Sulforaphane suppresses cell growth and collagen expression of keloid fibroblasts.

Keloids are fibroproliferative diseases characterized by the accumulation of an extracellular matrix including collagen. Various growth factors, or cytokines, and their receptors are overexpressed in keloids, and they are expected to be therapy targets. Sulforaphane, a dietary isothiocyanate, has recently shown anti-tumor, anti-inflammatory, and anti-fibrotic properties. In this study, we found that sulforaphane inhibited cell growth and reduced collagen at the mRNA and protein levels in keloid fibroblasts. Moreover, sulforaphane markedly suppressed the expression of IL-6 and α-SMA and inhibited Stat3 and Smad3 signaling pathways in keloid fibroblast KF112 cells. Sulforaphane induced G2/M cell-cycle arrest with the induction of p21 in KF112 cells. In addition, sulforaphane inhibited cell growth and suppressed the expression of collagen in keloid fibroblasts under a coculture with peripheral blood mononuclear cells. Furthermore, sulforaphane suppressed IL-6, Stat3, and Smad3 signaling in the coculture system. This study suggests that sulforaphane may be a novel keloid treatment.

Adipose-derived stem cells promote proliferation, migration, and tube formation of lymphatic endothelial cells in vitro by secreting lymphangiogenic factors.

Adipose-derived stem cells (ADSCs) are a promising new therapeutic modality for several diseases and have been applied to various clinical fields because of their multidifferentiation potential and capacity for growth-factor secretion. Recently, 2 in vivo studies showed ADSCs to have potential applications in lymphedema therapy. However, it remains unclear whether ADSCs have direct effects on lymphatic endothelial cells (LECs). In this study, human LECs were treated with murine ADSC-derived conditioned media. Changes in LEC proliferation, migration, and tube formation were assessed by WST-8 assay, transwell chamber assay, and Matrigel-based tube formation assay, respectively, with recombinant human vascular endothelial growth factor-C used as a positive control. Additionally, the expression of several lymphangiogenic factors in ADSCs was examined by quantitative reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay. Factors secreted by ADSCs induced LEC proliferation, migration, and tube formation more potently than recombinant human vascular endothelial growth factor-C. We confirmed by quantitative reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay that some of the lymphangiogenic factors of ADSCs were dramatically up-regulated under serum-starved conditions. These data indicate that ADSCs could directly contribute to lymphangiogenesis via secretory factors in vitro and may thus provide a therapeutic modality for patients with lymphedema.

Expansion abdominoplasty for a pregnant woman with severe abdominal wall contracture due to a major burn during childhood: a case report.

Normal abdominal expansion that occurs as a result of hormonal actions during pregnancy may be prevented by the presence of excessive scar tissue in individuals who have received severe burns. In these instances, the lack of abdominal expansion may cause maternal pain and put the infant at risk. A 23-year-old pregnant woman presented with severe abdominal wall contracture due to a major burn sustained during childhood. At 20 weeks of pregnancy, expansion abdominoplasty, consisting of zigzag incisions in the fascia to release the contracture and a split-thickness skin graft, was performed. The patient gave birth, via a planned cesarean operation at 36 weeks of pregnancy, to a baby girl in good condition; the postpartum course was uneventful.

Does a vascular supercharge improve the clinical outcome for free jejunal transfer?

To clarify whether a supercharged free jejunal transfer would have a different clinical outcome from the usual transfer method, we examined clinical data from cases of esophago-pharyngeal reconstruction. Fifty-three patients in whom the hypopharynx and cervical esophagus was reconstructed with a free jejunal transfer were divided into two groups: 19 normal procedures and 34 supercharged. Clinical outcomes including intraoperative and postoperative events, complications and deglutition were compared statistically. There were no significant differences between the groups in terms of the rates of free flap failure, leakage, stenosis, drinking status, dysphagia, or operating time. There were no significant advantages in clinical outcomes when using a supercharge. However, supercharged flaps with an intraoperative arterial thrombosis were all rescued and survived. Thus, a supercharge in free flap is not necessary for all cases. Its indication should be limited to cases when free flaps are not reliable because of intraoperative thrombosis and arterial insufficiency.

Successful retrograde arterial inflow through a muscular branch in a free anterolateral thigh chimeric flap transfer.

In this report, we present a case in which a free anterolateral thigh (ALT) flap was transferred for head and neck reconstruction after oropharyngeal cancer ablation, and a retrograde arterial inflow was used to salvage the flap when the main arterial pedicle showed usual repeated spasms. The flap was raised as a chimera flap comprising a fasciocutaneous flap and a vastus lateralis muscle flap. After reperfusion, the pedicle artery exhibited spasms repeatedly and vascular flow was unstable. Therefore, we performed arterial supercharge. In the distal portion of the muscle flap, a small arterial branch was dissected as a reverse-flow arterial pedicle. The recipient artery was also a retrograde limb of the superior thyroid artery. The flap survived; however, postoperative ultrasonographic echo evaluation revealed that the spastic descending branch of the lateral circumflex femoral artery was obstructed and that the reverse-flow muscular perforator alone nourished the whole flap. In free ALT flap transfer, a small perforator level artery was able to nourish a flap, even in a retrograde manner. Moreover, when the vasculature of the free flap is unstable, retrograde arterial supply to a small perforator can be an option to save the flap transfer.

Surgical treatment of dumbbell-shaped dermoid cyst extending into the orbit.

A 16-year-old male patient presented with a 3-year history of an enlarging right upper eyelid mass. His condition did not improve, and he complained of double vision on leftward gaze. A fixed, nontender, firm subcutaneous mass was clinically noted, and magnetic resonance imaging confirmed a partially cystic tumor in the right intratemporal and pterygopalatine fossae, which extended into the orbit through the inferior orbital fissure. Mass effects of the tumor and statistical analysis allowed for easy preoperative diagnosis. The tumor was easily removed without any complications by the combined use of coronal incision and lateral orbitotomy. This approach is useful for resection of lateral orbital tumors, including dumbbell-shaped tumors extending intraorbitally.

Congenital vulvar lipoma within an accessory labioscrotal fold.

Perineal lipomas are uncommon congenital anomalies. They mainly develop in male patients with an accessory scrotum, posterior to the original scrotum. However, on rare occasions, these lipomas can occur in female patients with an accessory labioscrotal fold. We report on three such cases, where the lipomas were found in the anterior part of the right side of the labia majora. None had other anomalies, with the exception of one who had premature growth of pubic hair on the accessory labioscrotal fold. Skin with a rugated scrotal appearance was present in all cases.

Double arterialized free jejunal flap.

In a standard free jejunal transfer, one artery and one vein are anastomosed. However, when raising the jejunal flap, a one-segment jejunum sometimes has two arteries and one accompanying vein as a vascular pedicle. Free jejunal transfer in which two arteries and one vein are anastomosed was designed. We report on the safety and advantages of using this artery-dominant transfer when performing microvascular anastomosis. This technique was used when a one-segment jejunum had two arteries and an accompanying vein. Eight patients underwent this arterial-supercharged free jejunal transfer. All flaps survived, and no complications developed except for two cases of intraoperative thrombosis before the procedure. It is important to transfer the artery-rich graft into the same physiological environment by reconstructing the similar hemodynamics. The grafts can be transferred without harm. This artery-dominant method can be an option when conditions are unfavorable for safer jejunal transfer.

Normal transvaginal delivery after abdominal wall reconstruction with tensor fascia lata muscle flap.

A 19-year-old woman presented with a tumor in the lower abdominal wall at the site of the scar that formed after appendectomy at age 7. The tumor mass was surgically removed, and the resulting full-thickness defect of the abdominal wall was reconstructed with autogenous tensor fascia lata muscle flap. Within 10 weeks of the reconstruction, she conceived and proceeded with an uneventful pregnancy and transvaginal delivery.

Low-cost Design and Manufacturing of Surgical Guides for Mandibular Reconstruction Using a Fibula.

BACKGROUND: Surgical cutting guides are used in mandibular reconstruction involving osteotomy of the mandible and fibula. Cutting guides produced using computer-aided design (CAD) and computer-aided manufacturing (CAM) technologies have been reported recently. These guides aim to increase the benefits to patients by improving the accuracy, shortening the operating time, and correcting occlusion. However, the availability of these advanced technologies is limited in some regions of the world. To test whether we could produce low-cost surgical cutting guides, we made surgical guides and investigated their accuracy. METHODS: Using free CAD software, we designed surgical cutting guides for the mandible and fibula and used these to perform virtual mandibular segmental osteotomies and fibula transplants in 12 model surgeries. The cutting guides were printed on a 3-dimensional (3D) printer. The model surgeries were performed using 3D mandibular models and cutting guides to check their accuracy. Deviations between the virtually simulated plan and the actual model surgery were investigated. RESULTS: CAD and CAM technologies were used to design and 3D print the cutting guides and models. The guided surgeries were performed. The deviations were about 1.3 mm for mandibular osteotomy, less than 1 mm for fibular osteotomy, and within 2.4 mm for reconstructions of the mandible. CONCLUSIONS: Without using expensive software or products, we were able to design surgical cutting guides for the mandible and fibula and used these to perform virtual simulation of mandibular segmental osteotomy and fibular reconstruction. Model surgeries using 3D-printed surgical guides showed that the accuracy of reconstruction was within a 3-mm deviation. In circumstances where commercial CAD/CAM guides are not available, it may be possible to use CAD/CAM surgical guides in the clinic if doctors are willing to volunteer their time for the design and printing.

Preventive effects on seroma formation with use of the harmonic focus shears after breast reconstruction with the latissimus dorsi flap.

BACKGROUND: Postoperative seroma is the most common complication of latissimus dorsi (LD) flap surgery for breast reconstruction. The use of EC for elevation of the flap might cause additional risk for seroma formation by injuring surrounding lymph vessels due to heat dispersion. There is a possibility that seroma formation can be prevented by using alternative devices such as harmonic focus (HF) shears that can dissect the tissue simultaneously with sealing the lymph vessels. METHODS: Forty-eight patients who underwent breast reconstruction with LD flaps since August 2011 up to April 2015 were enrolled. They were retrospectively split into two groups: 24 in group HF, 24 in group EC (conventional electrocautery). The primary outcome measures were rate of seroma formation and total volume of drain discharge and indwelling period of drainage at the anterior chest and donor site. Secondary outcome measures were length of hospital stay and duration of surgery. RESULTS: The incidence of seroma was 45.8% in the EC group and 20.8% in the HF group. The total volumes of the drain discharge and indwelling period of drainage in the back (donor site) were significantly decreased in the HF group. The length of the hospital stay and surgical time was significantly shorter for the HF group. CONCLUSIONS: The use of HF shears on the LD flap donor site is helpful for reducing seroma formation, the length of the drainage period, the surgical time, and the length of the hospital stay.

Adipose-Derived Stem Cells Promote Peripheral Nerve Regeneration In Vivo without Differentiation into Schwann-Like Lineage.

BACKGROUND: During recent decades, multipotent stem cells were found to reside in the adipose tissue, and these adipose-derived stem cells were shown to play beneficial roles, like those of Schwann cells, in peripheral nerve regeneration. However, it has not been well established whether adipose-derived stem cells offer beneficial effects to peripheral nerve injuries in vivo as Schwann cells do. Furthermore, the in situ survival and differentiation of adipose-derived stem cells after transplantation at the injured peripheral nerve tissue remain to be fully elucidated. METHODS: Adipose-derived stem cells and Schwann cells were transplanted with gelatin hydrogel tubes at the artificially blunted sciatic nerve lesion in mice. Neuroregenerative abilities of them were comparably estimated. Cre-loxP-mediated fate tracking was performed to visualize survival in vivo of transplanted adipose-derived stem cells and to investigate whether they differentiated into Schwann linage cells at the peripheral nerve injury site. RESULTS: The transplantation of adipose-derived stem cells promoted regeneration of axons, formation of myelin, and restoration of denervation muscle atrophy to levels comparable to those achieved by Schwann cell transplantation. The adipose-derived stem cells survived for at least 4 weeks after transplantation without differentiating into Schwann cells. CONCLUSIONS: Transplanted adipose-derived stem cells did not differentiate into Schwann cells but promoted peripheral nerve regeneration at the injured site. The neuroregenerative ability was comparable to that of Schwann cells. Adipose-derived stem cells at an undifferentiated stage may be used as an alternative cell source for autologous cell therapy for patients with peripheral nerve injury.

Use of systemic low-dose unfractionated heparin in microvascular head and neck reconstruction: Influence in free-flap outcomes.

BACKGROUND: Intravenous heparin administration is used to prevent thrombosis in free-flap transfer. However, it is unknown whether the use of heparin affects free-flap survival. The purpose of this study is to investigate the effect of heparin in free flap transfer. METHODS: Two hundred and six patients who received ablative surgery for head and neck cancer were classified into three groups. Group A received ablative surgery, neck dissection, and free-flap reconstruction, and postoperatively they were administered continuous intravenous unfractionated heparin (5000-10 000 units/day) until postoperative day 7 (POD7); group B received the same procedures as group A but without heparin; group C received only ablative surgery and neck dissection without heparin. As indicators of coagulation time, the prothrombin time-international normalised ratio (PT-INR) and the activated partial thromboplastin time (APTT) were measured, before surgery and on POD1, 3, and 7. Flap failure, bleeding, haematoma formation, re-exploration, and thromboembolic events were recorded. RESULTS: The PT-INR and APTT were 1.3-1.5-times longer in group A (p < 0.01), and 1.3-times longer (p < 0.01) in group B. The PT-INR and APTT were higher in groups A and B than C (p < 0.01). The free-flap success rate was not affected. Only the incidence of haematoma was increased in group A (p = 0.04). CONCLUSION: Heparin increased the haematoma formation, but did not change the incidence of free-flap failure. Thus, the intravenous low-dose heparin use does not affect microvascular flap survival.

Ultrasound Shear-Wave Elastography for Follow-Up Fat Induration after Breast Reconstruction with an Autologous Flap.

Fat induration is associated with necrosis and remains a common complication in breast reconstructions with autologous flaps after mastectomy. Fat induration can cause deep tissue infection, pain, distress, and anxiety. However, the diagnosis for this problem has not been objectively defined. In the current article, We will share our experience of using ultrasound shear-wave elastography with 14 patients who had clinical fat induration after breast reconstruction with a deep inferior epigastric perforator (DIEP) flap. The experience suggested that shear wave elastography may be a noninvasive tool to assess alterations of tissue stiffness in a reproducible fashion after breast reconstruction with DIEP flaps. Complications, such as fat necrosis and fatty induration, may occur as a result of unstable blood flow to the flap. Thereby, objective assessments of stiffness might make a major contribution to the understanding of hemodynamics of the DIEP flap after transplantation.

Adipose stromal cells contain phenotypically distinct adipogenic progenitors derived from neural crest.

Recent studies have shown that adipose-derived stromal/stem cells (ASCs) contain phenotypically and functionally heterogeneous subpopulations of cells, but their developmental origin and their relative differentiation potential remain elusive. In the present study, we aimed at investigating how and to what extent the neural crest contributes to ASCs using Cre-loxP-mediated fate mapping. ASCs harvested from subcutaneous fat depots of either adult P0-Cre/or Wnt1-Cre/Floxed-reporter mice contained a few neural crest-derived ASCs (NCDASCs). This subpopulation of cells was successfully expanded in vitro under standard culture conditions and their growth rate was comparable to non-neural crest derivatives. Although NCDASCs were positive for several mesenchymal stem cell markers as non-neural crest derivatives, they exhibited a unique bipolar or multipolar morphology with higher expression of markers for both neural crest progenitors (p75NTR, Nestin, and Sox2) and preadipocytes (CD24, CD34, S100, Pref-1, GATA2, and C/EBP-delta). NCDASCs were able to differentiate into adipocytes with high efficiency but their osteogenic and chondrogenic potential was markedly attenuated, indicating their commitment to adipogenesis. In vivo, a very small proportion of adipocytes were originated from the neural crest. In addition, p75NTR-positive neural crest-derived cells were identified along the vessels within the subcutaneous adipose tissue, but they were negative for mural and endothelial markers. These results demonstrate that ASCs contain neural crest-derived adipocyte-restricted progenitors whose phenotype is distinct from that of non-neural crest derivatives.

Adipose-derived stem cells produce factors enhancing peripheral nerve regeneration: influence of age and anatomic site of origin.

Adipose-derived stem cells (ADSCs) are attracting increased attention as a novel source in regenerative medicine. Transplantation of ADSCs promotes functional recovery in animal models of peripheral nerve injury, but the mechanism of enhanced nerve regeneration remains to be elucidated. In addition, it is important to examine whether the supportive functions of ADSCs are dependent on donor age or anatomic site of origin. In this study, we examined the effects of factors produced by mouse ADSCs on Schwann cells (SCs) and dorsal root ganglion (DRG) neurons in vitro and compared these effects among ADSCs from donors of different age and from different anatomic regions. ADSC-derived soluble factors supported survival and proliferation of SCs and promoted neurite outgrowth in DRG neurons. These beneficial effects were far superior to that of factors from 3T3-L1 cells and comparable to those of SC- and astrocyte (AC)-derived factors. ADSCs from different sources similarly retained their neurotrophic activity. Real-time reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay analyses demonstrated that ADSCs produced various growth factors, some of which were more abundant than in SCs and ACs. These results suggest that ADSCs promote peripheral nerve regeneration partly through paracrine secretion of trophic factors and regardless of donor age or anatomic site of origin.

Blood gas analyses in doubly-vascularised free jejunal transfers.

The vascular supercharge (additional microvascular anastomosis) has rarely been used for free flaps, and the blood circulation in the transferred tissue has not been recorded. We have made double vascular anastomoses during free jejunal transfer to reduce the possibility of loss of the flap from vascular occlusion. To evaluate the efficacy of additional arterial and venous anastomoses to improve the circulation in the transferred tissue, we analysed the results of blood gas measurements including venous partial pressure of oxygen (pO2) and carbon dioxide (pCO2) from the distal arcade vein. The free jejunal transfer was made using two pairs of arterial and venous anastomoses. Blood gas concentrations were analysed in samples drawn from the vein in the jejunal arcade before harvest, after the anastomosis of one paired artery and vein, after an additional arterial anastomosis, and after anastomoses of two pairs of artery/vein. The results showed that the venous pCO2 was not changed by increasing the number of anastomosed vessels. The venous pO2 was raised both by an additional arterial anastomosis and by two pairs of anastomoses, compared with that at the other two time points measured (p = 0.04, p = 0.02, respectively). An additional arterial anastomosis seemed to have more effect on the pO2 than an additional artery/vein pair. Additional arterial and venous supercharging therefore has a similar effect on hyperbaric oxygenation. This effect is mainly caused by arterial supercharging.