世界的に乳がん患者数は増加傾向にあるが，その一方で生存率も改善しており，治療後の生活の質が重要視されるようになってきた．乳房再建手術は，患者の乳房喪失による心理的苦痛を解消し，心理的回復を促す効果があるとされ，その重要性が増している．本邦では自家組織を用いた乳房再建が2006年に，人工乳房を用いた再建が2014年に保険収載され，乳がん手術後における乳房再建率は近年増加傾向にある．本稿では年々進化，多様化する乳房再建の現状について概説する．

The formation of hypertrophic scars and keloids is strongly associated with mechanical stimulation, and myofibroblasts are known to play a major role in abnormal scar formation. Wounds in patients with neurofibromatosis type 1 (NF1) become inconspicuous and lack the tendency to form abnormal scars. We hypothesized that there would be a unique response to mechanical stimulation and subsequent scar formation in NF1. To test this hypothesis, we investigated the molecular mechanisms of differentiation into myofibroblasts in NF1-derived fibroblasts and neurofibromin-depleted fibroblasts and examined actin dynamics, which is involved in fibroblast differentiation, with a focus on the pathway linking LIMK2/cofilin to actin dynamics. In normal fibroblasts, expression of α-smooth muscle actin (α-SMA), a marker of myofibroblasts, significantly increased after mechanical stimulation, whereas in NF1-derived and neurofibromin-depleted fibroblasts, α-SMA expression did not change. Phosphorylation of cofilin and subsequent actin polymerization did not increase in NF1-derived and neurofibromin-depleted fibroblasts after mechanical stimulation. Finally, in normal fibroblasts treated with Jasplakinolide, an actin stabilizer, α-SMA expression did not change after mechanical stimulation. Therefore, when neurofibromin was dysfunctional or depleted, subsequent actin polymerization did not occur in response to mechanical stimulation, which may have led to the unchanged expression of α-SMA. We believe this molecular pathway can be a potential therapeutic target for the treatment of abnormal scars.

Refractory axillary lymphorrhea is a postoperative complication of breast cancer with no established standard treatment. Recently, lymphaticovenular anastomosis (LVA) was used to treat not only lymphedema but also lymphorrhea and lymphocele in the inguinal and pelvic regions. However, only a few reports have been published on the treatment of axillary lymphatic leakage with LVA. This report presents a case of successful treatment of refractory axillary lymphorrhea after breast cancer surgery with LVA. A 68-year-old woman underwent nipple-sparing mastectomy for right breast cancer, axillary lymph node dissection, and immediate subpectoral tissue expander placement. Postoperatively, the patient developed refractory lymphorrhea and subsequent seroma around the tissue expander, and underwent postmastectomy radiation therapy and frequent percutaneous aspiration of the seroma. However, lymphatic leakage persisted, and surgical treatment was planned. Preoperative lymphoscintigraphy showed lymphatic outflow from the right axilla to the space around the tissue expander. There was no dermal backflow in the upper extremities. To reduce lymphatic flow into the axilla, LVA was performed at two sites in the right upper arm. The lymphatic vessels used for anastomosis were 0.35 mm and 0.50 mm in diameter, and each was anastomosed to the vein in an end-to-end fashion. The axillary lymphatic leakage stopped shortly after the operation, and there were no postoperative complications. LVA may be a safe and simple option for the treatment of axillary lymphorrhea.

Abstract Although the number of patients with breast cancer continues to rise worldwide, survival rates for these patients have significantly improved. As a result, breast cancer survivors are living longer, and quality of life after treatment is of increasing importance. Breast reconstruction is an important component that affects quality of life after breast cancer surgery. With the development of silicone gel implants in the 1960s, autologous tissue transfer in the 1970s, and tissue expanders in the 1980s, breast reconstruction has advanced over the decades. Furthermore, the advent of perforator flaps and introduction of fat grafting have rendered breast reconstruction a less invasive and more versatile procedure. This review provides an overview of recent advances in breast reconstruction techniques.

Abstract Hydrogen is effective against ischemia–reperfusion (I/R) injury in skin flaps. However, the difficulty of continuously administering a sufficient amount of hydrogen using conventional methods has been an issue in the clinical application of hydrogen-based therapy. An Si-based agent administered orally was previously shown to continuously generate a large amount of hydrogen in the intestinal environment. In this study, we assessed the effect of the Si-based agent on the inhibition of I/R injury in skin flaps using a rat model. In the I/R groups, the vascular pedicle of the abdominal skin flap was occluded for three hours followed by reperfusion. In the I/R + Si group, the Si-based agent was administered perioperatively. After reperfusion, flap survival rate, blood flow, oxidative stress markers, inflammatory markers/findings, and degree of apoptosis were evaluated. Flap survival rate was significantly higher, and histological inflammation, apoptotic cells, oxidative stress markers, and levels of inflammatory cytokine mRNA and protein expression were significantly lower, in the I/R + Si group compared to the I/R group. The Si-based agent suppressed oxidative stress, apoptosis, and inflammatory reactions resulting from I/R injury, thereby contributing to improvements in skin flap survival.

BACKGROUND: In breast reconstruction, both aesthetic outcomes and sensory function are important for postoperative quality of life. Innervated flaps are useful in reconstruction after conventional mastectomy (CM), which leaves a large portion of the skin paddle exposed on the body surface. However, whether they are also useful in skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) remains unclear. This study aimed to examine the usefulness of innervated flaps in restoring sensation after SSM and NSM using a rat model. METHODS: Dorsal cutaneous nerves of rats were entirely eliminated except for the medial branch of the dorsal cutaneous nerve of thoracic segment 13, resulting in an innervated field surrounded by a denervated field. The innervated field was elevated as an innervated island flap and then subcutaneously embedded, with the skin paddle deepithelialized entirely (NSM group, n = 5) or except at the center (SSM group, n = 6). In the control model (CM group, n = 5), the flap was sutured back into its original position. Postoperative changes in the mechanonociceptive field were evaluated using the cutaneous trunci muscle reflex test. Immunohistochemical evaluation of regenerated nerves in the new mechanonociceptive field was performed at postoperative week 12. RESULTS: In the SSM and CM groups, the mechanonociceptive field expanded around the skin paddle. In the NSM group, a new mechanonociceptive field appeared at postoperative week 4 and expanded thereafter. Areas of the mechanonociceptive field at postoperative week 12 did not differ significantly between the SSM and NSM groups, but were significantly smaller compared with the CM group and comparable to original flap areas. Histologically, S100- and PGP9.5-positive nerve fibers were observed in the dermis of the new mechanonociceptive field and subcutaneous flap tissue. CONCLUSIONS: Subcutaneously embedded innervated island flaps induced nerve regeneration and sensory reinnervation of the denervated skin, suggesting that innervated flaps may also be useful in reconstruction post-SSM/NSM.

The oncoplastic breast-conserving surgery working group (OPBCS WG) proposed a step-up guide for learning the OPBCS procedures. OPBCS step-up guide (draft) : ① Basic OPBCS ; Background mammary gland density and shapes of the breasts in a standing position should be evaluated in OPBCS. Evaluation by photography is also important. ② Volume displacement ; Step 1 ; In addition to glandular rearrangement, an invisible skin incision and site should be devised in order to improve the cosmetic outcome. It is possible to prevent late-onset deviation of the nipple-areolar complex (NAC) by adding the NAC re-centralization technique. Step 2 ; This category consists of techniques derived from breast reduction and mastopexy. Dual-plane undermining should be avoided and NAC re-centralization is needed in most cases. ③ Volume replacement ; Step 1 ; The tissue around the breast is used to fill the defect with a local flap, such as a transposition flap or advancement flap, and is generally used for small defects. Step 2 ; A distant pedicled flap, such as the LD flap or the chest wall perforator flap, is used for larger defects than those in Step 1. The procedure should be carefully selected based on the evaluation items in the Basic OPBCS.

BACKGROUND: No effective methods currently exist for breast neurotization in implant-based breast reconstruction. Here, we focused on direct neurotization (DN), in which axons regenerating from nerve stumps are directed to the mastectomy flap and aimed to assess whether DN can generate a new mechano-nociceptive field using a rat model of back skin sensory denervation. METHODS: Dorsal cutaneous nerves (DCNs) of rats were exposed and transected, leaving only the left medial branch of the DCN of thoracic segment 13 (mDCN-T13) intact. This procedure resulted in an isolated innervated field surrounded by a denervated field. The mDCN-T13 was transected, and the proximal nerve stump was sutured to the subdermis (DN subdermal group, n = 6) or dermis (DN dermal group, n = 5) of a different region of the denervated field. In the Crush group (n = 5), the intact mDCN-T13 was only crushed. We evaluated the generation of a new mechano-nociceptive field over time using the cutaneous trunci muscle (CTM) reflex test and histomorphometrically evaluated regenerating nerves in the reinnervated region. RESULTS: In the DN groups, the CTM reflex appeared in the DN area after postoperative week 4. The new mechano-nociceptive field gradually expanded afterwards, and by postoperative week 12, the area was substantially larger than the original region innervated by the mDCN-T13 in the DN dermal group, although not as large as that in the Crush group. In histomorphometric evaluations, many S100-positive myelinated fibers were observed in the dermis of the reinnervated area for all groups. CONCLUSION: In targeted sensory reinnervation, DN of the skin is revolutionary in that it allows a new innervated area to be generated at a desired location regardless of whether a distal nerve stump is available. DN may present an effective approach for breast neurotization in breast reconstruction after mastectomy, particularly for procedures that cannot use sensate flaps such as implant-based breast reconstruction.

Immediate fat grafting to the latissimus dorsi myocutaneous (LD) flaps is a breakthrough that addresses the issue of insufficient volume of LD. However, the use of this procedure in Asian patients has not yet been reported. Retrospective chart reviews were conducted on 54 Japanese cases of total breast reconstruction using fat-augmented LD flaps at our hospital from September 2017 to June 2019. There were 24 immediate reconstruction cases, 18 immediate two-stage reconstruction cases, nine delayed reconstruction cases, and three delayed two-stage reconstruction cases. Median age was 46 years (range, 29-69 years), and median body mass index was 21.5 (17-33.8). Median mastectomy specimen and flap weight was 225 g (123-993) and 225 g (130-796), respectively. The median volume of fat graft was 114 ml (46-305) for the LD flap and 58 ml (15-200) for the pectoralis major muscle. Of the 53 completed reconstruction cases, 38 (71.7%) achieved sufficient volume with the initial operation and six (11.3%) required additional fat grafting. The proportion of cases in the immediate reconstruction group, which achieved sufficient volume in the initial operation was significantly higher than those of the other three reconstruction groups (p = 0.007). Total breast reconstruction with fat-augmented LD flaps is a viable procedure for thin patients who have insufficient abdominal tissue, for those who wish to avoid abdominal scars, and for those in whom abdominal flaps have already been used. The procedure allows for large volume transplantation even with small skin paddles, which allows for smaller skin paddles to be designed without the need for extensive subcutaneous dissection.

症例は77歳男性で、左母指背側腫瘤を主訴とした。腫瘤は10年来認め、1ヵ月前より増大傾向で自壊し出血した。MRI所見で左母指背側皮下に42.4mm×27.3mm×18.3mm大の皮下腫瘤を認め、T1強調像で腫瘤辺縁が高～等信号、腫瘤主体が低信号、T2強調像で辺縁・主体とも高信号であった。皮膚自壊部分辺縁の生検の病理結果はpyogenic granulomaもしくはgranulation所見であった。局所麻酔下に腫瘤側壁の皮膚を温存して腫瘤を摘出した。病理所見は真皮と連続して線維性被膜に覆われた血腫であり、器質化血腫の像を呈し悪性所見は認めず、臨床経過と併せて標記の診断とした。術後5ヵ月で再発は認めていない。

BACKGROUND: Malignant invasion of the respiratory tract is a common complication in advanced cases of esophageal carcinoma. Resection and reconstruction can be extremely challenging, particularly when the invasion is intrathoracic. A circumferential tracheal resection with direct tracheal closure or mediastinal tracheostomy is often performed, but the outcome is not always favorable, with high morbidity rates, loss of vocal function, and reduced quality of life. METHODS: We present our experience in performing an intrathoracic tracheal reconstruction in which a conchal cartilage graft was used in combination with a pectoralis major muscle transposition. RESULTS: This was successfully done following the noncircumferential resection of the intrathoracic trachea due to mural invasion by a metastatic lymph node of esophageal carcinoma. CONCLUSIONS: We believe this report will contribute to the growing body of clinical expertise on procedures for intrathoracic tracheal reconstruction.

In cutaneous T-cell lymphoma (CTCL), which arises from skin-tropic memory T cells, malignant T cells and benign T cells are confined in the same skin lesions. It is thus difficult to evaluate the phenotypic characteristics and functional activities of benign T cells in CTCL. Disialoganglioside with three glycosyl groups (GD3) is increasingly expressed on the surface of solid malignant tumor cells and takes part in tumor progression and suppression of tumor immunity. However, the role of GD3 in CTCL is not well-understood. In this study, the malignant and benign T cells in CTCL skin lesions were distinguished by flow cytometry and their phenotypic characteristics were compared with those of T cells from control skin specimens. In CTCL skin lesions, the benign T cells included limited resident memory T cells (T_RM), which are sessile in skin and known to exert strong antitumor function. The benign T cells showed diminished Th17 property, and the expression of GD3 was high in the malignant T cells. The expression of GD3 in the malignant T cells inversely correlated with IL-17A production from the benign CD4 T cells. GD3 from the malignant T cells was implied to be involved in suppressing the Th17 activity of the benign T cells independent of the regulation of T_RM differentiation in CTCL. Revealing the role of GD3 in inhibiting the production of IL-17A in CTCL would aid the understanding of the suppressive mechanism of the antitumor activity by malignant tumor cells.

While the use of free flaps has become routine and is associated with a low complication rate, pedicled flaps remain a solid reconstructive option in various clinical situations. Pedicled flaps provide a reliable vascular supply and involve a simple surgical procedure. Although the procedure is advantageous from the standpoint of a low rate of flap ischemia, thrombosis, and total flap loss, these complications are still occasionally observed due to intraoperative pedicle injury, postoperative torsion, or compression. Here we report on a case of severe venous thrombosis in a pedicled latissimus dorsi (LD) flap used for breast reconstruction. The patient was a 52-year-old woman who underwent mastectomy and immediate breast reconstruction with a LD flap for left breast cancer. Postoperatively, the color of the skin paddle became dark blue over time. Emergent surgical exploration revealed kinking and narrowing of the thoracodorsal vessels and extensive venous thrombi. The kinked pedicles were repaired and selective thrombolytic therapy was performed. A thrombolytic agent was administered through the serratus anterior branch of the thoracodorsal artery in retrograde fashion while the thoracodorsal vessels were clamped just cephalad to the bifurcation. This allowed for draining of the thrombolytic agent and thrombi through the serratus anterior branch of the thoracodorsal vein without flowing into the systemic circulation. To the best of our knowledge, this is the first report of selective thrombolysis using a pedicle branch to treat venous thrombosis in a pedicled flap. If major vascular branches are available in a pedicled flap, selective thrombolytic therapy may be possible without disconnecting the pedicle, as in the present case.

Latissimus dorsi (LD) flaps are widely used in breast reconstruction for their ease of use and minimal sacrifice of the donor site. Various strategies to increase flap volume have been suggested, but tissue volume is often insufficient for patients with little subcutaneous fat. While lumbar artery perforator (LAP) flaps are advantageous for thin patients because they allow for the addition of a large amount of fat, the vascular pedicle is short and vascular grafts are often required. To address these shortcomings, we propose here a LD-LAP chimeric flap. Specifically, the LD flap and LAP flap are elevated as one piece, and the 6th or 7th intercostal artery perforators and lumbar artery perforators, which are harvested together with the flap, are connected via intra-flap crossover anastomosis. Anastomosis for both intercostal artery perforators and lumbar artery perforators was performed about 1 cm away from the flap. Indocyanine green angiography performed after anastomosis showed improved blood flow to the LAP flap portion of the chimeric flap. The chimeric flap was used in 4 patients, with a mean flap volume of 460 ml (range, 300-690 ml) and mean duration of 439 minutes (393-484 minutes) for reconstruction surgery. During the mean follow-up period of 29.5 months (range, 16-40 months), sufficient tissue volume was obtained and none of the patients developed flap necrosis. Although our method requires vascular anastomosis and may extend operative time, it substantially increases LD flap volume and thus is likely to be an effective auxiliary component to breast reconstruction using LD flaps.

BACKGROUND: In the typical procedure for secondary correction of the inframammary fold (IMF) following breast reconstruction, a large incision is often required, and this increases surgical invasiveness. The "drawstring method" is a simple procedure for recreating a smooth IMF. We modified the drawstring method and developed an essentially scarless method for IMF correction from small stab incisions. METHODS: Patients at our hospital who presented with IMF ptosis or loss of definition after breast reconstruction and required IMF correction, as well as those who requested IMF recreation for the contralateral breast, during the period spanning May 2016 to June 2019 were considered for this study. We collected and analyzed demographic data, as well as complications and postoperative outcomes. RESULTS: The new method was performed on 20 patients, with the following breakdown: IMF recreation after breast reconstruction with a deep inferior epigastric artery perforator flap (11 patients), IMF recreation after breast reconstruction with a breast implant (2 patients), IMF recreation after breast reconstruction with fat graft (5 patients), and IMF recreation for the contralateral breast (2 patients). Overcorrection of the IMF stabilized by 2-3 months postoperatively, resulting in a smooth and well-defined IMF. For non-breast implant cases, the implant volume increased at the lower pole. Slack in the suture was observed in only 2 patients of the deep inferior epigastric artery perforator group and in 1 patient of the breast implant group after 6 months postoperatively. CONCLUSIONS: Our new method allows for the recreation of an essentially scarless, smooth, and well-defined IMF. IMF definition can be adjusted by altering the depth of the barbed suture. Since this method can be performed under local anesthesia, it offers the benefits of reducing medical costs and physical burden on patients.

BACKGROUND: Platelet-rich plasma contains high concentrations of growth factors that stimulate proliferation and migration of various cell types. Earlier experiments demonstrated that local platelet-rich plasma administration activates Schwann cells to improve axonal regeneration at a transected peripheral nerve lesion. However, the optimal concentration of human platelet-rich plasma for activation of human Schwann cells has not been determined, and mechanisms by which platelet-rich plasma activates Schwann cells remain to be clarified. METHODS: Human Schwann cells were cultured with various concentrations of platelet-rich plasma in 5% fetal bovine serum/Dulbecco's Modified Eagle Medium. Cell viability, microchemotaxis, flow cytometry, and quantitative real-time polymerase chain reaction assays were performed to assess proliferation, migration, cell cycle, and neurotrophic factor expression of the human Schwann cells, respectively. Human Schwann cells were co-cultured with neuronal cells to assess their capacity to induce neurite extension. Neutralizing antibodies for platelet-derived growth factor-BB (PDGF-BB) and insulin-like growth factor-1 (IGF-1) were added to the culture to estimate contribution of these cytokines to human Schwann cell stimulation by platelet-rich plasma. RESULTS: An addition of platelet-rich plasma at 5% strongly elevated proliferation, migration, and neurotrophic factor production of human Schwann cells. Both PDGF-BB and IGF-1 may be involved in mitogenic effect of platelet-rich plasma on human Schwann cells, and PDGF-BB may also play an important role in the migration-inducing effect of platelet-rich plasma. Neutralization of both PDGF-BB and IGF-1 cancelled the promoting effect of platelet-rich plasma on neurite-inducing activity of human Schwann cells. CONCLUSION: This study may suggest the optimal concentration of platelet-rich plasma for human Schwann cell stimulation and potential mechanisms underlying the activation of human Schwann cells by platelet-rich plasma, which may be quite useful for platelet-rich plasma therapy for peripheral nerve regeneration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Angiosarcoma is a rare malignant tumour, which accounts for 1–2% of all malignant soft-tissue tumours. Most cases of angiosarcoma arise spontaneously, and malignant transformation of vascular malformation to angiosarcoma is extremely rare. We describe the case of a 70-year-old woman with a massive arteriovenous malformation in her shoulder, which gradually enlarged, despite repeated surgeries and radiation therapy over 53 years. She also presented with rapidly growing haemorrhagic masses in her oral cavity. Excision biopsy was performed, and the pathohistological diagnosis was angiosarcoma. Positron emission tomography–computed tomography revealed high fluorodeoxyglucose accumulation in the oral cavity and right shoulder, the latter of which was consistent with the location of the arteriovenous malformation. The masses in the oral cavity were diagnosed as metastatic angiosarcoma from the right shoulder, where the massive arteriovenous malformation was suspected to have malignantly transformed. This report describes a possible case of malignant transformation of arteriovenous malformation to angiosarcoma.

<p>In breast reconstruction using artificial materials, infection is highly likely to lead to reoperation or implant removal, and may affect the esthetic outcome. Standard aseptic operative and preoperative procedures for the prevention of surgical site infection (SSI) should be performed, and minimally invasive techniques need to be considered.</p><p>Risk factors for SSI include smoking, obesity, diabetes, large breasts, radiation, adjuvant chemotherapy, old age, immediate reconstruction, bilateral reconstruction, axillary dissection, methicillin-resistant <I>Staphylococcus aureus</I> carrier state, hypertension/hyperlipidemia, and immunodeficiency. In patients at high risk for infection, selecting an appropriate operative procedure, including autologous tissue-based reconstruction, sufficient informed consent, and preoperative planning are important.</p><p>Although continuous irrigation and implant replacement in infected patients is relatively effective, reinfection and capsular contracture are of concern. Therefore, careful follow-up is essential.</p>

Background: Although there have been many reports on the success of free jejunal flap transfer for pharyngoesophageal reconstruction, reports on salvage procedures for failed transfers remain sparse. In this report, we retrospectively reviewed our salvage procedures for failed jejunal transfers and previous articles describing salvage treatment in failed jejunal flap cases. Methods: This report includes 6 cases of failed jejunal flap transfer, leading to necessary salvage surgery. We reviewed all cases to examine salvage procedures and early postoperative complications such as fistula formation. We also assessed postoperative late complications and swallowing function during long-term follow-up. A review of the literature was performed via PubMed. Results: Rejejunal transfer was performed successfully in 3 of 6 cases. Gastric pull-up reconstruction was adopted in 2 cases. In 1 case, an external stoma was created because of the patient's poor medical condition. All 3 cases of rejejunal transfer and 1 gastric pull-up case recovered to resuming a normal diet. However, 1 gastric pull-up case required supplemental feeding with a jejunostomy tube. We reviewed 6 articles describing salvage treatment in failed jejunal flap cases. Conclusion: When free jejunal transfer fails, rejejunal transfer is optimal. However, in cases that lack suitable recipient vessels or have infection, a second jejunal transfer should not be considered. In such cases, gastric pull-up or colon interposition may be an alternative because they do not require vascular anastomosis. Pedicled pectoralis major flap is also an alternative, although the risk of salivary fistulas is very high.

Background: We previously reported that good surgical outcomes can be obtained with breast mold made by 3-dimensional printing. However, detailed breast shape is often difficult to create. Accordingly, we aimed to determine whether transplanting a flap and bioabsorbable mold in vivo would yield better results by retaining the flap shape inside the mold during the scar formation period. Methods: Vascularized adipose flaps were elevated in the bilateral inguinal region of male Sprague-Dawley rats (n = 7). A cone-shaped, bioabsorbable mold (LactoSorb mesh) was created using a template. On the experimental side, the flap was inserted into the mold and fixed. On the control side, a conical flap was created using absorbable sutures, based on a template. Results: The flaps were harvested 3 months postoperatively, and flap volume, base area, and projection were measured with 3-dimensional imaging. Volume and base area on the mold side tended to be smaller than those on the control side (P = 0.18 and 0.13, respectively) and close to the values of the template. In addition, the ratio of projection and base area value was significantly greater on the mold side than on the control side (P = 0.04). Histology revealed little inflammatory cell invasion, and scar tissue thickness around the flap showed no significant difference between the 2 groups (P = 0.76). Conclusions: This study demonstrated that soft-tissue morphology can be controlled to some extent with a bioabsorbable mold. Its clinical application in breast reconstruction requires further investigation.

Supplemental Digital Content is available in the text.

乳房温存術では大部分の乳腺組織が温存されるため、乳房の質感や知覚に優れる。一方で、切除部位・量や乳房形態によっては術後に大きな変形をきたすことがある。術後の乳房変形を最小限とするため、これまで様々なoncoplastic surgeryが報告されている。体格的に日本人は組織充填法の適応となり易く、中でも広背筋皮弁はその手技の簡便さと豊富な血流から、乳房温存術後における有力な再建法と言える。本稿では広背筋皮弁を用いた組織充填法について、その適応、手術法、および2次再建例や組織不足例における工夫について述べる。(著者抄録)

Schwann cells (SCs) play pivotal roles in the maintenance and regeneration of the peripheral nervous system. Although transplantation of SCs enhances repair of experimentally damaged peripheral and central nerve tissues, it is difficult to prepare a sufficient number of functional SCs for transplantation therapy without causing adverse events for the donor. Here, we generated functional SCs by somatic cell reprogramming procedures and demonstrated their capability to promote peripheral nerve regeneration. Normal human fibroblasts were phenotypically converted into SCs by transducing SOX10 and Krox20 genes followed by culturing for 10 days resulting in approximately 43% directly converted Schwann cells (dSCs). The dSCs expressed SC-specific proteins, secreted neurotrophic factors, and induced neuronal cells to extend neurites. The dSCs also displayed myelin-forming capability both in vitro and in vivo. Moreover, transplantation of the dSCs into the transected sciatic nerve in mice resulted in significantly accelerated regeneration of the nerve and in improved motor function at a level comparable to that with transplantation of the SCs obtained from a peripheral nerve. The dSCs induced by our procedure may be applicable for novel regeneration therapy for not only peripheral nerve injury but also for central nerve damage and for neurodegenerative disorders related to SC dysfunction.

Background: Autologous breast reconstruction can be performed for breasts with ptosis to a certain extent, but if patients desire to correct ptosis, mastopexy of the contralateral breast is indicated. However, accurate prediction of post-mastopexy breast shape is difficult to make, and symmetrical breast reconstruction requires certain experience. We have previously reported the use of three-dimensional (3D) imaging and printing technologies in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. In the present study, these technologies were applied to the reconstruction of breasts with ptosis. Methods: Eight breast cancer patients with ptotic breasts underwent two-stage unilateral DIEP flap breast reconstruction. In the initial surgery, tissue expander (TE) placement and contralateral mastopexy are performed simultaneously. Four to six months later, 3D bilateral breast imaging is performed after confirming that the shape of the contralateral breast (post-mastopexy) is somewhat stabilized, and a 3D-printed breast mold is created based on the mirror image of the shape of the contralateral breast acquired using analytical software. Then, DIEP flap surgery is performed, where the breast mold is used to determine the required flap volume and to shape the breast mound. Results: All flaps were engrafted without any major perioperative complications during both the initial and DIEP flap surgeries. Objective assessment of cosmetic outcome revealed that good breast symmetry was achieved in all cases. Conclusions: The method described here may allow even inexperienced surgeons to achieve reconstruction of symmetrical, non-ptotic breasts with ease and in a short time. While the requirement of two surgeries is a potential disadvantage, our method will be particularly useful in cases involving TEs, i.e., delayed reconstruction or immediate reconstruction involving significant skin resection.

Infectious complications represent one of the most prominent factors contributing to tissue expander (TE) loss in breast reconstruction procedures. Several patient characteristics that increase the risk for surgical-site infection or TE infection have been reported, but no study has focused on the relationship between atopic dermatitis (AD) and TE infection or surgical-site infection. Recently, we investigated 203 cases of breast reconstruction surgeries performed using TEs and noted that all 3 patients who had AD developed infectious complications that ultimately led to TE removal. Considering its pathophysiology, it is likely that patients with AD relatively easily develop infectious complications due to barrier dysfunction, abnormalities in innate immune responses, or colony formation by Staphylococcus aureus. Particular caution should be exercised for breast reconstruction using man-made materials in cases complicated by AD.

ティッシュ・エキスンパンダー(TE)を用いて2期的乳房再建を行った150例(160乳房)を対象として、感染例の検討、感染に影響する因子の解析を行った。対象は1次再建87例(93乳房)、2次再建62例(67乳房)、左右異時再建1例(2乳房)で、鼻咽腔MRSA保菌者は8例(9乳房)であった。全150例(160乳房)において術後にTE感染を認めたのは8例(9乳房)で、うち1次再建例は5例(6乳房)、2次再建例は3例(3乳房)であった。感染8例(9乳房)中、入れ替えを要したのは5例(6乳房)で、うち2例(2乳房)が最終的にTE抜去となった。危険因子解析では、肥満、腋窩郭清および鼻咽腔MRSA保菌が有意に術後TE感染を増加させる因子であることが示唆された。一方、年齢、乳癌術式、再建時期、術前・術後放射線照射、TE挿入位置、術中TE拡張量は術後TE感染に有意な影響を及ぼす因子ではなかった。

The loss of nociceptive function in the skin because of trauma or surgery can impair the quality of life. The recovery of nociceptor function is mediated by two different axonal responses: nerve growth factor (NGF)-dependent collateral sprouting of undamaged nerves and NGF-independent regeneration of damaged nerves. We reported previously that adipose-derived stem cells (ASCs) can transdifferentiate into Schwann cell (SC)-like cells (dASCs) and that transplantation of dASCs increases axonal density in skin flaps. In the present study, we used an animal model that allowed for the individual assessment of collateral sprouting and regeneration. In-vitro differentiation of ASCs to dASCs significantly increased the production of NGF and brain-derived neurotrophic factor (BDNF) to levels comparable with SCs. In-vivo experiments showed that dASC and SC transplantation significantly increased the area of the mechano-nociceptive field in both collateral sprouting and regeneration models, whereas ASC transplantation exerted no significant effect. Antibody blocking experiment showed that these effects of dASC transplantation in the regeneration model were partly mediated by BDNF. Interestingly, the final areas of nociceptive fields between the two experimental models did not differ significantly for any treatment condition. These results indicate that dASC transplantation differentially facilitates collateral sprouting and axonal regeneration by delivering NGF and other neurotrophic factors (e.g. BDNF), respectively. Although there is a limit to nociceptive field enlargement irrespective of axonal response, dASC transplantation could present a new approach for improving nociceptive function in denervated skin.

Background: When the inframammary fold (IMF) is excised in mastectomy procedures for oncologic reasons, it must be recreated to restore a natural breast shape. Despite refinements in surgical techniques, postoperative loss of a well-defined IMF can occur. This study aimed to assess the outcomes of IMF recreation after two-stage, implant-based breast reconstruction. Methods: We retrospectively reviewed 75 consecutive patients who underwent unilateral, two-stage, implant-based breast reconstruction between 2013 and 2015 at the authors' institution. Among them, IMF recreation was performed in 37 patients through a modified Nava's internal method. Aesthetic outcomes of the recreated IMFs were evaluated by observer assessment of two criteria, and critical factors affecting IMF outcomes were also analyzed. Results: We found that contralateral breast ptosis (p < 0.05) and lack of postmastectomy radiotherapy (PMRT, p < 0.01) were significant predictors of better IMF outcomes. Nipple-sparing mastectomy and skin-sparing mastectomy resulted in better IMF outcomes, as compared with non-skin-sparing mastectomy (p < 0.05 for each), while no significant difference was observed between them in patients who did not undergo PMRT (p = 0.19). Similarly, larger implant volume, but not projection of implant, was a predictor of better IMF outcomes when limited to patients who did not undergo PMRT (p < 0.05). Age, body mass index, timing of reconstruction, and extent of overexpansion had no significant effect on IMF outcomes. Conclusions: Based on these critical factors, the shape of the reconstructed breast and the need for reshaping the contralateral breast can be predicted. Special attention should be paid to patients with non-skin-sparing mastectomy and PMRT. When these patients desire a medium-to large-sized ptotic breast, conversion to autologous reconstruction can achieve symmetrical breast reconstruction.

Progress in microsurgery techniques has popularized the use of the perforator flap, which enables minimal invasion into the donor site without sacrificing muscle. In breast reconstruction as well, one procedure that has become increasingly common is the transplantation of subcutaneous fat from the lower abdomen as a deep inferior epigastric perforator (DIEP) flap to the affected area. Recent developments in 3D imaging are also quite significant, allowing for 3D photography and 3D printing to be done even at the individual patient level. We have also come to rely more heavily on 3D imaging technology for breast reconstruction employing DIEP flaps, and have reported on its utility. In the present chapter, we focus on our experiences thus far, and present tips for safe maneuvering of DIEP flaps, as well as the implementation status of 3D imaging technology and its utility with regard to breast reconstruction using DIEP flaps.

マイクロサージャリー技術の進歩により、筋肉を犠牲にせず、ドナー部位への侵襲が非常に小さい穿通枝皮弁が普及してきた。乳房再建においても、下腹部の皮下脂肪を深下腹壁動脈穿通枝皮弁(DIEP flap)として欠損部へ移植する方法が標準術式のひとつとなっている。また、乳癌手術後に一定の期間を経て施行される二次乳房再建では、乳房皮膚の不足を他部位の皮膚で補うのではなく、ティッシュ・エキスパンダー(TE)を用いて残存皮膚を拡張することで、色調・質感に優れた乳房を再建することができる。本稿では、DIEP flapとTEを用いた二次乳房再建法について、著者らの最近の工夫を交えて述べる。(著者抄録)

Background: One of the major problems with nerve grafts is that the survival of a graft segment, including endoneurial Schwann cells (SCs), is uncertain. We investigated whether the survival of nerve grafts is improved when adipose-derived stem cells (ASCs) are incorporated into the grafts. Methods: To examine the cell-protective effects of ASCs on SCs in vitro, we used an indirect coculture system. In vivo effects of the incorporation of ASCs into grafts were examined using a graft model in the rat common peroneal nerve. Grafts were entubulated to isolate them from the surrounding tissues, mimicking the clinical conditions of a poorly vascularized recipient bed. Thirty-six Lewis rats were divided into three groups, i.e., nerve graft only, entubulated nerve graft, and entubulated nerve graft+ASC transplantation. In each group, four rats and eight rats were used for short-term (10 days) and long-term (12 weeks) follow-up study, respectively. Results: After 24 hours of serum deprivation, the numbers of 7-aminoactinomycin D, and TUNEL-positive SCs significantly decreased when indirectly cocultured with ASCs (P<0.01). When ASCs were transplanted to the epineurial layer of the grafts, the number of endoneurial TUNEL-positive cells decreased significantly, as compared with grafts without ASCs, at 10 days postoperatively (P<0.05). Postoperative walking track analysis showed that the ASC-transplanted grafts showed significantly faster function recovery, as compared with grafts without ASCs (P<0.05). Conclusion: These results suggest that nerve autografts+ASC therapy could offer a new approach to obtaining optimal outcomes after peripheral nerve injury. (C) 2015 Wiley Periodicals, Inc.

Local flaps and composite grafting are the procedures of choice for reconstructing relatively small soft tissue defects. However, despite their limited conveyable volume, local flaps sometimes require a wide dissection area and long new incisions. Composite grafts also have serious limitations and require a well-vascularized recipient bed. To overcome these limitations, we used a free vascularized perivascular tissue flap based on the descending branch of the lateral femoral circumflex artery. Using this method, we performed reconstructions for seven patients (four cases in head and neck region and three cases in lower limb) with various soft tissue defects (ranged from 4.0 cm(3) to 40.0 cm(3)). This flap was easily elevated, without the need for precise preoperative flap design, and the flap volume was adjustable regardless of whether deep fascia and muscle were included. The flap has a rich vascular supply, which allows bone and cartilage tissue to be combined with the transfer of soft tissue, and satisfactorily treats chronic wounds with poor blood supply. (C) 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The free groin flap results in less donor-site morbidity than other skin flaps and is suitable for use in children and adolescents. However, the vascular pedicle is relatively short and vessel diameter is small, which makes vascular anastomosis technically difficult. To overcome this limitation, we harvested vein and arterial grafts from the flap elevation area without placing additional skin incisions. Use of short (2–3 cm) vein/arterial grafts greatly simplified flap insetting and vascular anastomosis. This procedure may expand the indications for free groin flap transfer.

In autologous breast reconstruction, skin envelope reconstruction is especially important given the flexibility of new breast parenchyma. Our experience suggests a better control of breast shape with subcutaneous tissue expander (TE) placement compared with submuscular TE placement. We speculate that capsule formation might be different in subcutaneous TE placement compared with submuscular TE placement. To elucidate this hypothesis, we collected capsules formed around the TE in two-stage breast reconstruction patients and evaluated differences in histology and capsule wall thickness between subcutaneous (n = 7) and submuscular (n = 8) TE placement. Our findings show that subcutaneous TE placement results in thinner capsule formation with low vascularity when compared with submuscular TE placement (354 ± 96 μm and 589 ± 92 μm, respectively P < 0.001). Because thin connective tissue can reduce postoperative shrinkage of the skin envelope, it would be beneficial to predict and control the shape of reconstructed breast. Although further study is needed, differences in vascularity between subcutaneous tissue and muscle might affect the thickness of capsules.

Radical parotidectomy often results in complex facial nerve defects involving the main nerve trunk and multiple distal nerve branches. Although cable nerve grafting often leads to good nerve regeneration, severe synkinesis due to aberrant axonal regrowth is inevitable. In such situations, the use of 2 motor sources to differentially reanimate the upper and lower face could minimize synkinesis. Here we describe a method of total facial nerve reconstruction in which the upper and lower face are differentially reconstructed with the hypoglossal nerve and facial nerve, respectively, using 2 interpositional nerve grafts. Reconstruction of the lower face with the facial nerve restored voluntary and coordinated animation, and reconstruction of the upper face with the hypoglossal nerve restored frontalis muscle tone and eye closure. These results suggest that our method could serve as an alternative to conventional techniques that use only the facial or hypoglossal nerve.

Recent advances in 3-dimensional (3D) surface imaging technologies allow for digital quantification of complex breast tissue. We performed 11 unilateral breast reconstructions with deep inferior epigastric artery perforator (DIEP) flaps (5 immediate, 6 delayed) using 3D surface imaging for easier surgery planning and 3D-printed molds for shaping the breast neoparenchyma. A single- or double-pedicle flap was preoperatively planned according to the estimated tissue volume required and estimated total flap volume. The DIEP flap was then intraoperatively shaped with a 3D-printed mold that was based on a horizontally inverted shape of the contralateral breast. Cosmetic outcomes were assessed as satisfactory, as confirmed by the postoperative 3D measurements of bilateral breasts. We believe that DIEP flap reconstruction assisted with 3D surface imaging and a 3D-printed mold is a simple and quick method for rebuilding a symmetric breast.

Twin studies, especially those involving monozygotic (MZ) twins, facilitate the analysis of factors affecting skin aging while controlling for age, gender, and genetic susceptibility. The purpose of this study was to objectively assess various features of facial skin and analyze the effects of environmental factors on these features in MZ twins. At the Osaka Twin Research Center, 67 pairs of MZ twins underwent medical interviews and photographic assessments, using the VISIA (R) Complexion Analysis System. First, the average scores of the right and left cheek skin spots, wrinkles, pores, texture, and erythema were calculated; the differences between the scores were then compared in each pair of twins. Next, using the results of medical interviews and VISIA data, we investigated the effects of environmental factors on skin aging. The data were analyzed using Pearson's correlation coefficient test and the Wilcoxon signed-rank test. The intrapair differences in facial texture scores significantly increased as the age of the twins increased (P=0.03). Among the twin pairs who provided answers to the questions regarding history differences in medical interviews, the twins who smoked or did not use skin protection showed significantly higher facial texture or wrinkle scores compared with the twins not exposed to cigarettes or protectants (P=0.04 and 0.03, respectively). The study demonstrated that skin aging among Japanese MZ twins, especially in terms of facial texture, was significantly influenced by environmental factors. In addition, smoking and skin protectant use were important environmental factors influencing skin aging.

皮下乳腺全摘後の乳房再建を広背筋皮弁で行う場合,再建乳房のボリューム不足を経験することがあるが,これは,再建ボリュームの過不足の判断が術者の裁量に委ねられてきたことによる。そこでわれわれは,乳癌切除量と広背筋皮弁採取量を術前に予測し,両者を照合することによって客観的に再建ボリュームの過不足を判断している。それぞれの予測式として,乳癌切除体積(ml)=0.229×[切除範囲面積(cm2)×患側乳房projection(cm)]+51.351,広背筋皮弁重量(g)=13.50×body mass index(kg/m2)+1.67×皮島面積(cm2)-163.26という回帰式が得られた。広背筋皮弁重量/乳癌切除体積の値が1.8〜2.0であれば,乳房の再建ボリュームは最適であろうと考えられた。以上により,皮下乳腺全摘後の広背筋皮弁再建における再建ボリュームの過不足を客観的に予測判断することができる。(著者抄録)

Background: Oxidative stress has been suggested as a mechanism underlying skin aging, as it triggers apoptosis in various cell types, including fibroblasts, which play important roles in the preservation of healthy, youthful skin. Catechins, which are antioxidants contained in green tea, exert various actions such as anti-inflammatory, anti-bacterial, and anti-cancer actions. In this study, we investigated the effect of (+)-catechin on apoptosis induced by oxidative stress in fibroblasts. Methods: Fibroblasts (NIH3T3) under oxidative stress induced by hydrogen peroxide (0.1 mM) were treated with either vehicle or (+)-catechin (0-100 mu M). The effect of (+)-catechin on cell viability, apoptosis, phosphorylation of c-Jun terminal kinases (JNK) and p38, and activation of caspase-3 in fibroblasts under oxidative stress were evaluated. Results: Hydrogen peroxide induced apoptotic cell death in fibroblasts, accompanied by induction of phosphorylation of JNK and p38 and activation of caspase-3. Pretreatment of the fibroblasts with (+)-catechin inhibited hydrogen peroxide-induced apoptosis and reduced phosphorylation of JNK and p38 and activation of caspase-3. Conclusion: (+)-Catechin protects against oxidative stress-induced cell death in fibroblasts, possibly by inhibiting phosphorylation of p38 and JNK. These results suggest that (+)-catechin has potential as a therapeutic agent for the prevention of skin aging.

Purpose: Surgical repair of symptomatic perineal hernia is challenging, especially via a perineal approach with limited exposure of the hernia sac. Furthermore, insecure fixation of autologous or synthetic materials to bony structures often results in recurrence. Here, we describe the application of a titanium mesh for perineal hernia repair. Methods: We performed hernia repair with a thin titanium mesh via a perineal approach in three patients who developed secondary perineal hernia following abdominoperineal resection. After the hernia sac was isolated and dissected, the titanium mesh was molded and placed over the ischium and coccyx to support the pelvic floor. Results: No major complications occurred, and all three patients were free of recurrence at follow-up after 73, 109, and 6 months, respectively. The patients experienced slight pain in the perineal region when sitting, which resolved within 6 months. Conclusion: Our successful preliminary results indicate that a titanium mesh is useful for perineal hernia repair by the perineal approach, as it can provide rigid support for the pelvic floor by its entire surface while ensuring stability without any fixation. © 2013 Springer-Verlag.

Corrective surgery following breast-conserving surgery is generally challenging due to severe fibrosis induced by postoperative radiotherapy. Although use of the latissimus dorsi myocutaneous flap offers a safe and reliable option, exposure of the skin paddle to the skin surface is often inevitable to achieve correction of nipple-areola complex malposition, leaving conspicuous, patchwork-like scars on the breast. In this report, we describe a 2-stage procedure using a subcutaneous tissue expander and the latissimus dorsi myocutaneous flap for the correction of both nipple-areola complex malposition and breast volume without skin paddle exposure. Although careful observation is necessary during skin expansion, this technique could offer an alternative option for patients undergoing corrective surgery following breast-conserving surgery.

Recent advances in perforator flap surgical techniques have allowed for safe and reliable autologous tissue transfer with minimal donor-site morbidity. Between April 2012 and January 2013, we performed immediate breast reconstruction using free medial circumflex femoral artery perforator (MCFAP) flaps in 15 patients after breast-conserving surgery. The flaps were harvested from patients in the lithotomy position, while a second surgical team simultaneously conducted tumour resection. Of the 15 procedures performed, three flaps were dissected as true perforator flaps, while 12 flaps were dissected as muscle-sparing perforator flaps. The mean flap weight was 138.5 g (range, 77-230 g) and the mean pedicle length was 5.7 cm (range, 3.0-9.0 cm). Recipient vessels for anastomosis were serratus branches in 10 patients, internal mammary vessels in three patients and thoracodorsal vessels in two patients. The mean duration of surgery was 6.74 h (range, 5.65-9.45 h). There were no major complications requiring surgical intervention. Researchers observed partial flap necrosis, which manifested as small firm lesions in two patients, as well as local wound infection and dehiscence in one patient, which resolved spontaneously. There were no instances of donor-site seroma formation or lymphoedema in any of the patients. An objective assessment of postoperative photographs showed that cosmetic results were mostly satisfactory. Donor-site scars along the medial groin crease were inconspicuous and readily concealed by clothing. Given its reliable vascularity and minimal donor-site morbidity, the free MCFAP flap can be a good alternative for partial breast reconstruction after breast-conserving surgery. (c) 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background: Sensory recovery of skin flaps is generally poor unless they are elevated as an innervated flap. The aim of this study was to elucidate if Schwann cell (SC)-like cells differentiated from adipose-derived stem cells (ASCs) could improve the cutaneous nerve regeneration in skin flaps. Methods: Microvascular island groin flaps were elevated bilaterally in 32 Lewis rats. On the right flap, the epigastric nerve was resected and ligated (noninnervated flap), and on the left flap, the nerve was crushed (innervated flap). ASCs, SC-like cells differentiated from ASCs (dASCs), SCs, or vehicle were simultaneously injected to the dermal and hypodermal layers of flap. After 20 weeks, the reinnervation pattern of flap was assessed im-munohistochemically using a neuronal marker, PGP9.5. Results: dASC cultures produced significantly higher amount of nerve growth factor and brain-derived neurotrophic factor compared with ASC cultures (P < 0.01), and the level was comparable to that of SC cultures. Although a long-term survival of the transplanted cells was not found, dASCs and SCs significantly increased reinnervation density in the periphery of both types of flaps (P < 0.05), and this effect was more pronounced in noninnervated flaps. On the other hand, ASC transplantation showed no statistically significant effect on the peripheral reinnervation (P > 0.05). In the center of flap, there was no statistically significant increase in reinnervation density in all groups irrespective of flap innervation (P > 0.05). Conclusions: dASCs could improve flap reinnervation by 2 mechanisms: First, neurotrophic factors produced by dASCs facilitated regrowth of cutaneous axons from the surroundings of flap. Second, nerve growth factor released by dASCs induced the collateral sprouting of undamaged axons in adjacent tissues. In addition to the use of innervated flaps, dASC transplantation therapy could be a new approach to improve the sensory recovery of skin flaps.

大阪大学にて2000年から2011年に乳房外Paget病と診断された69例を対象とした疫学的検討を行った。経過観察期間は1〜72ヵ月(平均観察期間35ヵ月)、初診時年齢は49〜97歳、平均年齢は72.4歳、男女比は2.5:1であった。発生部位は外陰部63例、肛門周囲4例、腋窩2例であった。病期分類は皮膚悪性腫瘍取扱いガイドラインに準じて行った。病期IAは38例、病期IBは17例、病期IIは3例、病期IIIは3例、病期IVは8例であった。治療は手術が60例、化学療法が9例、放射線療法が5例であった(重複あり)。5年生存率は病期I、II、IIIが100%、病期IVが0%であった。(著者抄録)

Increasing evidence has shown that adipose-derived stem cells (ASCs) could transdifferentiate into Schwann cell (SC)-like cells to enhance nerve regeneration, suggesting potential new cell-based transplantation therapy for peripheral nerve injuries and neurodegenerative disorders. For the implementation of these results to the clinical setting, it is of great importance to establish the differentiation of human ASCs (hASCs) into a Sc phenotype. In this study, we studied hASCs obtained from subcutaneous fat tissue of healthy donors. By a mixture of glial growth factors we differentiated them into Schwann cell-like cells (dhASCs). We then assessed their ability to act as Schwann cells in vitro and in vivo and also compared them with primary human Schwann cells (hSCs). Enzyme-linked immunosorbent assay showed that dhASCs secreted brain-derived neurotrophic factor (BDNF)/nerve growth factor (NGF) at a comparable level, and glial cell-derived neurotrophic factor (GDNF) at a level even higher than hSCs, whereas undifferentiated hASCs (uhASCs) secreted low levels of these neurotrophic factors. In co-culture with NG108-15 neuronal cells we found that both dhASCs and hSCs significantly increased the percentage of cells with neurites, the neurite length, and the number of neurites per neuron, whereas uhASCs increased only the percentage of cells with neurites. Finally, we transplanted green fluorescent protein (GFP)-labeled hASCs into the crushed tibial nerve of athymic nude rats. The transplanted hASCs showed a close association with PGP9.5-positive axons and myelin basic protein (MBP)-positive myelin at 8 weeks after transplantation. Quantitative analysis revealed that dhASCs transplantation resulted in significantly improved survival and myelin formation rates (a 7-fold and a 10-fold increase, respectively) as compared with uhASCs transplantation. These findings suggest that hASCs took part in supporting and myelinating regenerating axons, and thus have achieved full glial differentiation in vivo. In conclusion, hASCs can differentiate into SC-like cells that possess a potent capacity to secrete neurotrophic factors as well as to form myelin in vivo. These findings make hASCs an interesting prospect for cell-based transplantation therapy for various peripheral nerve disorders. (C) 2013 IBRO. Published by Elsevier Ltd. All rights reserved.

Transplantation of autologous Schwann cells (SCs) is a promising approach for treating various peripheral nerve disorders, including chronic denervation. However, given their drawbacks, such as invasive biopsy and lengthy culture in vitro, alternative cell sources would be needed. Adipose-derived stem cells (ASCs) are a candidate, and in this study rat ASCs transdifferentiated into a SC phenotype (dASC) cocultured with dorsal root ganglion neurons were shown to associate with neurites and to express myelin basic protein (MBP)-positive myelin protein. Furthermore, dASCs transplanted into a chronically denervated rat common peroneal nerve survived for at least for 10 weeks, maintaining their differentiated state. Immunohistochemical analysis revealed that transplanted dASCs associated with regenerating axons, forming MBP-/protein zero-positive myelin sheaths. The cell survival and myelin expression assessed by double labelling with S100 and glial fibrillary acidic protein were similar between the dASC- and SC-transplanted nerves. Importantly, transplantation of dASCs resulted in dramatically improved motor functional recovery and nerve regeneration, with a level comparable to, or even superior to, transplantation of SCs. In conclusion, dASCs are capable of myelinating axons in vivo and enhancing functional outcome after chronic denervation. (c) 2012 Wiley Periodicals, Inc.

Background: Activation of the Small GTP-binding protein Rho following the nerve injury contributes to the lack of regeneration in the peripheral nervous system. By elucidating the mechanisms leading to Rho activation, a nonsteroidal anti-inflammatory drug ibuprofen has been identified as a potent inhibitor of Rho activity. In this study we tested the hypothesis, that inhibiting Rho activity by ibuprofen will enhance posttraumatic regeneration after peripheral nerve injury. Methods: In adult female Wistar rats we introduced an experimental injury by excising a 5 mm piece of the tibial nerve and returning it to the injury site as an interpositional graft. The animals then received ibuprofen or phosphate buffered saline through an osmotic pump for a period of 3 weeks. Following the injury we recorded tibial functional index (TFI) on a weekly basis. After 3 months we measured nerve conduction velocity and peak amplitude of action potential (PAAP). Also, the histomorphometric analysis was carried out in the zone distal to the injury site. Results: We found that the animals receiving ibuprofen recovered the tibial nerve function more rapidly, with the TFI being significantly different 8, 9, 11 and 12 weeks after the injury. We also detected the values of the PAAP, the area of axons and the area of myelin to be significantly greater in the experimental group. Conclusions: Our results show that ibuprofen significantly enhanced regeneration after tibial nerve axotomy and repair in rats. This study is expected to set a stage for testing the ibuprofen in the human patients. (C) 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

In breast reconstruction, sensation in the reconstructed breasts affects the patients' quality of life along with its aesthetic outcome. Fortunately, less invasive procedures such as breast-conservative surgery (BCS) and skin-sparing mastectomy (SSM) have greatly contributed to the improved aesthetic outcome in immediate breast reconstruction. However, there are few reports on the recovery of breast sensation after BCS and SSM. We retrospectively reviewed 104 consecutive patients who underwent immediate breast reconstruction with the latissimus dorsi myocutaneous flap between 2001 and 2006 at our institution. The sensations of pain, temperature, touch, and vibration were examined at the nipple and skin envelope during the follow-up period (range: 12-61 months, mean: 31 months), and a stratified analysis was performed to determine the critical factors affecting the sensation recovery after BCS and SSM. We found that large breast size significantly impaired the recovery of sensation in the nipple and skin envelope after BCS as well as SSM. Older age and high body mass index value were the factors which negatively affected the sensation in the skin envelope after SSM. While all our BCS patients underwent postoperative radiation therapy, it did not negatively affect the recovery of sensation in SSM patients. On the basis of these findings, we could further improve the sensation of the reconstructed breasts after BCS and SSM. Especially after SSM, the use of innervated flaps is recommended in the patients with large breast, increased age, or obesity when the nipple-areola complex is resected.

神経端側縫合を応用した自家神経バイパスグラフト(BG)の有用性を検討するため、ラット神経腫モデルを用いて実験を行った。実験群は総腓骨神経を単純切除後即時縫合した群(対照群)、神経腫モデル作成と同時にBG施行した群(即時BG群)、モデル作成後3週間目にBG施行した群(二期的BG群)、モデル作成のみBGなし群(非BG群)とした。足跡分析によるperoneal functional index(PFI)は、全群で術後低下を認めたが、対照群および即時BG群は徐々に増加して5週目以降に、二期的BG群は8週目以降に非BG群と比較して有意に高値となった。10週目においては対照群、即時BG群、二期的BG群の間でPFIに有意差はなく、運動神経伝達速度、脛骨筋重量の回復にも有意差はなかった。神経短軸方向切片のトルイジンブルー染色による形態学的評価では、BG内にミエリン化した再生軸索を認め、全軸索数は二期的BG群で、軸索密度は即時BG群および二期的BG群で他群に比較して有意に高値であった。

In treating reversible facial paralysis, cross-facial nerve grafting offers voluntary and emotional reanimation. In contrast, rapid re-innervation and strong neural stimulation can be obtained with hypoglossal-facial nerve crossover. In this article, we describe the method of a combination of these techniques as a one-stage procedure. A 39-year-old man presented with facial paralysis due to nerve avulsion within the stylomastoid foramen. The sural nerve was harvested and two branches were created at its distal end by intraneural dissection. One branch was anastomosed to the contralateral facial nerve, and the other branch was used for hypoglossal-facial nerve crossover, followed by connecting the proximal stump of the graft to the trunk of the paralysed facial nerve in an end-to-end fashion. At 9 months postoperatively, almost complete facial symmetry and co-ordinated movements of the mimetic muscles were obtained with no obvious tongue atrophy. Since our method can efficiently gather neural inputs from the contralateral facial nerve and the ipsilateral hypoglossal nerve, it may become a good alternative for reanimation of reversible facial paralysis when the ipsilateral facial nerve is not available. (C) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Auricular composite grafts represent a well-established technique in facial reconstruction surgery, with several advantages including high survival rate as well as less contraction and good colour match. Although the revascularisation of composite grafts reportedly occurs by inosculation and angiogenesis through both the dermal-dermal connections and the wound bed, we hypothesised that the auricular dermis might have a distinct vascular profile as compared with other regions, that might contribute to the high survival rate of auricular composite grafts. To elucidate this hypothesis, we investigated the dermal vascular profiles of several regions in fresh cadavers using a von-Willebrand factor antibody-binding technique. We assessed the vascular profiles by calculating the blood vessel density and the endothelial surface. Furthermore, we present herein some clinical cases using novel composite grafts in which graft revascularisation was likely based on the dermal-dermal connections. There was a positive correlation between the blood vessel density and the endothelial surface. We found that the postauricular dermis had a significantly richer vascularity than other skin graft donor sites such as the peri-clavicle, groin, back, buttocks and thigh, whereas the scalp and sole demonstrated an abundant vascularity as the postauricle. Unexpectedly, the cheek dermis, which is just adjacent to the auricular region, had a poor vascular profile. Because of its rapid and reliable revascularisation through dermal-dermal connections, the auricular composite graft should be more widely used in reconstructive surgery. It offers an especially good alternative in treating intractable ulcers and in tracheal reconstruction. (C) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Objective: The superior orbital fissure syndrome results from damage to the nerves passing through the superior orbital fissure. In the present case, the superior orbital fissure syndrome developed after repair of facial bone fractures, although the symptoms were not observed before surgery and no obvious cause was found. To investigate the aetiology of this syndrome, we examined the superior orbital fissure anatomically. Methods: We measured the width of superior orbital fissure on the horizontal plane including the optic canal using the computed tomography (CT) scans of other patients and cadavers. Results: The results indicated that the width was 3.73 +/- 1.64 mm in the CT scans of patients and 3.21 +/- 1.09 mm in the cadavers. There was no significant difference between the width in the CT scans and cadavers. The width in the present patient on the affected side was 1.6 mm, that is relatively narrow. Conclusion: After operation, narrow superior orbital fissure may reduce the tolerance to compression of the nerves by oedema. We consider the narrow superior orbital fissure as a risk factor for superior orbital fissure syndrome. When the superior orbital fissure is congenitally narrow, the surgeons should try to avoid excessive pulling of the bone fragment and compression of the orbital tissue during repair of the facial bone fractures. (C) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

In peripheral nerve transection injury, continuity of axons as well as that of the basal lamina is disconnected. In such case, migrating Schwann cells (SCs) would be the only axonal guidance at an early stage of regeneration. However, it takes a few days for the dedifferentiated SCs to start migration, while axonal growth begins a few hours after injury. Consequently, the axons without guidance extensively branch out and wander off at the lesion, resulting in aberrant reinnervation. Therefore, enhancing SCs migration could be an attractive therapeutic strategy. In this study, we investigated the effects of the in vivo nerve predegeneration on SC migration and the time course of these changes. In our analysis, we established a novel animal model by nerve transplantation from S100-GFP mice (in which SCs constitutively express green fluorescent protein driven by the S100B promoter), by which SC migration could be exclusively visualized. Our results showed that SCs acquire the maximal migration ability with 14-day predegeneration, but subsequently it gradually decreased. There was a correlation between the time course of the changes in SC migration and the number of activated macrophages. These findings suggest that using predegenerated nerve grafts in repairing the transected nerves could facilitate SC migration into the recipient nerve stump. This technique could be beneficial for early establishment of axonal guidance and possible functional improvement after transection injury. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

We used a thin titanium mesh combined with a prelaminated free radial forearm flap to construct a framework to reconstruct a traumatic defect in an adult ear. The prelaminated forearm flap covered both the anterior and posterior aspects of the titanium framework. A raised ear could therefore be created.

Slit family of proteins is one of the repulsive axonal guidance cues, and it also plays an important role in neuronal migration and branching through the interaction with roundabout receptors. The function and role of Slit family proteins during peripheral nerve regeneration are still unknown. We examined the expressions of Slits 1-3 mRNAs in the facial nerve nuclei after facial nerve transection by in situ hybridization, using Sprague-Dawley rats. Slit 1 mRNA was weakly expressed in the facial motoneurons, and its expression increased from clay 5 to day 28 after transection, with the peak on day 14 after axotomy. Slits 2 and 3 mRNAs were expressed in the motoneurons of the facial nerve before injury, but the expression of Slit 2 mRNA was down-regulated from day 1 to day 7 after axotomy, with the peak on the first day after injury. Slit 3 mRNA expression in the axotomized side remained unchanged throughout the examination period. Slits 1 and 2 mRNA expression returned to the normal level on day 56 postoperatively. The difference in expression pattern of Slit family mRNA in the neurons during peripheral nerve regeneration suggests that it plays a different role in axonal regeneration after axotomy of peripheral nerves. (C) 2008 Elsevier B.V. All rights reserved.

Oligodendrocyte myelin glycoprotein (OMgp) has been thought to be expressed in the oligodendrocytes and inhibit the regeneration of the nerves by binding to the Nogo receptor expressed in neurons in the central nervous system (CNS). However, OMgp is expressed in the CNS in the neurons as well as oligodendrocytes. In order to help understanding the physiological role of neuronal OMgp, we examined the change of OMgp expression in the facial nucleus after the facial nerve transection. Real-time RT-pCR and Western blot analysis showed a clown-regulation of OMgp expression in the facial nucleus 5-7 (mRNA) or 5-14 (protein) days after transection. Thereafter, expression of OMgp returned to the control level at 28 clays after axotomy. Subsequent analysis using in silo hybridization histochemistry and immunohistochemistry established that the decrease of OMgp expression was attributable to the expression in facial motoneurons, but not in oligodendrocytes. These findings suggest a possibility that the change of neuronal OMgp expression might be involved in reconnection of neural circuit between axotomized facial neuron and upper motor neuron after transection. (C) 2008 Elsevier B.V. All rights reserved.

Background: The effectiveness of end-to-side nerve graft for multiple branch reconstruction was confirmed using a new rat four-branch facial nerve reconstruction model with end-to-side cross-face nerve graft. Methods: Forty Lewis rats were randomly divided into four groups with different reconstruction methods for four branches (bilateral buccal. and marginal branches) of the bilateral facial nerves as follows: group I In = 12), single sciatic nerve graft with end-to-side neurorrhaphy; group 11 (n = 12), four cable grafts using two sciatic and two ulnar nerves with end-to-end neurorrhaphy; group III (n = 8), no repair; and group IV (n = 8), sham operation. The four groups were compared with double retrograde tracing of the facial nucleus, electrophysiological and histomorphometrical assessment of the reconstructed facial nerve. Results: Although there were no significant differences between groups I and 11 in the electro-physiological. tests, group I showed more uniform and better reinnervation in the histomorphometrical assessment. Retrograde tracing of facial nucleus revealed significantly higher number of double-labeled neurons in group I although the total number of labeled neurons was not different between the two groups. Conclusions: End-to-side nerve graft shows a good functional recovery, requires less graft, and is easy to perform. With the availability of the side of the nerve graft itself as a nerve coaptation site, it can be an effective alternative in facial nerve reconstruction and be of great value in various kinds of peripheral nerve surgery. (C) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The purpose of this study was to determine whether sensory reinnervation with end-to-side neurorrhaphy preserves muscle mass in pedicled muscle flaps. A new muscle flap model innervated by the common peroneal nerve (CPN) was tested in rats. Animals were divided into group 1 (CPN transected without repair), group 2 (CPN transected and immediately repaired by end-to-end neurorrhaphy), and groups 3A and 3B (CPN transected and repaired with the sural nerve, by end-to-end and end-to-side neurorrhaphy, respectively). We evaluated the muscle-preserving effect by measuring muscle weight and performed histological and morphometric analyses 3 months after the procedure. Sensory reinnervation significantly preserved the muscle mass, although less than motor reinnervation. There was no significant difference between the end-to-end and end-to-side procedures. Results of morphometric analysis in each group paralleled those of mean muscle weight. Sensory reinnervation with end-to-side neurorrhaphy appears to be useful in the preservation of muscle flap mass.

ラット坐骨神経欠損モデルを用い、移植した正中神経の側面に腓骨神経の断端を縫合した端側縫合群と、正中神経および尺骨神経に脛骨神経、腓骨神経を端々縫合した群で再建効果を比較した。両群間で経時的機能回復評価に有意差はなく、再生軸索の連続性を評価する逆行性トレーサーを用いた検討でも有意差はなかった。前頸骨筋および腓骨神経の組織像にも有意差はなく、端側縫合は端々縫合と同等の効果が得られた。次に、神経の損傷部位より末梢側の側面に他の神経の近位端を端側縫合付加する方法(axonal supercharging tecnique)について検討した。縫合付加群は術後30日以降で付加なしの対照群と比較して有意に優れた知覚回復を認め、支配筋重量も有意に回復していた。また逆行性トレーサーを用いた検討では再生軸索の進入が確認され、組織像でも神経再生促進が示唆された。神経端側縫合付加は神経損傷後の機能回復促進に有効と考えられた。

With the recent advances in oncologic breast surgery breast reconstruction with the latissimus dorsi myocutaneous (LDM) flap without an implant has become a good option among other autologous tissue reconstructions available. However, only a few large-scale studies have so far evaluated the critical factors affecting its esthetic outcomes. We retrospectively reviewed 97 consecutive patients who underwent breast reconstruction with the LDM flap between 2001 and 2005 at our institution. The esthetic outcome in comparison with the normal breast was evaluated by means of observer assessment consisting of 7 criteria. A stratified analysis was performed to determine the factors affecting the esthetic outcomes after the breast-conservative surgery and skin-sparing mastectomy. We found that reconstruction of the lower half of the breast and exposure of the skin paddle resulted in poor esthetic outcomes after breast-conservative surgery. Large preoperative brassiere cup size, radiation history, axillary node dissection, and exposure of the skin paddle were the factors which negatively affected the overall outcomes after skin-sparing mastectomy. Age, body mass index, presence of nipple areola-complex defect, or design of skin paddle did not affect the esthetic outcomes. On the basis of these critical factors, we could determine the indications and limitations of breast reconstruction with LDM flap. In some cases, further technical modifications are still warranted, and we believe that these modifications will optimize the use of this flap in breast reconstruction.

目的:われわれは、顔面神経等の混合神経損傷後における機能回復がいまだ満足のいくものではない原因の一つとして、末梢神経軸索再生時に生じる過剰な軸索分枝が重要であると考えている。今回、正常ミエリンに存在し、軸索再生阻害因子として知られるMyelin-Associated Glycoprotein(以下、MAG)が、軸索分枝および機能回復に与える影響について検討した。方法:数%の軸索に蛍光蛋白質を発現するマウスにおいて、MAGを徐放投与し、軸索再生形態を検討した。さらに、ラット坐骨神経損傷モデルに対して同様にMAGを投与し、機能回復および神経再生の質的評価を行った。結果:MAG投与により末梢神経損傷後軸索分枝の程度は有意に抑制された。ラット坐骨神経損傷モデルにおいて機能回復が促進され、神経回復の質的向上を認めた。考察:MAG投与は、過剰な軸索分枝を抑制し、質的神経再生を向上させ、機能回復を促進することが明らかとなった。混合神経損傷後における新たな治療アプローチとなりうると考えられた。(著者抄録)

The mature peripheral nervous system (PNS) generally shows better regeneration of injured axons as opposed to the central nervous system (CNS). However, complete functional recovery is rarely achieved even in the PNS although morphologically good axonal regeneration often occurs. This mainly results from aberrant reinnervation due to extensive branching of cut axons with consequent failure of synchronized movements of the muscles. Myelin-associated glycoprotein (MAG), a well-characterized molecule existing both in the CNS and PNS myelin, is considered to be a potent inhibitor of axonal regeneration especially in the CNS. In the present study, we investigated whether MAG has any effects not only on axonal elongation, but also on axonal branching. We show herein that MAG minimized branching of the peripheral axons both in vitro and in vivo via activation of RhoA. Furthermore, after sciatic nerve transection in rats, focal and temporary application of MAG to the lesion dramatically enhanced the functional recovery. Using double retrograde labeling and preoperative/postoperative labeling of spinal neurons, reduced hyperinnervation and improved accuracy of target reinnervation was confirmed, respectively. In conclusion, as MAG significantly improves the quality of axonal regeneration, it can be used as a new therapeutic approach for peripheral nerve repair with possible focal and temporary application. (C) 2007 Wiley-Liss, Inc.

Object. In an attempt to improve peripheral nerve repair, the influence of the addition of reverse end-to-side neurorrhaphy for an injured peripheral nerve was investigated in the rat sciatic nerve transection model. Methods. Twelve Sprague-Dawley rats were divided into two groups (six rats in each group). In Group 1, the right sciatic nerve was cut at a point distal to the gluteal notch and repaired using end-to-end neurorrhaphy with four 10-0 nylon epineurial sutures. In Group It, after performing the same procedure as in Group I, the left sciatic nerve was cut distally and passed through a subcutaneous tunnel to the right side. The proximal stump of the left sciatic nerve was co-apted to the epineurial window of the right sciatic nerve distal to the injured point in an end-to-side fashion using 10-0 nylon epineurial sutures. The effects were evaluated using analgesimeter recordings for the hind paw, electrophysiological tests, measurement of the muscle contraction force, a double-labeling technique, weight measurement and histological examination of the gastrocnemius muscle, histological examination of the bilateral sciatic nerves, and immunofluorescent staining. Results. Results from the many tests used to evaluate the reverse end-to-side neurorrhaphy technique indicated that functional recovery of the denervated target organs was promoted by axonal augmentation. Conclusions. The reverse end-to-side neurorrhaphy technique could be useful in peripheral nerve repair.

The function of the p75(NTR) neurotrophin receptor (p75(NTR)) in nervous system regeneration is still controversial. Part of that controversy may be due to the fact that p75(NTR) is expressed by both neuronal and glial cell types and may have very distinct and even contradictory roles in each population. In this study, to elucidate the in vivo function of p75(NTR) in Schwann cells during remyelination after peripheral nerve injury, we established a new animal model for p75(NTR)-deficient Schwann cell transplantation in nude mice. We performed quantitative assessments of the functional, histological, and electro physiological recovery after sciatic nerve injury, and compared them with those of the P75(NTR)(+1+) Schwann cell transplanted animals. At 710 weeks after injury, the motor recovery in the p75(NTR)(-/-) Schwann cell transplanted animals was significantly impaired compared with that in the p75(NTR)(+/+) Schwann cell transplanted animals. The lower number of the retrogradely labeled motoneurons and the hypomyelination in the p75(NTR)(-/-) Schwann cell transplanted animals were evident at 6 and 10 weeks after injury. At 10 weeks after injury, the radial growth in the axon caliber was also impaired in NTR the P75(NTR)(-/-) Schwann. cell transplanted animals. Measurement of the amount of myelin proteins and the nerve conduction velocity at 10 weeks after injury reflected these results. In summary, the p75(NTR) expression in Schwann cells is important for remyelination process, and the motor recovery after injury is impaired due to impaired axonal growth, remyelination, and radial growth in the axon calibers. (C) 2007 Wiley-Liss, Inc.

The latissimus dorsi flap has been widely used in breast reconstruction surgery. Despite its potential advantages such as low donor morbidity and vascular reliability, the complication of donor-site seroma fort-nation frequently occurs. Consecutive 174 patients who underwent breast reconstruction with the latissimus dorsi flap from 2001 to 2006 were retrospectively reviewed. The age, body mass index (BMI), smoking history, timing of reconstruction, type of breast surgery and nodal dissection, and several other intraoperative data were analyzed. The overall incidence of postoperative seroma was 21%. Increased age (>50 years) and obesity (BMI >23 kg/m(2)) were significant risk factors for seroma formation (P = 0.02 and 0.004, respectively). The patients who underwent skin-sparing mastectomy or modified radical mastectomy had higher incidence of seroma formation (28% and 33%, respectively) as compared with those who had breast-conservative surgery (11%). A significant correlation was found between the type of breast surgery and the incidence of seroma (P = 0.04). The type of nodal dissection did not affect the incidence of postoperative seroma (P = 0.66). We concluded that increased age, obesity, and invasive breast surgery are risk factors for donor-site seroma formation after breast reconstruction with the latissimus dorsi flap. Close attention should be paid to prevent development of postoperative seroma when operating on such high-risk patients.

The treatment of neuroma-in-continuity is controversial. To bypass neuroma-in-continuity with a nerve graft using end-to-side neurorrhaphy is considered to be theoretically a good option. To test this therapeutic modality, we performed a nerve bypass graft in a neuroma-in-continuity rat model. An obstructive neuroma-in-continuity was created in a transected peroneal nerve by interposition using the aponeurosis of the spinal muscles. In the experimental animals, (1) immediate, (2) 3-week delayed, or (3) no ulnar nerve bypass graft was performed. The peroneal functional index (PFI), conduction velocity, tibialis anterior muscle weight, and histomorphometric analyses were performed and compared with control (simply cut and repair) animals. On postoperative day 70, the recoveries of the PFI values, conduction velocity, and tibialis anterior muscle weight in the bypassed animals showed no significant differences as compared with the control animals, and the extent of these recoveries in the bypassed animals were significantly superior to those in the no-graft animals. In the histomorphometric analysis, the mean percent nerve in the bypassed animals was significantly larger than that in the no-graft animals. In conclusion, this technique may be a good alternative to the current therapeutic techniques for neuroma-in-continuity when there is a significant retained function.

Background: The Rho family of small GTPases is responsible for various processes involving actin cytoskeleton in eukaryotic cells, including neurite outgrowth. Several substances found at the peripheral nerve injury site were shown to activate one member of this family, Rho. The activation of Rho leads to neurite outgrowth inhibition and the development of posttraumatic neuropathic pain. The authors used the clinically tested Rho-associated kinase inhibitor fasudil hydrochloride to enhance the functional recovery of the peripheral nerve in the rat. Methods: In the peroneal nerve interpositional graft model, the authors administered fasudil (experimental groups) or saline (control groups) (1) intraperitoneally and (2) directly into the graft by microinjection (n = 6 animals per experimental condition). Neural recovery was assessed during postoperative follow-up lasting 80 days by peroneal functional index, electrophysiologic, and histomorphometric analyses. Results: The peroneal functional index returned to values not significantly different from preoperative values on days 55 (fasudil injected into the graft) and 60 (fasudil injected intraperitoneally) in the experimental groups. In the control groups, this took 70 (saline injected intraperitoneally) and 75 days (saline injected into the graft). These results are supported by electrophysiologic and histomorphologic assessments. Conclusions: The authors determined that fasudil hydrochloride was capable of accelerating the functional regeneration after peripheral nerve axotomy, which is consistent with the results of reports about Rho cascade disruption in the central nervous system. Because fasudil hydrochloride is a clinically tested drug, it could be used to enhance neural regeneration in human patients as well.

After peripheral nerve injury, minimizing axonal misdirection has been a matter of importance to obtain good functional outcomes. In general, it becomes more challenging as the nerve defect length is longer. As previous works suggested that a conduit repair leaving a short gap could induce some target-specific reinnervation, we expected that a distally placed conduit combined with nerve graft would enhance the specificity of reinnervation, especially in dealing with a long gap. To test this, a 14-mm-long gap was created in the rat sciatic nerves and repaired with either 1) whole nerve graft (WG), 2) interfascicular nerve grafts (FG), or 3) whole nerve graft combined with distally placed silicone tube leaving a 5-mm gap (TUBG). At the end of follow up, the extent of target specific reinnervation (measurement of the compound muscle action potentials evoked by stimulation of the sciatic nerve and its tibial and common peroneal fascicles) and the accuracy of motoneuronal projection (sequential retrograde labeling of the common peroneal motor pool) were assessed. Both assessments revealed that groups FG and TUBG had a similar selectivity, which was significantly higher than in group WG. Consistent with these results, the functional recovery as assessed by walking track analysis showed no significant difference between groups FG and TUBG, whereas those were significantly superior to group WG. In contrast, histomorphometric assessment of the regenerating axons and wet muscle weight showed no significant difference among the three groups. In conclusion, conduit repair would have some effects on reducing motor axonal misdirection, and it might be more effective when used in the management of a large defect in combination with nerve graft. (C) 2007 Wiley-Liss, Inc.

Recent studies have provided evidence that p21(Cip1/WAF1) has not only cell cycle-associated activities but also other biological activities like neurite elongation. To investigate the role of p21(Cip1/WAF1) in the in vivo axonal regeneration in the peripheral nervous system, we developed a p21(Cip1/WAF1) knockout (KO) mice sciatic nerve injury model. We performed quantitative assessments of the functional, histological, and electrophysiological recoveries after sciatic nerve injury in p21(Cip1/WAF1) KO mice and compared the results with those of the wild-type mice. p21(Cip1/WAF1) KO mice showed a significant delay of the motor functional recovery between 21 and 42 days after sciatic nerve injury. The values of motor conduction velocity in p21(CiP1/WAF1) KO mice were significantly lower than those in the wild-type mice on postoperative day 28. The mean percent neural tissue and the mean nerve axon width of p21(Cip1/WAF1) KO mice were significantly less than those of the wild-type mice, which was caused by hyperphosphorylation of neurofilaments. Therefore, p21(Cip1/WAF1) was considered to be involved in radial axon growth and to be essential for the motor functional recovery following peripheral nervous system injury. (c) 2006 Elsevier B.V. All rights reserved.

水素による組織の酸化ストレス軽減効果が報告されて以来、多くの分野で医療応用へ向けた研究が行われている。形成外科分野でも、水素水や水素ガス投与が皮弁の虚血再灌流障害抑制効果を示すことが報告されている。近年、高用量の水素を持続的に体内で発生させる性質を持つ、シリコン製剤が開発された。このシリコン製剤を用いれば、これまでの課題であった水素の効率的な体内への 取り込みが可能となり、水素の臨床応用が広がる可能性がある。 本研究では、皮膚・軟部組織再建外科分野における水素の治療効果を、このシリコン製剤の使用とラットを用いた動物実験を通して検証することを目的とした。 本年度は、血管柄付き遊離皮弁移植における虚血再灌流障害に対するシリコン製剤の有効性を検証する動物実験を行った。具体的には、1%シリコン製剤含有食餌を摂取させたラットと、通常の食餌を摂取させたラットにおいて、浅下腹壁動静脈を血管茎とした腹部皮弁を挙上し、3時間程度血管茎のクランプを行うことで虚血再灌流障害を誘導した。術後、シリコン製剤を摂食させた群のラットでは、通常の食餌を摂食させた群のラットと比較して、皮弁の生着率が有意に改善し、組織の炎症所見、アポトーシスや炎症性サイトカイン・酸化ストレスマーカーの発現量等も有意に抑制されていた。この結果、シリコン製剤より発生する水素が、皮弁組織の虚血再灌流障害抑制効果を有することが判明し、移植組織の生着率向上に寄与し得ることが証明された。

In breast reconstruction, whether innervated flaps are useful in skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) remains unclear. This study aimed to examine the usefulness of innervated flaps in restoring sensation after SSM and NSM using a rat model. Dorsal cutaneous nerves of rats were entirely eliminated except for the medial branch of the dorsal cutaneous nerve of thoracic segment 13, resulting in an innervated field surrounded by a denervated field. The innervated field was elevated as an innervated island flap and then subcutaneously embedded. Postoperatively, the mechanonociceptive field expanded around the embedded innervated flap and nerve fibers were observed in the dermis of the new mechanonociceptive field. These results suggest that innervated flaps may be useful in reconstruction post-SSM/NSM.

This study is intended to clarify effects on skin regeneration by Chlorogenic acid. At first, the group was divided into a group to which chlorogenic acid was added and a group to which no chlorogenic acid was added (control), and the number of cells after 24 hours was compared. Chlorogenic acid showed a significant proliferation of fibroblasts as compared with the control group. Then, after stimulating fibroblasts with 10 μM chlorogenic acid, the state of activation of ERK1 / 2 and Akt, which are cell proliferation signals, was analyzed. As a result, activation of Akt was confirmed by stimulation with chlorogenic acid. Furthermore, the fibroblasts were stressed with hydrogen peroxide and then stimulated with 10 μM chlorogenic acid for 30 minutes. Chlorogenic acid was able to suppress the phosphorylation of JNK, which is a representative of cell death signals.

Retinoic acid is a key regulator of the promotion or repression of numerous gene expressions. Cyp26b1, RA degrading enzyme, regulates the concentration of retinoic acid and is deeply involved in tissue development, patterning, and cell proliferation and differentiation. The role of retinoic acid in embryonic development has been widely studied. In this study, by using Cyp26b1 ⊿chon mice, in which Cyp26b1 is deleted at the type 11 collagen expression site and retinoic acid concentration is increased, we were able to clarify that retinoic acid plays an important role in the growth of craniofacial bones during the growth period.

Background: There is no means of reinnervation in implant-based breast reconstruction. In this study, we focused on the direct neurotization (DN) method, which guides damaged sensory nerves directly to the skin. Methods: An innervated area surrounded by a non-innervated area was created by excising the part other than the left Th13 medial branch (mDCN-T13) on the back of the rat. The mDCN-T13 was cut, sutured to the dermis at another site, and the change in the innervated area was examined by the cutaneous muscle reflex. Results: Four weeks after the operation, a cutaneous muscle reflex appeared in agreement with the DN part. The new sensory area then gradually expanded. Conclusion: DN to the skin can create a new innervated area at any site without the presence of nerve stumps. This method can be a powerful method for the perception of reconstructed breasts.

In peripheral nerve transection injury, unlike crush injury, the nerve guidance connecting the dissecting nerves is lost. Neural guidance is recreated by Schwann cells but formed disorderly by scarring. As a result, abnormal nerve regeneration such as misdirection (regeneration to a wrong target tissue) occurs, which causes abnormal synkinesis and muscle spasms. In this study, we focused on adipose tissue-derived mesenchymal stem cells (ASCs) that suppress anti-inflammatory activity and scar formation, and examined the effect of ASC transplantation on the quality of peripheral nerve regeneration. As a result, although there was no significant functional recovery improvement effect by ASC transplantation, the frequency of deterioration of function due to joint contracture decreased. It has been suggested that ASC transplantation may have some regulatory effects.

We analyzed the durability as the implant of polyvinyl alcohol, cytotoxicity, biocompatibility in this study. In the acceleration deterioration examination, we did not recognize the change in compressive strength in silicon group and the PVA group, but recognized increase of the weight in before and after examination in a part of the PVA group. In the cytotoxic examination, we did not recognize the significant difference that was apparent to silicon group and the PVA group. In addition, the clear form change, the difference of the cytoskeletal change did not admit in both groups. In the rat subcutaneous implantation test, a shape expanded about PVA slightly, and there was the group where weight increased partly, and the PVA group recognized the accumulation of the inflammation cells such as a macrophage or the many nuclei giant cell in comparison with a silicon block of the control group.

One of the major problems with nerve grafts is that the survival of a graft segment, including endoneurial Schwann cells (SCs), is uncertain. In this study, we investigated whether the survival of nerve grafts improves when adipose-derived stem cells (ASCs) are incorporated into the grafts. Grafts were entubulated to isolate them from the blood supply of surrounding tissues, mimicking the clinical conditions of a poorly vascularized recipient bed. When ASCs were transplanted to the epineurial layer of the grafts, the number of endoneurial TUNEL-positive cells decreased significantly, as compared to grafts without ASCs, at 10 days postoperatively. Walking track analysis also revealed that animals with the ASC-transplanted grafts had significantly faster motor function recovery, as compared to those with grafts without ASCs. These results suggest that nerve autografts, in combination with ASC therapy, could offer a new approach to obtaining optimal outcomes after peripheral nerve injury.

The loss of nociceptive function in the skin due to trauma or surgery can impair the quality of life. The recovery of nociceptor function is mediated by two different axonal behaviors: collateral sprouting of undamaged nerves, and regeneration of damaged nerves. We previously reported that adipose-derived stem cells (ASCs) can transdifferentiate into Schwann cell (SC)-like cells (dASCs), and that transplantation of dASCs increases axonal density in skin flaps. In the present study, we used an animal model that allowed for the individual assessment of collateral sprouting and regeneration. In vivo experiments revealed that dASC and SC transplantation significantly increased the area of the mechano-nociceptive field in both collateral sprouting and regeneration models, while ASC transplantation had no significant effect.dASC transplantation could present a new approach for improving nociceptive function in denervated skin.

For the peripheral nerve defects greater than 3cm, transplantation of autologous nerve graft (ANG) is the only therapeutic option. However, ANG has several limitations, such as need for sacrifice of donor nerve and size mismatch between ANG and recipient nerve. The purpose of this study was the development of artificial nerve made-to-order that can be a substitute for ANG. The hybrid artificial nerve was produced by adding Schwann-like cells differentiated from adipose-derived stem cells to the acellular rat peripheral nerves. Although most of the added cells were replaced with the native Schwann cells in the recipient nerve, it accelerated the functional recovery, possibly by producing neurotrophic factors such as brain-derived neurotrophic factor.

The aim of this study was to elucidate if Schwann cell (SC)-like cells differentiated from adipose-derived stem cells (ASCs) could improve the cutaneous nerve regeneration in skin flaps. Island groin flaps were elevated bilaterally in 32 rats. ASCs, SC-like cells differentiated from ASCs (dASCs), or SCs were injected to the flaps, and the reinnervation density was immunohistochemically assessed. Although a long-term survival of the transplanted cells was not found, dASCs and SCs significantly increased reinnervation density in the periphery of flaps, and this was more pronounced in noninnervated flaps. On the other hand, ASC showed no statistically significant effect on the peripheral reinnervation. In the center of flap, there was no statistically significant increase in reinnervation density in all groups irrespective of flap innervation. In addition to the use of innervated flaps, dASC transplantation therapy could be a new approach to improve the sensory recovery of skin flaps.

末梢神経軸索が損傷を受けた際、様々なneuronal regeneration-associated genes (RAG)の誘導がニューロン、シュワン細胞においておこり、軸索再生を制御していることが明らかになってきた。我々は過去にcDNA microarrayにてp21遺伝子(p21)をRAG候補としてピックアップし、その再生神経軸索径拡大への関与を報告した。しかし、今回のp21KOマウスを用いた研究で再ミエリン化に関しては有意な関与を認めなかったため、p21と同様にRho kinaseシグナル系に属するp75遺伝子(p75)に着目した。p75のミエリン化における働きをin vivoにおいて解析する目的で、p75欠損マウスより採取したシュワン細胞を同種移植したモデルを作成した。このモデルの利点として、p75欠落神経細胞からの影響を排除し、シュワン細胞のみにおけるp75の解析ができる事が挙げられる。p75欠損神経移植群における移植神経内平均再生軸索径及びミエリンの厚さの評価では、p75欠損神経において有意に小さい値を示した。また神経伝導速度の評価においてもp75欠損神経移植群においてコントロール群と比してその回復は有意に阻害された。また、足跡分析による坐骨神経機能評価(SFI)においても同様にp75欠損神経移植群においてその回復が有意に阻害された。これらの結果よりシュワン細胞におけるp75は、軸索径やミエリンの厚みの増大、すなわち再生軸索の成熟に関わっている可能性が示唆された。