Kenichiro Kawai

Vascular anatomy of the anterolateral thigh flap.

Arterial and venous anatomy and their relation to the anterolateral thigh flap were examined in 10 specimens of six fresh cadavers in which radiopaque materials were injected into both the arterial and venous systems. Territories and positions of individual perforating arteries were measured, and the venous drainage pathway of the flap was analyzed. All specimens were radiographed stereoscopically to observe the three-dimensional structure of the arteries and veins. The territory of each perforating artery was smaller than expected. Most of the venous blood that had perfused the dermis was considered to pool in a polygonal venous network located in the skin layer and to enter the descending branch of the lateral circumflex femoral artery through large descending veins. The venous territories were considered different from the arterial territories. The findings in this study suggest that the design of the anterolateral thigh flap should be based on the venous architecture rather than on the arterial architecture and that the flap survival rate might be improved if thinning is performed appropriately.

Arterial anatomical features of the upper palpebra

The arterial anatomical features of the upper palpebra were examined in both sides of seven fresh cadavers that had been systemically injected with a lead oxide/gelatin mixture. All specimens were stereoscopically radiographed for analysis of the three-dimensional structure of the arteries and were macroscopically dissected for observation of the relationships between the arteries and the other tissues. Cross-sections were prepared from one specimen and examined histologically. In all cases, there were four arterial arcades in the upper palpebra, namely, the marginal, peripheral, superficial orbital, and deep orbital arcades. Each arcade provided small vertical branches. The vertical branches coursed on both sides of the orbicularis oculi muscle and on both sides of the tarsal plate. From these small vertical branches, fine vessels branched off to the skin, muscle, and tarsal plate. These findings are important for avoiding complications such as bleeding and are useful for designing local flaps, such as switch flaps, for reconstructive surgical procedures.

Effects of adiponectin on growth and differentiation of human keratinocytes--implication of impaired wound healing in diabetes.

Impaired wound healing is one of the most common complications associated with diabetes. Adiponectin is an abundant circulating adipocyte-derived cytokine that has beneficial effects on disorders accompanying diabetes. Herein we report that adiponectin has a regulatory effect on the growth and differentiation of HaCaT human keratinocyte cells. Furthermore, adiponectin regulated the expression of TGFbeta isoforms in keratinocytes in a dose-dependent manner, which implies that adiponectin modulates other types of cells related to wound repair via secretion of growth factors from keratinocytes. Moreover, TUNEL assay results revealed that adiponectin enhances apoptosis of keratinocytes. Taken together, the present results indicate that adiponectin has suppressive effects on the formation of hyperkeratosis commonly seen in patients with diabetic foot and its application may be beneficial for developing treatment for that disorder.

Arterial anatomy of the lower lip

The arterial anatomy of the lower lip was investigated in 12 sides of six fresh cadavers that had been injected systemically with a lead oxide and gelatin mixture. We found that the blood supply of the lower lip was derived from the facial artery and three dominant labial arteries: the inferior labial artery, the horizontal labiomental artery, and the vertical labiomental artery. The inferior labial artery was derived from the facial artery or superior labial artery, and ran through the submucous tissue horizontally. The horizontal labiomental artery arising from the facial artery was located between the depressor labii inferioris muscle and orbicularis oris muscle. The vertical labiomental artery arose from the submental artery. These three arteries provided small vessels that traversed vertically. These small vessels and the small branches of the facial artery, that run superficial and deep to the orbicularis oris muscle, formed a vascular network in subcutaneous and submucous tissues and minute vessels branched off to the skin, mucosa, and muscles.

Involvement of Keratinocyte Activation Phase in Cutaneous Graft Healing: Comparison of Full-Thickness and Split-Thickness Skin Grafts

Background. Little is known about keratinocytic activation in the graft take and healing process. Objective. To investigate the clinical and molecular differences between pure epidermal sheet graft (PESG), split‐thickness skin graft (STSG), and full‐thickness skin graft (FTSG). Methods. Three different thickness skin grafts (PESG, STSG, and FTSG) were performed onto three kinds of porcine wounds: shallow, deep, and full. Graft take, contraction, and Ki‐67 and &bgr;1 integrin expression in epidermis were studied. Results. All grafts took well. As expected, full wounds covered by PESG and STSG contracted more than those covered by FTSG, whereas shallow wounds covered by FTSG contracted more than those covered by STSG. No difference in contracture was observed among deep wounds covered by PESG, STSG, and FTSG. Up‐regulation of Ki‐67 and &bgr;1 integrin expression was greater in PESG and STSG, compared with little expression in FTSG. Conclusion. The keratinocytic activation phase may occur both in the STSG and PESG healing process, as well as serum imbibition, inosculatory, and revascularization phases.

Supercharged gastric tube pull-up procedure for total esophageal reconstruction.

Total esophageal reconstruction using a gastric tube is complicated because it sometimes causes postoperative complications such as anastomotic leakage, stenosis, or fistula formation resulting from insufficient blood flow at the distal end. To overcome this problem, during the past 5 years the authors performed seven additional microvascular anastomoses using the short gastric vessels of the gastric tube. No postoperative complications occurred except partial tracheal necrosis in 1 patient. Postoperative radiographic examination showed no reflux or stasis in all patients, and no evidence of necrosis at the anastomotic site of the pulled-up gastric tube was observed by postoperative endoscopy. This technique reduces risk and may contribute to the successful reconstruction of the digestive tract after total esophagectomy.Kawai K, Kakibuchi M, Sakagami M, et al. Supercharged gastric tube pull-up procedure for total esophageal reconstruction. Ann Plast Surg 2001;47:390–393

Growth Factor Measurement and Histological Analysis in Platelet Rich Fibrin: A Pilot Study

ObjectiveThe aim of this study was to compare growth factor amount contained in platelet rich fibrin (PRF) and compare with that in platelet rich plasma (PRP), and in whole blood. And also to investigate distribution of growth factors and cellular components in PRF.Materials and MethodsPRF and PRP were obtained from the same sample of peripheral blood. Extraction of proteins were done with lysis buffer, accompanied by freeze and thaw procedures. Concentration of two representative growth factors in platelets: platelet derived growth factor (PDGF) and transforming growth factor beta (TGF-β), were measured with enzyme-linked immunosorbent assay (ELISA). PRF was cut into three parts: (top, middle and bottom), and growth factor concentration was measured respectively. Paraffin embedded section of PRF was observed with Giemsa stain. Immuno-histochemical analysis with anti-PDGF and anti-TGF-β antibodies was also conducted.ResultsThe growth factor levels in PRF was higher than in peripheral blood and comparable to those in PRP. Growth factor levels in bottom part of PRF was much higher than in top and middle part. Microscopically, platelets and mono-nucleated cells were concentrated just above the yellow–red interface. Poly-nucleated cells were concentrated below the interface.ConclusionThe growth factors were surely concentrated in PRF. This result can support basis of good clinical outcomes. For effective application of PRF, the knowledge that growth factors and cells are not equally distributed in PRF should be utilized.

Hypertrophic scar contracture is mediated by the TRPC3 mechanical force transducer via NFkB activation

Wound healing process is a complex and highly orchestrated process that ultimately results in the formation of scar tissue. Hypertrophic scar contracture is considered to be a pathologic and exaggerated wound healing response that is known to be triggered by repetitive mechanical forces. We now show that Transient Receptor Potential (TRP) C3 regulates the expression of fibronectin, a key regulatory molecule involved in the wound healing process, in response to mechanical strain via the NFkB pathway. TRPC3 is highly expressed in human hypertrophic scar tissue and mechanical stimuli are known to upregulate TRPC3 expression in human skin fibroblasts in vitro. TRPC3 overexpressing fibroblasts subjected to repetitive stretching forces showed robust expression levels of fibronectin. Furthermore, mechanical stretching of TRPC3 overexpressing fibroblasts induced the activation of nuclear factor-kappa B (NFκB), a regulator fibronectin expression, which was able to be attenuated by pharmacologic blockade of either TRPC3 or NFκB. Finally, transplantation of TRPC3 overexpressing fibroblasts into mice promoted wound contraction and increased fibronectin levels in vivo. These observations demonstrate that mechanical stretching drives fibronectin expression via the TRPC3-NFkB axis, leading to intractable wound contracture. This model explains how mechanical strain on cutaneous wounds might contribute to pathologic scarring.

Supplementation of bone marrow aspirate-derived platelet-rich plasma for treating radiation-induced ulcer after cardiac fluoroscopic procedures: A preliminary report

Background: The frequency of encountering radiodermatitis caused by X-ray fluoroscopic procedures for ischaemic heart disease is increasing. In severe cases, devastating ulcers with pain, for which conservative therapy is ineffective, emerge. Radiation-induced ulcers are notorious for being difficult to treat. Simple skin grafting often fails because of the poor state of the wound bed. A vascularized flap is a very good option. However, the non-adherence of the well-vascularized flap with the irradiated wound bed is frequently experienced. Aim: To ameliorate the irradiated wound bed, bone marrow-derived platelet-rich plasma (bm-PRP) was delivered during the surgery. Materials and Methods: Four patients with severe cutaneous radiation injury accompanied by unbearable pain after multiple fluoroscopic procedures for ischaemic heart disease were treated. Wide excision of the lesion and coverage with a skin flap supplemented with bm-PRP injection was performed. Results: All patients obtained wound closure and were relieved from pain. No complication concerning the bone marrow aspiration and delivery of bm-PRP was observed. Conclusions: Supplementation of bm-PRP can be an option without major complications, time, and cost to improve the surgical outcome for irradiated wounds.

Multiple pilomatricomas in a patient with Turner syndrome

Dear Editor, Pilomatricoma is a benign tumor of the hair follicle matrix, and generally presents as a single dermal or subcutaneous nodule. Occurrence of multiple pilomatricomas is rare, but association with myotonic dystrophy has been recognized. Turner syndrome is associated with an abnormal or missing X chromosome, showing various clinical findings, such as sexual infantilism, cubitus valgus, webbed neck, and short stature. Cutaneous signs, including an increased number of melanocytic nevi, halo nevi, vitiligo, a tendency for hypertrophic scarring, and lymphangiectactic edema have been reported. Here, we report the case of a Japanese woman with Turner syndrome presenting with multiple pilomatricomas. A 5-year-old Japanese girl who was diagnosed with Turner syndrome by a chromosomal test because of having a webbed neck, cubitus valgus, a low posterior hair line, and syndactyly, was first referred to us with a subcutaneous nodular mass, 22 mm in diameter, on her left nucha. The lesion was removed and diagnosed histologically as a pilomatricoma. A subcutaneous lesion on her right back was also removed in her teens, and was diagnosed as a pilomatricoma. Subsequently, at the age of 22, she visited us again with two subcutaneous nodular masses on her back (Fig. 1a). The lesions were painless and solid, about 20 mm and 7 mm in diameter, respectively. They were excised and identified histologically as pilomatricomas. After that, two new lesions appeared on the left lower leg and forearm, which were removed and diagnosed histologically as pilomatricomas (Fig. 1b). Histologic analysis showed a composition of basaloid cells, shadow keratinocytes, and focal calcification (Fig. 1c,d). Since b-catenin has been suggested to play an important role in the formation of pilomatricomas, we performed immunohistochemical staining of b-catenin in the patient’s pilomatricomas. Immunohistochemistry showed b-catenin expression in the basoloid cells (Fig. 1e–g). Pilomatricoma is a benign tumor of the hair follicle matrix, and generally presents as a single dermal or subcutaneous nodule. Noguchi et al. first reported a case of Turner syndrome with multiple pilomatricomas in 1999. Since then, four English-language reports have been published to date. The etiology of occurrence of multiple pilomatricomas in Turner syndrome is unclear. Error in the expression of b-catenin, a signal transduction protein in the wingless-type (Wnt) signaling pathway, has been attributed to the development of pilomatricomas, and the presence of b-catenin nuclear localization in pilomatricomas indicates Wnt pathway activation. In our case, nuclear staining of b-catenin was observed. Furthermore, a mouse model of Turner syndrome showed a reduction of glypican-3, which is also involved in the Wnt/b-catenin pathway. Therefore, dysfunction of Wnt/b-catenin pathway may cause multiple pilomatricomas in Turner syndrome. However, some other factors which can fully explain this entity, rather than the factors related to Turner syndrome, may exist, and therefore, we believe further investigations are needed. Here, we reported a case of multiple pilomatricomas occurring with Turner syndrome. The etiology is still unclear, but Wnt/b-catenin pathway may be involved. In clinical practice, when physicians find a dermal or subcutaneous hard lesion in Figure 1. (a) Subcutaneous nodular masses on her back (arrows). She also showed a webbed neck. (b) Pilomatricoma on the left forearm (arrow). (c, d) Composition of basaloid cells, shadow keratinocytes, and focal calcification (Hematoxylin and eosin staining. Original magnification (c) 920 and (d) 9100). (e–g) b-catenin immunoreactivity and nuclear localization in basaloid cells of pilomatricoma (Original magnification (e) 920, (f) 9100, and (g) 9400).