論文

Purpose: To review our clinical cases and devise a protocol for selecting the best operative methods to reconstruct the scalp with a calvarial defect. Methods: We reviewed the original disease, the areas and depths of the scalp and calvarial defects, the methods of reconstruction, and complications in 20 patients. Results: The defect was caused by secondary cranial infection following decompressive craniectomy for intracranial hemorrhage (ICH) in 11 patients; extensive removal of the scalp and calvaria for resection of a malignant tumor in 6 patients; and by secondary cranial infection following removal of a malignant tumor in 3 patients. Cranial infection was frequently associated with abscess formation around the fixation screws and plates, suggesting that artificial materials induced the infection. We reconstructed the defect using free flaps in 15 patients and using local flaps in 5 patients. Conclusions: When restoring the calvaria in the primary operation, the use of metal screws and plates should be minimized to prevent cranial infection and subsequent scalp and calvaria defects. Local flaps are appropriate for reconstructing relatively small defects (<20 cm 2), whereas free flaps are better for reconstructing relatively large defects (>25 cm 2).

Purpose: The present study aims to evaluate morphologic variations of the upper tarsus in Asians. Methods: Measurements of superior-inferior and medial-lateral lengths were performed on 54 embalmed cadavers. The superior-inferior length of the tarsus was measured at the central and lateral parts. On the basis of the measured values, shapes of the tarsi were evaluated and categorized. Results: The tarsi were classified into 3 morphologic categories-the sickle, triangular, and trapezoid types. The upper margins of the sickle, triangular, and trapezoid type tarsi present round, triangular, and flat lines, respectively. Among the 54 examined specimens, 29 (55.6%), 16 (29.6%), and 9 (16.7%) belonged to the sickle, triangular, and trapezoid groups, respectively. Conclusions: The upper eyelid tarsi present morphologic variations with the Asian population. In performing surgical correction of blepharoptosis or surgical production of double-folds, this individual variation should be taken into consideration.

Purpose: Defects of the dura mater caused by surgical intervention are often reconstructed using artificial substitutes such as polytetrafluoroethylene membrane (Gore-Tex in commercial name). In cases where secondary infection develops after the initial operation, the artificial substitute used in the primary surgery needs to be removed, and the cranial defect should be covered with tissues abundant in blood supply. The present study discusses the necessity of secondary reconstruction of the dural defect in the recovery operation. Methods: A retrospective study was conducted on 12 patients in whom artificial substitute was exposed because of necrosis of the overlying tissues due to infection or radiation. In recovery operations, the artificial substitute was removed, and the conditions of the underlying defects were evaluated. Results: In all cases, capsule formation had developed to cover dural defects underneath the infected artificial substitutes. The capsules were transparent and watertight, presenting no leakage of cerebrospinal fluid. After coverage of the defect regions using free-flap transfer, no patient developed postoperative complications in follow-up periods of at least 6 months. Conclusions: Capsule formation occurs under artificial substitutes after replacement of the dura mater. Because the capsules retain the cerebrospinal fluid, replacement of the artificial materials is unnecessary in the secondary operation.

This report introduces a new method for the correction of cryptotia using an advancement flap supplied by both superior auricular muscle and skin pedicle. This procedure has many advantages: the design is simple, the procedure is easy, the hairline is not disturbed by the operation, the maintenance of a deep auricular sulcus allows the patient to wear glasses, the scar behind the auricle is not visible, recurrence of the cryptotia is prevented and there is no need for additional skin grafting. Satisfactory contour and protrusion of the upper part of the auricle were maintained postoperatively.

Skin fibrosis, in its mildest form, may present only a minor aesthetic problem, but in the most severe cases it can lead to debilitating pathologies of the skin, for example keloid and hypertrophic scars, and systemic sclerosis. In recent years, extensive basic research aimed at understanding the molecular mechanisms underlying fibrosis has revealed an impressive but baffling number of genes, molecules, and cell types that may contribute to this problem. However, one recurring and consistent theme in these studies is that inflammatory cells and their secreted mediators appear to be leading culprits in activating dermal fibroblasts to become fibrotic. This review will first describe the histology of normal versus fibrotic skin, and will also describe the process of wound repair, a primary cause of skin fibrosis. We will then focus on what is currently known about the molecular mechanisms underlying skin fibrosis, with particular attention paid to how inflammation contributes. Finally, current treatment strategies and emerging therapeutic targets will be discussed.

Background: Adipose-derived stem cells (ASCs) possess multipotency in vivo and in vitro, and thus are thought to be very promising precursors for use in regenerative medicine. ASCs can be concentrated from adipose tissue by enzymatic digestion and transplanted to increase angiogenesis or for cosmesis. ASC transplants are now being performed in a clinical setting. Although data on ASCs are extensive, the distribution of ASCs in human fat tissue has not been fully clarified. Thus, it is important to identify the distribution of ASCs to obtain cell populations rich in ASCs for clinical use. Methods: ASCs express CD34, a cell surface marker. As CD34 is also expressed by endothelial cells, we immunohistochemically stained 2-μm-thick serial paraffin sections of fat tissue obtained from various parts of formalin-fixed cadavers with anti-CD31 and anti-CD34 antibodies to distinguish ASCs from endothelial cells. Results: CD34(+)/CD31(-) cells were mainly found in connective tissue tracts and perivascularly. Among fat tissues obtained from various sites, fat tissues in the thoracic back and lower abdomen were richest in CD34(+)/CD31(-) cells. Conclusion: The concentrations of CD34(+)/CD31(-) cells in adipose tissues differ between sites. The sites most highly enriched for ASCs were identified, and it is now possible to select the best sites for collection of ASCs for transplantation.

When reconstructing the thoracic wall, non-adaptation of the suture line is a critical concern, especially when artificial implants are used. Therefore, a reliable and safe flap is required. Based on an anatomical study of cadavers, we decided to dissect the pectoralis major musculo-cutaneous flap into two parts, on the surface and beneath the muscle fascia, while preserving the muscle perforators. We designated the skin portion as the V-Y advancement flap or rotation V-Y advancement flap and the muscle flap as the transposition flap. Both flaps had different suture lines. We applied this method to two patients requiring reconstruction of anterior thoracic defects with artificial implants. One patient did not have adverse effects, and the flaps took well. The shape of the breast did not change significantly. However, the other patient was a heavy smoker. Although the V-Y advancement flap took well, the cutaneous triangular tip made at the time of tumour resection became necrotic. However, the underlying pectoralis major muscles successfully covered the implants and did not show any signs of infection. In conclusion, reconstruction of the anterior thoracic wall to change the suture line with a V-Y advancement flap, based on the muscle perforator and pectoralis major muscle flap, is a useful and reliable method, especially when an artificial implant is used.

Extramammary Paget's disease regularly requires a wide resection of skin, often including the anal tract. When reconstructing the anal tract, simulating natural anatomy by creating the thinnest possible flap is essential to prevent incontinence. We reconstructed the anal and perianal area using a posterior thigh trilobed flap. The lobe to be transposed to the anal duct had a square design and was thinned. The other lobes were used to cover perianal defects and the flap donor site. Using this method, we reconstructed three patients who required large perianal area and anal tract resections. All flaps took well, and after the initial healing process, the patients did not develop lasting incontinence. We conclude that the posterior thigh flap with a thin square wing is useful for reconstruction of the anal tract and perianal area.

Treatment of giant congenital melanocytic nevi (GCMNs) must be considered from both a cosmetic and a medical aspect of reducing the risk of a growing malignancy. We treated five patients who had a GCMN on the trunk with an enzymatically separated epidermal sheet taken from their excised GCMN skin. All patients underwent enzymatically separated epidermal sheet grafting at the age of 2 months. With the patient under general anaesthesia, we removed the affected area with an electric dermatome until the brown colour had almost completely disappeared. The removed skin was immersed in dispase I solution (1000 U ml-1) dissolved in Ringer's solution at 37 °C for 75-105 min until the epidermal sheet separated from the dermis without tension. Three back lesions and two abdominal lesions were treated. In all cases, the enzymatically separated epidermis grafted well, without infection. The amount of discharge that accumulated from immediately after the operation until the first dressing change (performed at 3 days after the operation) was reduced compared with that from curettage. The skin colour was light brown at first and gradually became lighter within a few months. The grafted areas were soft and did not show significant re-pigmentation. In most cases, hard hair did not grow on the treated area. Histological samples taken 1 year after the operation showed that the dermal layer was reconstituted without pigmented nevus cells. Enzymatically separated epidermal grafting is a useful method for the treatment of GCMN, is easy to perform and leaves cosmetically satisfactory results.

Autologous fat grafting has become a common procedure for augmenting soft tissue. However, there are still some problems with resorption and cyst formation after injection, which mainly arise from insufficient nourishment of the transplanted fat tissues. In this study, using a mouse model, we enzymatically digested fat tissues into unilocular fat cells, and then transplanted the unilocular fat cells by sub-dermal injection to allow the transplanted cells to easily spread within the injected area. Fat tissue was harvested from a green fluorescent protein transgenic mouse (C57BL/6), and the optimal digestion time was determined to be 30 min. The fat cells were then injected into the sub-dermal layer of the head skin of a C57BL/6 mouse. As a control, minced fat without digestion was also injected. The animals were sacrificed immediately after injection and on days 1, 2 and 3, as well as at weeks 1, 2 and 4 after injection, and the recipient skins were collected for microscopic observation. The unilocular fat cells were observed to spread in a solitary manner among the recipient tissues, and no necrotic areas or cysts were observed. The minced-fat-graft control showed central necrosis in the transplanted region. In addition, the minced fat tissue needed to be injected with an 18-gauge syringe, but the unilocular fat cells could be injected with a 26-gauge syringe. Thus, the unilocular fat-cell graft was determined to be a superior alternative to conventional fat grafts.

Proteus syndrome is a rare congenital hamartomatous condition that is characterized by a wide range of malformations, occasionally involving the head and the face. Skin and skeletal developmental malformations are common and may be manifested in significant physical anomalies. In this report, we describe the cases of 2 patients affected by this condition. For one patient, a recurrence occurred 4 years after the elimination of cranial hyperostosis. In the second patient, although we observed macrosomia and peculiar countenance in the context of craniofacial hyperostosis, the patient did not visit a clinic for approximately 50 years before seeking treatment. The management of the craniofacial involvement is described, and a literature overview is presented.

In reconstructing a large defect of the vulva, we combined the gluteal fold and the pudendal thigh flaps and made a bilobed flap. Using this gluteal fold pudendal thigh bilobed flap, we reconstructed a vagina with sufficient depth and width. The surrounding skin defect was simultaneously reconstructed. Sensation was intact in all areas of the reconstruction. In addition, the sutured lines of both donor sites are hidden in the gluteal and inguinal folds. Thus, the gluteal fold pudendal thigh bilobed flap seems to be ideal for reconstructing large vulvar defects.