Kyoichi Matsuzaki

Eye socket reconstruction with free flaps in patients who have had postoperative radiotherapy

It is difficult to fit an ocular prosthesis and correct periorbital depression deformity in a patient who has undergone radiotherapy after enucleation of the eye for retinoblastoma during infancy. Simultaneously, developmental disturbances of the eyelids and severe periorbital depression deformities develop. However, due to recent advances in microvascular surgery, free flap transplantation is increasingly used for eye socket reconstruction because of its good circulatory effects with enough volume to augment large periorbital tissue defects. In the present study, we report on our success in using a free groin flap, scapular flaps and parascapular flaps simultaneously for reconstruction of eye sockets and correction of depressed deformities.

Activation of heparanase by ultraviolet B irradiation leads to functional loss of basement membrane at the dermal-epidermal junction in human skin.

Recently, we reported that heparanase plays important roles in barrier-disrupted skin, leading to increased interaction of growth factors between epidermis and dermis and facilitating various cutaneous changes, including epidermal hyperplasia and wrinkle formation. However, the role of heparanase in sun-exposed skin remains unknown. Here, we show that heparanase in human keratinocytes is activated by ultraviolet B (UVB) exposure and that heparan sulfate of perlecan is markedly degraded in UVB-irradiated human skin. The degradation of heparan sulfate resulted in a marked reduction of binding activity of the basement membrane for vascular endothelial growth factor, fibroblast growth factor-2 and -7 at the dermal–epidermal junction. Degradation of heparan sulfate was observed not only in acutely UVB-irradiated skin, but also in skin chronically exposed to sun. Interestingly, heparan sulfate was found to be degraded in sun-exposed skin, but not in sun-protected skin. These findings suggest that chronic UVB exposure activates heparanase, leading to degradation of heparan sulfate in the basement membrane and increased growth factor interaction between epidermis and dermis. These changes may facilitate photo-aging.

Grafting of autologous-cultured epithelium after excision of tattoos

Nine patients with tattoos were treated with cultured epidermal autografts. The tattoos were excised down to the deep dermal layer, and the wounds were covered with cultured epidermal autografts. The areas grafted with cultured epidermal autografts were an average of 907 cm2 in size. The average percentage “take” of the cultured epidermal autografts was 86%. The average time for complete wound epithelialization was 20 days. The pain at the grafted sites was minimal. There was minimal scarring and no tendency for scar contracture. The appearance and elasticity of the grafted sites resembled those of adjacent normal skin 2 1/2 years after grafting. These findings demonstrate that cultured epithelium autografting is a suitable method for coverage of the tangentially excised tattoo wound.

Effect of skin flap ischemia on plasma endothelin-1 levels

A number of studies have been done relating to vasospasm. Vasospasm within the microvasculature of a flap can be one of the causes of ischemia and nonviability. Endothelin-1 (ET-1), a 21-amino acid polypeptide isolated from vascular endothelium culture media, is reported to be one of the most potent vasoconstrictors known. This experimental study, using a rabbit epigastric island flap, was designed to investigate whether skin flap ischemia influenced plasma ET-1 levels. After the ischemic insult, blood was drawn from the venous effluent of the flaps. Plasma ET-1 levels after 6 hours of ischemia were significantly increased compared with nonischemic controls; they were 29 pM, i.e., almost enough to induce vasoconstriction of arterioles. These results suggest that ET-1 is one of the factors responsible for partial necrbsis of the skin flap, which contributes to the genesis of the no-reflow phenomenon.

Treatment of nevus of Ota with autologous-cultured epithelium grafting combined with dermabrasion.

Nevus of Ota is an anomaly of the dermal melanocytes, which lies primarily in the deep dermis. It causes discoloration of the face and induces a remarkable disfigurement to the patients. This report demonstrates the favorable results of 3 male patients treated with autologous-cultured epithelium grafting combined with dermabrasion. The lesions on the cheek, forehead, and temple were dermabraded to the deep dermal layer. The cultured epithelium obtained from preauricular skin or medial upper arm were grafted on the wounds. The grafts took well, and most of the grafted site healed after 1 week. Facial appearances improved remarkably. There was minimal scar formation and minimal recurrence of nevus cell. After long-term follow-up, the grafted sites resembled the adjacent normal face skin in terms of appearance and texture.

Wound treatment and pain management: a stressful time.

This review and case study report considers the evidence to indicate that the progress of wound healing is negatively affected by the presence of stressors and in circumstances where patients are in pain. It considers the relationship between perceptions of pain, stress and delayed wound healing with a specific focus on guidance for clinical practice. It is appreciated that although the literature has examined these issues in the management of acute wounds, demonstrating that psychological stress can have detrimental effects on the wound‐healing process, the evidence to support this link in relation to chronic wounds is limited. The review considers evidence indicating that punch biopsy wounds heal more slowly in subjects under stress on account of caring for family members with long‐term illnesses and also considers briefly the relationship between cortisol secretion in response to stress and the consequent influences on cytokine levels and the wound‐healing process.

Reepithelialisation and the possible involvement of the transcription factor, basonuclin

This article briefly summarises the basic mechanism of reepithelialisation and discusses the possible role of the cell‐type‐specific transcription factor, basonuclin. Reepithelialisation is initiated by a signal resulting from the absence of neighbouring cells at the wound edge. Basal cells at the wound edge become flattened and lose their intercellular desmosomes and substratum attachment. The amount of cytoplasmic actinomyosin filaments that insert into the new adhesion complexes is increased, and contraction of those filaments produces cell movement. The epithelial cells at the wound edge migrate on a provisional matrix using the newly expressed integrin receptors. Once reepithelialisation is complete, the epithelial cells revert to the normal phenotype of basal epidermal cells, firmly attach to the newly developed basement membrane zone through hemidesmosomes and resume standard differentiation. Protein synthesis increases in the epidermal cells at the wound edge during reepithelialisation. Active protein synthesis requires accelerated transcription of ribosomal RNA genes. The transcription factor basonuclin binds to the ribosomal RNA gene promoter and increases the transcription of the genes. Therefore, it is speculated that basonuclin in epithelial cells is required in the process of reepithelialisation.

Changes in the expression of epidermal differentiation markers at sites where cultured epithelial autografts were transplanted onto wounds from burn scar excision

This study investigated the recovery process during which grafted cultured epithelium formed normal epidermis. The subjects were 18 patients whose burn scars were excised at a depth not exposing the fat layer and who subsequently received cultured epithelial autografts. A total of 24 samples were obtained from the grafted sites: 6 samples within 6 weeks (stage 1), 5 samples after 6 weeks and within 6 months (stage 2), 6 samples after 6 months and within 18 months (stage 3) and 7 samples beyond 18 months (stage 4) after transplantation. These samples were stained for monoclonal antibodies against filaggrin, transglutaminase (TG), cytokeratin 6 and involucrin. Their expressions were examined in the epidermis. The expression patterns were classified using a six‐grade scale. The grades of filaggrin and TG were significantly higher at stage 3 and 4 compared with stage 1. There was a marginally significant increase in the grade of cytokeratin 6 at stage 3 and it was significantly higher at stage 4 compared with stage 1. These results showed that wound healing continued at a molecular level until the end of stage 3. The recovery of involucrin was delayed compared with that of other markers. TG and involucrin are thought to be regulated independently at the grafted sites.

Treatment of Inverted Nipple with Subareolar Abscess: Usefulness of High-Resolution MRI for Preoperative Evaluation

Background. Inverted nipples with subareolar abscesses can recur due to insufficient resection. It is important to provide reliable curative treatment after determination of the extent of resection by preoperative imaging evaluation. Methods. Ten patients were treated for inverted nipples with subareolar abscess. Sonography and high-resolution MRI were used as preoperative imaging modalities. The endpoints of preoperative imaging evaluation were defined as the identification of the abscess site, isolated fistula site, and extent of inflammation. Results. In all patients, sonography confirmed the presence of abscesses but their locations could not be identified. Sonography could not confirm the presence of isolated fistula or inflammation. In contrast, high-resolution MRI not only confirmed the presence of abscesses but also revealed their positional relationships with the nipples. In addition, high-resolution MRI confirmed the presence of isolated fistulas and inflammation as well as revealed their positional relationships with the nipples. In all patients, no recurrence was observed, and satisfactory surgical results were obtained. Conclusion. High-resolution MRI is useful in determination of the extent of resection of subareolar abscess associated with inverted nipple.

Diabetic foot wounds in haemodialysis patients: 2-year outcome after percutaneous transluminal angioplasty and minor amputation.

Critical limb ischaemia (CLI) is known to be associated with high mortality. In some patients, surgery cannot be performed due to high risk of perioperative death and complications. In other cases, there is only pain at rest but no wound. Therefore, it is difficult to accurately predict the prognosis of individual patients. We examined the prognosis of CLI cases in which therapeutic footwear was made for ambulation after wounds healed. The subjects were 31 haemodialysis patients with diabetic foot wounds, which were treated with percutaneous transluminal angioplasty and minor amputation. The subjects were 22 men and 9 women. Female patients were significantly older than male patients (P = 0·046). Two‐year postoperative outcomes were survival in 19 patients and death in 12 patients. Eight of twelve deceased patients had a history of coronary intervention. There were 8 deaths among 13 patients with such history, indicating a marginally significant increase in the mortality rate (P = 0·060). Re‐amputation was performed in 6 of 19 patients who survived. Two years postoperatively, 41·9% of patients overall survived without re‐amputation. It is important to increase the number of cases for further study to improve the well‐being of CLI patients and to examine medical economics.