Yi-Chia Wu

Alleviation of Neuropathic Scar Pain Using Autologous Fat Grafting

AbstractTraumatic wounds inflict small- and large-fiber sensory nerve damage, causing neuropathic pain in scar tissue, thus impairing patients’ quality of life and leading to the development of psychological disorders. Autologous fat grafting has been clinically shown to improve scar quality, but few studies have explored the effects of this technique on pain. The purpose of this study was to assess the effect of fat grafting on treating neuropathic scar pain. From February 2008 to January 2013, 13 patients who were identified using the Douleur Neuropathique 4 Questions (scores >4/10) were enrolled in this study. The Visual Analog Scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) were used to evaluate pain preoperatively and 1 week, 4 weeks, and 24 weeks postoperatively. The mechanism of trauma, scar location and size, duration of allodynia, fat graft volume, pharmacologic therapy duration, and total follow-up time were recorded. Thirteen patients experiencing neuropathic pain were enrolled in this study. The mean ± SD age was 33.08 ± 16.35 years. The mean duration of pain was 4.29 ± 2.85 months. The mean VAS score before treatment was 7.54 ± 1.05. The mean VAS scores decreased by 4.38 ± 1.66 after 1 week of treatment (P = 0.009), 5.38 ± 2.06 after 4 weeks of treatment, and 5.62 ± 2.18 after 24 weeks of treatment. The mean NPSI scores were 49.38 ± 13.25 before treatment, 25 ± 14.4 after 1 week of treatment (P = 0.004), 21 ± 17.78 after 4 weeks of treatment, and 14.62 ± 16.88 after 24 weeks of treatment. The 13 patients followed a mean of 24 weeks; 10 (77%) of the patients had improvement of 5 or greater on the VAS score. The mean follow-up period was 19.3 ± 12.26 months (range, 6–38 months). No surgical complications were noted in this series. In our study, both VAS and NPSI scores decreased significantly, revealing that the autologous fat grafting can alleviate neuropathic scar pain 1 week after operation and in the long term.

Medial epicanthoplasty based on anatomic variations

The presence of epicanthal folds is a unique appearance in the eyelids of Asians. Various medial epicanthoplasty techniques have been discussed to achieve a better aesthetic result. Owing to the complexity of the surgery, a design based on anatomic variations of the epicanthal fold is imperative. From September 2006 to November 2010, the author performed medial epicanthoplasty procedures on 86 Asian patients. The whole procedure, including discrepant Z skin incision, myotomy and the plication of the medial canthal ligament (MCL), was performed layer by layer. The inner canthal distance (ICD) was measured and calculated by software ImageJ before and 3 months after surgery. All patients were satisfied with the long-term results and there were no recurrences of the epicanthal fold. The shortening ratios of the ICD ranged from 7.2% to 13.7% (average 10.78%) in the group without the plication of the MCL (57/86). In addition, the ICD shortening ratio ranged from 9.1% to 17.7% (average 15.66%) in the group with the MCL plication (29/86). The technique we described is aimed to correct layered structures including skin, muscle and the MCL of the medial epicanthus. Satisfactory results were ideally achieved with finer scar and natural cosmetic appearance in this series.

Two-year quality of life after free flap reconstruction in tumor-site discrepancy among Taiwanese with moderately advanced oral squamous cell carcinoma

BackgroundThis study describes 2-year impact on quality of life (QOL) in relation to the anatomical discrepancy among T4a oral cancer patients after free flap reconstruction in Taiwan.MethodsThirty-two patients who underwent tumor ablation with simultaneous microvascular free flap transfer at 2-year follow-up were recruited. They were divided into six subgroups, according to the resected area, consisting of: (1) buccal/retromolar trigone; (2) cheek; (3) commissure; (4) lip; (5) mandible; and (6) tongue. Functional disturbances and daily activity were analyzed using the Version-1 UW QOL Questionnaire with one more specific category: ‘Drooling’. Kruskal-Wallis rank sums analysis was used to test differences in average QOL scores between these subgroups. Post-hoc analysis was applied to assess influence of dominant categories between subgroups.ResultsThe category ‘Pain’ revealed the highest average score and reached significant statistical difference (P = 0.019) among all the categories, however, the category ‘Employment’ averaged the lowest score. Regarding ‘Pain’, there existed a statistical significance (P = 0.0032) between the commissure- and cheek-involved groups, which described the former showed poorer pain quality of life.ConclusionsThe commissure-involved group had the lowest average score, which might imply the worst QOL in our study, especially for the categories ‘Pain’ and ‘Drooling’. This present study of T4a patients was the first carried out in Taiwan implementing the QOL questionnaire, and its results may serve for future reference.

Combination of Vascular Intervention Surgery and Free Tissue Transfer for Critical Diabetic Limb Salvage.

BackgroundComplex, nontraumatic diabetic foot ulcers with peripheral vascular compromise often lead to extensive lower-limb amputation. The aim of this study is to determine the outcome of combined vascular intervention and free tissue transfer for critical diabetic limb salvage. Materials and MethodsA total of 26 consecutive diabetic patients with 28 legs with diabetic foot ulcers who underwent limb salvage with a combination of revascularization (bypass surgery or endovascular angioplasty) and free flap transfers were reviewed. There were 14 male and 12 female patients. The average age was 58.8 years (range, 35–85 years). Amputation-free survival and complete wound healing were defined as the primary endpoints. All preoperative and postoperative data were retrospectively analyzed. ResultsThirty flaps were used for reconstruction in 28 legs, including 21 free anterolateral thigh (ALT) perforator flaps, 3 ALT myocutaneous flaps, 5 gracilis muscle flaps, and 1 latissimus dorsi muscle flap. All flaps used end-to-side anastomoses for the recipient artery and end-to-end anastomoses for the recipient vein. The overall flap success rate was 90% (27/30). Two flaps failed completely because of severe arteriosclerosis, which resulted in anastomosed vessel thrombosis. New flaps were applied in both cases after debridement and trimming of necrotic tissue. One flap failed because of restenosis and inadequate perfusion combined with severe infection, resulting in pedicle thrombosis. A below-knee amputation was subsequently performed. Seven flaps exhibited a partial loss, including 6 ALT perforator flaps and 1 latissimus dorsi flap, because of inadequate margin perfusion. After debridement, the flap revision and wound care, 5 flaps healed uneventfully without additional intervention. The remaining 2 ALT perforator flaps required debridement with a skin graft. The limb-salvage rates were 92.8% after 1 year and 89.2% after 5 years. ConclusionsThe combination of peripheral arterial intervention and free tissue transfer resulted in successful wound healing and limb salvage instead of amputation in select diabetic patients with difficult-to-heal wounds.

Adipose-Derived Stem Cell Modulation of T-Cell Regulation Correlates with Heme Oxgenase-1 Pathway Changes.

Background: The authors’ previous proteome study revealed that haptoglobin was involved in adipose-derived stem cell modulation of allotransplant survival and T-cell regulation to induce immune tolerance. This study investigated whether adipose-derived stem cells could modulate T-cell regulation through haptoglobin and the downstream heme oxgenase-1 pathway in vitro. Methods: Splenocytes were isolated from Lewis rat spleens and then CD3+ T cells were purified using anti-CD3+ beads. Adipose-derived stem cells were harvested from Lewis rats and co-cultured with the T cells. After Transwell co-culture at different periods, the authors analyzed cell proliferation with a bromodeoxyuridine assay. Cell extractions and culture supernatants were collected for further analysis. Heme oxgenase-1 and related protein expression levels from the adipose-derived stem cells and T cells were detected using Western blotting. The related cytokine expression levels were analyzed with enzyme-linked immunosorbent assay kits. Flow cytometry was used to detect the regulatory T-cell proportion. Results: The adipose-derived stem cells significantly suppressed T-cell proliferation. The regulatory T-cell percentages were significantly increased in the adipose-derived stem cells that were co-cultured with T cells compared with T cells alone without adipose-derived stem cell co-culture. Heme oxgenase-1 expression in concanavalin A–stimulated T cells that were co-cultured with adipose-derived stem cells revealed a significant increase compared with concanavalin A–stimulated T cells alone. Cytokine assays of the culture supernatants revealed that transforming growth factor-&bgr; and interleukin-10 were significantly increased and interferon-&ggr; was statistically decreased in the adipose-derived stem cell–co-cultured T-cell group compared with other groups; however, blockade with a heme oxgenase-1 inhibitor (zinc protoporphyrin IX) protected against these changes. Conclusion: Adipose-derived stem cells modulate T-cell proliferation and enhance regulatory T-cell expression, and this correlated with heme oxgenase-1 expression and related cytokine pathway changes.

Meningitis and hydrocephalus secondary to panfacial fracture repair in a traumatic brain injury patient

The management of post-traumatic cerebrospinal fluid (CSF) leak in the context of facial bone fracture remains a surgical challenge. The complexity increases in those cases of concurrent traumatic brain injury and craniofacial fractures. The optimal timing for facial bone fracture repair is still controversial in traumatic CSF leak patients [1]. An unrestrained, non-helmeted 14-year-old female on a motor scooter sustained injuries when struck by an automobile. She had an initial loss of consciousness,withmultiple contusions and lacerations over the face, trunk and lower limbs. She was subsequently sent to the emergency room of a regional hospital with a Glasgow coma scale of E2V4M5. Brain computed tomography revealed type II frontobasal fracture, Le Fort I maxillary fracture, nasoorbitoethmoid fracture and intracerebral hemorrhage with pneumocephalus (Fig. 1). Shewas admitted to the intensive care unit for further evaluation and management. CSF leak ceased spontaneously 10 days later under conservative treatment. Her general condition improved gradually. The patient was referred to our hospital on the third week for further facial fracture repair. Open reduction and internal fixation of the right zygoma, disimpaction of the bilateral maxilla, orbital floor repair, and closed reduction of nasal bone were carried out on the 25th day after injury. The operation proceeded uneventfully. Prophylactic antibiotic was administered perioperatively, but 35 hours after the operation, fever, chills, vomiting and severe headache were noted. Physical examination revealed a positive Kernig’s and Brudzinski’s signs, raising suspicion for meningitis. Brain computed tomography revealed enlarged ventricles but showed no intracranial hemorrhage. Lumbar puncture

Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap.

Abstract The pectoralis major myocutaneous pedicled flap (PMMPF) – the “workhorse” for head and neck reconstruction – is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.

Autologous and not allogeneic adipose-derived stem cells improve acute burn wound healing

Adipose-derived stem cells (ADSCs) transplant has been reported to be a potential treatment for burn wounds. However, the effects of autogenicity and allogenicity of ADSCs on burn wound healing have not been investigated and the method for using ADSCs still needs to be established. This study compared the healing effects of autologous and allogenic ADSCs and determined an optimal method of using ADSCs to treat acute burn wounds. Experiments were performed in 20 male Wistar rats (weight, 176–250 g; age, 6–7 weeks). Two identical full-thickness burn wounds (radius, 4 mm) were created in each rat. ADSCs harvested from inguinal area and characterized by their high multipotency were injected into burn wounds in the original donor rats (autologous ADSCs group) or in other rats (allogenic ADSCs group). The injection site was either the wound center or the four corners 0.5 cm from the wound edge. The reduction of burn surface areas in the two experimental groups and in control group were evaluated with Image J software for 15 days post-wounding to determine the wound healing rates. Wound healing was significantly faster in the autologous ADSCs group compared to both the allogenic ADSCs group (p<0.05) and control group (p<0.05). Wound healing in the allogenic ADSC group did not significantly differ from that in control group. Notably, ADSC injections 0.5cm from the wound edge showed significantly improved healing compared to ADSCs injections in the wound center (p<0.05). This study demonstrated the therapeutic efficacy of ADSCs in treating acute burn wounds in rats. However, only autologous ADSCs improved healing in acute burn wounds; allogenic ADSCs did not. This study further determined a superior location of using ADSCs injections to treat burn wounds including the injection site. Future studies will replicate the experiment in a larger and long-term scale burn wounds in higher mammalian models to facilitate ADSCs therapy in burn wound clinical practice.

Impaired cutaneous T-cell attracting chemokine elevation and adipose-derived stromal cell migration in a high-glucose environment cause poor diabetic wound healing

Diabetic wound care is a major health care concern. The major cause of non‐healing of wounds in patients with diabetes mellitus (DM) patients mainly involves poor glycemic control, which hinders the migration of progenitor cells including mesenchymal stem cells to the wound site. In this study, we introduced adipose‐derived stromal cells (ADSCs) into wound sites and demonstrated that the local transplantation of ADSCs accelerated DM‐related wound healing. Furthermore, the migration ability of ADSCs, which diminishes in a high‐glucose environment, was partially restored by the exogenous replenishment of the cutaneous T‐cell attracting chemokine (CTACK/CCL27). Our findings suggest that CTACK is a potential novel therapeutic target in DM‐related wound healing.