Takatoshi Yotsuyanagi

A simple technique for reconstruction of the umbilicus, using two twisted flaps.

A successful umbilical reconstruction is described, using two twisted flaps with one pedicle. This technique is easy and simultaneously revises the scar of the abdominal wall. With this procedure, the umbilicus has a natural appearance with sufficient depression and normal-appearing wrinkles.

Functional reconstruction using a depressor anguli oris musculocutaneous flap for large lower lip defects, especially for elderly patients.

Described here is a new technique to reconstruct large lower lip defects using one or two musculocutaneous island flaps, which includes an innervated depressor anguli oris muscle and has a facial artery in its pedicle. Vermilion is simultaneously reconstructed using a mucosal transposition flap. Three patients who had a total lower lip defect and five patients who had a defect larger than one-half of the lower lip were treated by our procedure. All the flaps survived completely without any signs of vascular stasis. In six patients, sphincter function and sensation appeared within 3 months after surgery. In one patient who needed a total lower lip reconstruction, the depressor anguli oris muscle was atrophic and the motor nerve could not be found. This patient could not regain motion. One other patient complained of a sialorrhea accompanied by sensory loss; however, his sensation improved within 6 months after surgery. All of the reconstructed lower lips were large enough to enable the patient to wear dentures and were of a cosmetically acceptable appearance 1 year after surgery.

The external ear: More attention to detail may aid syndrome diagnosis and contribute answers to embryological questions

The human pinna has a complex shape and yet the basic components of normal structure are remarkably constant between individuals. It is precocious in its appearance during embryogenesis and it has been subject to many developmental and surgical studies, yet questions remain as to its primary embryogenesis and the causes of its malformations. Unfortunately, the vast majority of clinical reports of syndromes and of individuals with dysmorphic signs provide limited and inadequate description of the external ear. Given the intricate pattern of the pinna, and hence its potential for morphological variation, we think that more attention to the specific description of ear anomalies may lead to a better appreciation of the etiology and embryology of the malformations. Furthermore, in some cases correlation with specific syndromes may provide an aid to diagnosis. Towards those ends this paper reviews some of the controversy concerning the embryology of the pinna, and discusses a number of the better‐defined anomalies of the external ear. Although it has been suggested that anomalies of the insertion and orientation of intrinsic muscles of the pinna may be responsible for variations in external ear morphology, we think it likely that in many cases the anomalous insertions may be secondary.

nasal Reconstruction Based on Aesthetic Subunits in Orientals

&NA; Reconstruction based on the aesthetic subunit principle has yielded good aesthetic outcomes in patients with moderate to severe nasal defects caused by trauma or tumor resection. However, the topographic subunits previously proposed are often unsuitable for Orientals. Compared with the nose in white patients, the nose in Orientals is low, lacks nasal muscle, and has a flat glabella; the structural features of the underlying cartilage and bone are not distinctly reflected in outward appearance. The authors devised aesthetic subunits suitable for Orientals, and they used these units to reconstruct various parts of the nose. The major difference between these units and those presented previously is the lack of soft triangles and the addition of the glabella as an independent unit. The authors divided the nose into the following five topographic units: the glabella, the nasal dorsum, the nasal tip, and the two alae. The border of the nasal dorsum unit was extended to above the maxillonasal suture. The basic reconstruction techniques use a V‐Y advancement flap from the forehead to reconstruct the glabella, an island flap from the forehead to reconstruct the nasal dorsum and nasal tip, a nasolabial flap to reconstruct an ala, and a malar flap to reconstruct the cheek. A combination of flaps was used when the defect involved more than one unit. This concept was used for nasal reconstruction in 24 patients. In one patient undergoing reconstruction of the nasal dorsum and in one undergoing reconstruction of the nasal tip, the texture of the forearm flap did not match well, which resulted in a slightly unsatisfactory aesthetic outcome. In one patient in whom the glabella, nasal dorsum, and part of the cheek were reconstructed simultaneously, a web was formed at the medial ocular angle, and a secondary operation was subsequently performed using Z‐plasty. In one patient undergoing reconstruction with a forehead flap, defatting was required to reduce the bulk of the subcutaneous flap pedicle at the glabella. However, suture lines were placed in the most inconspicuous sites in all patients, and the use of a trapdoor contraction emphasized the three‐dimensional appearance of the nose. The use of these aesthetic subunits for reconstruction offers several advantages, particularly in Oriental patients. Because the nasal dorsum is reconstructed together with the side walls, tenting of the nasal dorsum is avoided, which prevents a flat appearance of the nose. A forehead flap is useful in the repair of complex defects. Defects of the alae should be separately reconstructed with a nasolabial flap to enhance the effect of the trapdoor contraction and to highlight the three‐dimensional appearance of the nose. Candidates for reconstruction should be selected on the basis of nasal structure. The results suggest that these units can also be used in some white patients. (Plast. Reconstr. Surg. 106: 36, 2000.)

Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commissure

Various methods of reconstructing lower lip partial defects have been reported, for example those using the upper lip such as the Abbe and Estlander flap techniques. However, when a large defect of the lower lip with oral commissure is presented, the choice of reconstruction method is often difficult. For such cases, the Estlander flap technique is often used, although displacement of the oral commissure is one of the remaining problems. In the case of large defects of the lower lip with oral commissure, we opted for a reconstruction method in which the entire upper lip was incised and extended, a portion of which was reflected as a traditional Estlander flap. Four cases were treated using this method, and in all cases there were no complications such as venous return disturbance, and the site healed well. Sensation returned within 3 months, and contraction of the lips appeared within 6 months. The symmetry of oral commissures was maintained and the appearance was almost cosmetically satisfactory. Our technique is especially useful for reconstructing defects affecting 1/3-2/3 of the lower lip including the oral commissure. This technique is cosmetically and functionally successful and the symmetry of the oral commissure is maintained.

Inhibition of endogenous MHC class II-restricted antigen presentation by tacrolimus (FK506) via FKBP51

The effect of tacrolimus (FK506) on down‐regulation of IL‐2 production by T cells is considered to be mainly responsible for its strong suppression of immunological events. In this study, we show that FK506 also has an affect on antigen presentation by antigen‐presenting cells in vitro. FK506 was able to inhibit the presentation of endogenous MHC class II‐restricted minor histocompatibility antigens in primary dendritic cells (DC) in vitro, but cyclosporine A (CsA) and rapamycin (RAP) were not. RNA interference (RNAi)‐mediated reduction of endogenous FK506‐binding protein (FKBP)51 expression resulted in a marked decrease in antigen presentation, suggesting that FKBP51 plays a role in endogenous MHC class II‐restricted antigen presentation. Since our model used naturally expressed cytosolic antigens in primary DC, these effects might have been due to novel properties of the immunosuppressive drugs and may allow us to elucidate a new paradigm for the immunosuppressive mechanism of FK506.

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle.

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog‐ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 × 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated. (Plast. Reconstr. Surg. 107: 1358, 2001.)

Resveratrol inhibits fibrogenesis and induces apoptosis in keloid fibroblasts

Keloids are benign dermal fibrotic tumors arising during the wound healing process. The mechanisms of keloid formation and development still remain unknown, and no effective treatment is available. Resveratrol, a dietary compound, has anticancer properties and, from recent studies, it has been suggested that resveratrol may have an antifibrogenic effect on organs such as the liver and kidney. Based on this idea, we investigated its effect on the regulation of extracellular matrix expression, proliferation, and apoptosis of keloid fibroblasts. Type I collagen, α‐smooth muscle actin, and heat shock protein 47 expression decreased in resveratrol‐treated keloid fibroblasts in a dose‐dependent manner. In addition, resveratrol diminished transforming growth factor‐β1 production by keloid fibroblasts. We also demonstrated that it suppressed their proliferation and induced apoptosis of the fibroblasts. Conversely, resveratrol did not decrease type I collagen, α‐smooth muscle actin, and heat shock protein 47 mRNA expression in normal skin fibroblasts and barely suppressed cell proliferation. Our data indicate that resveratrol may have an antifibrogenic effect on keloid fibroblasts without any adversely effects on normal skin fibroblasts, suggesting the potential application of resveratrol for the treatment of keloids.

Management of the hairline using a local flap in total reconstruction for microtia.

In cases of microtia with a low hairline, the manner in which hair is removed from the reconstructed auricle must be taken into consideration. This is one of the most common but difficult problems with reconstruction for microtia. The authors describe a new technique that uses a simple regional flap to resolve this problem. The hair-bearing skin in the estimated auricular region and its covering are removed using a local flap from the hairless mastoid region. This is done in the first stage of auricular reconstruction, the costal cartilage grafting is done in the second stage, and elevation of the auricle is done in the last stage. In 38 auricles of 36 patients who were treated from 1993 to 1995, eight auricles of eight patients were treated with this technique. In all cases, the hairless flap healed well, without vascular stasis or skin necrosis. In addition, no complications from using this technique occurred in the later stages of auricular reconstruction. With this technique, the skin of the flap provides a good texture and color match to the auricle. In addition, the skin of the flap has good elasticity for the cutaneous pocket for cartilage grafting. The harvested area of the flap can be hidden behind the reconstructed auricle. The authors initially wondered whether the marginal scar of the transposed flaps position in the auricle would be conspicuous. However, all of the scar became inconspicuous because it was positioned in the scaphoid fossa.

Helical crus reconstruction using a postauricular chondrocutaneous flap

The authors describe a helical crus reconstruction technique using a postauricular chondrocutaneous flap vascularized by the postauricular vessels. They used this procedure on 7 patients who had developed a large defect on the helical crus following surgery. In each patient the flap design was adjusted to fit the form of the defect. All flaps were in easy reach of the defect and all flaps survived without any complications. The reconstructed ears had good three-dimensional form, and the color and texture match was satisfactory. The flap donor site was not noticeable because it was hidden behind the ear. Constriction did not occur and a good form was maintained. Neither deformity due to scar contracture nor absorption of the cartilage was observed.