orbital reconstruction].

OBJECTIVE: To fabricate a rapid prototyping (RP) 3-D image models for individual reconstruction of orbital bony loss. METHODS: The skull was placed on a helical CT scanner table and the Frankfort plane was perpendicular to the table. The CT data was obtained by a Aquilion (TOSHIBA, Japan) with 1 mm thickness section in spiral mode. By adjusting of CT threshold value and pixels in order to stack the segmental defects, we obtained an approximate 3-dimension visual model of the scanned skull using MedGraphics software. An orbital RP model based on the dataset of the 3-dimension visual model was fabricated by RP machine. Both 3-dimension visual model and RP model were measured against the skull with several anatomic landmarks to examine the accuracy of the models, and the errors were analysed. RESULTS: Integrity precision rapid RP models of the orbital region were reconstructed. The anterior orbital rim, middle orbital section and posterior orbital section were all fabricated. Optic foramen, superior orbital fissure, infraorbital foramen, inferior orbital fissure, lacrimal sac socket and naso-lacrimal duct were shown clearly. But some fine hole and slot, such as the anterior ethmoidal foramen, posterior ethmoidal foramen and zygomaticofrontal suture were not obviously seen. The mean difference between the 3-dimension visual model and the skull was 0.10 +/- 1.02mm. For the RP and dry skull, the mean difference was 0.22 +/- 1.04mm. There were no statistical differences between them. CONCLUSIONS: Integrity precision orbital RP models were fabricated which fulfilled the requirements of the individual reconstruction with bony orbital pathologic changes. The keys to fabricate the precision orbital RP models included a closer cooperation between the surgeon and engineer, thin CT slice in 1mm thick and an appropriated threshold value. Better results for the orbital deformities should be achieved for the contour of orbital region or eye function.

[Transforming growth factor-beta superfamily in the regulation of new bone formation].

OBJECTIVE: To review the recent advances in transforming growth factor-beta(TGF-beta) superfamily study and its role in new bone formation. METHODS: The latest original articles related to this subject were retrieved extensively, especially the effect of TGF-beta, bone morphogenetic proteins(BMPs) and activin(ACT) on distraction osteogenesis. RESULTS: TGF-beta, BMPs and ACT play important roles in prompting new bone formation and each of them has different effects. Among them, TGF-beta can stimulate the proliferation of osteoblast and synthesis of extra cellular medium; BMPs can initiate the differentiation of interstitial cell to osteocyte; then ACT displays the combine effect of above two factors. CONCLUSION: TGF-beta superfamily can regulate new bone formation and thus shorten the course of mandibular distraction osteogenesis.