Fumiaki Shimizu

Sural perforator flap: Assessment of the posterior calf region as donor site for a free fasciocutaneous flap

Three kinds of free fasciocutaneous flap from the posterior calf region have been described in the literature: the medial sural perforator flap, the lateral sural perforator flap, and the traditional posterior calf fasciocutaneous flap that is supplied by superficial cutaneous vessels. Moreover, it has been reported that superficial cutaneous vessels are of a suitable size for microanastomosis when deep musclocutaneous perforators are absent or relatively tiny. To establish a safe technique for free fasciocutaneous flap elevation from the posterior calf region, we examined the number and location of the musculocutaneous perforators and the size of superficial cutaneous vessels at their origin from the popliteal artery in six formalinized cadavers. We found that all legs had at least one perforator either from the medial sural artery or the lateral sural artery. By contrast, we failed to find superficial cutaneous vessels of suitable size for microanastomosis in three legs, and there was no significant inverse relationship between the diameter of the superficial cutaneous artery and the number of musculocutaneous perforators. Our results suggest that the medial sural perforator flap and the lateral sural perforator flap might be the surgeons first and second choice, respectively. The traditional posterior calf fasciocutaneous flap should be the third choice because our study suggests that its availability is doubtful. Another site is recommended, when preoperative Doppler study suggests that the existence of musculocutaneous perforator is in doubt. Two clinical cases, with a medial sural perforator flap and a lateral sural perforator flap, respectively, are presented.

Paraneoplastic pemphigus associated with corneal perforation and cutaneous alternariosis: A case report and review of cases treated with rituximab

Hisashi KOKUBA, Masakazu TAKAHARA, Bungo OHYAMA, Takashi HASHIMOTO, Masutaka FURUE Department of Dermatology, Hiroshima Red Cross Hospital, Atomic-bomb Survivors Hospital, Hiroshima, Department of Dermatology, Kyushu Central Hospital, Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, and Department of Dermatology, Kurume University School of Medicine, Fukuoka, Japan

A case of fulminant type 1 diabetes mellitus, with a precipitous decrease in pancreatic volume, induced by nivolumab for malignant melanoma: analysis of HLA and CTLA-4 polymorphisms.

Nivolumab is a monoclonal antibody directed against PD1 (programmed cell death 1) that can improve survival in patients with metastatic melanoma. Such immune checkpoint inhibitors have been known to induce type 1 diabetes mellitus (T1D) [1, 2].A 54-year-old woman reported enlarging black nodules on her left sole, which had been present for seven months (figure 1A). CT imaging revealed swollen lymph nodes in the left inguinal and pelvic regions (figure 1B). After clinical diagnosis of malignant melanoma [...]

Analysis of 256 cases of basal cell carcinoma after either one‐step or two‐step surgery in a Japanese institution

Basal cell carcinoma (BCC) is a common skin cancer that arises from the cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. In the present report, 256 cases treated surgically between 1999 and 2008 in our department were retrospectively analyzed. The most frequent BCC locations included the face (77.8%), especially the nose (26.9%) and eyelids (21.5%). Incomplete excisions occurred in 21 cases. Two patients experienced local recurrence; one of these patients exhibited a bone metastasis while the other had a metastasis of the parotid gland without the local recurrence. The rate of local BCC recurrence was 0.78%, which is lower than that described in previous reports. We categorized BCC into four histological types: superficial, solid, adenoid and infiltrative. The solid type was the most frequent histological type (62.1%). For preventive recurrence, we treated BCC patients with two‐step surgery when the tumor was large or histologically invasive. At the first step, we excised the tumor with a sufficient safety margin, and at the second step, we performed reconstruction after the histological confirmation that no remnant malignant cells were in the tumor margins. In the present report, no local recurrence occurred in patients following the two‐step surgery. Therefore, two‐step surgery is recommended for tumors at locations and with histological types related to frequent recurrence.

Inability to detect sentinel lymph node metastasis due to an obstruction of the lymphatics by metastatic Merkel cell carcinoma

of life impact and clinical severity on adherence to topical acne treatment. J Cutan Med Surg 2009; 13: 204–208. 3 Bowes LE, Manstein D, Rox Andersen R. Effects of 532 nm KTP laser exposure on acne and sebaceous glands. Lasers Med Sci 2003; 18(Suppl 1): S6–S7. 4 Baugh WP, Kucaba WD. Nonablative phototherapy for acne vulgaris using the KTP 532 nm laser. Dermatol Surg 2005; 31: 1290–1296. 5 Chang SE, Ahn SJ, Rhee DY et al. Treatment of facial acne papules and pustules in Korean patients using an intense pulsed light device equipped with a 530to 750 nm filter. Dermatol Surg 2007; 33: 676–679. 6 Key DJ. Single-treatment skin tightening by radiofrequency and long-pulsed, 1064 nm Nd:YAG laser compared. Lasers Surg Med 2007; 39: 169–175. 7 Roh MR, Chung HJ, Chung KY. Effects of various parameters of the 1064 nm Nd:YAG laser for the treatment of enlarged facial pores. J Dermatolog Treat 2009; 20: 223–228.

Algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps.

Background In case of composite cranial defect including the dura mater, the cranial bone, and the scalp, the fascial component of the anterolateral thigh flap can be used for dural reconstruction. However, the advantages and applications of the fascial component depending on the type of defect have not been thoroughly discussed. We made the algorithm for reconstruction of composite cranial defects using the fascial component of free anterolateral thigh flaps. Patients and Methods Six cases of composite cranial defects were reconstructed using free anterolateral thigh flaps with the fascial component. The type of method used was classified into 3 types. Type 1 involves separating the fascia from the flap completely and using it as a nonvascularized component. In type 2, the fascia is not separated from the flap and is instead used as a vascularized component. Type 3 involves separating the vascularized adipofascial component from the skin paddle and using it as a chimeric pattern flap. The algorithm for determining the type of fascial component is applied depending on the condition of the defect. Results All flaps were transferred successfully in every case. In 4 cases, the type 1 method was used. The type 2 and 3 methods were used in 1 case each. Cranial bone reconstruction was performed in 3 cases. There were no major complications after the procedures. Conclusions The fascial component is useful for dural reconstruction. The type of fascial component used is selected depending on the condition of the defect.

Drug-induced hypersensitivity syndrome due to carbapenem antibiotics.

Drug‐induced hypersensitivity syndrome (DIHS) is characterized by a serious adverse systemic reaction that usually appears after a 3–6‐week exposure to certain drugs, for example, anticonvulsants. Many different precipitating factors have been reported, but the pathophysiology of DIHS remains unknown. However, reactivation of members of the human herpesvirus (HHV) family, and of HHV‐6 in particular, has been reported in patients with DIHS. We report the case of a 64‐year‐old man who developed a generalized erythematous rash, fever, hepatic failure, lymphadenopathy and an increased number of atypical lymphocytes. In addition, reactivation of HHV‐6 and cytomegalovirus (CMV) was demonstrated by real‐time quantitative amplification by polymerase chain reaction. The patient was given a diagnosis of DIHS due to carbapenem antibiotics based on his clinical course, laboratory data, and results of lymphocyte‐stimulation tests with various drugs. This is the first report, to our knowledge, of DIHS induced by carbapenem antibiotics.

Novel and recurrent C1 inhibitor gene mutations in nine Japanese patients with hereditary angioedema

C1 inhibitor (C1-INH) deficiency (hereditary or acquired gioedema; HAE [OMIM106100] or AAE) is characterized by curring episodes of subcutaneous or submucosal swellings, pically involving the face, limbs, tongue, bowels or upper airways ]. Laryngeal attack can cause airway obstruction which may be tal. Therefore, prompt diagnosis and treatment are essential. Two assical types of HAE, type 1 and 2, are autosomal dominant sorders due to heterozygous deficiencies of the C1-INH gene ERPING1). Type 1 shows decreased antigenic and functional vels of C1-INH and type 2 shows normal levels of antigenic -INH but low levels of functional C1-INH [2]. DNA screening of the C1-INH gene establishes the genetic termination of the C1-INH deficiency. It is especially useful for e diagnosis of sporadic cases accounting for 20–30% of patients ith HAE as a result of de novo mutations without family history of gioedema [3]. According to the C1-INH mutation database AEdb, http://hae.enzim.hu), more than 250 different mutations ve been reported [4]. The mutations have been found distributed er all exons and splice sites of the C1-INH gene. Gross mutation is sponsible for approximately 15% of the mutations detected in tients with HAE, and the remaining 85% being due to small/point utations. This database has been well established by reports ainly from Europe and North America, while the genetic formation of HAE in Asian races is uncertain. The prevalence HAE type 1 and type 2 has been estimated at 1/50,000 [2]. On the her hand, a nation-wide prevalence survey of HAE in Japan has own only 52 type 1 or type 2 patients with HAE, even though panese population is about 128 million [5], and only 23 utations have been reported in Japan so far [6]. Similarly, only 3 HAE patients have been reported from China, which is the ost populous country in the world [7]. In this study, we investigated the genetic analysis of nine panese patients with HAE in order to increase the genetic formation of HAE in Japan. HAE was diagnosed based on repeated isodes of swelling in the skin and/or mucosa and decreased vels of C1 inhibitor function and C4 in plasma. Genomic DNA was tracted from peripheral blood of the patients by using Genomic A Mini Kit (Invitrogen, Carlsbad, CA). Polymerase chain reaction CR) were carried out using 9 pairs of primers to amplify the 8 ons, referring to previously described information [8]. DNA quencing was performed using an Applied Biosystems 3100ant DNA Analyzer (Applied Biosystems, Warrington, UK). The udy was approved by the Genome Ethics Committee for perimental Research Involving Human Subjects, Hiroshima iversity Hospital, and written informed consent for participan was obtained from the patient and/or their families. se w Subjects of this study consisted of four male and five female tients with an age range from 20 to 69 years. Five patients had milial history of angioedema and the other four patients were oradic cases. Genetic analysis of the C1-INH gene in this study vealed 4 frameshift mutations, 2 nonsense mutations, one issense mutation, one splice site mutation and large deletion. these mutations, 4 mutations: p.Arg40fsX17 (c.119insA), Ala46fsX9 (c.138_207del), p.Asp256fsX22 (c.766delG) and Gln338X (c.1012C > T) were novel (Fig. 1) and 5 mutations: Lys329fsX7 (c.987delG) [6], p.Arg466His (c.1397G > A) [4], p. g492X (c.1480C > T) [4], splicing defect (c.551-2_A > G) [4] and large rearrangement (>650 kbp including entire exons), which as reported separately [8], were recurrent (Table 1). Based on the netic analysis from our study and previous reports about panese patients with HAE, the mutations were widely distributacross the C1-INH gene and the distributions of the mutations by pes in Japan do not seem to be apparently different from those ported in Europe. We have classified four individuals into type 1 HAE and one dividual into type 2 HAE by the level of C1-INH protein. We could t classify four individuals because of lack of the serum test of C1H protein level. According to previous studies, almost 100% in pe 2 HAE showed missense mutations and it almost invariably sults in HAE type II when mutations occur within the C1-INH active site located in exon 8 at arginine 444 [9]. All of four classified individuals showed nonsense or frameshift mutations hich caused premature termination expecting to lead to reduced pression of C1-INH. Actually, the mutation in patient 1, Arg492X, was identified in type 1 HAE. From these observations, e speculated that these 4 unclassified individuals were type 1 E. Only one patient was found with HAE type 2 in this study 1%), which is in accordance with another report in Japan (12.5%) ]. Previously the prevalence of type 2 has been reported around % [2], but a recent study showed the number of type 2 was 6% of tients with HAE identified in several countries of Europe [10]. erefore, there seem to be regional variation in occurrence garding HAE type 2. Among nine patients in this study, two patients received acheostomy due to severe swelling on the respiratory trunk. mamoto et al. [6] also reported that 32% patients with HAE had acheostomy or tracheal intubation in Japan. The risk of severe spiratory symptoms in Japanese patients with HAE was as quent as in western countries. Therefore, proper diagnosis of E is necessary to prevent the patients from asphyxiation. oreover DNA screening of the C1-INH gene is useful in that it veals the segregation of genetic carriers of HAE within affected

Pigmented median raphe cyst of the penis.

To the Editor, Median raphe cyst represents a relatively rare cystic lesion on the median raphe, which extends from the urethral meatus to the anus. Since the first report by Mermet in 1895,1 several terminologies, including median raphe cyst, ‘mucoid cyst of penile skin’ and ‘genitoperineal cyst of the medium raphe’ have been used.2 There is a general agreement that median raphe cyst is derived from the urethral mucosa or urethral gland (Littre’s gland).3 It appears commonly in children or adolescents with a mean size of less than 20 mm.4 Rarely, median raphe cyst contains melanin and melanocytes and clinically has a pigmented appearance. Such a cyst is called pigmented median raphe cyst.5 We report herein a case of pigmented median raphe cyst with a review of the literature. A 6-year-old boy presented with a brownish nodule on the ventral aspect of the penis, which had been noticed 5 years previously and increased in size with body growth. On physical examination, the nodule was slightly elevated with a smooth surface and was elliptical in shape, elastic soft and movable, measuring 2 × 8 mm on the median raphe of the penis (Fig. 1). The nodule was resected, and no local recurrence was noted 10 months postoperatively. Microscopic examination of the resected specimen showed a unilocular cyst in the dermis (Fig. 2A). The inner surface of the cyst was smooth and lined by one to several layers of uniform bland cuboidal cells with abundant brown pigment (Fig. 2B). No cells showed decapitation secretion reminiscent of apocrine origin. The brown pigment was melanin, as it stained black by the Fontana–Masson method and bleached by potassium permanganate–oxalic acid solution. Although it was difficult to detect melanocytes with hematoxylin–eosin staining, immunostaining for Melan A/MART-1 by alkaline phosphatase and fast-red highlighted them at the basal layer (Fig. 2C). Fig. 1. A brownish elliptic-shaped nodule on the median raphe (arrows) of the penis.

Mycobacterium smegmatis soft tissue infection.

immediate adverse reactions were due to the toxic effects of dextranomer. There have been two case reports of delayed adverse reactions to Matridex. In one, a 43year-old woman presented with multiple hard nodules on both cheeks and periocular regions after Matridex injection. Histopathological examination showed diffuse granulomatous reactions of the dermis and a unique pattern of the two exogenous materials, with HA appearing as filamentous, blue-gray structures with bizarre configurations and the dextranomer microspheres appearing as multiple bluish, spherical particles. Histopathologically, our patient also showed both HA and dextranomer microparticles, but there were some differences in their morphology. Amorphous materials were observed, but filamentous materials were not. Moreover, in addition to purplish spherical structures, our patient showed translucent cyst-like structures, like Swiss-cheese. At present, therefore, there is insufficient evidence to determine typical histopathological findings in Matridex granulomas. The exact pathomechanism of foreign body granuloma following Matridex injection is not known. Because Matridex contains HA, granulomatous inflammation after HA filler injection may be caused by bacterial contamination, residual chemical agents used in the cross-linking process, or the breakdown products of chemically modified HA. Alternatively, granuloma formation may be due to the dextranomer microspheres. For example, intravenous injection of Sephadex, a type of dextranomer bead, was found to trigger granulomatous inflammation of the lungs in rats. In summary, we have described a rare case of foreign body granuloma following Matridex injection. Although not common, practitioners should be aware of the possibility of Matridex-associated foreign body granuloma.