Cryopreserved cultured epidermal allografts achieved early closure of wounds and reduced scar formation in deep partial-thickness burn wounds (DDB) and split-thickness skin donor sites of pediatric patients.

Burn treatment in children is associated with several difficulties, e.g. available skin replacement is small, donor area could expand, and subsequent hypertrophic scar and contracture could become larger along with their physical growth. In order to have better clinical results, the authors prepared cryopreserved cultured epidermal allografts from excess epidermal cells of other patients, and applied the epidermal allografts to 55 children, i.e. 43 cases of deep partial-thickness burn wounds (DDB) due to scald burn and 12 cases with split-thickness skin donor sites. In the 43 DDB patients, epithelialization was confirmed 9.1+/-3.6 days (mean+/-S.D.) after treatment. In 10 of the 43 patients, epithelialization was comparable between the area which received the epidermal allografts (grafted area) and the area which did not receive the epidermal allografts but was covered with usual wound dressing (non-grafted area). As a result, epithelialization day was 7.9+/-1.7 in grafted areas and 20.5+/-2.3 in non-grafted areas. In the 12 patients with split-thickness skin donor sites, epithelialization was confirmed 6.3+/-0.9 days after treatment. Epithelialization of the grafted and non-grafted areas was comparable in 8 of the 12 patients, and it was 6.5+/-1.1 days and 14.1+/-1.6 days, respectively. In these 10 DDB patients and 8 split-thickness skin donor site patients, redness and scar formation were also milder in the grafted area. The 55 patients have been followed up for 1-8 years (mean, 4.75 years), and scar formation was suppressed in both DDB and split-thickness skin donor sites. These findings showed that cryopreserved cultured epidermal allografts achieve early closure of the wounds and good functional outcomes.

Reliable, minimally invasive oromandibular reconstruction using metal plate rolled with pectoralis major myocutaneous flap.

The purpose of this study was to minimize the surgical invasiveness to the donor site and the amount of the primary reconstruction time after oromandibular tumor resection. Oromandibular reconstruction was performed only using a pectoralis major myocutaneous flap and a metal plate. The pectoralis major myocutaneous flap was grafted to the oral cavity defect by rolling and wrapping around the metal plate with the muscle of the flap. No early postoperative complications have been noted in all seven patients. An average of 2 years and 1 month has past since surgery, and to date no infections, plate exposure, or plate breakage have been observed in any of the patients. The safety of the oromandibular reconstruction using a metal plate was improved by rolling the muscle of the pectoralis major myocutaneous flap around the metal plate. The present method was shown to be a rational technique that allowed primary reconstruction of the oral cavity and mandible in a minimally invasive manner in a short time.

Eyelids and eye socket reconstruction using the expanded forehead flap and scapha composite grafting.

After trauma or excision of malignant tumor, it is difficult to achieve satisfactory results when reconstructing deformed eyelids and the socket for an ocular prosthesis. The authors demonstrate examples of successful reconstruction for a prosthetic eye that provided adequate and aesthetic soft-tissue support achieved by applying a three-step surgical procedure of reconstruction of the eye socket, the eyelids, and the tarsus and eyelid margin. Because it is highly vascularized and its distal end can be divided into two or three portions for easy three-dimensional reconstruction, the expanded forehead flap alone, with a galea flap, or with a free rectus abdominis muscle perforator flap was used. The expanded forehead flap also provides excellent thin upper lid contour and good color-matching with a recipient site. For the eye socket, sufficient volume of tissue was provided from the expanded forehead flap with or without a galea or a free rectus abdominis muscle perforator flap, and a deep and convex fornix was formed. This resulted in a good fit and in stability of the ocular prosthesis. The surface and the inner lining of the eyelids were reconstructed using portions of the expanded forehead flap. For the tarsus and eyelid margin, conventional reconstruction techniques use cartilage of the concha, which has limitations of length and which does not fit the shape of the tarsal margin. The authors used the scapha composite graft, and a natural shape and good elasticity resulted.

Take percentage and conditions of cultured epithelium were improved when basement membrane of the graft was maintained and anchoring mesh was added.

To achieve a higher take rate for epithelial grafts, this study investigated grafting techniques. Seventy-seven nude mice received flap grafting in which cultured human epithelium was grafted inside the flap, and 55 nude rats received transplantation of epithelium to a full-thickness skin defect. In each group, four models were studied, including model 1, in which epithelium was cultured with the conventional method; model 2, in which epithelium was cultured with fibrin gel to avoid sheet damage, then absorptive mesh was incorporated into the epithelium for anchoring to the graft bed; model 3, in which epithelium was cultured with fibrin gel and combined with absorptive mesh and artificial dermis containing fibroblasts; and model 4, in which the model 2 epithelium was grafted after artificial dermis was transplanted. The take for these models was evaluated grossly and histologically. The results show that the take percentage of models 2 and 3 was significantly higher than that of model 1 (conventional epithelium) and that there was no significant difference between model 3 (simultaneous grafting) and model 4 (two-step grafting). The difference in the take percentages of the grafts to the flap and to the full-thickness skin defect was also insignificant. In immunohistochemistry, human keratin appeared in all epidermis layers and diversification of the layer was observed in models 2, 3, and 4. In these three models, type IV collagen appeared in the basal layer and the formation of basal membrane was confirmed. These findings suggest that epithelia cultured on fibrin gel and combined with absorptive mesh could be used in a new technique for better, more stable take.

Long-term viability of cryopreserved cultured epithelial grafts.

Human cultured epithelial grafts are frozen for long-term preservation. To assess the viability of these stored grafts, their cell survival rate and colony-forming efficiency of grafts cryopreserved at -135 degrees C and at -80 degrees C were followed over time. Flow cytometry showed that the cell survival rate of the grafts cryopreserved at -135 degrees C for 1 month, 6 months and 1 year averaged 89.3%, 61.7% and 61.6%. Cryopreservation at -80 degrees C maintained cell survival rate as well for 1 month, but after 6 months of cryopreservation survival was reduced at -80 degrees C (35.2%) compared with that of -135 degrees C. In histological examination, the cell structure and basal layer were very well preserved after 6 months of storage at -135 degrees C, but not at -80 degrees C. Cell survival rate at -135 degrees C was also assessed by colony-forming efficiency. Colony-forming efficiency of the grafts cryopreserved for 1 month, 6 months and 1 year averaged 66.1%, 58.5% and 55.1% of control (noncryopreserved) grafts. These findings suggest that, even when cultured epithelial grafts are subjected to long-term cryopreservation, cell viability remains sufficient, reculturing is possible, and that graft banking could be used for clinical applications.

Surgical treatment for epidural abscess in the posterior cranial fossa using trapezius muscle or musculocutaneous flap.

Two patients developed an epidural abscess in the posterior cranial fossa following tumor dissection from the occipital region of the head and underwent surgical treatment. After debridement of necrotic and infectious tissues inside the abscess was performed, the empty cavity was filled and the tissue defect was reconstructed by using a trapezius muscle flap or a trapezius musculocutaneous flap. Both patients had good clinical results, and their abscesses were healed. The trapezius muscle flap and trapezius musculocutaneous flap were quite useful in the treatment for epidural abscess in the posterior cranial fossa.

Treatment of micrognathia with edentulous maxilla by sagittal split mandibular osteotomy and a subperiosteal implant immobilized with transmaxillary screws.

Micrognathia complicated by edentulous maxilla was treated by performing sagittal-split mandibular osteotomy and immobilizing a subperiosteal implant using transmaxillary screws. The patient was a 42-year-old man who had a birdlike facial deformity caused by significant hypoplasia of the mandible. He also demonstrated significant malocclusion attributable to micrognathia and edentulous maxilla caused by resorption of the alveolar bone. These conditions impaired his mastication and articulation, making it impossible for him to eat regular food or carry out normal conversation. A subperiosteal implant was placed on the edentulous maxilla, and was rigidly immobilized to the maxilla using five transmaxillary screws. A prosthesis was then attached to the implant, and by using the implant as the point of reference and the anchor, the mandible was moved forward by sagittal-split mandibular osteotomy. Intermaxillary fixation was subsequently performed. The postoperative course has been favorable, and his facial complexion has improved significantly. One and a half years after his surgery, there has been no sign of complications or malocclusion caused by mandibular retraction. He is now able to eat regular food and speak normally.

Plasma-treated lenowoven polyethylene ribbon for bone fixation at dentoalveolar osteotomy.

Plasma-treated lenowoven polyethylene ribbon was used for splinting between teeth around osteotomy lines in anterior segmental dentoalveolar osteotomy. This fixation was continued for 2 to 3 months, during which there was no damage or fall of the ribbon. In addition, the patients were able to eat their usual food, had much less pain in the teeth and oral mucosa, did not feel uncomfortable in the mouth, had no tooth damage or carious teeth, and had a good aesthetic appearance. In all eight jaws (five patients), accurate and strong bone fixation was achieved based on the planned occlusion. Patient complaints and pain were obviously less with this method than other methods. Polyethylene ribbon is quite useful for bone fixation in anterior segmental dentoalveolar osteotomy.

Expression of the SART-1 tumor rejection antigen in breast cancer.

We investigated in breast cancers the expression of the SART-1 gene encoding tumor rejection antigens. SART-1 mRNA was expressed in all of the samples tested. The SART-1(800) antigen was detectable in 20 of 50 (40%) breast cancer tissues and all breast cancer cell lines tested, but not in normal breast tissues. The SART-1(800)+ breast cancer cells transfected with HLA-A2601 or HLA-A2402 cDNA were recognized by the HLA-A26-restricted and SART-1-specific cytotoxic T lymphocytes (CTLs) or the HLA-A24-restricted and SART-1-specific CTLs, respectively. Among the 20 SART-1(800)+ tumors, 9 or 8 tumors expressed estrogen receptor or progesterone receptor, respectively. Therefore, the patients with HLA-A26 or -A24 haplotype might be appropriate candidates for specific immunotherapy with the SART-1 peptides independently or in combination with hormone therapy.

An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction.

A conventional single pedicled TRAM (transverse rectus abdominis myocutaneous) flap is a musculocutaneous flap widely used for breast reconstruction. However, complications such as partial flap necrosis, fat necrosis, and fatty induration may occur as a result of unstable blood flow circulation to the flap. One major factor is venous congestion in the flap. In an effort to obtain more stable TRAM flap blood circulation, we anastomosed the ipsilateral deep inferior epigastric vein of a pedicled TRAM flap to the thoracodorsal vein. This procedure provides superdrainage by means of enhanced venous perfusion. This flap with superdrainage augmentation is referred to as a superdrainaged TRAM flap (12 patients). Changes in cutaneous blood flow were also assessed by measurement of cutaneous blood flow in zone IV using a laser blood flow meter (8 patients). The patients who underwent breast reconstructive surgery using this technique showed no evidence of postoperative complications such as flap necrosis, fat necrosis, or fatty induration. Satisfactory results were obtained during breast reconstruction in patients who had previously undergone a radical mastectomy with resultant large areas of tissue defects. In addition, the two patient groups, 12 patients with superdrainaged TRAM flap and 20 patients with single pedicled TRAM flap, were compared to assess differences in complications. The incidence of partial flap necrosis, fat necrosis, and fatty induration was lower among patients with superdrainaged flap than those with single pedicled flap.

Functional reconstruction of swallowing and articulation after total glossectomy without laryngectomy: money pouch-like reconstruction method using rectus abdominis myocutaneous flap.

When a total glossectomy is performed without a laryngectomy, the functional recovery of swallowing and articulation is extremely important in maintaining the patient's quality of life. The authors established a money pouch-like reconstruction method in which a round and raised tongue is rebuilt using a rectus abdominis myocutaneous flap. In this method, the skin island of the rectus abdominis myocutaneous flap is created about 20 percent larger than the defect in both width and length. The skin island is sutured to the defect such that the excess skin folds into the shape of a money pouch. This allows the tongue to be reconstructed with its tip and dorsum touching the hard palate and its base bulging in the dorsal and posterior directions. Misswallowing was not detected in the three patients who had this surgery, and each of them had improved articulation sufficient to carry out daily conversations.

A Reconstruction Method Using Musculopericranial Flaps that Prevents Cerebrospinal Fluid Rhinorrhea and Intracranial Complications after Extended Anterior Skull Base Resection.

Anterior skull base defects after extended anterior skull base resection including unilateral orbit and the dura were reconstructed using the temporal musculopericranial (TMP) flaps or frontal musculopericranial (FMP) flap in 14 patients. Dural defect was reconstructed with the TMP or FMP flap by making it overlap on the remaining dura around the defects. These flaps were also used, in principle, for the separation of the nasal cavity. For bone defects on the anterior skull base, a bone graft was transplanted in the place between the flap for dural reconstruction and the flap for the separation of the nasal cavity. Bone grafting was nor performed in patients who had an extensive defect and for whom a free flap was used for the separation. After surgery, CSF rhinorrhea did not occur in the 14 patients. Twelve patients did not develop any postoperative complications. Two patients had epidural abscess, but with debridement and the drainage to the nasal cavity, they did not develop severe intracranial complications. We conclude that reconstruction using musculopericranial flaps is a reliable and versatile method with minimum invasion and the shortest operation hours. In particular, musculopericranial flap for dura reconstruction was highly efficacious for the prevention of CSF rhinorrhea.

Evaluation with three-dimensional computed tomography after anterior skull base reconstruction using two musculopericranial flaps and a grafted bone.

Postoperative evaluation by three-dimensional (3D) computed tomography (CT) was performed in 15 patients who underwent anterior skull base reconstruction using two musculopericranial flaps and a grafted bone sandwiched between the two flaps. Especially in the case of large bone grafts (4 x 4 cm or more), the graft was positioned with the convex side facing upward into the cranial cavity to avoid creating an intracranial dead space. The extent of the absorption and changes in the contour of the grafted bone were evaluated. Imaging was done at a CT level of 150 using a Proceed 3-D CT scanner (Yokogawa Medical Co., Tokyo, Japan). Donor bone for grafting to the skull base was harvested the cranium in 10 patients and the ilium in 5 others. Patients ranged in age from 7 to 76 years (mean, 47); there were 10 men and 5 women. The grafted bone ranged in size from 1 x 2 cm to 5 x 8 cm (1 x 2 cm to about 4 x 3 cm: 10 patients; 4 x 4 to about 5 x 8 cm: 5 patients).No marked absorption of grafted bone was seen in these 15 patients, and no brain hernia occurred. In patients with large bone grafts (4 x 4 cm to about 5 x 8 cm), a graft that had been positioned with the convex side facing upward into cranial cavity at the time of transplant was subsequently observed to be transformed into a downward convex contour of normal skull base. Fostoperative infection did not occur because of the dead space nor were there any symptom of pressure on the brain because of the upward convexity of the grafted bone.The present reconstructive method is not only a minimum invasive but also a safe and reliable method for anterior skull base surgery.

Occurrence of desmoid tumors following surgery for familial adenomatosis coli--report of two cases.

Twenty-five patients with adenomatosis coli were subjected to operations, and two in which desmoid tumors appeared after the operation on familial adenomatosis coli are described here. These patients were 26 and 37 year-old males. After the total colorectomy, each tumor was associated with soreness and was palpated in the lower abdominal wall, and operations were performed. The histological findings from the resected specimens, 12 cm and 34 cm in size, indicated desmoid tumors. Poliposis of the large intestine with desmoid tumors, as a complication, has been reported in 23 previous cases in Japan.