Case Report: A Rare Case of Esophagogastric Junctional Squamous Cell Carcinoma After the Successful Treatment of Neuroendocrine Carcinoma: Clonal Tumor Evolution Revealed by Genetic Analysis.

Neuroendocrine carcinoma (NEC) of the esophagogastric junction (EGJ) is a rare disease with no established treatments. Herein, we describe a case of recurrent squamous cell carcinoma (SCC) after achieving complete response to chemotherapy against NEC of the EGJ. A 67-year-old man was referred to our hospital because of epigastric discomfort. Computed tomography imaging and esophagogastroduodenoscopy revealed ulcerated tumors at the EGJ. Endoscopic biopsy revealed small tumor cells with a high nuclear/cytoplasmic ratio, suggesting small-cell NEC. Immunohistochemistry (IHC) analysis showed tumor cells with an MIB-1 index of 80%. The patient achieved complete response after 10 cycles of chemotherapy. Follow-up endoscopic examination revealed small red-colored mucosal lesions in the center of the cicatrized primary lesion. Re-biopsy detected cancer cells harboring large eosinophilic cytoplasm with keratinization and no evidence of NEC components. IHC of the cells were cytokeratin 5/6-positive and p53-negative. The tumor persisted without evidence of metastases after chemoradiotherapy, and total gastrectomy with lymph node dissection was performed. Pathological assessment of the resected specimens revealed SCC, without evidence of NEC. The patient survived without a recurrence for >3 years after the initial presentation. Somatic mutation profiles of the primary NEC and recurrent SCC were analyzed by targeted amplicon sequencing covering common cancer-related mutations. Both tumors possessed TP53 Q192X mutation, whereas SMAD4 S517T was found only in SCC, suggesting that both tumor components originated from a founder clone with a stop-gain mutation in TP53. The somatic mutation profile of the tumors indicated that that loss of heterozygosity (LOH) at the TP53 gene might have occurred during the differentiation of the founder clone into NEC, while a SMAD4 mutation might have contributed to SCC development, indicating branching and subclonal evolution from common founder clone to both NEC and SCC. The mutation assessments provided valuable information to better understand the clonal evolution of metachronous cancers.

Novel Osteogenic Behaviors around Hydrophilic and Radical-Free 4-META/MMA-TBB: Implications of an Osseointegrating Bone Cement.

Poly(methyl methacrylate) (PMMA)-based bone cement, which is widely used to affix orthopedic metallic implants, is considered bio-tolerant but lacks osteoconductivity and is cytotoxic. Implant loosening and toxic complications are significant and recognized problems. Here we devised two strategies to improve PMMA-based bone cement: (1) adding 4-methacryloyloxylethyl trimellitate anhydride (4-META) to MMA monomer to render it hydrophilic; and (2) using tri-n-butyl borane (TBB) as a polymerization initiator instead of benzoyl peroxide (BPO) to reduce free radical production. Rat bone marrow-derived osteoblasts were cultured on PMMA-BPO, common bone cement ingredients, and 4-META/MMA-TBB, newly formulated ingredients. After 24 h of incubation, more cells survived on 4-META/MMA-TBB than on PMMA-BPO. The mineralized area was 20-times greater on 4-META/MMA-TBB than PMMA-BPO at the later culture stage and was accompanied by upregulated osteogenic gene expression. The strength of bone-to-cement integration in rat femurs was 4- and 7-times greater for 4-META/MMA-TBB than PMMA-BPO during early- and late-stage healing, respectively. MicroCT and histomorphometric analyses revealed contact osteogenesis exclusively around 4-META/MMA-TBB, with minimal soft tissue interposition. Hydrophilicity of 4-META/MMA-TBB was sustained for 24 h, particularly under wet conditions, whereas PMMA-BPO was hydrophobic immediately after mixing and was unaffected by time or condition. Electron spin resonance (ESR) spectroscopy revealed that the free radical production for 4-META/MMA-TBB was 1/10 to 1/20 that of PMMA-BPO within 24 h, and the substantial difference persisted for at least 10 days. The compromised ability of PMMA-BPO in recruiting cells was substantially alleviated by adding free radical-scavenging amino-acid N-acetyl cysteine (NAC) into the material, whereas adding NAC did not affect the ability of 4-META/MMA-TBB. These results suggest that 4-META/MMA-TBB shows significantly reduced cytotoxicity compared to PMMA-BPO and induces osteoconductivity due to uniquely created hydrophilic and radical-free interface. Further pre-clinical and clinical validations are warranted.

UV-Photofunctionalization of Titanium Promotes Mechanical Anchorage in A Rat Osteoporosis Model.

Effects of UV-photofunctionalization on bone-to-titanium integration under challenging systemic conditions remain unclear. We examined the behavior and response of osteoblasts from sham-operated and ovariectomized (OVX) rats on titanium surfaces with or without UV light pre-treatment and the strength of bone-implant integration. Osteoblasts from OVX rats showed significantly lower alkaline phosphatase, osteogenic gene expression, and mineralization activities than those from sham rats. Bone density variables in the spine were consistently lower in OVX rats. UV-treated titanium was superhydrophilic and the contact angle of ddH2O was ≤5°. Titanium without UV treatment was hydrophobic with a contact angle of ≥80°. Initial attachment to titanium, proliferation, alkaline phosphatase activity, and gene expression were significantly increased on UV-treated titanium compared to that on control titanium in osteoblasts from sham and OVX rats. Osteoblastic functions compromised by OVX were elevated to levels equivalent to or higher than those of sham-operated osteoblasts following culture on UV-treated titanium. The strength of in vivo bone-implant integration for UV-treated titanium was 80% higher than that of control titanium in OVX rats and even higher than that of control implants in sham-operated rats. Thus, UV-photofunctionalization effectively enhanced bone-implant integration in OVX rats to overcome post-menopausal osteoporosis-like conditions.

A Newly Created Meso-, Micro-, and Nano-Scale Rough Titanium Surface Promotes Bone-Implant Integration.

Titanium implants are the standard therapeutic option when restoring missing teeth and reconstructing fractured and/or diseased bone. However, in the 30 years since the advent of micro-rough surfaces, titanium's ability to integrate with bone has not improved significantly. We developed a method to create a unique titanium surface with distinct roughness features at meso-, micro-, and nano-scales. We sought to determine the biological ability of the surface and optimize it for better osseointegration. Commercially pure titanium was acid-etched with sulfuric acid at different temperatures (120, 130, 140, and 150 °C). Although only the typical micro-scale compartmental structure was formed during acid-etching at 120 and 130 °C, meso-scale spikes (20-50 µm wide) and nano-scale polymorphic structures as well as micro-scale compartmental structures formed exclusively at 140 and 150 °C. The average surface roughness (Ra) of the three-scale rough surface was 6-12 times greater than that with micro-roughness only, and did not compromise the initial attachment and spreading of osteoblasts despite its considerably increased surface roughness. The new surface promoted osteoblast differentiation and in vivo osseointegration significantly; regression analysis between osteoconductivity and surface variables revealed these effects were highly correlated with the size and density of meso-scale spikes. The overall strength of osseointegration was the greatest when the acid-etching was performed at 140 °C. Thus, we demonstrated that our meso-, micro-, and nano-scale rough titanium surface generates substantially increased osteoconductive and osseointegrative ability over the well-established micro-rough titanium surface. This novel surface is expected to be utilized in dental and various types of orthopedic surgical implants, as well as titanium-based bone engineering scaffolds.

Biological and Physicochemical Characteristics of 2 Different Hydrophilic Surfaces Created by Saline-Storage and Ultraviolet Treatment.

OBJECTIVES: Hydrophilicity/hydrophobicity of titanium surfaces may affect osseointegration. Ordinary titanium surfaces are hydrophobic. Recently, 2 different methods of storing titanium in saline solution or treating it with ultraviolet (UV) light were introduced to generate surface hydrophilicity. This study compared biological and physicochemical properties of 2 different hydrophilic titanium surfaces created by these methods. MATERIALS: Acid-etched control, saline-stored, and UV-treated titanium surfaces were assessed by scanning electron microscopy, energy dispersive spectroscopy, and x-ray photoelectron spectroscopy. The attachment, spreading behaviors, mineralization, and gene expression of osteoblasts were examined. RESULTS: Similar microroughness was found on control and UV-treated surfaces, whereas foreign deposits were observed on saline-stored surfaces. Control and UV-treated surfaces consisted of Ti, O, and C, whereas saline-stored surfaces showed Na and Cl in addition to these 3 elements. Atomic percentage of surface carbon was higher in order of control, saline-stored, and UV-treated surfaces. Osteoblasts cultured on saline-stored surfaces showed higher levels of calcium deposition and collagen I expression than control. Osteoblasts on UV-treated surfaces showed significantly increased levels for all parameters related to cell attachment, cell spreading, the expression of adhesion and cytoskeletal proteins, mineralization, and gene expression compared with control, outperforming saline-stored surfaces for most parameters. CONCLUSION: Despite similar hydrophilicity, saline-stored and UV light-treated surfaces showed substantially different biological effects on osseointegration, associated with different surface chemistry and morphology.

Biological and osseointegration capabilities of hierarchically (meso-/micro-/nano-scale) roughened zirconia.

PURPOSE: Zirconia is a potential alternative to titanium for dental and orthopedic implants. Here we report the biological and bone integration capabilities of a new zirconia surface with distinct morphology at the meso-, micro-, and nano-scales. METHODS: Machine-smooth and roughened zirconia disks were prepared from yttria-stabilized tetragonal zirconia polycrystal (Y-TZP), with rough zirconia created by solid-state laser sculpting. Morphology of the surfaces was analyzed by three-dimensional imaging and profiling. Rat femur-derived bone marrow cells were cultured on zirconia disks. Zirconia implants were placed in rat femurs and the strength of osseointegration was evaluated by biomechanical push-in test. RESULTS: The rough zirconia surface was characterized by meso-scale (50 µm wide, 6-8 µm deep) grooves, micro-scale (1-10 µm wide, 0.1-3 µm deep) valleys, and nano-scale (10-400 nm wide, 10-300 nm high) nodules, whereas the machined surface was flat and uniform. The average roughness (Ra) of rough zirconia was five times greater than that of machined zirconia. The expression of bone-related genes such as collagen I, osteopontin, osteocalcin, and BMP-2 was 7-25 times upregulated in osteoblasts on rough zirconia at the early stage of culture. The number of attached cells and rate of proliferation were similar between machined and rough zirconia. The strength of osseointegration for rough zirconia was twice that of machined zirconia at weeks two and four of healing, with evidence of mineralized tissue persisting around rough zirconia implants as visualized by electron microscopy and elemental analysis. CONCLUSION: This unique meso-/micro-/nano-scale rough zirconia showed a remarkable increase in osseointegration compared to machine-smooth zirconia associated with accelerated differentiation of osteoblasts. Cell attachment and proliferation were not compromised on rough zirconia unlike on rough titanium. This is the first report introducing a rough zirconia surface with distinct hierarchical morphology and providing an effective strategy to improve and develop zirconia implants.

Evaluation of the CT Parameters to Suppress Renal Cysts Pseudoenhancement Effect: Influence of the Virtual Monochromatic Spectral Images, the Model-based Iterative Reconstruction Algorithm and the Aperture Size in Phantom Model.

PURPOSE: The purpose of this study was to evaluate the effect of the virtual monochromatic spectral images (VMSI) and the model-based iterative reconstruction (MBIR) images, to evaluate the influence of the aperture size (40- and 20-mm beam) on renal pseudoenhancement (PE) compared with the filtered back projection (FBP) images. METHODS: The renal compartment-CT phantom was filled with iodinated contrast material diluted to the attenuation of 180 Hounsfield units (HU) at 120 kV. The water-filled spherical structures, which simulate cyst, were inserted into the renal compartment. Those diameters were 7, 15 and 25 mm. These were scanned by conventional mode (helical scan, 120 kV-FBP) and dual energy mode. 70 keV-VMSI were reconstructed from the dual energy mode, and MBIR images were reconstructed from conventional mode at 40- and 20-mm aperture. Additionally, the phantom was scanned using non-helical mode with 20-mm aperture, and FBP images were reconstructed. The CT value of the PE for cyst areas was measured for these images. RESULTS: The CT values of the cysts were 20.0-14.3 HU on the FBP images, 12.8-12.7 HU on the 70 keV-VMSI (PE-inhibition ratio was 36.0-11.2%) and 16.2-14.0 HU on the MBIR images (19.0-2.1%), respectively, at 40-mm aperture. The PE-inhibition ratio scanned by 20-mm aperture was improved by 28.0% with FBP, 32.8% with 70 keV-VMSI and 29.6% with MBIR compared with 40-mm aperture. One of the FBP images with non-helical mode was 11.6 HU. CONCLUSIONS: The best CT technique to minimize PE was the combination of 70 keV-VMSI and 20-mm aperture.

In vivo expression and regulation of genes associated with vascularization during early response of sutures to tensile force.

Sutures are fibrous tissues that connect bones in craniofacial skeletal complexes. Cranio- and dentofacial skeletal deformities in infant and adolescent patients can be treated by applying tensile force to sutures to induce sutural bone formation. The early gene expression induced by mechanical stress is essential for bone formation in long bones; however, early gene expression during sutural bone formation induced by tensile force is poorly characterized. In vivo studies are essential to evaluate molecular responses to mechanical stresses in heterogeneous cell populations, such as sutures. In this paper we examined in vivo early gene expression and the underlying regulatory mechanism for this expression in tensile-force-applied cranial sutures, focusing on genes involved in vascularization. Tensile force upregulated expression of vascular factors, such as vascular endothelial growth factor (Vegf) and endothelial cell markers, in sutures within 3 h. The expression of connective tissue growth factor (Ctgf) and Rho-associated coiled-coil containing protein kinase 2 (Rock2) was also upregulated by tensile force. A CTGF-neutralizing antibody and the ROCK inhibitor, Y-27632, abolished tensile-force-induced Vegf expression. Moreover, tensile force activated extracellular signal-related kinase 1/2 (ERK1/2) signaling in sagittal sutures, and the ERK1/2 inhibitor, U0126, partially inhibited tensile-force-induced Ctgf expression. These results indicate that tensile force induces in vivo gene expression associated with vascularization early in tensile-force-induced sutural bone formation. Moreover, the early induction of Vegf gene expression is regulated by CTGF and ROCK2.

Urethroplasty Using Diverticular Tissue for Hypospadias.

CASE: The patient was a 3-year-old with hypospadias. Urethroplasty was performed as a two-stage procedure, but a severe urethral stricture occurred due to a postoperative infection and the patient was virtually in urinary retention. An emergency cystostomy was performed, and thereafter urethral reconstruction was performed. A large urethral diverticulum had formed in the scrotum. The inner wall of the diverticulum was found to be completely epithelialized and well vascularized. Therefore, it was elevated as a skin flap and a neourethra was reconstructed up to the glans region using the diverticular tissue. OUTCOME: Postoperative complications were not observed, and micturition was satisfactory. CONCLUSION: A urethral diverticulum is one of the often encountered complications of hypospadias surgery. However, there are only a few literature reports related to the treatment of urethral diverticulum. In addition, there are almost no reports on reconstructions using urethral diverticular tissue. In this report, we describe such a treatment experience.

An anatomical and histological study of the vascularized iliotibial tract graft.

BACKGROUND: An examination of the vascular anatomy of the iliotibial tract (IT) has not been previously reported. Because a flap resists infection better than an avascular graft, a vascularized IT graft is useful for reconstructive surgeries pertaining to infected wounds or wounds in contact with artificial material. The purpose of this study was to examine the vascular anatomy of the IT. MATERIALS AND METHODS: The study sample consisted of 39 limbs of freshly frozen cadavers. The study was divided into three parts. The ascending and transverse branches of the lateral circumflex femoral artery (LCFA) of all cadavers were injected with latex. Distance from the tensor fasciae latae muscle and the most distal point at which the vessel on the IT was stained by latex was recorded. A microscopic observation was performed for these limbs. The deep femoral artery (DFA) or superior lateral genicular artery (SLGA) was also observed. RESULTS: The length of the IT fed by the LCFA was 162.3 ± 36.2 mm. The IT vascularity was located between the layered structure of the fascia and there was a vascular source for the IT within 1 mm above the IT by optical microscopy. The vascularity derived from the DFA or SLGA was not confirmed in any specimens. CONCLUSIONS: Blood supply of the IT was derived from the LCFA and a vascularized IT graft could be elevated in length to approximately 16 cm. This knowledge may be useful for improving the safety of surgery when transferring an IT flap. © 2015 Wiley Periodicals, Inc. Microsurgery 36:325-329, 2016.

Long-term radiographic evaluation of risk factors related to implant treatment: suggestion for alternative statistical analysis of marginal bone loss.

OBJECTIVE: Secular change in marginal bone loss (MBL), which is the index adopted for implant success criteria, has often been used to evaluate risk factors. However, the need to revise these criteria has recently been indicated due to rapid developments in implant treatment. The purpose of this study was to evaluate risk factors by analyzing MBL with an alternative statistical method. MATERIAL AND METHODS: The analyses were performed on the outcomes of 366 patients with 1,902 implants during an average follow-up period of 84.8 months (with a maximum follow-up of 258 months). Instead of evaluating annual MBL, time was calculated as one of the explanatory variables because the correlation between MBL and time was small (correlation coefficient of 0.09010). Analysis of covariance (ANCOVA) was used for exploratory assessment of each factor, and multiple regression analysis was then utilized to identify risk factors. The multiple regression analysis was performed twice, once among all implants and another in which one implant per patient was randomly selected. RESULTS: As a result of multiple regression analysis, smoking habits showed a significant effect on MBL. Age, sex, diabetes mellitus, implant positions, guided bone regeneration, and sinus floor elevation did not affect MBL. IMZ® implants were associated with significantly higher MBL than were ANKYLOS® and SPI® implants. There was no significant difference between Straumann® and other implants. CONCLUSION: Our results showed that another statistical process, which eliminated the effect of time rather than comparing annual MBL, could be applied to evaluate MBL because the correlation between MBL and time was small.

Computer simulation of orthodontic tooth movement using CT image-based voxel finite element models with the level set method.

Orthodontic tooth movement (OTM) is an adaptive biomechanical response of dentoalveolar components to orthodontic forces, in which remodeling of the alveolar bone occurs in response to changes in the surrounding mechanical environment. In this study, we developed a framework for OTM simulation by combining an image-based voxel finite element method, with a surface-tracking level set method using three-dimensional computer models. For a case study to demonstrate its capability of expressing clinical tooth movement, we observed displacement and rotation of the tooth under three types of force conditions. The simulation results demonstrate that the proposed simulation method has the potential to predict clinical OTM.

Differentiation of Odontoblast-Like Cells From Mouse Induced Pluripotent Stem Cells by Pax9 and Bmp4 Transfection.

UNLABELLED: The field of tooth regeneration has progressed in recent years, and human tooth regeneration could become viable in the future. Because induced pluripotent stem (iPS) cells can differentiate into odontogenic cells given appropriate conditions, iPS cells are a potential cell source for tooth regeneration. However, a definitive method to induce iPS cell-derived odontogenic cells has not been established. We describe a novel method of odontoblast differentiation from iPS cells using gene transfection. We generated mouse iPS cell-derived neural crest-like cells (iNCLCs), which exhibited neural crest markers. Next, we differentiated iNCLCs into odontoblast-like cells by transfection of Pax9 and Bmp4 expression plasmids. Exogenous Pax9 upregulated expression of Msx1 and dentin matrix protein 1 (Dmp1) in iNCLCs but not bone morphogenetic protein 4 (Bmp4) or dentin sialophosphoprotein (Dspp). Exogenous Bmp4 upregulated expression of Msx1, Dmp1, and Dspp in iNCLCs, but not Pax9. Moreover, cotransfection of Pax9 and Bmp4 plasmids in iNCLCs revealed a higher expression of Pax9 than when Pax9 plasmid was used alone. In contrast, exogenous Pax9 downregulated Bmp4 overexpression. Cotransfection of Pax9 and Bmp4 synergistically upregulated Dmp1 expression; however, Pax9 overexpression downregulated exogenous Bmp4-induced Dspp expression. Together, these findings suggest that an interaction between exogenous Pax9- and Bmp4-induced signaling modulated Dmp1 and Dspp expression. In conclusion, transfection of Pax9 and Bmp4 expression plasmids in iNCLCs induced gene expression associated with odontoblast differentiation, suggesting that iNCLCs differentiated into odontoblast-like cells. The iPS cell-derived odontoblast-like cells could be a useful cell source for tooth regeneration. SIGNIFICANCE: It has been reported that induced pluripotent stem (iPS) cells differentiate into odontogenic cells by administration of recombinant growth factors and coculture with odontogenic cells. Therefore, they can be potential cell sources for tooth regeneration. However, these previous methods still have problems, such as usage of other cell types, heterogeneity of differentiated cells, and tumorigenicity. In the present study, a novel method to differentiate iPS cells into odontoblast-like cells without tumorigenicity using gene transfection was established. It is an important advance in the establishment of efficient methods to generate homogeneous functional odontogenic cells derived from iPS cells.

Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema.

BACKGROUND: Vascularized lymph node transfer has become a popular surgical option to improve lower extremity lymphedema (LEL), although potential donor sites are limited. The free supraclavicular flap with deep cervical lymph nodes has been recently associated with a minimal risk of secondary lymphedema caused by donor site dissection. However, the effectiveness of this procedure has not yet been evaluated. METHODS: Vascularized supraclavicular lymph node transfer (VSLNT) was performed for patients with International Society of Lymphology late stage II or more severe LEL. The results were compared with lymphaticovenular anastomosis (LVA) performed for patients with the same stages of severity. To evaluate improvement in lymphatic function, indocyanine green lymphography and lymphoscintigraphy were performed. RESULTS: Vascularized supraclavicular lymph node transfer was performed in 13 limbs of 13 patients. The results were compared with 43 limbs of 33 patients who underwent multiple LVA. No severe complications were observed in either group. Improvement in lymphatic function, as measured by the LEL index, was 26.5 ± 4.4 and 21.2 ± 2.0 in the VSLNT and LVA groups, respectively. Lymphatic function was improved in 7 cases in the VSLNT group and 10 cases in the LVA group. CONCLUSIONS: Vascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage LEL. Lymphaticovenular anastomosis is also effective, but to a lesser degree than VSLNT. However, LVA is less invasive and requires a shorter hospital stay.

Clonal analysis reveals nerve-dependent and independent roles on mammalian hind limb tissue maintenance and regeneration.

The requirement and influence of the peripheral nervous system on tissue replacement in mammalian appendages remain largely undefined. To explore this question, we have performed genetic lineage tracing and clonal analysis of individual cells of mouse hind limb tissues devoid of nerve supply during regeneration of the digit tip, normal maintenance, and cutaneous wound healing. We show that cellular turnover, replacement, and cellular differentiation from presumed tissue stem/progenitor cells within hind limb tissues remain largely intact independent of nerve and nerve-derived factors. However, regenerated digit tips in the absence of nerves displayed patterning defects in bone and nail matrix. These nerve-dependent phenotypes mimic clinical observations of patients with nerve damage resulting from spinal cord injury and are of significant interest for translational medicine aimed at understanding the effects of nerves on etiologies of human injury.

The "push-down" technique using a novel micro-forceps for microvascular venous coupling.

A microvascular coupling system was developed and introduced for clinical application to facilitate fast and safe anastomosis of small vessels. However, operators often encounter some difficulty, particularly in pinning the vascular wall onto the ring-pins. To overcome the difficulty, the authors developed the "push down" technique and made newly-designed micro-forceps. These forceps have been used in 111 venous couplings involving 96 critical anastomoses. This study reports herein the patency results showing effectiveness and safety of the "push down" technique using a prototype micro-forceps in the pinning procedure in a microvascular coupling system.

Suitable therapy options for sub-clinical and early-stage lymphoedema patients.

BACKGROUND: The best therapeutic approach for patients with sub-clinical lymphoedema and symptomatic early-stage lymphoedema has not been determined yet. METHODS: The prognosis of lymphatic function after lymphadenectomy for gynaecological cancer was observed in a cohort study of 192 lower limbs. Lymphatic function was evaluated by indocyanine green lymphography. Splash patterns were examined to determine if patients with this pattern tended to progress to symptomatic lymphoedema, and the efficacy of the compression therapy was also investigated. We also investigated the efficacy of lymphaticovenular anastomosis (LVA) in patients who exhibited a stardust pattern. RESULTS: Patients with splash patterns on lymphography may progress to symptomatic lymphoedema with a significantly higher frequency compared with the others, with a relative ratio of 1.62. Compression therapy did not slow the progression of patients with splash patterns to stardust patterns. LVA for the patients who had recently shown stardust patterns eliminated the need for compression therapy in 44.8% of patients. CONCLUSION: Patients with splash patterns should be followed up carefully for sub-clinical lymphoedema. However, there is no method to completely prevent these patients from developing stardust patterns associated with symptomatic lymphoedema. When patients become symptomatic, their lymphatic function may be improved by LVA. However, the limited effectiveness of this procedure should be clearly explained to patients before surgery.

Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage.

BACKGROUND: Reconstruction of the great toe defect is difficult. The most distal point of the rotation arc of a retrograde-flow medial plantar flap is the plantar side of the proximal phalanx. The purpose of this report was to present a new procedure that extends the rotation arc of this flap. Results of anatomic study and application in two patients were presented. METHODS: An anatomical study was conducted on 10 freshly frozen cadavers to determine the rotation arc of the medial plantar flap based distally on the lateral plantar vessels. To enable anterograde venous drainage, two accompanying veins of the vascular pedicle were separated and anastomosed to each other. This surgical procedure was implemented in two clinical cases with the great toe defect. The maximum size of the elevated flap was 4 × 7 cm. The status of venous congestion of the flap was determined using the blood glucose measurement index. RESULTS: We confirmed that the rotation arc of the medial plantar flap based distally on the lateral plantar vessels could reach the tip of the great toe, preserving all lateral plantar nerves and plantar metatarsal arteries. In the two cases, the congestion of the flap improved with anterograde venous drainage and the flaps survived completely. CONCLUSION: A pedicled medial plantar flap with anterograde venous drainage may be a useful alternative option for the reconstruction of relatively large great toe defects.

Postoperative patency of the retrograde internal mammary vein anastomosis in free flap transfer.

BACKGROUND AND AIM: A caudal limb of the internal mammary vein (IMV) can be used as an additional venous drainage route in free flap transfer. However, there remains the possibility that unrecognised occlusion of the retrograde IMV occurs in the early postoperative period due to non-physiologic flow, thus affecting venous drainage. There are no reports regarding the postoperative patency rates of the anastomosed retrograde IMV. This study aimed to clarify the efficacy of the retrograde IMV as an additional venous drainage route in the case of two-vein anastomosis in free flap transfer. PATIENTS AND METHODS: We performed a hospital-based prospective case series study to clarify the patency rates of retrograde IMV anastomoses as an additional venous drainage route in cases of two-vein anastomosis in free flap transfer. Both antegrade and retrograde IMV anastomoses were performed in patients who underwent free flap transfer using the IMV as a recipient vein. The postoperative flow vector and peak blood velocity of the retrograde IMV anastomosis were examined using two-dimensional phase contrast magnetic resonance imaging (2D PC-MRI) and colour Doppler imaging. RESULT: A total of five retrograde IMV anastomoses in five patients were performed in the study period. The postoperative patency rate of the retrograde IMV was 60%. In the patent group, the postoperative peak venous blood velocity of the retrograde IMV was significantly slower than that of the antegrade IMV (4.6 ± 0.5 vs 7.2 ± 0.8 cm s(-1), P < 0.05). CONCLUSION: We described the postoperative patency rate of retrograde IMV anastomosis in cases of two-vein anastomosis in free flap transfer. Further study is needed to evaluate the reliability of the retrograde IMV as an additional venous drainage route.