Tsutomu Kashimura

Endoscopic transmaxillary repair of orbital floor fractures: a minimally invasive treatment.

Abstract Although endoscopic transmaxillary repair of orbital floor fractures is a minimally invasive treatment, controversy remains regarding the method for supporting the orbital floor after elevation of the orbital contents. To date, a urethral balloon catheter has been widely used. However, it can be difficult to leave the catheter in place for a long time period due to the inconvenience, and prolapse of the orbital contents may recur in the case of its premature removal. This study described the techniques for endoscopic reduction and use of a balloon for orbital floor fractures. From June 2006 through November 2011, 30 of 52 patients (57.7%) with an isolated orbital floor fracture underwent endoscopic transmaxillary repair. A maxillary sinus balloon (#3007, Koken Co., Japan) was inserted into the maxillary sinus to support the orbital floor after endoscopic transmaxillary reduction, and the connecting tube of the balloon was pulled into the nasal cavity through the maxillary ostium. After confirmation of accurate reduction by postoperative CT, the connecting tube was shortened and hidden in the nasal cavity. The balloon was left in place for 4–8 weeks, and then removed via the maxillary ostium on an outpatient basis. Complete resolution of the preoperative diplopia was achieved in 93%, and no late-developing enophthalmos was seen in 97% of the patients. There were no significant complications. This technique is safe and permits prolonged retention of the balloon, without interfering with daily life.

The Effect of Mature Adipocyte-Derived Dedifferentiated Fat (DFAT) Cells on a Dorsal Skin Flap Model.

ABSTRACT Background: Dedifferentiated fat (DFAT) cells, isolated from mature adipose cell, have high proliferative potential and pluripotency. We report on the expansion of flap survival areas on the back of rats administrating DFAT cells. Materials and Methods: Intraperitoneal adipose tissue was collected from a male Sprague-Dawley (SD) rat. The mature fat cells were cultured on the ceiling surface of culture flask to isolate DFAT cells. On day 7 of the culture, the flask was inverted to allow normal adherent culture. A dorsal caudal-based random pattern flap measuring 2 × 9 cm was raised on each SD rat. We prepared a control group (n = 10) and a flap base injection group in which DFAT cells were injected 2 cm from the flap base (n = 10) and a flap center DFAT injection group (n = 10). In which DFAT cells at 1 × 106 cells/0.1 ml were injected beneath the skin muscle layers of the flap. The flap survival areas were assessed on day 14 after surgery. Results: The mean flap survival rates of the control group, flap center injection group and flap base injection group were 53.6 ± 6.1%, 50.6 ± 6.4% and 65.8 ± 2.4%, respectively. The flap survival areas significantly expanded in the flap base injection group (p < .05). In H-E staining beneath the skin muscle layer connective tissue thickened in the flap base injection group. In the India ink staining, abundant neovascularization was observed inside the thickened parts. Conclusion: The injection of DFAT cells into the flap base promoted the expansion of survival areas.

Effects of mature adipocyte-derived dedifferentiated fat (DFAT) cells on generation and vascularisation of dermis-like tissue after artificial dermis grafting

Abstract Although artificial dermis (AD) is effective for skin reconstruction, it requires two separate procedures, because the AD must be vascularised before skin grafts. To shorten the period of the dermis-like tissue generation before the secondary skin grafting must be beneficial. Dedifferentiated fat (DFAT) cells are isolated from mature adipose cell suspensions and have potential to differentiate into multiple cell types including endothelial cells. This study aimed to investigate effects of DFAT cells on dermal regeneration after AD grafts in rats. The effects of combination use of DFAT cells and basic fibroblast growth factor (bFGF) were also tested to mimic clinical situations. DFAT cells were isolated from SD rats. Full-thickness wounds were created on the back of rats followed by AD grafting. Five groups were established; Group I: control, Group II: treated with DFAT cells, Group III: treated with bFGF, Group IV: treated with both of DFAT cells and bFGF, and Group V: treated with Green fluorescent protein (GFP)-labelled DFAT cells and bFGF. Histological evaluation was serially performed. Group IV showed markedly promoted vascularisation of dermis-like tissue. In particular, capillary infiltration into the dermis was obtained within 2 days. Immunohistochemical examination revealed that the transplanted DFAT cells had differentiated into endothelial cells and participated in angiogenesis. Group IV also showed a marked increase in the thickness of the dermis like tissue. The present results suggest that the use of DFAT cells under bFGF treatment could be beneficial to shorten the period required for dermal regeneration and vascularisation and contribute to use AD more effectively and safely.

Dermatofibrosarcoma protuberans on the chest with a variety of clinical features masquerading as a keloid: is the disease really protuberant?

Dear Editor: Dermatofibrosarcoma protuberans (DFSP) is regarded a locally invasive, low-grade sarcoma. DFSP is typically characterized by its protuberant appearance. The DFSP in our patient had a clinically heterogeneous appearance, which is very rare, so the DFSP was initially misdiagnosed as a keloid. A 46-year-old male presented with a progressing skin lesion on his anterior chest. The erythema with itching had developed in his 20s, and the nodules appeared gradually. The nodules were thought to be keloids, so he received intralesional steroid injections for a few years at a dermatological clinic. However, that therapy had little effect, and he was referred to our department. He presented with an 8.0×10.0-cm shiny, atrophic skin-colored plaque, in which indurated erythema and painful keloid-like nodules were observed (Fig. 1). These nodules were also found on his chest area. The atrophic plaque (Fig. 2A), erythema (Fig. 2B), and nodule (Fig. 2C) were biopsied. Fig. 1 Clinical features of the 3 different lesions: shiny atrophic plaque (8.0×10.0 cm), indurated erythema, and painful, keloid-like red nodules (largest nodule: 2.0×1.5 cm) on the anterior chest. Fig. 2 Histopathological features of the lesions (HE a few proliferating spindle cells are seen (B). Erythematous plaque (C); storiform pattern is evident, but cellularity is low (D). Keloid-like nodule (E); typical ... Histologically, the 3 samples showed common basic structures. The epidermis consisted of atrophic and spindle-shaped cells, showing little atypism; the cells proliferated in a storiform pattern throughout the dermis and even extended to the lobular structures of fatty tissue. The tumor cells were CD34 positive. To identify the histological differences according to clinical status, we examined the cellularity and positive staining rates for Mib-1 in the atrophic plaque, erythema, and nodule. The cellularity count for each sample was performed in 10 randomly selected areas at high magnification (×200). The degree of cellularity in the nodular lesion (Fig. 2F) was higher than that in the other lesions (Fig. 2D, E). The mitotic index was similar among the 3 lesions. Later, the tumor was resected along the planned 3-cm margin. The overlying skin defect was reconstructed using a flap from the greater pectoral muscle. At the follow-up after 2 years, the patient was found to be free of the disease. DFSP is typically characterized by its protuberant appearance during early or middle adulthood. However, several cases of clinical and pathological unusual variants, such as Bednars tumor and myxoid, sclerosing, fibrosarcomatous, atrophic, and nonprotuberant DFSP have been reported1. Our patient showed unique and various clinical features in a single location, including atrophic plaque, indurated erythema, and keloid-like nodules. What factors cause these different clinical appearances? The atrophic variant of DFSP is most commonly found on the trunk of women2. Furthermore, atrophic DFSP is more common among children and young adults3 than among the elderly. Martin et al.4 reported a nonprotuberant form of DFSP, and nearly half of their patients identified their early DFSP-related skin changes as patches, and the nonprotuberant stage lasted for 7.6 years. In those cases, the clinical appearance of the lesions resembled that of morphea, morpheaform basal cell carcinoma, atrophoderma, or angioma lesions. The COL1A1-PDGFB fusion gene is present in all the cases of DFSP subtypes. The different types of fusions between COL1A1 and PDGFB, however, are not related to the differences in clinical or histological features5; the factors contributing to these clinical differences have not yet been clarified. DFSP is not always protuberant, and awareness of this rare clinical presentation may assist in the early diagnosis of unusual variants of DFSP.

False-negative monitoring flap in free jejunal transfer.

We treated a case that exhibited dissociation between blood flow in the transferred jejunum and the monitoring flap. The monitoring flap showed a false-negative, indicating blood flow to be favorable despite blood congestion in the transferred jejunum. The patient was a 69-year-old man. After tumor resection, reconstruction was performed with free jejunal transfer. Vascular anastomosis was performed on the jejunal artery and transverse cervical artery and on the jejunal vein (V1) and external jugular vein. After esophagus anastomosis, blood congestion was noted in the transferred jejunum. An engorged arcade vein (V2) was observed in the mesenterium on the transferred jejunum side. Therefore, it was anastomosed to the external jugular vein bifurcation. The first postoperative day, thrombus had formed in the vein (V2). The transferred jejunum side vein (V2) was re-anastomosed to the external jugular vein, and improved blood flow was observed in the transferred jejunum. Monitoring transferred jejunum blood flow with monitoring flap exteriorization appears to be a simple and highly reliable method. However, because the monitoring flap cannot directly evaluate transferred jejunum blood flow, blood flow obstruction can occur between the transferred jejunum and the true situation may not be reflected.

One-step grafting procedure using artificial dermis and split-thickness skin in burn patients

The study aimed to achieve a one-step grafting procedure using artificial dermis and split-thickness skin. We performed simultaneous grafting of artificial dermis and skin in two severely burned patients. Artificial dermis was treated with fresh autogenous platelet-derived wound-healing factors (PDWHF), cryopreserved allogeneic cultured endothelial cells, and fibroblasts. Dermal microvascular endothelial cells and fibroblasts were obtained from a single human donor’s skin. The cultured cells were cryopreserved until use in grafting. The PDWHF was prepared from autogenous blood from each patient prior to the surgery. In two patients, the artificial dermis treated with this method was grafted to a full-thickness burn wound. Immediately after artificial dermis grafting, meshed split-thickness skin was grafted. In each case, the skin graft took well, and the skin texture was acceptable. Histological examination revealed that bovine collagen tissue remained in the dermis after surgery, indicating the success of the simultaneous grafting of the artificial dermis and the skin. The present study indicates that one-step grafting of artificial dermis and split-skin is possible when the artificial dermis is treated with PDWHF and cultured endothelial cells and fibroblasts.Level of Evidence: Level V, therapeutic study.

Stability of Orbital Floor Fracture Fixation After Endoscope-Assisted Balloon Placement

Abstract In recent years, endoscope-assisted balloon fixation using transantral and endonasal approaches has gained popularity as a minimally invasive treatment for orbital floor fractures. However, the optimal duration for balloon placement and the efficacy of the method have not been fully evaluated. The authors report their assessment of this method using postoperative and chronological measurements of the maxillary sinus volume. Fourteen patients with blowout fracture of the orbital floor who underwent reduction using endoscopic transantral and endonasal approaches followed by 6-week fixation with a balloon were evaluated. The volume of the maxillary sinus was measured for comparison using computed tomography at the time of balloon removal and 6 months after the surgery. The ratio of change in the maxillary sinus volume (maxillary sinus volume 6 months after surgery/maxillary sinus volume at balloon removal) for all subjects was 0.90 to 1.04 (0.96 ± 0.44, mean ± SD). No postoperative reduction in volume was detected, indicating satisfactory fixation. Postoperative computed tomography showed bone regeneration in the orbital floor in all patients in whom the fractured bone fragments were removed. No subjects had remaining enophthalmos greater than 2 mm. The postoperative change in the maxillary sinus volume was small, confirming the efficacy of 6-week balloon placement. This method was effective even in patients in whom fractured bone fragments were removed. Therefore, it is advisable to remove the fractured bone fragments if there is concern that the fragments will stray into the orbit due to inflation of the balloon.

Effects of combination therapy using basic fibroblast growth factor and mature adipocyte-derived dedifferentiated fat (DFAT) cells on skin graft revascularisation

Abstract Background. Although the benefits of basic fibroblast growth factor (bFGF) for wound healing and angiogenesis are well known, its effects on the process of skin graft revascularisation have not been clarified. It was hypothesised that bFGF would be beneficial to promote taking of skin grafts, but that the effect might be limited in the case of bFGF monotherapy. Therefore, this study investigated the efficacy of combination therapy using bFGF and dedifferentiated fat (DFAT) cells. DFAT cells have multilineage differentiation potential, including into endothelial cells, similar to the case of mesenchymal stem cells (MSC). Methods. Commercially available human recombinant bFGF was used. DFAT cells were prepared from SD strain rats as an adipocyte progenitor cell line from mature adipocytes. Full-thickness skin was lifted from the back of SD strain rats and then grafted back to the original wound site. Four groups were established prior to skin grafting: control group (skin graft alone), bFGF group (treated with bFGF), DFAT group (treated with DFAT cells), and combination group (treated with both bFGF and DFAT cells). Tissue specimens for histological examination were harvested 48 hours after grafting. Results. The histological findings for the bFGF group showed vascular augmentation in the grafted dermis compared with the control group. However, the difference in the number of revascularised vessels per unit area did not reach statistical significance against the control group. In contrast, in the combination group, skin graft revascularisation was significantly promoted, especially in the upper dermis. Conclusion. The results suggest that replacement of the existing graft vessels was markedly promoted by the combination therapy using bFGF and DFAT cells, which may facilitate skin graft taking.

Verrucous nevoid melanoma with satellite lesions on the scalp of a young man

A 32-year-old man presented to our outpatient clinic with a 1-month history of a gradually enlarging painful nodule on his left parietal region. Physical examination revealed a 3.0 9 3.5 cm papillomatous and slightly elevated tumor, which was gray–brown in the center and red– brown at the margin. Several small red papules were disseminated away from the tumor within the range of 1.5 cm (Fig. 1). The lymph nodes in his neck were not swollen. The patient had no pigmented macules or alopecia since birth. Levels of 5-S-cysteinyl DOPA were within normal limits. Systemic metastases were not found by computed tomography. An incisional biopsy was carried out and was histologically diagnosed as nevoid malignant melanoma (NMM). Three weeks later, the tumor was excised surgically, and a split-thickness skin graft was implanted under general anesthesia. The excised specimen showed hyperkeratosis with partial parakeratosis, papillomatosis of the epidermis, and an irregular proliferation of the tumor cells with strong nuclear atypia, mitoses, and hyperchromatism in the dermis. No pagetoid melanocytes Figure 1 A 3.0 9 3.5 cm papillomatous and slightly elevated tumor, which was gray–brown in the center and red–brown at the margin. Several small red papules were disseminated away from the tumor within the range of 1.5 cm