A patient with macrodystrophia lipomatosa bilaterally affecting the entire upper extremity: reporting of a rare case and literature review.

The patient, a 58-year-old Asian female, had the progressive, bilateral overgrowth of the entire upper extremity since her childhood and has undergone debulking surgery twice in her country. However, overgrowth progressed after surgery. The patient was diagnosed with Macrodystrophia lipomatosa (MDL) by physical and imaging findings in our departments.

Clinical features of primary vein grafts in free tissue transfers.

The outcomes of free tissue transfers combined with vein grafts have been inconsistent, and discussions continue regarding their appropriate use. Of the 142 free tissue transfers that we performed from January 2004 to December 2011, we retrospectively analyzed 15 consecutive patients who underwent free tissue transfers in combination with vein grafts. Etiologies included trauma (8 patients), infection (4), and tumor (3). Types of free tissue transfers were fibula (4), anterolateral thigh (3), groin (3), jejunum (3), latissimus dorsi (1), and dorsal pedis (1). Vein grafts were used for the artery (6), vein (2), or both (7). The donor veins were the saphenous vein (12) and the external jugular vein (3). The mean length of the grafted veins was 10.8 cm (range: 4-18 cm). Even though complications of congestion occurred in 2 patients, these flaps survived by reexploration. The flap success rate was 15 of 15 (100%) of vein grafted free flaps versus 124 of 127 (97.6%) of free flaps not requiring vein grafts. To improve the success rate of free tissue transfers combined with vein grafts, securing healthy recipient vessels, meticulous surgical handling, a reliable vascular anastomosis technique, and strict postoperative monitoring are crucial.

Single-stage reconstruction of a full-thickness alar defect using a folded nasolabial flap combined with a redundant skin turnover flap.

BACKGROUND: The reconstructive strategy for full-thickness nasal skin defects should include recreation of a cutaneous cover, support, and internal nasal lining. The most challenging aspect of this procedure is provision of the nasal lining. These reconstructions typically require a 2-step process. Satisfactory nasal skin reconstruction in a single operation is ideal. OBJECTIVE: We used a folded nasolabial flap combined with a turnover flap for reconstruction of full-thickness alar defects. METHODS: The donor material of the lining flap was a combination of the distal portion of the nasolabial flap and redundant skin resected during its transposition. The redundant skin flap was turned upside down, with the skin surface inside the nasal cavity. The remaining portion of the defect was covered with a folded nasolabial flap. RESULTS: This procedure was successful in all 5 patients. All flaps survived completely without evidence of necrosis or narrowing of airways. Aesthetic concerns, including effacement of the nasofacial sulcus, were minor. CONCLUSION: This method has the advantage of providing well-vascularized tissue of appropriate color, texture, and thickness for external coverage, as well as a satisfactory internal lining in a single-stage procedure.

Effects of neuropeptides and their local administration to cutaneous wounds in sensory-impaired areas.

Wound healing in sensory-impaired areas such as diabetic foot and spinal cord injuries is intractable. Previous studies have shown that delayed wound healing both of wound contraction and epithelialization in denervated rat skin. The aim of this study was to investigate whether the wound healing process was affected by the administration of substance P to skin defects and histological analysis in denervated skin. Full thickness circular skin defects 15 mm in diameter were made symmetrically on the denervated area and the normal innervated area, and substance P and vehicle was administered over a period of 3 days by injecting with a syringe. The rate of wound contraction and epithelialization were measured. The wound surface area in saline injections were larger than the group of substance P injections in denervated area and controls (p < 0.05) on day 3. Wound healing in local administration of substance P to denervated skin defect was equal to in normal animals. It seems that the presence of substance P in the wound area positively affects the early stages of wound healing.

Free tensor fascia lata flap and synthetic mesh reconstruction for full-thickness chest wall defect.

A large full-thickness chest wall defect over 10 cm in diameter requires skeletal reconstruction and soft tissue coverage. Use of various flaps for soft tissue coverage was previously reported, but en bloc resection in each case affects these flap pedicles and sizes. We present a case of a 74-year-old man with a soft tissue tumor involving the left lateral chest wall. We performed an en block resection and skeletal reconstruction using a mesh, free tensor fascia lata (TFL) flap for soft tissue coverage. This procedure could be performed in one position. A fixed fascia lata of the flap was also useful for tight reconstruction with the mesh. We suggest that free TFL and/or anterior lateral thigh flap is a useful technique to reconstruct anterior to posterior lateral chest wall defects.

Surgical management of breast deformity in a young patient with localized scleroderma: a case report and literature review.

Localized scleroderma in the chest region of adolescent girls leads to incomplete breast development and breast asymmetry, for which patients may require treatment. The site of localized scleroderma, its activity, the surgeon, and the patient's desires influence the selection of treatment method. There have been few reports on surgical treatment of this disease. In the current report, we present a case in which improved breast asymmetry was achieved through multiphased surgery, and we review treatment methods and indications of this disease.

Effects of CB-VEGF-A injection in rat flap models for improved survival.

BACKGROUND: Various carriers have been tested as drug delivery systems in an attempt to sustain the action of growth factors. Gene therapy has also been adopted to achieve lasting effects but without satisfactory results. Because the authors believe that the angiogenic effect of vascular endothelial growth factor (VEGF) can be enhanced by anchoring the fusion protein composed of the Clostridium-derived collagen-binding domain and recombinant VEGF-A164 (CB-VEGF-A) in the tissue, they examined the changes in blood flow of random pattern flaps following treatment of the dorsal region of the rat with the fusion proteins before skin flap elevation. METHODS: The authors administered CB-VEGF-A subcutaneously into the dorsal region of Sprague-Dawley rats 7 days before creation of skin flaps, and compared the necrosis rate observed on the seventh day after flap elevation with that of vehicle controls. The authors also performed comparison with a group treated by subcutaneous administration of non-collagen-binding domain-binding VEGF. The skin flaps were also examined histologically. RESULTS: The flap necrosis rate was lower in the CB-VEGF-A group (36.7 ± 7.4 percent) than in the control group (48.2 ± 5.4 percent). However, no improvement was observed in the non-collagen-binding domain-binding VEGF group. Moreover, histologic examination revealed an increase in the subcutaneous blood vessel counts. CONCLUSION: CB-VEGF-A has an angiogenic effect on rat dorsal skin flaps and improves flap survival.

Preoperative risk factors of lymph node metastasis in cutaneous squamous cell carcinoma.

Lymph node metastasis of cutaneous squamous cell carcinoma ("SCC") affects the prognosis. A variety of risk factors of lymph node metastasis have been reported. Predicting lymph node metastasis prior to surgery, which is a major treatment method for cutaneous SCC, contributes to the effects of treatment. Factors that can be obtained prior to surgery were weighed between a lymph node metastasis group and a non-metastasis lymph node group. One hundred and sixty-four cutaneous SCC patients were operated on. The following factors, which can be obtained prior to surgery, were compared between the lymph node metastasis group and the non-metastasis lymph node group: age, sex, tumour size, symptom period, lesions, and local recurrence. The detection rate from lymph node metastasis of the sentinel lymph node biopsy using the blue dye technique was studied. Among all subjects, lymph node metastasis was observed in 17 cases (10.4%). Lower lip SCC was observed only in the higher metastasis rate. Significant local recurrence occurred more frequently in the lymph node metastasis group. For other factors, no significant difference was observed between the lymph node metastasis group and the non-metastasis lymph node group. A sentinel lymph node biopsy was given in 21 cases, two false-negative cases were observed, and local recurrence and lymph node metastasis were observed postoperatively. Operation should be given to the lower lip SCC and local recurrence cases considering lymph node metastasis. It is hard to say that the sentinel lymph node biopsy of cutaneous SCC using the blue dye technique has sufficient detection rates.

Osteogenic potential of human umbilical cord-derived mesenchymal stromal cells cultured with umbilical cord blood-derived fibrin: a preliminary study.

This study examined the potential for osteogenesis via regenerative medicine using autologous tissues (umbilical cord (UC) and umbilical cord blood (UCB)) in nude mice. The study was designed to provide the three elements required for regenerative medicine (cell, scaffold, and growth factor) and autoserum for culture by means of autologous tissues. Mesenchymal stromal cells were obtained from UC (UC-MSCs). Fibrin, platelet-rich-plasma, and autoserum were obtained from UCB as scaffold, growth factor and serum for culture respectively. UC-MSCs were obtained from Wharton jelly and cultured with UCB-derived fibrin (UCB-fibrin) for 3-4 weeks to induce their differentiation into osteoblasts. They were implanted subcutaneously into the dorsum of male nude mice for 6 weeks prior to undergoing assessment. The assessments performed were haematoxylin and eosin, and alizarin red staining, immunohistochemical staining of human mitochondria, scanning electron microscopy, scanning electron microscopy with energy dispersive X-ray spectrometry and real-time reverse transcriptase-polymerase chain reaction to assess the expressions of osteoblast markers. Consequently, the differentiation of UC-MSCs into osteoblasts and the production of hydroxyapatite were verified. This study suggested the possible formation of bone tissue using biomedical materials obtained from UC and UCB.

Osteogenic potential of human bone marrow-derived mesenchymal stromal cells cultured in autologous serum: a preliminary study.

PURPOSE: As part of the authors' research on potential osteogenesis by filling bone defects with human bone marrow-derived mesenchymal stromal cells (hBM-MSCs) in patients with cleft lip and palate, they examined the cytoproliferative potential and cytobiological activity of hBM-MSCs in vitro and their osteogenic potential in vivo without performing osteoinduction. MATERIALS AND METHODS: The hBM-MSCs were collected from iliac cancellous bone and then used in primary culture, followed by 2 subcultures using an autologous serum (AS)-containing medium and a fetal bovine serum (FBS)-containing medium. Cytoproliferative potential and cytobiological activity as expressed by bone markers (alkaline phosphatase and osteocalcin) in hBM-MSCs cultured in the AS-containing medium (AS-cultured hBM-MSCs) and the FBS-containing medium (FBS-cultured hBM-MSCs) were examined in vitro, and the osteogenic potential of AS- and FBS-cultured hBM-MSCs was examined in mice. RESULTS: On day 6 of the second subculture, the number of hBM-MSCs per milliliter of specimen from 8 pediatric patients was significantly larger (P < .05) in FBS-cultured compared with AS-cultured hBM-MSCs. The alkaline phosphatase activity of hBM-MSCs was significantly greater (P < .05) when cultured in the AS-containing medium compared with the FBS-containing medium. The in vivo study showed the formation of an osteoid-like matrix rather than definite bone tissue. CONCLUSIONS: 1) FBS is appropriate for the cytoproliferation of hBM-MSCs; 2) the AS-containing medium is likely to have a good possibility of inducing the differentiation of hBM-MSCs; and 3) AS-cultured hBM-MSCs contain a group of cells that spontaneously differentiate into an osteoid-like matrix without performing osteoinduction.

Osteogenic potential of human umbilical cord-derived mesenchymal stromal cells cultured with umbilical cord blood-derived autoserum.

OBJECTIVE: Osteogenesis in the bone defect at the site of an alveolar cleft is important to enable patients with cleft lip and palate to acquire dental articulation. The presence of umbilical cord-derived mesenchymal stem cells has been reported. In this study, we used autoserum derived from the umbilical cord blood (UCB) of neonates in an attempt to examine the osteoblastic differentiation potential of umbilical cord-derived mesenchymal stromal cells (UC-MSCs) in nude mice. MATERIALS AND METHODS: UCB, hydroxyapatite, and rhBMP were used as the supply source of autoserum, scaffold, and osteoinductive growth factor, respectively. MSCs, obtained from Wharton's jelly and cultured for 3-4weeks to induce their differentiation into osteoblasts, were implanted subcutaneously into the dorsum of male nude mice for 6weeks before the assessment by real-time reverse transcriptase chain reaction of osteoblast marker expression. RESULTS: UCB-derived autoserum was a viable source for the culture and implantation of UC-MSCs. The osteoblastic differentiation potential of UC-MSCs was demonstrated in nude mice by performing immunohistochemical staining and by the presence of osteoblast marker expression. CONCLUSIONS: Our results confirm the osteogenic potential of UC-MSCs and provide basic evidence for the realization of regenerative medicine using autologous tissues.

Effect of EGF and bFGF on fibroblast proliferation and angiogenic cytokine production from cultured dermal substitutes.

Growth factors accelerate wound healing but the underlying mechanisms remain poorly understood. The aim of this study was to investigate the effect of epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) on fibroblast proliferation and production of angiogenic factors from cultured dermal substitutes (CDS). In the first experiment, fibroblasts were seeded into a flask at a density of 1 × 10(4) cells/cm(2).Cell proliferation was assessed after culturing in media containing EGF or bFGF at concentrations ranging from 2 to 50 µg. The number of fibroblasts increased significantly in the presence of EGF or bFGF, but fibroblasts detached from the flasks in the presence of 50 µg bFGF. In the second experiment, CDS were prepared by incorporating fibroblasts into collagen gels. To make a wound surface model, the CDS was elevated to the air-liquid interface, on which a spongy sheet of hyaluronic acid (HA) containing EGF or bFGF was placed. The amount of vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) released from the CDS after 1 week of cultivation was measured by ELISA. When the CDS was covered with a HA sponge containing EGF (Group 1), fibroblasts released 3.5-times more VEGF compared with a HA-alone sponge (control group). When covered with a HA sponge containing bFGF (Group 2), 8.7-times more VEGF was released compared with the control group. Fibroblasts in Groups 1 and 2 released 9.6- and 9.3-times more HGF, respectively, compared with the control group. Thus, EGF stimulates fibroblasts to produce VEGF and HGF, in addition to its ability to enhance epidermal cell proliferation.

Clinical trial of allogeneic cultured dermal substitutes for intractable skin ulcers.

The effect of allogeneic cultured dermal substitute (CDS) on wound healing was evaluated in 9 intractable skin ulcers in 5 patients who had failed to improve despite conventional topical treatment with basic fibroblast growth factor (bFGF) for more than 2 months. In general, the topical application of bFGF is effective in facilitating wound healing. However, skin regeneration was very slow in the present 9 cases. In this study, to improve the condition of these wounds, allogeneic CDS was applied once a week for 2 months. The wound healing process was evaluated, focusing on the reduction ratio of wound size through the granulation tissue formation associated with epithelialization. In all 9 cases, the wound size was successfully decreased after the application of CDS, and ulcers were completely resurfaced in 2 cases. In all cases, except the 2 cases showing complete wound closure, the mean wound size decreased to 33.3% of the original size, i.e., a mean reduction ratio of 33.3%. The present results indicate that allogeneic CDS can promote wound healing of intractable skin ulcers that fail to improve despite treatment with bFGF.

Role of COX-2 in lymphangiogenesis and restoration of lymphatic flow in secondary lymphedema.

The pathophysiology of secondary lymphedema remains poorly understood. To clarify the roles of cyclooxygenase (COX)-2 in enhancement of lymphangiogenesis during secondary lymphedema, we tested a mouse tail model and evaluated the recurrence of lymph flow. To induce lymphedema, a circumferential incision was made in the tail of anesthetized mice to sever the dermal lymphatic vessels. The maximum diameters of the tails were measured weekly. We found that the diameters of the tails around the wounds were markedly increased after surgery, and reached maximum size 2 weeks after wounding in mice without a COX-2 inhibitor, celecoxib (Celecoxib-). Expression of COX-2 in wound granulation tissues was markedly increased 1 week after surgery compared with unwounded naive control mice. In Celecoxib-, recurrence of lymphatic flow in the wound granulation tissues was detected 3 weeks after surgical treatment. In contrast, lymphatic flow was markedly suppressed in mice treated with celecoxib (Celecoxib+). Newly formed lymphatic structures were identified in the granulation tissues formed at wounded lesions in Celecoxib-, whereas those were markedly suppressed in Celecoxib+. Interstitial tissue pressures in the distal areas of the tail wounds were markedly increased in Celecoxib+ with reduced expression of vascular endothelial cell growth factor (VEGF)-C. F4/80-positive cells were accumulated to the wound granulation tissues in Celecoxib-, and the accumulation of these cells was suppressed in Celecoxib+. Prostaglandin E(2) (PGE(2)) upregulated the expressions of VEGF-A and VEGF-C in cultured macrophages, but not human lymphatic microvascular endothelial cells. The present study therefore suggests that lymphangiogenesis, together with recurrence of lymph flow after surgical induction of lymphedema, is upregulated by COX-2 possibly via generation of PGs.

Medical treatment for burn patients with eating disorders: a case report.

There have been many cases of burn patients who also suffer from psychiatric problems, including eating disorders. We present a case of a 38-year-old female with an eating disorder and depression who became light-headed and fell, spilling boiling water from a kettle on herself at home sustaining partial thickness and full thickness burns over 5% of her total body surface area: left buttock and right thigh and calf. Eating disorders (in the present case, anorexia nervosa) cause emaciation and malnutrition, and consent for hospitalization from the patient and/or family is often difficult. During the medical treatment of burns for these patients, consideration not only of physical symptoms caused by malnutrition but also the psychiatric issues is required. Therefore, multifaceted and complex care must be given to burn patients with eating disorders.

Hes1 is required for the development of craniofacial structures derived from ectomesenchymal neural crest cells.

The cranial neural crest cells contribute extensively to the formation of skeletogenic mesenchyme in the head and neck. Hes1 functions as a repressor of basic helix-loop-helix transcription factors and is implicated in controlling the maintenance of undifferentiated cells and the timing of cell differentiation. We show here that Hes1 homozygous null mutant mice exhibit multiple craniofacial malformations including calvaria agenesis, defective anterior cranial base, shortened maxilla and mandible, and abnormal palate and tongue. In the null mutant cranium, the calvarial bones, meninges including the dura mater and skin were not formed, and the brain was therefore exposed without the outer cover. The defective anterior cranial base in the mutants was attributable to the lack of presphenoid bone and the flexed cranial base angle, which was in contrast with the flat cranial base of wild-type mice. Furthermore, in the null mutants, palatal shelf growth was impaired because of the early elevation of the palatal shelves, resulting in a narrow palate and oral cavity, which were consistently associated with a small size of the tongue. These craniofacial anomalies could be the result of the defective development of neural crest cells. Taken together, it is supposed that Hes1 signaling plays an essential role in regulating the development of various craniofacial structures derived from the cranial neural crest cells.

Significance of CD271 in bone marrow mesenchymal stem cells--changes by cryopreservation.

In investigating the biological activities of bone marrow mesenchymal stem cells (BMMSCs), an important task is cell sorting of effective BMMSCs. In the present study, we examined the usefulness of CD271 as a cell surface marker of BMMSCs. Specifically, we investigated (1) CD271 expression before and after freezing, (2) difference between the CD271(+) and CD271(-) fractions regarding calcium formation level after bone differentiation, and (3) method of harvesting effective BMMSCs from marrow tissue. CD271 was partially expressed in cryopreserved BMMSCs (CBMMSCs). We used CD271 in separating CBMMSCs into different cell groups and compared the calcium formation levels between the CD271-expressed and CD271-nonexpressed groups. A significant amount of BMMSCs existed even in the CD271(-) fraction, and the calcium formation level was high in 4 of 5 CD271(-) fraction specimens. The same investigation was conducted on nonfrozen BMMSCs. No major difference was found in CD271 expression compared with CBMMSCs. However, the calcium formation level of the CD271(+) fraction was higher in 3 of 5 specimens. We presumed that CD271 expression might have been substantially changed during culture and cryopreservation. We compared the method of directly culturing bone marrow tissue and that of washing the sample before culture and confirmed that the calcium formation level of BMMSCs was higher when the marrow tissue was washed before culture.

Hes1 regulates formations of the hypophyseal pars tuberalis and the hypothalamus.

The hypophyseal pars tuberalis surrounds the median eminence and infundibular stalk of the hypothalamus as thin layers of cells. The pars tuberalis expresses MT1 melatonin receptor and participates in mediating the photoperiodic secretion of pituitary hormones. Both the rostral tip of Rathke's pouch (pars tuberalis primordium) and the pars tuberalis expressed alphaGSU mRNA, and were immunoreactive for LH, chromogranin A, and TSHbeta in mice. Hes genes control progenitor cell differentiation in many embryonic tissues and play a crucial role for neurulation in the central nervous system. We investigated the Hes1 function in outgrowth and differentiation of the pars tuberalis by using the markers for the pars tuberalis. In homozygous Hes1 null mutant embryos, the rostral tip was formed in the basal-ventral part of Rathke's pouch at embryonic day (E)11.5 as well as in wild-type embryos. In contrast to the wild-type, the rostral tip of null mutants could not extend rostrally with age; it remained in the low extremity of Rathke's pouch during E12.5-E13.5 and disappeared at E14.5, resulting in lack of the pars tuberalis. Development of the ventral diencephalon was impaired in the null mutants at early stages. Rathke's pouch, therefore, could not link with the nervous tissue and failed to receive inductive signals from the diencephalon. In a very few mutant mice in which the ventral diencephalon was partially sustained, some pars tuberalis cells were distributed around the hypoplastic infundibulum. Thus, Hes1 is required for development of the pars tuberalis and its growth is dependent on the ventral diencephalon.

A novel cell-adhesive scaffold material for delivering keratinocytes reduces granulation tissue in dermal wounds.

Novel peptide-conjugated chitosan membranes were fabricated and used to deliver keratinocytes to dermal wounds in mice. Three active peptides of 12 or 13 amino acids each, RLVSYNGIIFFLK (A5G27), ASKAIQVFLLAG (A5G33), and AGTFALRGDNPQG (A99) were selected from a cell-adhesive peptide library of laminin, a major constituent of basement membrane. The peptides were synthesized and coupled to chitosan membranes, and the resulting peptide-chitosan membranes were tested for keratinocyte attachment. Two of the peptides that bind to cell surface heparin-like receptors (A5G27 and A5G33) were found to promote strong keratinocyte attachment, whereas the one that binds to integrin (A99) was inactive. Subsequently, A5G27- and A5G33-chitosan membranes were tested as vehicles for keratinocyte delivery in a wound model. We found that keratinocytes were delivered into the full-thickness wound with either membrane. Using the A5G33-chitosan membrane, we further evaluated the activity of the delivered keratinocytes in wound healing. Immunohistochemistry for granulation tissue markers, including tenascin and alpha-smooth muscle actin, showed that keratinocyte delivery by the present peptide-chitosan membranes in the wound bed provided a favorable condition for keratinocyte migration along the wound surface and reduced granulation tissue formation.