The rectus abdominis myocutaneous flap combined with vascularized costal cartilages in reconstructive craniofacial surgery

The efficacy of osteocutaneous or vascularized bone flaps for reconstruction of massive skeletal and soft-tissue defects has been supported by recent descriptions in the literature. In this article we presented an alternative technique, which is the rectus abdominis myocutaneous flap combined with vascularized eighth and ninth costal cartilages, for reconstruction of midfacial composite defects. The vascular pedicle of the composite flap is the deep inferior epigastric artery and vein. The costal cartilages are supplied by the perichondrial vascular network through the anterior intercostal vessels connecting with the deep epigastric vascular system. Vascularized costal cartilages are considered to reduce the incidence of postoperative complications and resorption of this material. This technique is a useful tool for restoration of craniofacial contour in reconstructive head and neck surgery.

Pelvic ring reconstruction with a vascularized bone flap of femur

We have used a vascularized bone flap of femur for pelvic ring reconstruction after tumor resection in which amputation of the lower extremity was required. The vascularized femoral graft is an alternative technique in restoration of pelvic ring continuity with vascularized bone autografts.

The antithrombotic effects of recombinant human soluble thrombomodulin (rhsTM) on tissue factor-induced disseminated intravascular coagulation in crab-eating monkeys (Macaca fascicularis)

We evaluated the antithrombotic effects of recombinant human soluble thrombomodulin (rhsTM) in plasma and in a monkey model. rhsTM dose-dependently prolonged activated partial thromboplastin time (APTT) in the following order: humans > monkeys > rats >> rabbits. The prolongation of APTT by rhsTM was also observed in protein C-deficient plasma. rhsTM activated protein C and inactivated factor Va in human and monkey plasma, but not in rat plasma. These findings suggest that the antithrombotic activities of rhsTM are fully expressed in human and monkey. Therefore, to evaluate the whole activity of rhsTM in a clinical model, tissue factor (TF) was intravenously infused into crab-eating monkeys to induce disseminated intravascular coagulation (DIC). Pretreatment with rhsTM reduced fall in fibrinogen with a biphasic and moderate dose-dependency curve, and reduced thrombin-antithrombin III (TAT) levels with a flat linear dose-dependency, while heparin prevented fall in fibrinogen with a steep linear dose-dependency curve without reducing TAT levels. Further evidence suggesting that rhsTM activates protein C in vivo was also obtained. Taken together, the data indicate that rhsTM fully expresses its antithrombotic activities in human and monkey but not in rat and rabbit, and rhsTM prevents TF-induced DIC in monkeys by suppressing thrombin generation.

Correction of inverted nipple with modified star flap technique

The authors describe the application of the modified star flap technique for correction of inverted nipples. This technique allows easy identification and dissection of the lactiferous ducts under a clear direct view without trans-nipple incision. The secure deep dermal buried sutures around the nipple base in three directions maintain the newly everted nipple. The blood supply to the nipple flap is reliable through the dermal and subdermal plexus from the remaining non-incised site of the nipple and areola region.

Expression analysis of mortalin, a unique member of the Hsp70 family of proteins, in rat tissues

We have investigated the expression of mortalin in rat tissues by Northern analysis, RNA in situ hybridization, and immunohistochemical studies. By Northern assay, the highest level of expression was detected in brain, heart, and skeletal muscle followed by lung, liver, and kidney, and the least level of expression was detected in testis and spleen. RNA in situ and immunohistochemical studies showed that mortalin expression is significantly higher in upper nondividing layers than in the lower basal layers of skin, in neurons and nerve fibers than in surrounding glial cells in brain, in cardiomyocytes than in nonmyocytes in heart, and in interstitial secretory tissue than in germinating follicles in ovary. Such tissue- and cell-specific expression patterns of mortalin coordinates with its earlier reported antiproliferative function in normal cells. However, a deregulation of the expression is observed in rat brain tumor along with the detection of nonpancytosolic mortalin in rat glioma cell line C6. The study suggests that mortalin is involved in pathways that regulate division capacities of cells in vivo.

Multiple cerebral infarctions in a patient with refractory idiopathic thrombocytopenic purpura

Multiple cerebral infarctions were observed in a patient with refractory idiopathic thrombocytopenic purpura who was positive for lupus anticoagulant (LAC) when her platelet counts were 2000 microL-1. It is suspected that LAC may have played an important role in the pathogenesis of this patient's cerebral infarctions, although she had severe thrombocytopenia.

[Clinical efficacy of silver sulfadiazine (AgSD: Geben cream) for ulcerative skin lesions infected with MRSA]

The clinical efficacy was evaluated on 1% silver sulfadiazine (AgSD) cream (Geben cream) for the treatment of ulcerative skin lesions infected with MRSA (methicillin-resistant Staphylococcus aureus). 1% AgSD cream was applied once a day to cutaneous ulcers such as burns or decubitus or various other ulcers, infected with MRSA, in 13 patients. MRSA was eradicated in 45.5% of 11 evaluable patients. The clinical efficacy rate of 1% AgSD cream was 72.7% in this series of treatment. No side effects were noted in any of the patients, either locally or systemically. The results of the present study have indicated that 1% AgSD cream is useful for cutaneous ulcers such as burns or decubitus, infected with MRSA.

Particulate bioglass compared with hydroxyapatite as a bone graft substitute

Bioactive ceramics, notably hydroxyapatite, have been used clinically in various situations in which bone augmentation and restoration are required. Particulate material has been used either alone or in conjunction with freeze dried or autologous bone, with variable clinical success. In this study a bioactive glass, 45S5 Bioglass, has been compared with hydroxyapatite in an animal model to discover whether the 2 major disadvantages of hydroxyapatite may be overcome. These are the difficulty of placing and retaining the particulate in the defect and the length of time needed before full bony restoration is achieved. Bioglass is shown to be easy to manipulate and hemostatic and allows full restoration of bone in 2 weeks, rather than the 12 weeks needed for the particulate hydroxyapatite to produce a comparable response. The Bioglass particulate is used up in the process, and any problems that may be associated with the production of a composite of bone and biomaterial are avoided in the fully restored bone. In any procedure that requires bony augmentation, this rapid response to Bioglass is expected to provide a clinical advantage.

Quinoline-induced chromosome aberrations and sister chromatid exchanges in rat liver

Induction of chromosome aberrations and sister chromatid exchanges (SCEs) was studied in hepatocytes of F344 rats exposed in vivo to the hepatocarcinogen quinoline (Q). Hepatocytes were isolated 4-48 hr after a single dose of 200 mg/kg body weight or 24 hr after 28 repeated doses (once a day) of 25-200 mg/kg body weight/day by gastric intubation, and allowed to proliferate in Williams' medium E supplemented with epidermal growth factor. Cells were fixed after a culture period of 48 hr. A single dose of Q induced chromosome aberrations in up to 22% of metaphase cells, and SCEs with a frequency of up to 1.27 per chromosome 12 hr after the dose, while the control values were 1% and 0.63 per chromosome, respectively. Treatment with 28 repeated doses of Q induced significant chromosome aberrations and SCEs dose-dependently. Cytogenetic damage induced induced in the liver by repeated doses of Q was greater than induced by a single dose. Furthermore, Q induced replicative DNA synthesis in the liver, but failed to induce micronucleus formation in the bone marrow. The noncarcinogen 8-hydroxyquinoline was also examined and found to be essentially non-genotoxic to rat liver. These results show that Q is a genotoxic carcinogen to rat liver and the present method of in vivo cytogenetic assay should be useful for evaluating the genotoxicity of hepatocarcinogens.

Treatment of esophageal cancer in patients over 80 years old

A total of 828 patients with esophageal cancer were treated at the Second Department of Surgery of Tokai University in the 20-year period from 1975 to June 1994, including 45 patients over 80 years old. We reviewed these elderly patients to assess the optimum therapeutic approach for such individuals. In recent years, the number of elderly patients with esophageal cancer has steadily been increasing. Advanced cancer is more common among this group, but early cancer has also been detected more frequently in recent years. Of the 45 elderly patients (80%) in our series, 36 were encountered in the last 10 years. As 28.9% of the patients had multiple cancers, a careful workup was necessary preoperatively. Since most patients (88.9%) had complications and were also in a poor general condition, limited surgery was recommended in consideration of the postoperative quality of life. The indications for endoscopic mucosal resection (EMR) may be able to be extended to submucosal1 (sm1) cancer without lymph node swelling. Postoperative complications occurred in 60% of those undergoing surgical resection or esophageal bypass, although death only resulted in 1 case. The 5-year survival rate after surgical resection was 30.8%. These results therefore support the use of surgical treatment for selected elderly patients with esophageal cancer.

[Bone marrow transplantation versus maintenance chemotherapy for adult acute leukemia in first remission]

We compared the outcome of bone marrow transplantation (BMT) with that of maintenance chemotherapy for adults with acute leukemia who achieved first remission in Japanese Red Cross Nagoya First Hospital. From 1976 to 1993, 17 patients with acute myelogenous leukemia (AML) and 10 patients with acute lymphoblastic leukemia (ALL) received allogeneic BMT from HLA genotypically identical siblings in first remission, 4 patients with ALL undertook purged autologous BMT using monoclonal antibody and complement, and 55 patients with AML and 27 patients with ALL were treated with maintenance chemotherapy. The estimated 6-year disease free survival (DFS) of AML patients was significantly higher in the BMT group than in the chemotherapy group (77.3% vs 42.6%; p < 0.01). For ALL patients, the estimated 6-year DFS was 72.5% in the allo-BMT group and 100% for the auto-BMT group, but no patient was disease free more than 2 years in the chemotherapy group (p < 0.0001). We conclude that BMT after several courses of consolidation chemotherapy is the optimal treatment of choice in patients with AML and ALL in first remission. A prospective study is needed to confirm the efficacy of BMT after intensive consolidation chemotherapy.

An anatomic study of the latissimus dorsi-rib flap: an extension of the subscapular combined flap

The anatomy of the vascular perforators between the latissimus branch of the thoracodorsal vessels and the lateral branch of the dorsal rami of the intercostal vessels was studied in a series of 10 dissections in 5 preserved cadavers to develop the latissimus dorsi myocutaneous flap combined with a vascularized rib. The distances between the communicating perforators and the spinous process and the iliac crest, which become a good guide for design of the rib flap, were measured. An extension of the combined flap including the scapular osteocutaneous flap, latissimus dorsi myocutaneous flap, and vascularized eleventh and twelfth ribs that is nourished by a "single" subscapular vascular system was demonstrated. This technique, which provides a large amount of skin, muscle, and bone, is very effective for reconstruction of an extended composite maxillary and mandibular defect.

Microsurgical reconstruction of chest- and abdominal-wall defects associated with intraperitoneal vessels

Microsurgical reconstruction of abdominal or chest-wall defects requires extreme precision but may still raise serious problems. In previous publications many methods have been reported, including free fascia graft, synthetic mesh, pedicled flap, and free flap with microvascular anastomoses. Free-flap transfer has become a popular operative procedure for such reconstructions. The recipient vessels utilized have been mainly the external peritoneal system. In some cases, however, it is very difficult to find adequate recipient vessels in the external peritoneal region. Intraperitoneal vessels may be obviously exposed in the surgical field because there has been a full-thickness defect of the abdominal or chest wall. These vessels are rather easily found and dissected. Their diameter is about 1 to 2 mm, appropriate for microvascular anastomoses with flap vessels in the reconstruction. Using intraperitoneal vessels for the recipient vessels has rarely been reported. The authors report three cases of reconstruction of full-thickness defects of the abdominal or chest wall, using these vessels as recipients for free flaps.

Use of the expanded skin flap in esthetic reconstruction of postburn deformity

Tissue expansion is very useful in the restoration of postburn deformities. We describe two esthetic reconstructions of postburn deformity with expanded skin flaps. In case No. 1, the patient was plagued with the pigmented skin graft used for coverage of a burn ulcer on the lateral chest. The graft was completely replaced by expanded skin flaps and esthetic improvement was obtained. In case No. 2, the patient had postburn alopecia including the right hairline and sideburn. The expanded scalp free flap harvested from the contralateral side was used and an excellent result was obtained. We submit that tissue expansion is the technique of choice for esthetic reconstruction of postburn deformities.

[Sickle cell anemia]

Sickle cell anemia is a disease having both hemolytic anemia and vasocclusive phenomenon. The mutant gene product (hemoglobin S[HbS], beta 6glu-->val) has the tendency to polymerize at low oxygen tension and cause the sickling phenomenon. This has been assumed to be the dominant factor of the pathophysiology in the sickle cell anemia. In addition, unstable HbS, disturbed cation homeostasis and adhesiveness of sickle cell to the endothelium are sufficient to impact on clinical features. The unstable HbS generates oxidant, induces iron decompartmentalization and cellular dehydration, resulting in abnormal microrheology, endothelial adhesivity, phospholipids destabilization and protein defects. These membrane defects and HbS polymerization (RBC sickling) play the important role on the pathophysiology (hemolytic anemia and vasocclusion) in sickle cell anemia.

Genetic differences between the pancytosolic and perinuclear forms of murine mortalin

To determine the genetic relation between the pancytosolic (uniformly distributed in cytoplasm-p66mot-1) and the perinuclear (p66mot-2) mortalin proteins found in normal and immortal mouse cells, respectively, we initiated the present study using PCR cloning, sequencing, and single nucleotide primer extension analyses. The results indicate that the difference between mot-1 and mot-2 at 2 bp in the open reading frame does not arise by mutations in the immortalized cells. Intriguingly, both mot-1 and mot-2 sequences were detected in genomic DNA from normal (CMEF) and immortal (RS-4) cells derived from the CD1-ICR mouse strain. We extended the analyses to four other strains of mouse and detected both mot-1 and mot-2 sequences in genomic DNA from the Balb/c mouse also. Swiss and C57BL/6 mice exhibited only mot-2 and the C3H He mouse only mot-1. Southern analyses on a mouse strain that showed the presence of only mot-2 (Swiss) and one that showed both mot-1 and mot-2 (CD1-ICR) by PCR revealed that there are structural differences between mot-1 and mot-2 loci. Furthermore, there appears to be a correlation between frequency of spontaneous immortalization of cultured mouse fibroblasts and the mot loci present in the mouse strain from which they were derived.

The combined flap based on a single vascular source: a clinical experience with 32 cases

This article provides a retrospective review of 32 combined flap transfers. It consists of two or more flaps based on independent vascular branches from a single vascular source. This series included the combined flap based on the subscapular-circumflex scapular-thoracodorsal vascular system in 24 patients and the profunda femorislateral circumflex femoral vascular system in 8 patients. Twenty-four combined flaps were transferred as free flaps and eight as pedicled flaps. The combined flap based on the subscapular system has very good indications for massive and three-dimensional composite defects in the head and neck region. The combined flap based on the lateral circumflex femoral-profunda femoris system is useful for reconstruction of large defects in the groin, perineal, and lower abdominal regions.

Japanese siblings with missense mutation (717Val --> Ile) in amyloid precursor protein of early-onset Alzheimer's disease

We report Japanese siblings with the missense mutation 717Val --> Ile in the amyloid precursor protein. The maternal grandmother died of an unknown dementing disorder. The proband's mother had gradually increasing amnesia beginning at age 64, which was diagnosed as Alzheimer's disease (AD). She died in a psychiatric hospital (duration of illness: 16 years). Both the proband and her elder sister were affected at about age 55 years. Disturbances of memory, judgment, and emotion, as well as personality changes, occurred first, with dementia eventually predominating. The elder sister died of pneumonia (duration of illness: 9 years). The amyloid precursor protein (APP) gene was analyzed from each sibling. Genomic DNAs obtained from blood samples were amplified by the polymerase chain reaction (PCR) method. PCR products were digested with the restriction enzyme Bcl I. The resulting restriction fragment length polymorphisms (RFLPs) showed the missense mutation 717Val --> Ile in both patients, but not in a normal control. DNA sequencing showed the presence of the 2149G --> A missense mutation only in the patients. We conclude that this familial AD may originate from the missense mutation 717Val --> Ile in the amyloid precursor protein gene and that the clinical picture is typical of AD, except for normal-pressure hydrocephalus and psychiatric phenomena.

[Five cases of hereditary high red cell membrane phosphatidylcholine hemolytic anemia in three families]

Five cases of hereditary high red cell membrane phosphatidylcholine hemolytic anemia in three families were described. All cases were clinically manifested by jaundice and splenomegaly. Hemolysis was evident from indirect hyperbilrubinemia, reticulocytosis and decrement of serum haptoglobin. Red blood cells showed morphological abnormalities such as poikylocytosis, anisocytosis and target cells on blood smears. Both direct and indirect Coombs' tests were negative. Ham test, sugar water test and hemoglobin electrophoresis showed no abnormalities. Osmotic fragility test showed decreased membrane fragility. Lipid analysis of red cell membrane showed increment of phosphatidylcholine content and decrement of sphingomyelin content, although plasma lipids were essentially normal. Influx and efflux of sodium through the red cell membrane were both increased. Splenectomy was performed without effect on one patient and the mother of other patients.

Effects of lipo-prostaglandin E1 on random pattern flaps in rabbits

The effects of lipo-prostaglandin (PG) E1, which are lipid microspheres containing PGE1, were examined using 2 x 12 cm random pattern skin flaps on the backs of five rabbits. Five rabbits acted as controls. Both surviving length (8.5 (3.1) compared with 4.9 (1.8) cm) and surviving area (22.1 (9.3) compared with 11.5 (6.1) cm2) of the skin flap were significantly increased (p < 0.03 in each case). In three additional rabbits the blood flow on the distal side of the skin flap, where it was poor, was measured using a laser image blood flowmeter. Blood flow was improved five to 15 minutes after injection of lipo-PGE1 and was maintained for at least 60 minutes. In conclusion, lipo-PGE1 increased the blood flow of the random skin flaps, resulting in significant enlargement of the surviving area of skin flaps.

The effect of a collagenous implant on deep dermo-periosteal defects in the rabbit

In plastic surgery, extensive wounds with exposed bone and loss of the periosteum (i.e., deep dermo-periosteal defects) are difficult to treat, even with split-thickness skin grafts, because such grafts rarely survive. Even when these grafts do survive, functional impairment often occurs subsequently. The application of a collagen sponge (Terudermis, Terumo, Tokyo) to such wounds has previously been reported to accelerate granulation tissue formation, resulting in would healing and graft survival. However, this previous report only presented data relating to gross morphological appearance. In this paper, we present histological evidence to demonstrate the beneficial effect of the collagen sponge on experimental dermo-periosteal scalp defects in rabbits. About two weeks after the application of collagen sponge to the experimental wounds, a well-vascularized granulation tissue was formed. Autologous split-thickness skin grafts applied to this new granulation tissue were found to be viable one week after grafting. The results confirm histologically that collagen sponge is effective for the treatment of deep dermo-periosteal defects which would not have regenerated skin cover with conventional therapies such as skin grafting or the temporary use of dermoprotective materials followed by skin grafting.

Facial contouring surgery with the scapular osteo-adipo-fascial flap

Recently, deepithelialized scapular or parascapular flaps have been used for reconstruction of facial contour. The authors used a scapular osteo-adipo-fascial flap, based on the subscapular vascular system, accompanied with scapular bone on the angular branch, for surgical correction of facial contour in two cases. At follow-up, both patients showed aesthetic improvements, and were pleased with the results. The scapular osteo-adipo-fascial flap provides a technique to reconstruct facial contour, including the bony structure as well as the soft tissue.

Rise time and amplitude of visually elicited EPSPs of tectal neurons of the frog

Visually elicited activities in response to on-off of diffuse light and moving patterns were recorded from tectal neurons of the frog by means of perforated in vivo whole cell recording technique. Rise time histograms of EPSPs had a single or multiple peaks. Comparing the histogram patterns for each stimulus, retinal fiber classes and positions of synapses on the dendrites could be correlated. In most cells, R3 fibers made synapses on proximal dendrites, whereas R1/R2 fibers on distal dendrites, which was consistent with anatomical findings. Preliminary quantum analysis of EPSP amplitudes was performed by fitting the histograms with a binomial curve and parameters q and n were determined. The result showed that the number n of synapses on distal dendrites is larger than those on proximal dendrites.

Superiority of the microvascularly augmented flap: analysis of 50 transverse rectus abdominis myocutaneous flaps for breast reconstruction

Our experience with 50 transverse rectus abdominis myocutaneous (TRAM) flap transfers was evaluated as to the types of TRAM flaps, indications for breast reconstruction with a TRAM flap, and complications. The TRAM flap was transferred as a free flap in 7 patients, a unipedicled flap in 14 patients, and a microvascularly augmented flap in 29 patients. Microvascular augmentation was performed through the contralateral inferior epigastric vascular system to the superiorly pedicled muscle in 10 patients who had undergone radical mastectomy and the ipsilateral inferior epigastric vascular system in 19 patients who had undergone modified radical mastectomy. In this series, the incidence of flap-site complications, including total flap loss, partial flap loss, and fat necrosis, was lowest in the microvascularly augmented flap group. Particularly, incidence of partial flap loss in the microvascularly augmented flap group was significantly lower than in the unipedicled flap group (p < 0.01). These outcomes demonstrated the superiority of the microvascularly augmented TRAM flap for breast reconstruction.

The effects of lipo-prostaglandin E1 on axial pattern flaps in rabbits

The effects of lipo-prostaglandin E1 (lipo-PGE1), lipid microspheres containing PGE1, on axial pattern flaps were examined using 12 x 20 cm axial pattern flaps based on the right superficial inferior epigastric vessels on the abdomens of rabbits. The surviving area of the skin flap in the lipo-PGE1 group (0.197 +/- 14.1 cm2; n = 10) was significantly increased (p < 0.02) compared with the saline control group (110.4 +/- 5.5 cm2; n = 10). Changes in pedicle blood flow after lipo-PGE1 administration were determined using an ultrasonic pulsed Doppler flowmeter (n = 5). Blood flow in the artery was increased immediately after administration, and it was maintained for 40 minutes. The surface blood flow at the caudal end of the flap on the nonpedicle side, where it was poor, was measured using laserflowgraphy. Blood flow in the skin flap surface was improved 5 to 15 minutes after lipo-PGE1 administration, and it was maintained for as long as 60 minutes. Venous occlusion of the skin flap was also improved (n = 3). In conclusion, lipo-PGE1 increased the blood flow in the axial pattern flaps, resulting in significant enlargement of the surviving skin flap area.

Cheek reconstruction with an expanded prefabricated musculocutaneous free flap: case report

We present a case of reconstruction of the left cheek with a prefabricated musculocutaneous flap. A pedicled serratus anterior muscle flap was transferred to the left chest, deep to skin. The muscle flap and overlying skin were expanded. The expanded, prefabricated musculocutaneous flap was then transferred as a free flap to the left cheek defect.

An anatomic study for the rectus abdominis myocutaneous flap combined with a vascularized rib

The anatomy of the vascular connections between the eighth intercostal vessels and the deep epigastric vessels was studied in a series of 20 dissections in 10 preserved cadavers to develop the rectus abdominis myocutaneous flap combined with a vascularized rib. The distance between the point where the eighth intercostal vessels attached to the costal margin and the xiphoid process and the arcuate line, which become a good guide for design of the flap, was measured. The average length of the vascular pedicle of a vascularized rib was over 10 cm. Possible clinical uses of this compound flap for reconstruction of a composite maxillary or mandibular defect are described.

Penetration of flomoxef into human maxillary and mandibular bones

Penetration of flomoxef into the maxillary and mandibular bones was assayed clinically to provide data about its usefulness for the prevention of postoperative infection after maxillofacial surgery. Twenty-one patients undergoing maxillofacial surgery at our department were given flomoxef 2 g dissolved in 20 ml of physiological saline intravenously over 3 minutes during operation, and the serum, maxillary and mandibular concentrations were measured 1, 3, and 6 hours after injection by the band culture method using Escherichia coli 7437 as the indicator strain. The mean concentrations were 53.4, 16.1, and 2.6 micrograms/ml, respectively, in the serum, 17.6, 7.8, and 1.0 micrograms/g in maxillary bone, and 16.4, 4.2, and 0.9 micrograms/g in mandibular bone. The mean bone:serum ratios at 1, 3, and 6 hours were 33.0%, 48.2%, and 36.8%, respectively, for maxillary bone, and 30.7%, 26.2%, and 35.7% for mandibular bone. When compared with previously reported data on the bone:serum ratios in jaw of various other intravenous antibiotics, our results show that penetration of flomoxef into maxillary and mandibular bone is extremely high. As all the intramaxillary and intramandibular concentrations exceed its MIC80 values against clinical isolates of bacteria frequently isolated in cases of infection in the oral and maxillofacial region, it is apparent that one intravenous shot of flomoxef 2 g allows penetration of the drug into the maxillary and mandibular bones at effective concentrations. Flomoxef is therefore potentially useful for the prevention and treatment of infections in the oral and maxillofacial region, as it has excellent penetration into the maxillary and mandibular bones.

Two-dimensional analysis of hemodynamic changes in axial and random pattern flaps

The present study was performed to evaluate the time course of hemodynamic change in axial and random pattern flaps two-dimensionally. The axial pattern flap, including the central auricular artery and vein, and the random pattern flap without these vessels were created in the auricles of the rabbit. The blood flow of these flaps was investigated and assessed using laserflowgraphy, which provides a two-dimensional analysis of microcirculation. In the axial pattern flap, a gradient of blood flow toward the short axis of the flap and decreased blood flow in the surrounding area were noticed immediately after operation. The hemodynamic changes became less marked with time. In the random pattern flap, a gradient of blood flow toward the long axis of the flap was noticed around 6 hr after operation and the blood flow in the surrounding area increased throughout the investigations.

Fascia-vascularized vs. muscle-vascularized prefabricated flaps using tissue expanders: an experimental study in a rat model

The aim of this study was to compare the applicability and viability of a fascia-vascularized pedicle (FVP) with those of a muscle-vascularized pedicle (MVP) in the prefabrication of a secondary vascularized pedicle flap using a tissue expander. Experiments were carried out in 32 male Wistar rats. The animals were divided into two groups--Group 1 (n = 10), using a skeletonized pedicle of the right saphenous artery, vein, and nerve with a segment of 8 x 10 mm fascia on its distal end (FVP group); and Group 2 (n = 10), using a 3-mm perivascular cuff of muscle with a segment of 8 x 10 mm fascia and gracilis muscle on its distal end (MVP group). The experiments demonstrated that there was a larger area of flap survival in the expanded muscle-vascularized pedicle flaps (96.6 +/- 3.6 percent) than that found in the expanded fascia-vascularized pedicle flaps (83.0 +/- 14.4 percent) in this rat model (p < 0.005). The microangiography of the flaps showed increased vascularity of the muscle cuff at the end of the vascular pedicle in Group 2.

Combined V figure-shaped scapular osteocutaneous and latissimus dorsi myocutaneous flap for composite mandibular reconstruction

BACKGROUND

As early as 1981, the scapular crest was reported as a versatile donor site of vascularized bone flap. In our institute, much attention has been paid to applying a compound flap based on the subscapular vascular system for composite mandibular reconstruction.

METHODS

The combined V figure-shaped scapular osteocutaneous and latissimus dorsi myocutaneous flap has been used for primary or secondary reconstruction of the mandible, intraoral mucosa and/or external skin following major ablation of the malignant tumors in seven patients.

RESULTS

There was one total flap failure. Satisfactory results were obtained in the remaining patients.

CONCLUSIONS

The V figure-shaped scapular bone flap supplied by the angular branch provides a long rotation arc of vascular pedicle, a long bony segment of more than 14 cm, and a good contour of mental protuberance. The combination of the scapular osteocutaneous flap with latissimus dorsi myocutaneous flap allows reliable reconstruction of massive and three-dimensional composite mandibular defects.

An anatomic study for a vascularized bone flap of femur

The anatomy of the nutrient vessels of the shaft of the human femur was studied in a series of 20 dissections in 10 preserved cadavers and 8 clinical stereoscopic angiograms of the femoral region in 7 adult patients. The number and external diameter of the nutrient artery and the distance of the nutrient vessel from the greater trochanter and the origin of the profunda femoris artery were measured. A single or two nutrient vessels of large caliber originated from the perforating branches of the profunda femoris artery constantly entered at the points along the linea aspera of the femur. The average distance of the nutrient artery from the point where the profunda femoris artery arose from the femoral trunk, which means length of the vascular pedicle of a bone flap, was over 11 cm. We foresee the future use of a vascularized bone flap of the femur combined with the surrounding muscle and the lateral thigh fasciocutaneous flap based on the profunda femoris vascular system.

"Boomerang" rectus abdominis musculocutaneous free flap in head and neck reconstruction

Immediate head and neck reconstruction after cancer resection using the "boomerang" rectus abdominis musculocutaneous (RAM) free flap was performed in 13 patients over the past 2 years. The skin paddle of the flap is designed as a boomerang shape based on the anatomical construction of the dominant perforators from the inferior epigastric vascular system. A versatile technique of the boomerang RAM flap provides effective use for reconstruction of the complex defects at the skull base, orbital, nasal cavity, paranasal sinuses, oropharynx, palate, buccal mucosa, tongue, floor of mouth, and neck. It also allows a reconstructive surgical team to elevate the flap simultaneously with a head and neck surgical team before the size and location of the defect are exactly determined and greatly reduces operating time. This flap will be a routine technique for immediate head and neck reconstruction after cancer resection.

Enhanced expression of multiple forms of VEGF is associated with spontaneous immortalization of murine fibroblasts

The mechanism(s) involved in immortalization that constitute the first step during malignant transformation has been the subject of our interest. By the use of spontaneously immortalized mouse embryonic fibroblasts we have earlier identified two stages of immortalization which are characterized by growth characteristics of the cells, their conditioned medium and the protein markers such as p53, p81 and mortalin (Kaul et al. (1994) Biochim. Biophys. Acta, in press). The present study was planned to purify the mitogenic factors from the conditioned medium of stage II cells. Sequential purification by chromatography followed by peptide sequencing has characterized one of these as vascular endothelial growth factor (VEGF). Further analysis by RT-PCR suggests that the spontaneously immortalized stage II fibroblasts have enhanced synthesis and secretion of VEGF as compared to their mortal parent cells. Expression of a novel 304 bp long form of VEGF is identified in immortal fibroblasts in addition to the three known alternatively spliced forms. The study points to the involvement of VEGF function during spontaneous immortalization of mouse embryonic fibroblasts.

Identification of genetic events involved in early steps of immortalization of mouse fibroblasts

The spontaneously immortalized early passaged fibroblasts from three different strains of mouse are observed to represent two distinct stages of immortalization. The cells at stage I are characterized by slow growth rate, contact inhibition and requisition of serum factors for their growth and proliferation. Stage II cells are marked by fast, multilayer growth that is independent of serum supplementation in growth medium and by the elevated levels of the two marker proteins, i.e., p53 and p81. The change from cytosolic distribution of mortalin, a senescence inducing protein (J. Biol. Chem. (1993) 268, 6615-6621; 22239-22242) to the perinuclear locale is detected as an early event during cellular immortalization. Furthermore, the distinct stages could be characterized by thermal analysis of intact cells, that to the best of our knowledge is employed for the first time for the analysis of cellular mortal and immortal phenotypes. The study characterizes at least two distinct end points in rodent transformation suggesting that there are multiple routes to immortalization.

Uniquely higher incidence of isolated or combined deficiency of band 3 and/or band 4.2 as the pathogenesis of autosomal dominantly inherited hereditary spherocytosis in the Japanese population

To clarify the pathogenesis of hereditary spherocytosis (HS), red cell membrane protein components were analyzed by sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE) with a 3.5-17% exponential gradient according to the method of Fairbanks et al. and of Laemmli in 47 HS cases from 32 unrelated Japanese families. The relative contents of each membrane protein fraction, which was stained by Coomassie blue, were expressed as their ratios to those of total membrane proteins. The density of each band of red cell membrane proteins in 47 HS patients was compared to that in 10 normal controls or in 4 high-reticulocyte controls. Various isolated or combined deficiencies of membrane proteins in these HS patients were detected by identifying the amounts of membrane proteins, which were > 1 S.D. (91%) or 2 S.D. (53%) of the mean values of normal controls, and > 1 S.D. (100%) or 2 S.D. (98%) of those of high-reticulocyte controls. Contrary to the commonly held belief that most of the autosomal dominantly-inherited HS demonstrate isolated or combined deficiency of ankyrin (ANK) and/or spectrin (SP), a much lower incidence of isolated or combined deficiency of SP and/or ANK was observed in these Japanese HS patients; 19% (> 1 S.D.) or 12% (2 S.D.) compared to normal controls, or 2% (1 S.D.) or 4% (2 S.D.) compared to high-reticulocyte controls. Instead, the incidence of isolated or combined deficiency of band 3 (B3) and/or band 4.2 (B4.2) was markedly elevated in these Japanese HS patients; 50% (1 S.D.) or 39% (2 S.D.) compared to normal controls, or 78% (1 S.D.) or 88% (2 S.D.) compared to high-reticulocyte controls. Other combined deficiencies were also observed, but the incidence was much lower. Therefore, distinct characteristics, i.e., higher incidence of isolated or combined deficiency of B4.2 and/or B3 with much lower incidence of ANK and/or SP deficiency, were observed in Japanese HS patients.

Prognostic evaluation of cutaneous malignant melanoma based on the pTNM classification

The prognoses of 100 consecutive melanoma patients were analyzed on the basis of Breslow's thickness and Clark's levels as well as according to stage employing the 1987 UICC pTNM classification. Among patients with lesions < or = 1.50 mm thick, the 10-year survival rate was 100% for both pT1 (n = 13) and pT2 (n = 6) disease, 73.4% for pT3a disease (n = 26), 62.2% for pT3b disease (n = 15), 69.3% for pT3 (n = 41) disease, and 38.7% for pT4 disease (n = 38). Significant differences in survival were found between the pT4 group and the pT1/pT3a or pT3 groups. The 10-year survival rate was 100% for level II (n = 13) and level III (n = 13) disease, 58.3% for level IV (n = 46) disease, and 34.5% for level V (n = 26) disease. Significant differences were found between level V and other levels. The survival rate at 10 years was 100% for stage I (n = 18), 63.3% for stage II (n = 24), and 52.5% for stage III (n = 55). In stage IV (n = 3), there was only one patient who survived for 42 months. There were significant differences in survival among all stages except I and II. The 10-year survival rate in 3 subgroups of stage III was 58.9% for pT4pN0M0 patients (n = 14), 63.2% for pT,pN1M0 patients (n = 31), and 20% for pT,pN2M0 patients (n = 10). Significant differences were found between the pT,pN1M0 and pT,pN2M0 subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Antithrombotic effects of recombinant human soluble thrombomodulin (rhs-TM) on arteriovenous shunt thrombosis in rats

We examined the antithrombotic effect of recombinant human soluble thrombomodulin (rhs-TM) using an arteriovenous shunt thrombosis model and its influence on hemostasis in rats. Intravenous administration of rhs-TM (0.5-4 mg/kg) significantly inhibited thrombus formation and prolonged ex vivo activated partial thromboplastin time (APTT) in a dose-dependent manner. Thrombus formation was inhibited to the same extent in animals treated with heparin (25-200 U/kg) and in those treated with rhs-TM (0.5-4 mg/kg), but heparin had a much stronger effect on prolonging APTT. In the hemorrhagic study using the rat template bleeding time method, rhs-TM exhibited the prolongation of the bleeding time only at the highest effective dose (rhs-TM; 4 mg/kg) of the thrombosis experiments. Thus, rhs-TM exhibits the inhibitory effect on thrombus formation with less APTT prolongation in comparison with heparin and without significant pertubation of hemostasis.

A cadaver investigation of the blood supply of the galeal frontalis flap

The vascular anatomy of the galeal frontalis flap was studied in 12 fresh cadavers by an intraarterial dye injection technique. Special attention was directed to the length limit of this flap. The general belief that the galeal frontalis flap has a robust vascularity by means of the supratrochlear and supraorbital arteries was not demonstrated in this study. In the medial half of the forehead, superficial branches of both arteries penetrated the frontalis muscle immediately above the supraorbital rim and ran superficially in the subcutaneous tissue. In the lateral half, some of the superficial branches of the supraorbital artery traveled with the frontalis muscle and anastomosed with the frontal branch of the superficial temporal artery. Deep branches of the supratrochlear and supraorbital arteries showed an axial distribution on the periosteum only for a short distance. One or two branches of the supraorbital artery were found to take a superficial course within the subgaleal layer, pierce the frontalis muscle, and anastomose with the superficial temporal artery. These findings suggest that the galeal frontalis flap should be elevated in the lateral forehead. The preservation of the periosteum with the flap is recommended in order to ensure the temporoparietal extension.

Experience with arteriovenous malformations treated with flap coverage

Fourteen patients with arteriovenous malformations were treated with surgical resection followed by well-vascularized tissue transfer. Free-tissue transfers were used in 12 of the patients and axial local flaps in 2 patients to reconstruct the region with arteriovenous malformations. The feeding arteries of the arteriovenous malformations were used as recipient vessels in all cases of free-tissue transfers without any trouble in microvascular anastomosis. With an average follow-up of 3 years and 2 months, 12 patients showed no clinical recurrence (86 percent). Follow-up angiography in seven patients showed complete disappearance of malformations in two patients and residual malformations not enlarged in three patients. Two patients had residual malformations that were noted to be increasing in follow-up angiograms, and they also had clinical evidence of recurrence. In these patients an intramaxillary recurrence in one and intraorbital in the other appeared at about 1 and 3 years, respectively, after surgery. This therapeutic concept can be expected to provide great remission in the treatment of arteriovenous malformations.

Facial reconstruction with free-tissue transfer

The article provides a retrospective review of 25 free-tissue transfers for facial reconstruction on 24 recipient sites in 21 patients. The recipient sites of the face were classified into frontal (4 patients), orbital (2 patients), nasal (2 patients), buccal (11 patients), and oral region (5 patients). The transferred flaps included 16 fasciocutaneous flaps (6 forearm flaps, 5 scapular flaps, 2 anteromedial thigh flaps, 1 lateral arm flap, 1 dorsalis pedis flap, and 1 deltopectoral flap) and 8 myocutaneous flaps (6 latissimus dorsi myocutaneous flaps, 1 serratus anterior myocutaneous flap, 1 rectus abdominis myocutaneous flap, and 1 prefabricated flap). Thinning modifications such as the expansion, reduction, or extension techniques were performed in the myocutaneous flap to avoid having a bulky flap. In our view, the flap from the trunk matches the facial skin color better than that from the extremity. Satisfactory results were attained in all cases in which a complete replacement of the facial aesthetic unit was performed.

[Concordant improvement of progressive systemic sclerosis and chronic myelogenous leukemia with interferon-alpha treatment]

A 44-year-old woman with progressive systemic sclerosis (PSS) visited our clinic because of leukocytosis and thrombocytosis. She was diagnosed as having chronic myelogenous leukemia (CML) with PSS, and was treated with interferon-alpha 2b (IFN-alpha) after pretreatment of hydroxyurea as a cytoreduction. Complete hematological remission was obtained two months later, and four months later minimal cytogenetic response was achieved by IFN-alpha. Her PSS symptoms were also improved to some extent as judged by Rodnan's total skin score, maximal opening distance of oral cavity, and range of motion of wrists. Our results suggest that IFN-alpha is probably beneficial not only for CML itself but also for PSS, too.

Red cell membrane disorders in the Japanese population: clinical, biochemical, electron microscopic, and genetic studies

Based on studies on 610 cases of hereditary red cell membrane disorders, the characteristic features of the incidence of these disorders in the Japanese population are described. These patients were screened by a protocol on red cell morphology (scanning electron microscopy), on red cell membrane proteins (sodium dodecylsulfate polyacrylamide gel electrophoresis, and kinetics of membrane proteins), biophysical studies (ektacytometry, mechanical stability and fluorescence recovery after the photobleaching method), membrane transport (sodium influx and efflux, and anion transport), gene analysis (spectrins, band 4.2 and band 3), surface markers (blood type antigens and sialic acid content), and development and expression of membrane proteins (using a two-phase liquid culture system). Among the molecular abnormalities detected, alpha-spectrin mutation appeared rare (only one family with spectrin alpha I/74), as opposed to two beta-spectrin mutations in Japan out of seven worldwide cases. Two unrelated kindreds with a chromosomal abnormality; that is, del (8) (p11.2-p21.1), were found that involved the possible contribution of ankyrin to the pathogenesis of hereditary spherocytosis. Anomalies of a transmembrane domain of band 3 were detected in two independent kindreds with impaired anion transport. Among 16 HE patients, 13 cases were partially band 4.1 deficient. Complete band 4.2 deficiency of the Nippon type (GCT-->ACT at codon 142 in band 4.2 gene) was observed in 17 cases of 13 unrelated kindreds. Other forms of band 4.2 deficiency without the mutation were also detected in three kindreds. Band 7 deficiency was found in seven cases with hereditary stomatocytosis independent of the presence or absence of cation transport abnormalities. A relatively high incidence of hereditary high red cell membrane phosphatidylcholine hemolytic anemia was disclosed by the analysis of red cell membrane lipids.