Interdisciplinary Prevention and Management of Wound-Related Complications in Extracranial-to-Intracranial Bypass Surgery.

Extracranial-to-intracranial (EC-IC) bypass surgery may be necessary in patients with moyamoya disease and other ischemic conditions. However, there is a potential risk of wound-related complications in some cases. In this study, we report our approach to the prevention of wound-related complications in EC-IC bypass. Technical considerations and pitfalls of surgery are also discussed. This study included 89 patients with ischemic-onset moyamoya disease and atherosclerotic disease who underwent 108 superficial temporal artery (STA)-to-middle cerebral artery bypass procedures. Our study emphasized 3 major features. First, 3-dimensional simulation imaging was used to confirm STA anatomy. Second, the STA was meticulously dissected on the epigaleal layer to protect the galeal layer. Third, scalp skin ischemia was taken into consideration at each step until skin closure. There was no neurologic morbidity or mortality in this series. There were 2 cases of major wound-related complications requiring plastic surgical intervention, and 4 cases of minor complications that were treated conservatively. In major complication cases, the scalp defect was treated with pedicle flap reconstruction. In EC-IC bypass surgery, interdisciplinary management involving neurosurgery, plastic surgery, and radiology should reduce wound-related complications and achieve safe surgery.

Abnormality of Auricular Muscles in Congenital Auricular Deformities.

BACKGROUND: It has been suggested that there is a close association of abnormality in auricular muscles with various congenital auricular deformities. However, there has been no investigation to determine what muscles are involved and how they affect the deformity. The authors examined abnormalities of auricular muscles for patients with various auricular deformities. METHODS: The authors examined 77 auricles of 62 patients with congenital auricular deformities, including cryptotia, Stahl's ear, prominent ear, lop ear, and others. The superior and posterior auricular muscles from the extrinsic auricular muscle group and the auricular oblique and transverse muscles from the auricular intrinsic muscle group were investigated. RESULTS: The authors found characteristic features of the abnormality of the muscle for each auricular deformity. In nearly all cases of cryptotia, abnormality was found in the superior auricular, auricular oblique, and auricular transverse muscles. Abnormal insertion was found mainly in the superior auricular muscle and was the main cause of cryptotia. In Stahl's ear, the major abnormality was abnormal insertion of the auricular transverse muscle, which creates an abnormal cartilaginous prominence in the scapha. The abnormality in cases of prominent ear was clearly limited mostly to the auricular transverse muscle and, in some cases, to the posterior auricular muscle. In lop ear, abnormality was mostly found in the auricular transverse muscle, with elongation, and in the superior auricular or auricular oblique muscle in some cases. CONCLUSIONS: There is a tendency for a specific muscle abnormality to be found in each deformity. It is important to identify the abnormal muscle and correct the abnormality during the operation.

Correction of Lobule-type Microtia: Part 2: The Stage of Ear Elevation.

BACKGROUND: Here, we introduce our recent operative technique for ear elevation that results in (1) minimal morbidity for patients, (2) symmetric appearance, (3) clearer 3-dimensional structure with a deep concha, (4) good aesthetic appearance by hiding the grafted area behind the ear, and (5) maintenance of deep temporoauricular sulcus and angle. METHODS: After a skin incision, the ear is elevated with temporoparietal fascia underlying the cartilage. On the conchal area, undermining is performed just below the skin so that the deep concavity can be maintained. Scalp and neck skin behind the ear is undermined subcutaneously and lifted up cranially to hide the entire area of grafted skin behind the ear. The postauricular surface is covered by full-thickness skin from the lower abdomen. A protective splint is applied for 3 months while sleeping. RESULTS: A total of 137 ears in 121 patients were corrected with our technique and followed up for at least 3 years. All of the scar tissue could be hidden behind the ear, an aesthetically excellent result. CONCLUSIONS: Our technique made it possible to acquire an excellent and symmetrical shape of the ear. The important points in our procedure are as follows: (1) subcutaneous posterior undermining to enlarge the conchal cavity, (2) careful arrangement of the temporoauricular angle and auriculo-earlobe angle, (3) reduction in the area of temporally grafted skin to hide all scars behind the ear, and (4) protection of the ear to maintain the shape using a postoperative splint.

Double combined Z-plasty for wide-scar contracture release.

Z-plasty is one of the most widely employed techniques in plastic surgery and mainly serves the following purposes: elongation along the axis of the scar, dispersal of the scar followed by breaking up the straight-line scar and realigning the scar within the lines of minimal tension. It is useful especially to release linear-scar contracture, yet difficult for wide scars. This report describes a novel technique to release contracture effectively for any wide scars using a new design called double combined Z-plasty. The design is simple. The main limb is set to incise the wide scar, and this main limb is shared as a peripheral limb by two other Z-plasty designs. From the main limb, each central limb is designed along the margin of the scar in the opposite direction. The main and central limbs have 90° between them. Other peripheral limbs are then designed facing laterally to the intact skin to make 60° for the central limb. After skin incision, two triangular intact skin flaps could be inserted into the wide scar from both sides, making it possible to release contracture. We performed this technique on eight patients. All wounds healed well and scar contracture was satisfactorily released. This procedure is very useful for wide-scar contracture, compared to conventional Z-plasty.

Combined revascularization and free-tissue transfer for limb salvage in a Buerger disease patient.

Buerger disease is a limb-threatening condition occurring in young smokers, and its treatment has been a challenging problem, although a large number of medical and surgical options have been suggested. Combined surgery for revascularization and free-tissue transfer for Buerger disease is an aggressive and attractive option. This complex surgery enables successful treatment of tissue loss caused by ischemia. We performed revascularization and free-tissue transfer to the critically ischemic limb in a patient with Buerger disease. In this case, the procedure is attempted to salvage a limb from amputation.

Mozart ear: diagnosis, treatment, and literature review.

Mozart ear is a congenital auricular deformity, which is mainly characterized by a bulging appearance of the anterosuperior portion of the auricle, a convexly protruded cavum conchae, and a slit-like narrowing of the orifice of the external auditory meatus. It is said to be uncommon, and because no one has yet fully described neither the disease nor the treatment, the concept of Mozart ear has not been unified. This report describes a case of a 13-year-old girl presented with an unusual congenital deformity which showed the features of Mozart ear. It is an extremely rare deformity that only about 4 clinical cases have been reported in medical literature thereby a treatment method has not been fully discussed. For surgical correction of our cases, we excised deformed conchal cartilage, turned it over, regrafted, and maintained a cosmetically positive result. We also reviewed and described the origin, current concept, and treatment method of Mozart ear.

The usefulness of the collagen and elastin sponge derived from salmon as an artificial dermis and scaffold for tissue engineering.

Collagen sponge is one of the medical materials that are frequently used in clinical medicine. However, the problem of prion disease harmfully affected the usage of mammals-derived medical materials. Since there have been no reports about prion disease occurring in marine products, we produced the collagen and elastin sponge (CES) made from salmon, and investigated whether the CES could be a substitute for mammalian collagen sponge. Fibroblasts were seeded in the CES to examine whether the CES could be used as a scaffold for tissue engineering. The results of the WST-1 assay showed that the fibroblasts were viable and were well proliferated in the CES. To examine whether the CES could be used as an artificial dermis, the CES and TERUDERMIS (traditional collagen sponge) were grafted onto the skin defects on the dorsum of rats. The histological findings of these ulcers showed non-significant difference between the CES and TERUDERMIS. Because of the safety, the abundance of the resources, and the possessing same ability as TERUDERMIS, the biomedical materials derived from marine products may be a substitute for those derived from mammals.

Three cases of giant pilomatrixoma--considerations for diagnosis and treatment of giant skin tumours with abundant inner calcification present on the upper body.

BACKGROUND: Pilomatrixoma frequently occurs as a solitary, small tumour on the face or upper extremities of people younger than 20 years. METHODS: We report three cases of giant pilomatrixoma. In all these cases, outward appearances and imaging investigations suggested malignant tumours. Preoperative biopsies suggested that case 1 was a basal cell carcinoma, but cases 2 and 3 had no malignant features on biopsy. Two of the cases experienced rare complications - hypercalcaemia caused by parathyroid-related protein (PTHrP) production and multiple occurrences. RESULTS: All three tumours were removed with a 1-3-cm margin. The postoperative histopathologies showed pilomatrixoma in all three cases. CONCLUSIONS: Rarely, pilomatrixoma develops to a giant size with various atypical outward appearances consistent with a malignant tumour. Preoperative clinical appearances frequently lead to misdiagnosis, and preoperative examinations are unreliable. Therefore, when a giant tumour with abundant inner calcification is present in a young patient, the possibility of a pilomatrixoma should be considered.

Reverse facial artery flap from the submental region.

BACKGROUND: Of all the local flaps that allow elevation of a sufficiently large-sized flap while also leaving an inconspicuous donor-site scar, the submental island flap is frequently used for the reconstruction of a defect in the lower two-thirds of the face. However, this flap has certain disadvantages such as the technique being slightly difficult to perform and, more importantly, that it carries a significant risk of injury to the facial nerve. METHODS: Here, we propose the reverse facial artery flap, elevated from the submandibular region. Our method creates a flap that includes only the platysma under the skin island, without either the submental or facial artery. However, above the superior border of the skin island, the flap includes the facial artery along with subcutaneous soft tissue. The blood circulation of the skin island is in a random pattern and that of the subcutaneous pedicle is in an axial pattern. RESULTS: Four cases were treated using our method. There were no complications in all four cases, and the results were also cosmetically very good. CONCLUSIONS: As compared to the submental island flap, our method is easier to perform and carries a much lower risk of damage to the marginal mandibular branch of the facial nerve, as the facial artery crosses over the facial nerve at only one point. In addition, the method produces a thin flap. Therefore, when considering correction of a small-sized defect in the lower two-thirds of the face, our method has a number of advantages over the submental island flap.

Reconstruction of a red lip that has a defect in one half, using the remaining red lip.

It is difficult to reconstruct the red lip and achieve good functional results such as normal sphincter force, sensitivity and movement of the lip. In addition, it is also difficult to attain colour and texture matches. We reconstruct a red lip that has a defect in one half, using the remaining red lip. Using the technique reported herein, we can achieve excellent functional and aesthetic results. Functionally, sphincter force and sensation recover early and the movement of the lip returns to normal. In addition, the reconstructed lip develops a symmetrical and natural appearance.

The acute surgical management of injury to the helix and antihelix in patients with large body surface area burns.

Deformity or loss of the ear may be caused by superficial dermal burns or deep burns. The depth of ear burns is progressive because the ear protrudes from head and is easily affected by external pressure. Therefore, burn wounds of the ear should be debrided as early as possible, before irreversible changes of the cartilage, and covered with healthy tissue. We describe a surgical procedure for treatment of the extensively burned ear. With this technique, the helix is covered by a postauricular advancement flap, and the antihelix is covered by a skin graft. Because the procedure is straightforward and can be completed within a short time, it can be performed at the same time as other life-saving measures. The use of a skin flap permits adequate debridement in terms of both depth and width, minimising the risk of infection. The helix can be reconstructed to provide a natural appearance, and late ulcer formation due to external irritation is prevented. We have treated 15 ears on 11 patients with this procedure and have consistently obtained a satisfactory outcome.

Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commissure.

Various methods of reconstructing lower lip partial defects have been reported, for example those using the upper lip such as the Abbe and Estlander flap techniques. However, when a large defect of the lower lip with oral commissure is presented, the choice of reconstruction method is often difficult. For such cases, the Estlander flap technique is often used, although displacement of the oral commissure is one of the remaining problems. In the case of large defects of the lower lip with oral commissure, we opted for a reconstruction method in which the entire upper lip was incised and extended, a portion of which was reflected as a traditional Estlander flap. Four cases were treated using this method, and in all cases there were no complications such as venous return disturbance, and the site healed well. Sensation returned within 3 months, and contraction of the lips appeared within 6 months. The symmetry of oral commissures was maintained and the appearance was almost cosmetically satisfactory. Our technique is especially useful for reconstructing defects affecting 1/3-2/3 of the lower lip including the oral commissure. This technique is cosmetically and functionally successful and the symmetry of the oral commissure is maintained.

Immunosuppressive effect on T cell activation by interleukin-16- and interleukin-10-cDNA-double-transfected human squamous cell line.

It is well known that induction of immunotolerance with allogeneic skin transplantation is generally difficult. This study attempted to find an immunosuppressive protocol for skin allograft rejection involving interleukin-16 (IL-16) and interleukin-10 (IL-10), because both are known to inhibit mixed lymphocyte reaction (MLR). The data indicated that IL-16 enhanced the immunosuppressive effect of IL-10. IL-16-cDNA- and IL-10-cDNA-double-transfected squamous cell carcinoma cell line were used as an in vitro model and they produced more than 20 ng/ml of IL-16 and 100 pg/ml of IL-10 in the supernatant, which significantly inhibited MLR and also the activation of allogeneic lymphocytes, which were stimulated directly by allogeneic double-cDNA-transfectant cells. Thus allogeneic skin graft producing IL-16 and IL-10 might have a local immunosuppressive action that could prolong graft survival.

A circumferential incision technique to release wide scar contracture.

SUMMARY: Wide scar contracture in patients with large burns is generally treated with a skin graft or flap after release of the contracture. In children, however, the creation of a new scar at the donor site should be avoided because additional operations are sometimes required later in life. Patients with large scars often lack adequate donor sites. We describe a simple technique that effectively reduces wide scar contracture without the use of a skin graft or flap. A spindle-shaped incision line is designed around the contracted scar. The major axis of the spindle should coincide with the direction of strongest contracture. Incision of the skin releases the contracture, and the surrounding skin returns to a normal position. If satisfactory release of the contracture is not obtained by a simple incision, the surrounding skin is slightly undermined. The doughnut-like skin defect resulting from undermining is sutured again, taking care to avoid increased tension in the direction of contracture. We used this technique to treat 28 scar contractures in 21 patients. All sites had good outcomes without any complications, such as congestion or haematoma. Scar contracture markedly resolved, both subjectively as well as objectively. Hard red scars consistently became whiter and softer after the operation. The design is similar to the double opposing V-Y plasty or rhomboid flap but the significant feature of our technique is that the design includes the entire scar in the central area. It makes it possible to release multiple contracture bundles or a largely contracted area at one time. This technique is simple, safe, minimally invasive for patients, and requires no other donor sites. It should be tried before resorting to the use of skin grafts or flaps in patients with large scar contractures.

Inhibition of endogenous MHC class II-restricted antigen presentation by tacrolimus (FK506) via FKBP51.

The effect of tacrolimus (FK506) on down-regulation of IL-2 production by T cells is considered to be mainly responsible for its strong suppression of immunological events. In this study, we show that FK506 also has an affect on antigen presentation by antigen-presenting cells in vitro. FK506 was able to inhibit the presentation of endogenous MHC class II-restricted minor histocompatibility antigens in primary dendritic cells (DC) in vitro, but cyclosporine A (CsA) and rapamycin (RAP) were not. RNA interference (RNAi)-mediated reduction of endogenous FK506-binding protein (FKBP)51 expression resulted in a marked decrease in antigen presentation, suggesting that FKBP51 plays a role in endogenous MHC class II-restricted antigen presentation. Since our model used naturally expressed cytosolic antigens in primary DC, these effects might have been due to novel properties of the immunosuppressive drugs and may allow us to elucidate a new paradigm for the immunosuppressive mechanism of FK506.

Skin graft of double transgenic pigs of N-acetylglucosaminyltransferase III (GnT-III) and DAF (CD55) genes survived in cynomolgus monkey for 31 days.

BACKGROUND: Our previous study reported that cynomolgus monkey did not hyperacutely reject a skin xenograft from a N-acetylglucosaminyltransferase III (GnT-III) transgenic pig. In the present study, we reported on the survival time of skin xenografts in GnT-III, DAF (CD55), and double (D/G) transgenic pigs, and the effect of FK506 thereon. MATERIAL AND METHODS: Skin from GnT-III, DAF and D/G transgenic pigs were transplanted to cynomolgus monkeys. Under general anesthesia, full thickness skin defects (1.5 x 1.5 cm each) were made on the back of the monkey. Pig abdominal skin, obtained using an electric dermatome, was cut into pieces and transplanted onto the monkey wounds and fixed. In addition, skins of GnT-III and D/G pigs were also transplanted to cynomolgus monkeys that had been treated intramuscularly with FK506 at a dose of 0.5 mg/kg/day for 14 days after transplantation. Grafts were observed and photographed each day and skin graft biopsies were done on days 3, 5, 7, 10, 11, 14, 21, 28 and 31 after transplantation. Graft rejection was assessed histologically, based on our previous criteria for skin allografts. RESULTS: Even in the immuno-suppressive drug free condition, skin xenografts of GnT-III, DAF and D/G transgenic pigs were not hyperacutely rejected in early phase after transplantation by the cynomolgus monkey. The pattern of these xenograft rejections was histologically similar to those for rat allograft rejections. Most of the GnT-III, DAF and D/G pig skin grafts remained nearly intact up to day 5, but slight lymphocyte infiltration was noted on day 7 (grade 1). On day 9, while the GnT-III skin showed moderate lymphocyte and eosinophilic infiltration, the DAF and D/G pig skin grafts showed complete epidermal separation (grade 3). On the other hand, in the case of cynomolgus monkeys treated with FK506, the GnT-III skin showed complete epidermal separation (grade 3) on day 21. In addition, one of the D/G skin graft was intact on day 21 and moderate lymphocyte infiltration and intraepidermal blister formation (grade 1) was finally seen on day 31. CONCLUSION: Our data show the possibility that both the DAF and GnT-III double transgenic pig skin xenografts can be used in place of human skin allografts in cases of severe burns.