Keisuke Imai

Clinical application of cultured autologous human auricular chondrocytes with autologous serum for craniofacial or nasal augmentation and repair.

Background: The repair of a craniofacial or nose deformity requires a large volume of reconstructive material. A conventional cartilage graft does not provide a sufficient volume of reconstructive material. Therefore, augmentation of the facial form to the defect shape is quite difficult. The authors developed a new treatment method that provides a sufficiently large volume of reconstructive material and enables an easier reconstruction of the original shape. Methods: Ages of the patients ranged between 9 and 63 years. Approximately 1 cm2 of auricular cartilage was collected from the auricular concha. Isolated chondrocytes were cultured with autologous serum that accelerates cell proliferation. The cells were subcultured and formed a gel-form mass. This mass, together with autologous serum, was grafted (injected) on the periosteum and into the subcutaneous pocket. The volume of grafted cultured chondrocytes ranged from 1.7 to 40 cc (1 to 5 × 107 cells/cc). The lesion changed from soft gel form into hard cartilage tissues within 2 to 3 weeks and stabilized. Results: Excellent or good satisfactory results were obtained in all patients and have been maintained for periods ranging from 3 to 34 months. No patient experienced absorption of cultured chondrocytes. Biopsy of the newly formed tissues showed that it was an elastic cartilage derived from the original tissue. Conclusions: A small number of chondrocytes obtained from a 1-cm2 auricular cartilage are successfully cultured into a large number of cells in a gel form. Those autologous auricular chondrocytes in a gel form allow for the repair of complicated shapes of the defect area. This technique is applicable to various treatments for craniofacial or nose deformity.

Generating Ears from Cultured Autologous Auricular Chondrocytes by Using Two-Stage Implantation in Treatment of Microtia

Background: Microtia is a congenital ear hypoplasia associated with auricular defects. Conventional treatment involves implanted costal cartilage. The impact of surgical invasion and donor-site morbidity can be particularly severe in pediatric patients, and the collectable volume of autologous cartilage is limited. The authors therefore developed a new technique for microtia and applied it to treat four patients. Methods: Through the development of a multilayer chondrocyte culture system and two-stage implantation technique, the authors successfully generated human ears. In culture, the chondrocytes are expanded to a sufficiently large volume, produce rich chondroid matrix, and form immature cartilaginous tissues. In the authors’ two-stage implantation, the cultured chondrocytes are injection-implanted into the lower abdomen of the patient, where the cells grow into a large, newly generated cartilage with neoperichondrium in 6 months. This cartilage is harvested surgically, sculptured into an ear framework, and implanted subcutaneously into the position of the new ear. Results: The cultured chondrocytes formed a mature cartilage block with sufficient elasticity for use as an auricular cartilage. The formed block had the same histologic origin as elastic cartilage. The ear framework produced from this block was implanted into the auricular defect area, and an auricle with a smooth curvature and shape was subsequently configured. In the 2 to 5 years of postoperative monitoring, the neocartilage maintained good shape, without absorption. Conclusions: The authors’ four patients are the first successful cases of regenerative surgery for microtia using cultured ear chondrocytes. The benefits of the technique include minimal surgical invasion, lower donor-site morbidity, lessened chance of immunologic rejection, and implantation stability.

Reconstruction of palate with radial forearm flap; a report of 3 cases

A prosthesis is the preferred method for the closure of a palatal defect following maxillectomy, with fairly satisfactory results. However, some patients suffer from symptoms due to mismatch of the prosthesis. We have reconstructed palatal defects using radial forearm flaps in 3 cases. The forearm flap is utilised for palatal reconstruction in the double-folded form. The flap is thin and pliable, there are no problems in regard to bulk and drooping of the flap, and the patients can wear the denture with minimal discomfort. We believe that reconstruction of the palate with a forearm flap is a useful procedure, especially for patients suffering from symptoms due to mismatch of the prosthesis.

Reconstruction of penis with free deltoid flap

Two cases of reconstruction of the penis with a free deltoid flap are described. The urethra was reconstructed with part of the flap and external coverage of the penis was provided with the remainder. In one case an autogenous rib cartilage graft was inserted in the reconstructed penis as a strut. Postoperatively both patients can urinate standing up, and for the one in which a rib cartilage graft was used sexual intercourse is possible. Both cases have good recovery of tactile and protective sensation in their reconstructed penis.

Successful stenting seven days after atherothrombotic occlusion of the intracranial internal carotid artery.

Purpose: To report a case of successful stenting after a subacute stroke. Case Report: A 75-year-old man presented with sudden onset of right-sided weakness and difficulty speaking. Imaging revealed an occlusion of the left petrous to lacerum internal carotid artery (ICA) segment and slightly decreased cerebral blood flow in the left hemisphere; there were stenoses of the ostial and cavernous ICA segments on the right. On the seventh day after the stroke, he underwent protected carotid angioplasty of the left intracranial ICA occlusion to reduce the high risk of ischemic stroke owing to bilateral disease. An external arteriovenous shunt was established with an occluding balloon in the proximal ICA and a filter in the femoral vein. After protected balloon dilation of the ICA occlusion, a 3.5times18-mm balloon-expandable coronary stent was deployed across the residual stenotic segment. An intraluminal filling defect of the petrous ICA segment suggested an arterial dissection or intraluminal thrombus, so another 2 coronary stents were deployed. Macroscopically visible materials were captured in the filter. The patient had a good clinical course and was discharged without neurological deficits on the twelfth day after the stroke. Angiography at 3 months confirmed no restenosis of the stented vessel. Conclusion: This experience suggests that short atherothrombotic intracranial ICA occlusions can be opened in the subacute stroke stage without distal migration of thrombi under proximal protection and flow reversal.

Two-stage transplantation of cell-engineered autologous auricular chondrocytes to regenerate chondrofat composite tissue: clinical application in regenerative surgery.

Background: The authors have developed a unique multilayered culture method that expands to large volumes elastic chondrocytes from a small piece of human auricular cartilage. In this study, the authors applied the two-stage transplantation method for cultured auricular chondrocytes to difficult cases of nasal/chin reconstruction where subcutaneous tissue is thin or scarred. Methods: Auricular chondrocytes were cultured and expanded to sufficiently large volumes, and then, in a two-stage transplantation process, injection-transplanted into a patient’s lower abdomen, where they were regenerated into larger chondrofat composite tissue in 6 months and used as a material for nasal/chin reconstruction. The authors then performed histologic and electron microscopic analysis of serial cross-sections and magnetic resonance imaging analysis of the chondrofat composite tissue. Results: The cultured auricular chondrocytes consistency regenerated intraabdominally to a larger, stable neocartilage, with adherent fat tissue within 6 months. Eighteen patients (nose, n = 14; chin, n = 4) underwent this procedure, and the chondrofat composite tissue was stable after 1 to 5 years’ postoperative follow-up. The chondrofat composite tissue maintained good shape, with no major complications. Magnetic resonance imaging showed that the chondrofat composite tissue was regenerated and vascularized in the abdomen in all 18 cases (100 percent). Infection and total absorption were not seen. Only partial absorption was noted (5.6 percent). Conclusions: The chondrofat composite tissue was found to be a new innovative graft material in which neocartilage is regenerated to be continuous with fat tissue by means of the neoperichondrium. It has thereby become possible to perform the previously impossible simultaneous reconstruction of cartilage and fat tissue.

An evaluation of hard palate mucosa graft as a lining material in alar reconstruction: a 7-year experience applied to the full-thickness alar defect.

The authors present their experience with 25 hard palate mucosa grafts used as lining material in the reconstruction of full-thickness alar defects. Good “take” was obtained in 22 grafts; the other three grafts incurred necrosis of the overriding skin flaps and postoperative infection. Degree of shrinkage was 11 to 15 percent of grafted size in patients with the type of defect that did not include the alar margin; shrinkage was 26 to 35 percent in patients with the type that included more than 50 percent of the alar margin. In all patients who had a good graft take, the nasal cavities were maintained and there was no nasal obstruction or collapsing during strong breathing. The healing time of the palate donor site varied from 7 days to 5 weeks, depending on the size of the defect. No patients experienced any symptoms at the donor site after healing. The authors concluded that hard palate mucosa can be considered a useful material in alar reconstruction because of the ease in graft harvesting and its support features. When the defect is large enough to involve the total unilateral ala nasi, even though the degree of postoperative shrinkage is comparatively high, hard palate mucosa may be the most suitable material to ensure good take of the graft and less possibility of donor-site morbidity.

Tandem Balloon Protection during Emergency Carotid Artery Stenting of a Stenotic ICA Lesion with Intraluminal Thrombus

Purpose: To report a technique for emergency CAS of a stenotic internal carotid artery (ICA) lesion with an intraluminal thrombus, which predisposes to distal thromboembolism and could aggravate pre-existing neurological symptoms. Case Report: A 77-year-old man with fluctuating stroke underwent successful emergency CAS for an ICA stenosis with intraluminal thrombus using a tandem balloon protection technique featuring proximal balloon blockade and a PercuSurge GuardWire system for distal protection. Conclusion: This experience suggests that emergency CAS with tandem balloon protection is a potential treatment for a stenotic lesion with an intraluminal thrombus in patients with fluctuating stroke.

Magnetic resonance imaging findings of craniofacial fibrous dysplasia

There have been few reports in the literature concerning the magnetic resonance imaging (MRI) appearances of fibrous dysplasia. We reviewed MRIs of 4 patients with craniofacial lesions. Using a 1.5-T Signa Unit (General Electric, Milwaukee, WI), both T1- and T2-weighted MRI scans were performed. In our 4 patients, the fibrous dysplastic lesions were characterized by a decreased signal on both T1- and T2-weighted images. And all lesions had sharply demarcated borders. The fine image of fibrous dysplasia by MRI is extremely useful, not only as a diagnostic aid, but also as an invaluable guide to surgery.

Preoperative and postoperative orbital volume in patients with Crouzon and Apert syndrome.

Abstract Crouzon and Apert syndromes are frequently complicated by ocular abnormalities and patients with these syndromes often present with abnormal ocular morphology. The present study assesses orbital volume and ocular complications in patients associated with Crouzon and Apert syndromes. During an 8-year period starting in 2002, fronto-orbital advancement was used for cranial expansion on 23 cases of syndromic craniosynostosis. Of those, it was possible to evaluate 5 Crouzon and eight Apert syndrome cases. Orbital volume was measured using multislice CT scans. Both preoperative and postoperative orbital volumes were compared with normal orbital volume. Preoperative orbital volume was 5.8 to 10.0 cm3 (mean, 7.1 cm3) in patients with Crouzon syndrome and 7.2 to 10.8 cm3 (mean, 9.1 cm3) in patients with Apert syndrome. Postoperative intraorbital volume was 9.4 to 11.2 cm3 (mean, 10.4 cm3) in patients with Crouzon syndrome and 11.6 to 13.2 cm3 (mean, 12.4 cm3) in patients with Apert syndrome. The mean of orbital volume relative to the normal volume was 58% preoperatively and 74% postoperatively in patients with Crouzon syndrome and 69% (56–81%) preoperatively and 88% (81–95%) postoperatively in patients with Apert syndrome. In conclusion, orbital volume was smaller in the Crouzon syndrome group than in the Apert syndrome group, and symptoms, such as exophthalmos and exotropia, were noted in the Crouzon syndrome group. Orbit expansion did not fully restore normal orbital volume, but in most cases, it was useful for alleviation of preoperative symptoms (exophthalmos/eyeball prolapse, corneal erosion, conjunctivitis).