Head and neck malignant melanoma: margin status and immediate reconstruction.

Head and neck melanoma often approaches critical structures. Therefore, excision is often limited, leading to positive margins, and increased local recurrence. Immediate reconstruction carries concern for rearrangement or concealment of cancerous tissues. Therefore, reconstruction is often delayed until confirming negative margins on permanent pathology. Our purpose is to identify variables associated with a positive margin and establish criteria for reconstruction timing. We reviewed 117 consecutive patients who underwent wide local excision of head and neck melanoma. Reconstruction was immediate for 107 and delayed for 10. Six percent of patients had a positive margin after wide local excision with no difference in incidence between immediate and delayed reconstruction (P = 0.11). Tumor characteristics associated with a positive margin were locally recurrent, ulcerated, and T4 tumors (P < 0.05); and delayed reconstruction should be considered in these circumstances. Immediate reconstruction is safe for the majority of head and neck melanoma and should be based on knowledge of tumor characteristics.

Wnt signaling induces epithelial differentiation during cutaneous wound healing.

BACKGROUND: Cutaneous wound repair in adult mammals does not regenerate the original epithelial architecture and results in altered skin function. We propose that lack of regeneration may be due to the absence of appropriate molecular signals to promote regeneration. In this study, we investigated the regulation of Wnt signaling during cutaneous wound healing and the consequence of activating either the beta-catenin-dependent or beta-catenin-independent Wnt signaling on epidermal architecture during wound repair. RESULTS: We determined that the expression of Wnt ligands that typically signal via the beta-catenin-independent pathway is up-regulated in the wound while the beta-catenin-dependent Wnt signaling is activated in the hair follicles adjacent to the wound edge. Ectopic activation of beta-catenin-dependent Wnt signaling with lithium chloride in the wound resulted in epithelial cysts and occasional rudimentary hair follicle structures within the epidermis. In contrast, forced expression of Wnt-5a in the deeper wound induced changes in the interfollicular epithelium mimicking regeneration, including formation of epithelia-lined cysts in the wound dermis, rudimentary hair follicles and sebaceous glands, without formation of tumors. CONCLUSION: These findings suggest that adult interfollicular epithelium is capable of responding to Wnt morphogenic signals necessary for restoring epithelial tissue patterning in the skin during wound repair.

Contribution of bone marrow-derived cells to skin: collagen deposition and wound repair.

The bone marrow provides inflammatory cells and endothelial progenitor cells to healing cutaneous wounds. To further explore the bone marrow contribution to skin and healing wounds, we used a chimeric mouse model in which the bone marrow from enhanced green fluorescent protein (EGFP) transgenic mice is transplanted into normal C57BL mice. We found that normal skin is a target organ for bone marrow-derived cells from both the hematopoietic and the mesenchymal stem cell pool. We present evidence that the bone marrow contribution to normal skin and the healing cutaneous wound is substantially greater than the previously recognized CD45+ subpopulation, where 15%-20% of the spindle-shaped dermal fibroblasts were bone marrow-derived (EGFP+). Furthermore, the bone marrow-derived cells were able to contract a collagen matrix and transcribe both collagen types I and III, whereas the skin-resident cells transcribed only collagen type I. Whereas endothelial progenitor cells were found early during the wound repair process, bone marrow-derived endothelial cells were not seen after epithelialization was complete. Our data show that wound healing involves local cutaneous cells for reconstituting the epidermis but distant bone marrow-derived cells and the adjacent uninjured dermal mesenchymal cells for reconstituting the dermal fibroblast population.

Ketorolac may control more than pain.

Life-threatening acute respiratory distress syndrome (ARDS) complicates the recovery of patients with burn and inhalation injury. The study by Enkhbaatar and co-workers in this issue of Clinical Science suggests that reducing the early and robust inflammatory cascade may provide patients with protection from developing cardiopulmonary compromise seen early after burn and inhalation injury.

Retroviral delivery of dominant-negative vascular endothelial growth factor receptor type 2 to murine wounds inhibits wound angiogenesis.

Vascular endothelial growth factor (VEGF) is a potent paracrine signal for initiating angiogenesis. Although VEGF can bind to several cell surface receptors, VEGF receptor type 2 (VEGFR2, a.k.a. KDR or flk-1) is the primary receptor responsible for VEGF-induced endothelial cell proliferation. To determine whether the VEGF-VEGFR2 signaling axis has an important role in wound healing angiogenesis, we used a retrovirus to deliver a signaling-defective truncated VEGFR2 (tm VEGFR2) to block VEGF-VEGFR2-induced endothelial cell proliferation in murine wounds. We show that the retroviral construct effectively blocked phosphorylation of VEGFR2 in vitro and we were able to express the truncated receptor in murine wounds. We achieved significant reduction of angiogenesis and granulation tissue formation in murine wounds, but this did not lead to delayed wound closure. In contrast, there was a corresponding increase in wound contraction, showing that functional VEGFR2 intracellular signaling is not critical for normal closure of excisional dermal wounds. Our results show a novel relationship between wound bed vascularity and wound contraction.

Human genomics and microarrays: implications for the plastic surgeon.

The Human Genome Project was launched in 1989 in an effort to sequence the entire span of human DNA. Although coding sequences are important in identifying mutations, the static order of DNA does not explain how a cell or organism may respond to normal and abnormal biological processes. By examining the mRNA content of a cell, researchers can determine which genes are being activated in response to a stimulus. Traditional methods in molecular biology generally work on a "one gene: one experiment" basis, which means that the throughput is very limited and the "whole picture" of gene function is hard to obtain. To study each of the 60,000 to 80,000 genes in the human genome under each biological circumstance is not practical. Recently, microarrays (also known as gene or DNA chips) have emerged; these allow for the simultaneous determination of expression for thousands of genes and analysis of genome-wide mRNA expression. The purpose of this article is twofold: first, to provide the clinical plastic surgeon with a working knowledge and understanding of the fields of genomics, microarrays, and bioinformatics and second, to present a case to illustrate how these technologies can be applied in the study of wound healing.

Tissue dispersion and flow cytometry for the cellular analysis of wound healing.

Injury induces a flux in the cellular composition of tissues as part of the wound healing response. There is no reliable and rapid method to quantify and characterize the cellular composition of the matrix-rich wound. Our aim was to develop a rapid method to quantify the cellular composition in wounds by tissue dispersion and flow cytometry. Age- and weight-matched mice were wounded on the dorsum using a 1.5 x 1.5 cm2 template, and the wounds were excised at predetermined time points. Tissues were dispersed into single-cell suspensions and labeled with antibodies to cell surfaces and intracellular antigens. Flow cytometry was performed to quantify the percentage of each cell population and cell death. We found that our tissue dispersion protocol resulted in low cell death (4%-6%) and very high yield (80-220 x 10(6) cells/g). Furthermore, cell surfaces and intracellular antigens were preserved to provide accurate identification of the different cell populations. With the appropriate modifications, this protocol is likely to be applicable for the viable retrieval and identification of cells from skin and other collagen-dense tissues.