Kazunori Yasumura

Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema.

OBJECTIVE Lymphaticovenous anastomosis has been used for patients with peripheral lymphedema. However, the efficacy of this procedure is controversial due to a lack of evidence regarding postoperative patency. We sought to determine midterm postoperative patency of lymphaticovenous side-to-end anastomoses (LVSEAs) using indocyanine green fluorescence lymphography. METHODS This was a retrospective observational study set in a teaching hospital. Of 107 patients with chronic lymphedema who underwent 472 LVSEAs, 57 (223 anastomoses) consented to fluorescence lymphography and comprised the study cohort. The intervention consisted of a microsurgical LVSEA performed with a suture-stent method. Patients also had preoperative and postoperative complex decongestive physiotherapy. Anastomosis patency was assessed using indocyanine green fluorescence lymphography ≥6 months after surgery. Patency rates were calculated using Kaplan-Meier analysis. We assessed volume reduction on the operated-on limb and compared this between patients in whom anastomoses were patent and those in whom anastomoses were not obviously patent. RESULTS Patency could be evaluated only at the dorsum of the foot, ankle, and lower leg because the near-infrared rays emitted by the special camera used could not penetrate the deep subcutaneous layer containing collective lymphatics in areas such as the thigh. Several patterns were observed on fluorescence lymphography: straight, radial, and L-shaped. Cumulative patency rates of LVSEAs were 75% at 12 months and 36% at 24 months after surgery. No significant difference in volume change of the affected limb was seen between the 34 patients with patent anastomosis (600 ± 969 mL) and the 24 patients without obvious evidence of patency (420 ± 874 mL). CONCLUSIONS Although further study is required to determine factors leading to anastomotic obstruction and to optimize the results of microlymphatic surgery, the present LVSEA technique appears promising.

Breast reconstruction using free posterior medial thigh perforator flaps: intraoperative anatomical study and clinical results.

Background: The free posterior medial thigh perforator flap is a fasciocutaneous flap on the posterior and medial thigh, based on perforators from the deep femoral vessels. In this study, the authors evaluated the anatomical basis of posterior and medial thigh perforators from the deep femoral vessels. Methods: Between June of 2006 and May of 2012, 67 patients underwent breast reconstruction using the posterior medial thigh flap. Perforators greater than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator diameters, perforator locations, pedicle length, and distance of the perforating point from the proximal thigh crease. Results: Of 70 flaps, 69 survived, but one developed total necrosis. The total number of perforators was 272, and the mean number was 3.9. The number of perforators coursing through the adductor magnus muscle was largest, followed by those coursing between the adductor magnus and semimembranosus muscle septocutaneously. Musculocutaneous perforators from the adductor magnus were located more proximally than the septocutaneous perforators between the adductor and semimembranosus muscle. Conclusions: The posterior medial thigh flap is suitable as a first-line option for breast reconstruction in women with a small to moderate breast size. This flap provides enough large perforators to support a soft-tissue transfer from the posterior and medial thigh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Influence of the frequency of laser toning for melasma on occurrence of leukoderma and its early detection by ultraviolet imaging

Laser “toning” with a Q‐switched neodymium‐doped yttrium aluminum garnet (Nd:YAG) laser has recently been described to be effective for the treatment of melasma. Leukoderma is a refractory complication of laser toning for melasma, but it can be detected early with ultraviolet (UV) imaging. We assessed the relationship between leukoderma and the frequency or total number of laser toning sessions, as well as the effectiveness of UV imaging for detecting leukoderma.

Inhibition of Rho-associated kinases disturbs the collective cell migration of stratified TE-10 cells

BackgroundThe collective cell migration of stratified epithelial cells is considered to be an important phenomenon in wound healing, development, and cancer invasion; however, little is known about the mechanisms involved. Furthermore, whereas Rho family proteins, including RhoA, play important roles in cell migration, the exact role of Rho-associated coiled coil-containing protein kinases (ROCKs) in cell migration is controversial and might be cell-type dependent. Here, we report the development of a novel modified scratch assay that was used to observe the collective cell migration of stratified TE-10 cells derived from a human esophageal cancer specimen.ResultsDesmosomes were found between the TE-10 cells and microvilli of the surface of the cell sheet. The leading edge of cells in the cell sheet formed a simple layer and moved forward regularly; these rows were followed by the stratified epithelium. ROCK inhibitors and ROCK small interfering RNAs (siRNAs) disturbed not only the collective migration of the leading edge of this cell sheet, but also the stratified layer in the rear. In contrast, RhoA siRNA treatment resulted in more rapid migration of the leading rows and disturbed movement of the stratified portion.ConclusionsThe data presented in this study suggest that ROCKs play an important role in mediating the collective migration of TE-10 cell sheets. In addition, differences between the effects of siRNAs targeting either RhoA or ROCKs suggested that distinct mechanisms regulate the collective cell migration in the simple epithelium of the wound edge versus the stratified layer of the epithelium.

Polyamines release the let-7b-mediated suppression of initiation codon recognition during the protein synthesis of EXT2

Proteoglycans (PGs), a family of glycosaminoglycan (GAG)-protein glycoconjugates, contribute to animal physiology through interactions between their glycan chains and growth factors, chemokines and adhesion molecules. However, it remains unclear how GAG structures are changed during the aging process. Here, we found that polyamine levels are correlated with the expression level of heparan sulfate (HS) in human skin. In cultured cell lines, the EXT1 and EXT2 enzymes, initiating HS biosynthesis, were stimulated at the translational level by polyamines. Interestingly, the initiation codon recognition by 43S preinitiation complex during EXT2 translation is suppressed by let-7b, a member of the let-7 microRNA family, through binding at the N-terminal amino acid coding sequence in EXT2 mRNA. Let-7b-mediated suppression of initiation codon depends on the length of 5′-UTR of EXT2 mRNA and its suppression is inhibited in the presence of polyamines. These findings provide new insights into the HS biosynthesis related to miRNA and polyamines.

Blepharoplasty in Senile Blepharoptosis: Preoperative Measurements and Design for Skin Excision

BACKGROUND For patients with senile ptosis, aesthetic blepharoplasty can be combined with ptosis surgery. However, the amount of skin excision necessary in blepharoplasty is not clearly defined by measurements of the upper eyelids. OBJECTIVES The authors preoperatively evaluate the amount of skin to be excised in blepharoplasty. METHODS Fifty patients with bilateral senile ptosis were included in this study. The amount of skin to be excised from the upper eyelids was selected based on preoperative measurements of redundant skin, equivalent to the maximum lid height (MLH) while manually stretching the eyelid upwards minus resting lid height (RLH) with the eyes closed passively. Ptosis surgery (such as plication of the aponeurosis) followed blepharoplasty. RESULTS Preoperatively, mean MLH was 35 mm on the right and 36 mm on the left. Mean RLH was 25 mm bilaterally. The mean amount (height) of excised skin was 10 mm on the right and 11 mm on the left. At six months postoperatively, mean MLH and RLH were 29 and 23 mm on both sides, respectively. Significant differences between pre- and postoperative MLH and RDH were seen on both sides (P<.001). No complications due to overexcision were observed, but revision was performed for two patients with asymmetry of the lid folds and five patients with recurrence of drooping. CONCLUSIONS Preoperative measurements of upper eyelid heights (stretched and at rest) appear useful in determining the amount of skin excision required in blepharoplasty for senile ptosis. LEVEL OF EVIDENCE 4.

Unilateral breast reconstruction using bilateral inferior gluteal artery perforator flaps.

Background: For reconstructing moderate-to-high projection breasts in nulliparous patients with insufficient abdominal tissue or prior abdominal surgeries, a unilateral inferior gluteal artery perforator (IGAP) flap is an alternative procedure. In patients with slim hips, however, unilateral gluteal tissue is insufficient and inferior gluteal crease displacement may develop postoperatively. Donor-site asymmetry is also a major disadvantage. In these circumstances, bilateral IGAP flaps provide sufficient tissue without significant gluteal deformity. Methods: We retrospectively reviewed 20 patients who underwent unilateral breast reconstruction using bilateral IGAP flaps by a single surgeon between November 2007 and December 2012. A quantitative outcome assessment was performed and compared with that of 22 unilateral IGAP flap patients operated on by the same surgeon. Results: Twenty patients underwent reconstruction with 40 IGAP flaps. Of the 40 flaps, 39 survived and 1 developed total necrosis due to repeated venous thrombosis. In 15 of 20 patients, the size of reconstructed breast was comparable to that of the contralateral breast. Final inset flap weight was 462.3 g for bilateral flaps and 244.3 g for unilateral flaps. Total operating time was 671.1 minutes (bilateral flaps) and 486.8 minutes (unilateral flaps). Conclusions: Use of bilateral IGAP flaps for breast reconstruction helps to avoid asymmetry of the inferior buttock volume and shape. Bilateral flaps provide sufficient tissue volume and allow for reconstruction of a breast comparable to the unaffected side. In patients with moderate-to-high projection breast whose abdominal tissue cannot be used for reconstruction, IGAP flaps may be a suitable alternative.

Intraoperative lacrimal intubation to prevent epiphora as a result of injury to the nasolacrimal system after fracture of the naso-orbitoethmoid complex.

Treatment of fracture of the naso-orbitoethmoid (NOE) complex is difficult. There are not only aesthetic issues but also functional consequences related to the lacrimal system. Because prophylactic lacrimal intubation for such fractures remains controversial, we have assessed the effectiveness of intraoperative lacrimal intubation to prevent epiphora as a result of such injuries. Thirteen patients diagnosed with craniomaxillofacial fractures including fractures of the NOE complex were included in the study; 10 had unilateral fractures and 3 bilateral. Computed tomography (CT) showed all patients had displaced fragments that had the potential to damage the lacrimal duct. In 7 patients the fractures included the canthal region and in 6 they did not. All patients were treated by open reduction and internal fixation under general anaesthesia, followed by intraoperative lacrimal intubation unilaterally or bilaterally as required. Lacrimal intubation with a silicone tube was successful in all 13 patients (16 sides). The tube was removed 2-9 months (mean 3.8) postoperatively and no subsequent epiphora were seen during follow-up (mean (3-29 months) 11.3 months). Lacrimal intubation for at least 2 months may prevent epiphora caused by injury to the nasolacrimal system after fractures of the NOE complex.

Subacute phase treatment of subperiosteal hematoma of the orbit with epidural hematoma in the frontal cranial fossa: Case report

BackgroundSubperiosteal hematoma of the orbit is one of the rare lesions that cause exophthalmos after craniomaxillofacial trauma. Presently, there is no consensus for how to treat this disease. Although some reports have suggested a conservative type of therapy, others have recommended surgical treatments be done during the early stages.Case presentationThis case report provides details on the clinical course of a 9-year-old girl with subperiosteal hematoma of the orbit. In this particular patient, a rare case of ipsilateral subfrontal extradural hematoma was also observed. Due to our performing the surgical intervention during the subacute stage, functional complications as well as cosmetic problems were avoided.ConclusionOur results demonstrate that surgical treatments for subperiosteal hematoma of the orbit should be delayed until it can be confirmed that a patient has no other complications. On the other hand, once it has been confirmed that the patient has no other existing problems, immediate surgical therapy with a small skin incision followed by the setting of a drain is recommended in order to achieve an early resolution and avoid complications.

Use of Occlusal Splint for Noninvasive Fixation of a Reference Frame in Orbital Navigation Surgery

AbstractIntroduction When prepping for navigation surgery, a reference frame must be fixed to the patient’s head with a Mayfield clamp, bone anchor, headset, or headband. Fixation of the clamp or bone anchor with a screw or head pins is invasive, whereas use of a headband or headset is noninvasive. However, during orbital surgery for blowout fractures or orbital tumors, surgeons or instruments can interfere between the reference frame and the optical tracking navigation system, even if using noninvasive fixation.Materials and methods We used an occlusal splint for noninvasive fixation of a reference frame in orbital navigation surgery to overcome the problems.ResultsA surgeon could operate without interferences between the reference frame and the optical tracking navigation system during orbital navigation surgery.ConclusionWe recommend the use of an occlusal splint for noninvasive fixation of a reference frame in orbital navigation surgery.