The use of calcium phosphate cement paste for the correction of the depressed nose deformity

The authors report the use of calcium phosphate cement paste as a material for correction of depression after nasal bone fracture, and evaluate its usefulness. Biopex R (Mitsubishi Material Corporation, Tokyo, Japan) was used in this study as calcium phosphate cement (CPC), which was developed in Japan. CPC injection was used in six patients (four women and two men) with depressed nose deformity after nasal bone fracture. The patients' ages ranged from 29 to 67 years (mean, 49 years), and the follow-up period ranged from 12 to 27 months. The amount of injected cement varied from 0.5 to 2.5 mL, approximately. There was no postoperative infection or allergic reaction in any patient. Clinical and X-ray photography findings showed that a reduction in volume of the injected cement occurred gradually as long as 7 to 8 months after surgery. After that period, the volume was mostly maintained. It seemed that the degree of reduction was approximately 10% to 15% of the original volume. Satisfactory results were obtained in all cases. The authors conclude that the use of CPC is an option for the correction of depressed nose deformity and that its application must be determined in each case, considering its advantages and disadvantages.

Clinical comparison of the scanning CO2 laser and conventional surgery in the treatment of ingrown nail deformities

AIM

To compare statistically the clinical effects and postoperative course of the scanning CO(2) laser and conventional surgical method to evaluate the clinical effectiveness of the former for the treatment of ingrown nail deformities.

METHODS

We performed vaporization of the nail matrix using the scanning CO(2) laser in 25 cases with ingrown nail deformities.

RESULTS

In 21 cases, the recurrence of ingrown nail deformity was not observed during follow-up. All cases were free of postoperative infection. Use of the scanning CO(2) laser reduced postoperative pain, and all patients were able to return to their daily activities by day 3 post-surgery without any problems.

CONCLUSIONS

Statistically, the operating time and the duration of postoperative pain were reduced significantly by the scanning CO(2) laser. Furthermore, patients treated with CO(2) laser were able to return to daily life significantly sooner.

Chronic expanding hematoma in the temporal region

A rare case of chronic expanding hematoma in the right temporal region that developed into a large mass over the course of 12 years is reported. The patient, who had a history of blunt trauma to her right temporal region at the age of 4 months, noticed a slowly growing mass at the same site over the last few months. Computed tomography revealed a well-circumscribed subcutaneous tumor. The tumor was completely resected. Histopathologically, the diagnosis of chronic expanding hematoma was confirmed.

Use of Calcium Phosphate Cement for Bone Defect After Harvesting Radial Forearm Osteocutaneous Flap

To resolve esthetic and psychologic discomfort of patient due to the lack of radius after harvesting radial forearm osteocutaneous flap, we filled the bone defect and recreated its contour using calcium phosphate cement (CPC; Biopex; Mitsubishi Material Corporation, Tokyo, Japan). Injection of CPC was performed in 5 patients (3 women and 2 men). The patients' age ranged from 61 to 72 years (mean, 65 years), and the follow-up period ranged from 8 to 18 months. The size of the radius harvested varied from 10 x 35 mm to 10 x 50 mm. The width of the harvested bone was approximately 25% to 35% of the circumference of radius. Injected CPC volume varied from 3 to 4 mL, approximately. There was no postoperative infection or allergic reaction in any patient, and movement of hand was also with no problem. The X-P findings showed that the bone defect was filled with a uniform, high-density mass. The injected cement reduced in volume gradually during the fourth or fifth postoperative months, but the degree of reduction was mild in any case, which is probably less than 5% of the injected amount, allowing successful recreation of the contour of the radius. We conclude that the use of CPC for filling the defect of the bone donor site after harvesting radial osteocutaneous flap is valid method to keep a patient free from esthetic and psychologic discomfort due to the lack of the radius.

Dermatofibrosarcoma protuberans arising from a burn scar of the axilla

It is well-known that the development of a malignant tumor in a chronic burn scar is one of the long-term complications of a severe burn. Most of these tumors are squamous cell carcinomas, and sarcomas are much rarely seen in chronic burn scars. In the previous literature, 24 cases of burn scar sarcomas were reported. The authors report the second case of dermatofibrosarcoma protuberans arising in a chronic, severe burn scar. A 68-year-old woman with a reddish tumor in the right axilla was referred to the authors' hospital. The patient had sustained severe burns in the right axilla, upper arm, and trunk at the age of 6 years. A biopsy specimen revealed dermatofibrosarcoma protuberans. There was no evidence of distant metastasis. The tumor was excised widely to include the surrounding burn scar. Two years after the operation, there was no evidence of tumor recurrence. As surgeons, we should recognize the possibility of the occurrence of various malignant tumors including sarcomas on burn scars.

Expression of N-Cadherin and αN-Catenin in the Degeneration/Regeneration Process of Rat Skeletal Muscle after Nerve Injury

The authors investigated the expression of N-cadherin and alphaN-catenin (which is strongly related to N-cadherin function) in the denervation/reinnervation process using a rat sciatic nerve and gastrocnemius model. In a rat model, the right sciatic nerve was exposed at the mid-thigh region, and the nerve was transected with small scissors. Then, the nerve was sutured using 10-0 monofilament perineurial nylon sutures. At various periods up to 24 weeks after the operation, the gastrocnemius muscle of the treated hindlimbs was removed. Four rats were used at each time point in both groups. N-cadherin and alphaN-catenin expressions were detected by Western blot analysis and immunofluorescent staining with anti N-cadherin and alphaN-catenin antibodies. The level of N-cadherin was already elevated in the first postoperative week, and the level in the second postoperative week was almost the same as in the first. The level decreased gradually after the fourth postoperative week and, in the ninth postoperative week, returned to almost the same as the control level. The level of alphaN-catenin was almost the same as the control (1.0) within the second postoperative week. After the fourth postoperative week, the level elevated gradually, with a peak in the sixth postoperative week. The level then decreased and returned almost to that of the control after the twelfth postoperative week. Immunofluorescent staining was observed along the muscular membrane in all specimens of both proteins, and the time course of the degree of immunofluorescent staining was similar to the results of Western blot analysis. These results suggest that N-cadherin and alphaN-catenin expressions are elevated in the degeneration/regeneration processes of the muscle after nerve injury, but that the kinetics between the two proteins differ.

Expression of p53 family in scars

BACKGROUND

There have been some reports on the relationship between p53 and keloid formation. However, there have been no studies comparing the p53 expression among scars in various stages of maturity. However, p63 and p73 have been identified as p53-related genes and have been found to be similar to p53 in their structures and functions and these proteins have also been suggested to relate to scar formation.

OBJECTIVE

We investigate the expression of three proteins of the p53 family in scars with various clinical manifestations and discuss the shared features and differences of these proteins.

METHODS

Forty untreated scar lesions consisting of keloids, hypertrophic scars, and atrophic scars were prepared for investigation. We detected the expression of p53, p63 and p73 proteins using Western blot analysis and histopathological study in each sample.

RESULTS

The 40 lesions were divided into four groups according to their clinical manifestations: keloid (Group A), red hypertrophic scar (Group B), white and hard hypertrophic scar (Group C), atrophic white scar (Group D). In Groups A and B, the histopathological findings demonstrated increased fibroblasts, capillary vessels and infiltration of inflammatory cells. In Group C, most of these changes decreased but proliferation of collagen fibers was evident. In Group D, the degree of proliferation of collagen fibers was much less and capillary vessels and infiltration of inflammatory cells were not evident. The levels of p53 protein elevated in Groups A, B and C and were higher in order of Groups A, B and C. In Group D, the level of p53 was almost the same as that of the control. The level of p63 protein was almost the same as that of the control in all groups. The level of p73 protein was elevated only in Group C.

CONCLUSION

The p53 family members behave in a different manner in various scar tissues. It is suggested that these proteins play different roles in scar formation and the development of unfavorable scars.

Adult umbilical hernia with vertical dislocation

We present a case of adult umbilical hernia with vertical dislocation along the abdominal wall. The hernial sac arose from the internal ring and connected to the umbilicus 20 mm below the internal ring. The postoperative course was uneventful. Two years and four months after the operation there was no evidence of recurrent hernia even when abdominal pressure was increased, and the umbilicus looked acceptable. An umbilical hernia is usually within the umbilicus. The hernial sac arose from the internal ring so should be called an umbilical hernia not an epigastric hernia. It is unusual that the umbilical hernia dislocates vertically along the abdominal wall, while the umbilicus stays depressed. This atypical form of umbilical hernia has not been described previously as far as we know.

Successful Free Osteocutaneous Scapular Flap Transfer for Mandibular Reconstruction in a 93-Year-Old Patient

With the extension of the average life span and the development of surgical technique, anesthesia, and pre- and postoperative management, operations for elderly patients have become more widely accepted. In the field of plastic surgery, free-flap transfers using microvascular techniques have become a common surgical procedure in reconstruction of the head and neck region after surgical removal of a cancer. There have been several reports of free-flap transfer in patients older than 90 years, but the authors know of no reports of free osteocutaneous flap transfer for mandibular reconstruction, which is a very invasive free-flap surgery, for such patients. The mandible plays a significant role in various kinds of dynamic functions, such as mastication, deglutition, and articulation. Disorder of these functions causes a deterioration in the patient's quality of life. The authors have performed a mandibular reconstruction using an osteocutaneous scapular free flap after resection of a gingival cancer invading the mandibular bone in a 93-year-old Japanese woman. In our case, an osteocutaneous scapular free flap, which permits the patient rapid rehabilitation of the lower leg, is thought to be a good choice because it allows the patient to get out of bed as quickly as possible in the postoperative period to minimize additional complications.

Expression of alpha, beta, and gamma catenins in vascularized and nonvascularized nerve grafts during the regeneration process

The authors investigated the expression of three kinds of catenins (alpha, beta, gamma) in vascularized and non-vascularized nerve grafts, using the rat sciatic nerve model. The vascularized nerve, 15 mm in length, was elevated with its nutrient vessels in the left hindlimb of rats. In the right hindlimb, a 15-mm segment of the sciatic nerve was elevated (resected) without the nutrient vessels as a non-vascularized nerve. Both nerves were sutured to the original site. At various periods up to 14 weeks after operation, the entire graft was removed. Expression of three catenins was detected by Western blot analysis and histochemical staining, using the antibody to each catenin. The level of beta catenin increased during nerve regeneration in both the vascularized and non-vascularized grafts, while the level of alpha and gamma catenins did not increase in both grafts. There was no difference in the level of the three catenins between the two methods of nerve grafting. Histochemical findings showed that at the 4th and 14th postoperative weeks, alpha and gamma catenins were stained diffusely in both grafts, while beta catenin was stained around the regenerating axons in both grafts. The degree of beta catenin was greater in the 4th postoperative week than in the 14th postoperative week, but no obvious difference in the degree of staining of the three catenins between two grafts was found. These results suggest that beta catenin may play a different role from alpha and gamma catenins in nerve regeneration, and that the expression of these catenins is not influenced by vascularization of the nerve graft.

Auricular composite graft for skin defect of the philtrum dimple

Our method of performing an auricular composite graft for a skin defect of the philtrum dimple in a patient whose lip is not damaged and has retained its original softness and elasticity is presented. After resecting the lesion, an auricular composite graft is harvested from the conchal region. The size of the graft is almost the same as the size of the resected lesion, although the cartilage is harvested in an elliptical shape, and its size is approximately 60% in area of the overriding skin of the graft. The graft is harvested from the site, which has a similar curvature to the defect. The cartilage is sutured tightly to the graft bed at a minimum of four points with 6-0 absorbable suture. The transversal axis of the harvested cartilage is sutured as vertically as possible so as to fit the direction of the wrinkle line of the upper lip. The skin is sutured to the defect margin using 5-0 nylon suture. The graft donor site is closed primarily. This method has been used for the closure of six comparatively large skin defects after resecting a skin lesion (pigmented nevus in three cases and hypertrophic scar in three cases) in the philtrum dimple in six patients. In all cases, the upper lip was not damaged and retained its original softness and elasticity. The "take" of the graft was complete in all patients, and the donor site healed without any problem. In all cases, postoperative shrinkage of the graft was not significant during the follow-up period, and the graft had a smooth surface. In addition, no patients suffered from a feeling of discomfort in moving the mouth, and an acceptable shape of the philtrum dimple was achieved in all cases. There were no deformational changes in the graft donor site. In conclusion, our method is valid in the patient whose lip is not damaged and has retained its original softness and elasticity and in whom a full-thickness skin graft is selected as the covering method for a skin defect of the philtrum dimple.

Influence of periosteum on donor healing after harvesting hard palate mucosa

The authors report the influence of periosteum on healing of palatal defect based on more than 10 years of experience of harvesting hard palate mucosa. Between June of 1991 and May of 2001, the authors harvested 80 hard palate mucosae as graft material for skin and mucosa defects. All grafts were harvested from the center of the hard palate. Patients ranged in age from 10 to 82 years old. Of 80 mucosae, 54 were harvested with periosteum, and periosteum was not retained in the defect bed. The other 26 mucosae were harvested without periosteum, which was therefore retained in the defect bed. The healing time increased depending on the defect size in both groups of patients retaining and not retaining periosteum. There was a significant relationship between the defect size and healing time in both groups (Spearman's rank correlation test, p < 0.0001 in both groups). In the two groups, there was no significant relationship between patient age and healing time in the patients with defect smaller than 1.99 cm or larger than 2.00 cm2. There were no significant differences in the rate of patients with pain and bleeding between the groups retaining and not retaining periosteum. In the group not retaining the periosteum, all 54 patients showed a flat or atrophic smooth surface at more than 6 months after epithelization and had no discomfort. However, 17 patients showed flat or atrophic smooth surface in the group retaining the periosteum and the remaining 9 patients showed hypertrophy at more than 6 months after epithelization, with accompanying discomfort. The rate of the patients with hypertrophy in the group of patients retaining periosteum was significantly high as compared with that in the group of patients not retaining periosteum (p = 0.000013, Fisher's exact test). In 26 patients retaining periosteum, the age of the patients with hypertrophic surface was significantly younger than that of the patients with flat or atrophic surface (p = 0.0010, Welch's -test), and the defect size in the patient with hypertrophic surface was significantly smaller than that of the patients with flat or atrophic surface (p = 0.0028, Welch's t-test). In conclusion, our study demonstrated that the existence of periosteum in the palate donor bed does not contribute to reduced healing time or reduced pain. Rather, retaining the periosteum caused hypertrophy of the donor site, leading to discomfort, especially in young patients with a comparatively small defect.

Hard palate mucosal grafts for defects of the nail bed

The authors present 2 children in whom a hard palate mucosal graft was used for a defect of the nail bed after resecting subungual exostosis. After the tumor was resected with the overriding nail bed, hard palate mucosa without periosteum was grafted to the nail bed defect. In both patients the graft took completely, and within 2 weeks after the operation the patients were able to enjoy activities of daily life, including athletic movement, without any symptoms. Nail growth was uneventful and was complete in 4 or 5 months after the operation without any complications. The authors think that a hard palate mucosal graft is a valid choice for a defect of the nail bed, and the mucosa does not need to be harvested with periosteum. The grafting of hard palate mucosa without periosteum to a defect of the nail bed contributes to a shorter healing time, resulting in a reduction in the period of restriction of movement in activities of daily life, and this is a great advantage in children.

Usefulness and limitations of artificial dermis implantation for posttraumatic deformity

We have previously reported the use of artificial dermis implantation to cover exposed major vessels and to correct a depressed region after tissue resection and bone deformity with satisfactory results. In this paper, we present cases with depressed lesions and adhesive lesions after trauma, treated with artificial dermis implantation. Artificial dermis (Terudermis, Terumo Co. Ltd., Tokyo, Japan) was implanted in 12 cases of posttraumatic deformity. Eight of the 12 cases involved a depressed lesion, and the other four involved adhesive lesions. There was no postoperative infection or allergic reaction in any of the patients. Improvement of the deformity was obtained in all cases, but the degree of volume reduction in traumatic cases is likely to be more severe than that in the non-traumatic cases previously reported. In conclusion, artificial dermis implantation is an easy, safe, and useful method to correct a posttraumatic deformity, such as a depression or an adhesion, although it is important to note that depressions require overcorrection in order to obtain satisfactory results, as compared with non-traumatic cases treated with artificial dermis.

Penile reconstruction for extramammary Paget's disease

The authors report their experience of an extremely rare case of extramammary Paget's disease presenting a deformational change of the penis, which required penile reconstruction after tumor resection. Tumor cells had invaded the dermis beyond the basement membrane of the epidermis. Tumor cells were found at the epithelium of the urethra, but had not invaded the corpus cavernosum. However, fibrotic changes were found in the corpus cavernosum. More than half the length of the penis was resected. Penile reconstruction was performed using a free sensory radial forearm flap. The defects in the mons pubis, scrotum, and the remaining corpus cavernosum were covered using a meshed split skin graft or sheeted split skin graft. Ten months after the operation, the tumor had not recurred and no metastasis was found. The urinary stream was narrow compared with that of a healthy man, but urinary voiding had not been disturbed. Sensory recovery was 12 mm with the two-point discrimination test at the distal end of the reconstructed penis.

Evaluation of scars after harvest of the temporoparietal fascial flap depending on the design of the skin incision

The authors evaluated the conspicuousness of the temporal scar caused by two incision patterns after harvesting the temporoparietal fascial flap: a straight incision and a zigzag incision. The 27 scars of 27 patients were examined in this study. Fifteen patients underwent a straight incision and 12 patients had a zigzag incision. This study showed that the zigzag incision resulted in more conspicuous scars than the straight incision and that this effect was more evident in younger patients than in older patients, at least in Japanese. In a comparison of older patients and younger patients irrespective of the skin incision patterns, the scars were substantially more conspicuous in the younger patients. A simple and short incision is preferred when harvesting the temporoparietal fascial flap and more careful management is required for young patients.

Preshaped hydroxyapatite tricalcium-phosphate implant using three-dimensional computed tomography in the reconstruction of bone deformities of craniomaxillofacial region

We prepared solid life-sized models and templates of implants based on three-dimensional computed tomography data in six cases with a bone deformity of the craniomaxillofacial region. After simulation surgery using these models and templates, the preshaped hydroxyapatite-tricalcium phosphate (HAP-TCP) implants were prepared to fill in the facial bone defects, and implantation was performed. Consequently, implants fitted the individual bone defects, and satisfactory facial contouring was obtained in five cases. In one case with severe cutaneous scarring in the grafted site, it was necessary to reduce the volume of the preshaped HAP-TCP implant during surgery. In conclusion, the three-dimensional, solid, life-sized model and template are useful for preoperative detailed simulation, and the use of preshaped HAP-TCP implants based on the template probably contributes to successful reconstruction of complex facial bone deformities and to the reduction of surgical invasion, resulting in achievement of better results.

Correction of bone deformity after resection of dermoid cyst using artificial dermis implantation

We report cases of the dermoid cyst patients with a bone deformity that were treated with artificial dermis implantation. After resecting the tumor, three or five sheets of artificial dermis (Terudermis, Terumo Co. Ltd, Tokyo, Japan) are placed into the depressed site in order to create symmetrical surface with the contralateral side. Neither of the cases presented here showed allergic or infectious reaction during postoperative follow-up period. In both cases, the texture of the implanted region is almost the same as the contralateral side and is almost symmetrical. We believe that artificial dermis may be a useful implantation material to correct depressions in the patient with dermoid cysts.

Difference of molecular response to ischemia-reperfusion of rat skeletal muscle as a function of ischemic time: study of the expression of p53, p21(WAF-1), Bax protein, and apoptosis

The authors investigated the expression of p53, p21(WAF-1), Bax protein, and apoptosis to elucidate the cellular response to ischemia-reperfusion of skeletal muscle using the rat lower limb model. The rat left lower limb was dissected in the inguinal region, isolating the bony femoral muscles, and the femoral vessels were clamped to produce an ischemic condition. After 3 or 6 hours, the clamps were removed and the gastrocnemius muscle was resected at various times up to 72 hours after reperfusion. Five specimens of the muscle were obtained at each time point from 5 rats. When any rat died during the study, additional rats were used until 5 specimens could be obtained from 5 rats at each time point. The expression of three proteins was detected by Western blot analysis. The apoptotic cells were detected using terminal deoxytransferase-mediated dUDP (deoxyuridine[-5']diphosphate) nick-end labeling assay. Histopathological study showed severe interstitial edema and leukocyte infiltration at 6 hours of ischemia compared with 3 hours of ischemia. Moreover, at 6 hours of ischemia, muscle fiber fragmentation was observed at 72 hours after reperfusion whereas no fragmentation was found at 3 hours of ischemia. At 3 hours of ischemia, p53 and p21(WAF-1) accumulated after reperfusion, and there was a time lag in the time of onset of elevation and the peak time point between these two proteins. The level of Bax protein did not elevate and the rate of apoptotic cells did not increase. At 6 hours of ischemia, p53 and p21(WAF-1) also accumulated, but the kinetics of p21(WAF-1) were similar to that of p53 in the time of onset of elevation and the peak time point after reperfusion. In addition, the level of Bax protein increased and apoptosis was induced. These results demonstrated that p53 and p21(WAF-1) accumulated after 3 and 6 hours of ischemia of skeletal muscle during reperfusion. Moreover, it was demonstrated that the kinetics of induced p53, p21(WAF-1) and Bax protein differ between 3 hours and 6 hours of ischemia, and it is speculated that this difference plays an important role in determining the consequence of the cell exposed to ischemia.

[A study on the maternal plasma C21 steroids concentration during pregnancy]

During pregnancy, C21 steroids such as progesterone (P4), and cortisol (F), have been reported to be closely involved in uterine contraction. To clarify the association between changes in steroid hormones and the onset of delivery, we measured the concentrations of six C21 steroids in maternal blood by high performance liquid chromatography. Changes in each steroid hormone were evaluated by analysis of variance during pregnancy. Pregnenolone, a source of C21 steroids, gradually increased during pregnancy. P4 and 17P4, its metabolite, reached a peak 3 weeks before delivery and noticeably decreased thereafter. Accompanying a decrease in P4 and 17P4, 20P4 and F, its metabolite, were noticeably increased. The association among these steroid hormones was also evaluated. The correlation between P4 and F was reversed after 3 weeks before delivery. These results suggest that steroid hormones in the maternal blood begin to change dynamically about 3 weeks before delivery. In particular, a decrease in P4 and an increase in F seem to be closely related to the onset of delivery.