Tetsunori Yoshida

Crystalline lamellae in the endothelial cells of a type of hemangioma characterized by the proliferation of immature endothelial cells and pericytes—angioblastoma (Nakagawa)

Two babies were found to have large hemangiomas. Histologically there were many islands of compactly packed mesenchymal cells in the deep dermis and subcutaneous tissue. Electron microscopically there was proliferation of immature endothelial cells and pericytes. Characteristic crystalline lamellae were in the endothelial cells. Our two cases seemed to be an independent entity from other benign angiomas because of the distinct clinical, histologic, and ultrastructural features. The suggested diagnosis was angioblastoma (Nakagawa; Miki and Matsumoto), hypertrophic hemangioma (Watson and McCarthy), and benign hemangioendothelioma (Stout).

Facial Reconstruction with Free-Tissue Transfer

The article provides a retrospective review of 25 free-tissue transfers for facial reconstruction on 24 recipient sites in 21 patients. The recipient sites of the face were classified into frontal (4 patients), orbital (2 patients), nasal (2 patients), buccal (11 patients), and oral region (5 patients). The transferred flaps included 16 fasciocutaneous flaps (6 forearm flaps, 5 scapular flaps, 2 anteromedial thigh flaps, 1 lateral arm flap, 1 dorsalis pedis flap, and 1 deltopectoral flap) and 8 myocutaneous flaps (6 latissimus dorsi myocutaneous flaps, 1 serratus anterior myocutaneous flap, 1 rectus abdominis myocutaneous flap, and 1 prefabricated flap). Thinning modifications such as the expansion, reduction, or extension techniques were performed in the myocutaneous flap to avoid having a bulky flap. In our view, the flap from the trunk matches the facial skin color better than that from the extremity. Satisfactory results were attained in all cases in which a complete replacement of the facial aesthetic unit was performed.

Experience with Arteriovenous Malformations Treated with Flap Coverage

Fourteen patients with arteriovenous malformations were treated with surgical resection followed by well-vascularized tissue transfer. Free-tissue transfers were used in 12 of the patients and axial local flaps in 2 patients to reconstruct the region with arteriovenous malformations. The feeding arteries of the arteriovenous malformations were used as recipient vessels in all cases of free-tissue transfers without any trouble in microvascular anastomosis. With an average follow-up of 3 years and 2 months, 12 patients showed no clinical recurrence (86 percent). Follow-up angiography in seven patients showed complete disappearance of malformations in two patients and residual malformations not enlarged in three patients. Two patients had residual malformations that were noted to be increasing in follow-up angiograms, and they also had clinical evidence of recurrence. In these patients an intramaxillary recurrence in one and intraorbital in the other appeared at about 1 and 3 years, respectively, after surgery. This therapeutic concept can be expected to provide great remission in the treatment of arteriovenous malformations.

Prefabricated flaps using tissue expanders : An experimental study in rats.

The aim of this study was to determine if muscle vascularized pedicle flaps (MVP flaps) elevated in expanded tissue on the rat would survive to the same or greater area than flaps elevated in nonexpanded tissue. The animals were divided into three groups: group I (n = 10), with a tissue expander; group II (n = 10), with a tissue expander but not expanded; and group III (n = 10), with a thin silicone sheet (Biobrane). The mean surviving area of group I (96.6 ± 3.6 percent) was statistically higher than that of group II (73.2 ± 24.7 percent) (p < 0.05) and group III (59.5 ± 25.1 percent) (p < 0.005). These experiments demonstrate that there is a larger area of flap survival in expanded muscle vascularized pedicle flaps than that found in nonexpanded flaps in rats. The mechanism of increased vascularity associated with tissue expansion is still unclear, but microangiography of flaps showed increased vascularity of the pedicle itself, especially in group I.

Adenoid Cystic Carcinoma of the Skin: -An Immunohistochemical and Ultrastructural Study-

Adenoid cystic carcinoma of the skin was studied. Histologically, tumor cells were arranged in a tubular and a cribriform pattern, mainly in the reticular dermis. Immunohistochemically, epithelial membrane antigen was reactive with the tumor cells, but S‐100 protein, vimentin, and carcino‐embryonic antigen were not. On electron microscopy, we confirmed the findings of previous reports; tumor cells were arranged to form luminal structures; most of them were pseudolumina containing fine mucin granules, basal laminae, and collagen fibers, but some were true lumina with numerous microvilli and junctional complexes. New findings of this study were bizarre‐shaped, electron‐dense, net‐like structures within the true lumina which were considered to be a type of mucin.

Reconstructive considerations after resection of malignant melanoma in the head and neck

Little has been written about reconstructive methods after resection of melanomas in the head and neck region. We investigated reconstructive methods retrospectively related to the site and size of the melanomas resected by examining the medical records of 28 patients who had malignant melanomas of the head and neck resected at our hospital from 1984 to 2001. The tumour distribution was 12 in the cheek, 6 in the conjunctiva, 2 in the upper lip, 2 in the lower lip, one each in the lower eyelid, eyebrow, scalp, nose, and auricle. Reconstructive methods were 18 skin grafts, seven local flaps, and three free flaps. Three patients who had skin grafts required secondary reconstruction using free flaps. No local recurrences were observed. Reconstructions with local flaps give better aesthetical and functional results than free flaps and skin grafts. Immediate reconstruction with a flap is safe and it does not affect observation of local recurrences.

«Boomerang» rectus abdominis musculocutaneous free flap in head and neck reconstruction

Immediate head and neck reconstruction after cancer resection using the “boomerang” rectus abdominis musculocutaneous (RAM) free flap was performed in 13 patients over the past 2 years. The skin paddle of the flap is designed as a boomerang shape based on the anatomical construction of the dominant perforators from the inferior epigastric vascular system. A versatile technique of the boomerang RAM flap provides effective use for reconstruction of the complex defects at the skull base, orbital, nasal cavity, paranasal sinuses, oropharynx, palate, buccal mucosa, tongue, floor of mouth, and neck. It also allows a reconstructive surgical team to elevate the flap simultaneously with a head and neck surgical team before the size and location of the defect are exactly determined and greatly reduces operating time. This flap will be a routine technique for immediate head and neck reconstruction after cancer resection.

Pharmacokinetics of Meropenem in Experimentally Burned Rats

The pharmacokinetics of meropenem were investigated to examine its penetration into the skin of third degree burned rats. The rats were divided into two groups. One group acted as the control, and the other group had third degree burns induced by immersing their backs into 80°C water for 20 seconds. The rats in each group were given 20 mg/kg of body weight of meropenem intravenously by one bolus injection seven days after burn inducement or depilation. In the non‐burned control group, the maximum concentrations of meropenem in the serum and skin of 6.03 µg/ml and 0.12 µg/g were respectively obtained 15 minutes after the injection and decreased very rapidly thereafter. In the burned rats, the maximum concentrations of meropenem in the serum, skin (eschar), and exudate fluid of 7.07 µg/ml, 1.44 µg/g and 5.99 µg/ml were respectively obtained 15 minutes after the injection and decreased very slowly. The penetration of meropenem into the burned skin was higher than that into the normal skin. These results suggest that meropenem is a very useful antibiotic in the treatment of burn infection.

Prognostic Evaluation of Cutaneous Malignant Melanoma Based on the pTNM Classification

The prognoses of 100 consecutive melanoma patients were analyzed on the basis of Breslows thickness and Clarks levels as well as according to stage employing the 1987 UICC pTNM classification. Among patients with lesions ≦1.50 mm thick, the 10‐year survival rate was 100% for both pT1 (n=13) and pT2 (n=6) disease, 73.4% for pT3a disease (n=26), 62.2% for pT3b disease (n=15), 69.3% for pT3 (n=41) disease, and 38.7% for pT4 disease (n=38). Significant differences in survival were found between the pT4 group and the pT1/pT3a or pT3 groups. The 10‐year survival rate was 100% for level II (n=13) and level III (n=13) disease, 58.3% for level IV (n=46) disease, and 34.5% for level V (n=26) disease. Significant differences were found between level V and other levels. The survival rate at 10 years was 100% for stage I (n=18), 63.3% for stage II (n=24), and 52.5% for stage III (n=55). In stage IV (n=3), there was only one patient who survived for 42 months. There were significant differences in survival among all stages except I and II. The 10‐year survival rate in 3 subgroups of stage III was 58.9% for pT4pN0M0 patients (n=14), 63.2% for pT,pN1M0 patients (n=31), and 20% for pT,pN2M0 patients (n=10). Significant differences were found between the pT,pN1M0 and pT,pN2M0 subgroups. These findings indicate that the survival of pT1, pT2 and stage I patients is extremely good. In contrast, the prognosis of patients with pT3, pT3b or pT4, and stage III or IV disease is significantly poor. Within stage III, the prognosis of the pT,pN2M0 subgroup is significantly poor, and the classification of pN2 patients may need to be reconsidered.

Clinical Evaluation of Cutaneous Malignant Melanoma with Histologically Involved Lymph Node Metastases

Thirty‐six cases of cutaneous malignant melanoma with histologically involved lymph nodes were studied during a 2–10 year study period, and the characteristics of the metastasized nodes and the associated prognosis were compared. The results were as follows: 1) the survival rate in cases with 3 or fewer (n=16) metastasized nodes was significantly higher than in cases with 4 or more positive nodes (n=20); 2) the survival rate in cases in which metastasized nodes were limited to one regional lymph node section (n=12) was significantly higher than in cases where metastasis extended to two or more intra‐regional sections of nodes (n=24); 3) cases which had nodes measuring 3.00 cm or less (n=25) had significantly higher survival rates than those with nodes of 3.01 cm or more (n=11). Therefore, the results indicate that the number of metastasized lymph nodes, the extension into regional lymph node sections, and the size of the metastasized lymph node(s) can be considered as important prognostic factors for melanoma patients.