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Endothelial-to-mesenchymal transition is a phenotypic conversion characterized by down-regulation of vascular endothelial markers and the acquisition of a mesenchymal phenotype. We hypothesized that keloid fibroblasts are of endothelial origin and that endothelial-to-mesenchymal transition substantially contributes to collagen accumulation during the development and progression of keloids. Wingless protein (Wnt-3a) protein expression was examined using immunohistochemistry in keloid tissues. Human dermal microvascular endothelial cells (HDMECs) were treated with Wnt-3a. mRNA and protein expression of endothelial (vascular endothelial cadherin) and mesenchymal (vimentin, snail family transcription factor [slug], and α-smooth muscle actin) cell markers were measured using real-time RT-PCR and immunocytochemistry, respectively. Additionally, coexpression of CD31 (cluster of differentiation 31), and endothelial cell marker, and vimentin in the vascular endothelium of keloid tissues was examined using immunofluorescence. Wnt-3a overexpression was observed in human keloid tissues. Wnt-3a treatment significantly reduced vascular endothelial cadherin mRNA expression and induced vimentin and slug mRNA expression in HDMECs. HDMECs became spindle-shaped and exhibited reduced expression of CD31 and increased expression of vimentin, slug, and α-smooth muscle actin. Moreover, coexpression of CD31 and vimentin was observed in the dermal vascular endothelium of keloid tissues from two patients with clinically active keloids. In conclusion, transient conversion of HDMECs to a mesenchymal phenotype may contribute to dermal fibrosis of keloid and hypertrophic scars.

Background Recently, higher proliferative activity and collagen production in the peripheral parts of keloids have been reported. Therefore, we hypothesized that insufficient removal of active proliferating and collagen-producing fibroblasts at the scar margin might cause a high recurrence rate of hypertrophic scars and keloids. To address this hypothesis, we evaluated the influence of surgical margins on the recurrence of hypertrophic scars and compared the recurrence rates between intramarginal excision and extramarginal excision. Methods A retrospective review was performed of patients with car tire injury-induced hypertrophic scars treated by surgical excision from 2004 to 2010. To evaluate the influence of surgical margins on the recurrence of hypertrophic scars, we divided these patients into two groups, the intramarginal excision group and the extramarginal excision group, and compared the recurrence rate. Results A total of 15 patients with car tire injury-induced hypertrophic scars were treated with surgical excision and skin grafting. The recurrence rate in those with intramarginal excision was significantly higher than in those with extramarginal excision. All patients treated with intramarginal excision experienced hypertrophic scar recurrence within six months. Three of nine patients exhibited recurrence when the hypertrophic scars were excised with a 3–5 mm margin. Conclusion Extramarginal excision with complete removal of the abnormal collagen bundles followed by skin grafting is a viable alternative to reconstruction of the foot after hypertrophic scar excision, and this treatment can effectively decrease issues related to recurrence.

Endothelial cell senescence is closely related to tissue aging and age-related vascular disease. Detailed pathophysiology and essential biomarkers of skin aging are not well known. A recent report suggests that advanced glycosylation end products, especially N(ϵ) -(carboxymethyl)lysine (CML) modification of vimentin, accelerate the aging process.To identify protein biomarkers of aging in skin.Proteomics analysis was performed to identify differentially expressed proteins in human dermal microvascular endothelial cells (HDMEC) treated with ultraviolet (UV) or intense pulsed light (IPL). Proteome maps of UV-treated, IPL-treated, and untreated HDMEC were constructed, with identification of altered protein spots by matrix-assisted laser desorption/ionization mass spectrometry. Differential expression and glycation modification of vimentin were found by this approach and further examined by fluorescence-activated cell sorting.Twenty-two differentially expressed protein spots were identified. Among them, vimentin was specifically up-regulated in UV-treated HDMECs. On the other hand, it was down-regulated after IPL. Increased expression of CML-vimentin in HDMEC during culture (Passage 6 vs. 12) was noted, and this effect was reversed by IPL treatment.Vimentin and CML should be useful markers for cell senescence, as well as for evaluating the level of aging. Also, targeting increased vimentin expression and its advanced glycation end products could present a target for the treatment of skin aging.

Background: Decorin is a natural transforming growth factor-b1 (TGF-b1) antagonist. Reduced decorin synthesis is associated with dermal scarring and increased decorin expression appears to reduce scar tissue formation. To investigate the therapeutic potential of decorin for keloids, human dermal fibroblasts (HDFs) and keloid-derived fibroblasts (KFs) were transduced with decorin-expressing adenovirus (dE1-RGD/GFP/DCN), and we examined the therapeutic potential of decorin-expressing Ad for treating pathologic skin fibrosisMethod: Decorin expression was examined by immunofluorescence assay on keloid tissues. HDFs and KFs were transduced with dE1-RGD/GFP/DCN or control virus, and protein levels of decorin, epidermal growth factor receptor (EGFR), and secreted TGF-β1 were assessed by western blotting and ELISA. And collagen type I, III, and MMP-1, 3 mRNA levels were measured by real-time RT-PCR. Additionally, we immunohistochemically investigated expression levels of the major extracellular matrix (ECM) proteins in keloid spheroids transduced with dE1-RGD/GFP/DCN.Results: Lower decorin expression was observed in the keloid region compared to adjacent normal tissues. After treatment with dE1-RGD/GFP/DCN, secreted TGF-βl and EGFR protein expression were decreased in TGF-b1-treated HDFs and KFs. Also, type I, III collagen mRNA levels were decreased and expression of MMP-1, 3 mRNA was strongly upregulated. In addition, expression of type I, III collagen, fibronectin, and elastin was significantly reduced in dE1-RGD/GFP/DCN-transduced keloid spheroids.Conclusion: These results support the utility of decorin-expressing adenovirus to reduce collagen synthesis in KFs and keloid spheroid, which may be highly beneficial in treating keloids.

Soft tissue augmentation using acellular dermal matrix has gained popularity to overcome the shortcomings of autogenous and alloplastic materials. Sometimes it needs multilayered stacking to obtain enough volume. In this study, we investigated the efficacy of multilayered implantation using acellular dermal matrix (MatriDerm(®)) for soft tissue augmentation. MatriDerm was implanted subdermally on each side of the dorsum of nude mice (n = 20), stacked two layers thick in the control group and three layers thick in the experimental group. Alterations of thickness, degree of angiogenesis, and collagen and elastin fiber syntheses were observed over 40 days. Three-layered implantation with MatriDerm maintained its volume similarly as in two-layered implantation, although the thickness decreased after 30 days in both groups. At the early stage of implantation, angiogenesis and collagen and elastin fiber syntheses occurred fluently on the central portion, which is the farthest away from the surface in contact with the host tissue. Collagen and elastin fibers became more concentrated over time, and the original structure of MatriDerm could not be maintained due to being replaced with newly formed collagen and elastin fibers 40 days after implantation. Multilayered implantation with MatriDerm is considered appropriate for tissue ingrowth and can be used as a substitute for soft tissue augmentation.

Background.The biochemical characteristics of keloid-derived fibroblasts differ from those of adjacent normal fibroblasts, and these differences are thought to be the cause of abnormal fibrosis. Therefore, we investigated the characteristic proteins that are differentially expressed in keloid-derived fibroblasts using proteomics tools.Objective.We attempted to investigate the novel proteins that play important roles in the pathophysiology of keloids.Methods.Proteomics analysis was performed to identify differentially expressed proteins in keloid-derived fibroblasts. Keloid-derived fibroblasts and adjacent normal fibroblasts were analyzed with 2-DAGE. We validated these proteins with immunoblot analysis, real-time RT-PCR, and immunohistochemistry.Results.Sixteen differentially expressed protein spots were identified in keloid-derived fibroblasts. Among them, heat shock protein 70 (Hsp70) was specifically upregulated in keloid-derived fibroblasts. Also, immunohistochemistry and western blot analysis revealed increased Hsp70, TGF-β, and PCNA expressions in keloids compared to normal tissue.Conclusion.Hsp70 is overexpressed in keloid fibroblasts and tissue. The overexpression of Hsp70 may be involved in the pathogenesis of keloids, and the inhibition of Hsp70 could be a new therapeutic tool for the treatment of keloids.

Aberrant activation of the canonical Wingless type (Wnt) signaling pathway plays a key role in the development of hypertrophic scars and keloids. This aberrant activation of the canonical Wnt pathway and its potent profibrotic effects suggest that Wnt pathway can be a potential target for the development of novel anti-fibrotic agents. In this study, we evaluated the anti-fibrotic potential of a soluble Wnt decoy receptor (sLRP6E1E2)-expressing non-replicating adenovirus (Ad; dE1-k35/sLRP6E1E2) on human dermal fibroblasts (HDFs) and keloid spheroid. Wnt family member 3a and its effector β-catenin expression in keloid tissues were analyzed by hematoxylin and eosin and immunohistochemical staining. HDFs were transduced with dE1-k35/sLRP6E1E2 or control Ad vector (dEl-k35/LacZ), and then luciferase reporter assay for β-catenin activity was performed. Furthermore, change in type-I and -III collagen mRNA levels in HDFs were measured by quantitative real time PCR. Wnt intracellular signaling and secreted transforming growth factor-β1 (TGF-β1) protein expression were examined by western blot and the enzyme-linked immunosorbent assay, respectively. The effect of sLRP6E1E2 on the nuclear localization of β-catenin and Smad 2/3 complex was evaluated by immunofluorescence staining. Lastly, the expression levels of major extracellular matrix components were investigated by immunohistochemistry in keloid spheroids after transduction with dEl-k35/LacZ or dE1-k35/sLRP6E1E2. Higher Wnt3a and β-catenin expression was observed in the keloid region compared to the adjacent normal tissues. The activity of β-catenin and mRNA expression of type-I and -III collagen were significantly decreased following treatment with dE1-k35/sLRP6E1E2. The expression of LRP6, β-catenin, phosphorylated glycogen synthase kinase 3 beta, Smad 2/3 complex, and TGF-β1 were decreased in Wnt3a- or TGF-β1-activated HDFs, following administration of dE1-k35/sLRP6E1E2. Moreover, dE1-k35/sLRP6E1E2 markedly inhibited nuclear translocation of both β-catenin and Smad 2/3 complex. The expression levels of type-I and -III collagen, fibronectin, and elastin were also significantly reduced in keloid spheroids after treatment with dE1-k35/sLRP6E1E2. These results indicate that Wnt decoy receptor-expressing Ad can degrade extracellular matrix in HDFs and primary keloid spheroids, and thus it could be highly beneficial for treatment of keloids.

The hormone relaxin has been shown to affect the extracellular matrix by inhibiting collagen synthesis and expression in fibroblasts stimulated with a profibrotic agent. It also increases matrix metalloproteinase (MMP) expression. To investigate its effect on expression of collagen and MMPs in keloid fibroblasts and human dermal fibroblasts, the authors introduced a relaxin-expressing adenovirus (dE1-RGD/lacZ/RLX) into a human dermal fibroblast cell line and keloid fibroblasts.Both fibroblasts were infected with dE1-RGD/lacZ/RLX or control virus, and protein levels of relaxin and secreted transforming growth factor (TGF)-β1 were assessed by enzyme-linked immunosorbent assay, and mRNA levels of collagen type I, collagen type III, MMP-1, and MMP-3 were assessed by real-time reverse-transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay. Expression of Smad3 and phosphorylated Smad3 was also examined, and relaxin's effect on Smad2/3 complex localization was evaluated.When human dermal fibroblasts and keloid fibroblasts were transduced with dE1-RGD/lacZ/RLX or dE1-RGD/lacZ (control), mRNA expression of type I and type III collagen was markedly decreased by relaxin regardless of TGF-β (10 ng/ml) treatment. Expression of Smad3 and phosphorylated Smad3 was reduced in keloid fibroblasts and decreased translocation of Smad 2/3 complex from cytosols to the nucleus of the human dermal fibroblasts with TGF-β after dE1-RGD/lacZ/RLX transduction, suggesting that relaxin reduces collagen synthesis by blocking TGF-β signaling. Analyses revealed that MMP-1 and MMP-3 expression were significantly increased in human dermal fibroblasts and keloid fibroblasts after dE1-RGD/lacZ/RLX transduction.These results suggest that the antifibrotic effect of relaxin-expressing adenovirus may have therapeutic effects on keloids.

Background Coverage of defects of the pretibial area remains a challenge for surgeons. The difficulty comes from the limited mobility and availability of the overlying skin and soft tissue. We applied variable pedicled perforator flaps to overcome the disadvantages of local flaps and free flaps on the pretibial area. Methods Eight patients who had the defects in the anterior tibial area were enrolled. Retrospective data were obtained on patient demographics, cause, defect location, defect size, flap dimension, originating artery, pedicle length, pedicle rotation, complication, and postoperative result. The raw surface created following the flap elevation was covered with a split thickness skin graft. Results Posterior tibial artery-based perforator flaps were used in five cases and peroneal artery-based perforator flaps in three cases. The mean age was 54.3 and the mean period of follow-up was 6 months. The average size of the flaps was 63.8 cm2, with a range of 18 to 135 cm2. There were no major complications. No patients had any newly developed functional deficit of the lower leg. Conclusions We suggest that pedicled perforator flaps can be an alternative treatment modality for covering pretibial defects as a simple, safe and versatile procedure.

We developed a three-dimensional organotypic multicellular spheroid scar model to mimic the microenvironment of human keloid tissues. Keloid tissues were cultured for 7 days. Changes in total cellularity and apoptotic index in the primary keloid spheroid cultures were evaluated histologically and with a TUNEL assay, respectively. The expression profiles of transforming growth factor-β (TGF-β), collagen I, collagen III, elastin, fibronectin, matrix metalloproteinase-2, and matrix metalloproteinase-9 were examined with immunohistochemistry. In addition, these expression profiles were investigated after treating primary keloid spheroids with triamcinolone acetonide. Cell viability and morphology of ex vivo cultured keloid spheroids were maintained, and the apoptotic index did not increase for up to 1 week in culture. Keloid spheroids cultivated ex vivo retained the major characteristics of keloids, such as high levels of collagen I and TGF-β expression for up to 7 days. The biological activity of keloids responding to TGF-β was also maintained during ex vivo culture. Moreover, ex vivo triamcinolone acetonide treatment of cultivated keloid spheroids significantly reduced collagen I, collagen III, elastin, and fibronectin expression levels, in accordance with clinical observations. The three-dimensional organotypic multicellular spheroid keloid culture will allow investigators to study keloid pathogenesis and test potential keloid therapeutic agents.

Objective Extensive defects of the perineal area, with exposure of the testes, are difficult to reconstruct. For the reconstruction of these defects, we applied gracilis muscle flap combined with pudendal artery perforator fasciocutaneous flap, which provided us a reliable cutaneous flap and allowed us to cover exposed testes with sufficient muscular volume. Methods We retrospectively analyzed 7 patients from 2004-2011 whose penoscrotal defects had been reconstructed using gracilis muscle flap and an internal pudendal artery perforator flap. Six had Fournier's gangrene and 1 had extramammary Paget's disease. We examined characteristics of the patients, preoperative management, operative procedure, and their clinical courses. Results All flaps survived during the entire follow-up periods. The mean width of the defects was 10.14 cm and the mean length was 9.29 cm. The width of the fasciocutaneous flap was approximately 6-10 cm, whereas the length ranged from 10-15 cm. The reconstructed areas were in good functional and esthetic conditions. Conclusion The combination of the gracilis muscle flap and the internal pudendal artery perforator fasciocutaneous flap provides pliable and reliable soft tissue coverage for extensive penoscrotal defects with adequate bulkiness and minimal donor site morbidity.

Background: Situs inversus totalis is a rare congenital anomaly, and has reported incidence of 1 out of every 4000 to 10,000 individuals.1–6 Surgical procedures for these patients are tech...

Pharyngocutaneous fistula is one of the fatal complications occurring after head and neck reconstruction with neck node dissection. Even minor salivary leakage from the fistula could cause serious infection and threaten the viability of the transferred flap or even lead to the rupture of jugular vein. In such cases, proper management is difficult, and the chances for recurrence rise. We used a collagen patch (TachoComb) for fistula prevention and treatment. TachoComb, a collagen patch integrated with activated thrombin and fibrinogen, was used to prevent postoperative fistula formation in the initial reconstruction by applying them on sites with a high risk of salivary leakage. The patch was applied to 16 patients who had hypopharyngeal reconstruction, and the results were evaluated and compared with patients who had reconstruction without a collagen patch. A fistula occurred in 1 (6%) of 16 patients who received the collagen patch, whereas it occurred in 6 (14%) of 43 patients who underwent reconstruction without the collagen patch. In addition, the collagen patch was also used to treat postoperative fistula in 2 patients, and the results were successful after a single revision. Our results suggest that the collagen patch can be effective in the prevention and treatment of postoperative fistula after head and neck reconstruction, especially pharynx and cervical esophagus.

Relaxin (RLX) has multiple vascular actions, including vasodilation and angiogenesis, which occur via induction of vascular endothelial growth factor (VEGF) expression. We generated a RLX-expressing (dE1-RGD/lacZ/RLX) adenovirus and investigated whether it enhances skin flap survival. Thirty Sprague-Dawley rats were divided into three groups: RLX-expressing adenovirus group, control virus group, and phosphate-buffered saline (PBS) group. Two days before surgery and immediately after flap elevation, the caudally based flap that was 3 × 9 cm in size was subdermally injected with the dE1-RGD/lacZ/RLX virus (10⁷ PFU), dE1-RGD/lacZ virus (10⁷ PFU), or PBS. The surviving area of the flap and the amount of blood flow were measured. On postoperative day 10, CD31-positive vessels and VEGF protein expression were examined. We observed a significant increase in the survival area of the flap in the RLX group. Doppler measurement also showed significantly increased blood flow immediately after the operation and on postoperative days 7 and 10. CD31-positive vessels and VEGF protein expression were significantly greater in the RLX group. Thus, administration of RLX-expressing adenovirus into elevated skin flaps increased VEGF expression, the number of capillaries, and blood flow to the flap, thereby improving skin flap survival.

In the present study, we used the diabetic mouse as a model of delayed wound healing to investigate the effects of human cord blood mesenchymal stem cells (CB-MSC) on wound healing.A delayed wound healing model was used by db/db mice. Study models were divided by an injection of human CB-MSC with phosphate buffered solution (PBS) by a different method. One was a locally topical injection, the other was a systemic injection via the end tail vein. Both models were treated with 2.0 × 10(6) CB-MSC after an 8-mm full thickness defect was made by a skin punch biopsy on the back. We evaluated the wound size, transforming growth factor (TGF)-β, and vascular endothelial growth factor histologic evaluation, and vessel counts. Engraft of CB-MSC was detected by an antihuman antibody.Wound healing was accelerated in the experimental group in the topical injection model with statistical significance on the 6th, 9th, and 12th day (P0.05). In the systemic injection model, wound healing was completed from the 9th day, but there was no statistical significance. TGF-β increased in the first week and decreased in the third week in the experimental groups of both models. But there were opposite results in the control groups of both models. The statistical differences were found in first and third week in topical injection and in the third week in systemic injection (P0.05). Vascular endothelial growth factor increased in all groups and in all models as the wound healing. But statistical significance did not show between all experimental and control groups. Anti-human antibody immunochemical staining was positive in the wound.We concluded that CB-MSC had a positive effect on wound healing. Statistically significant results were noted in the topical injection model. We also reported good effects on the systemic injection model, although we did not find any statistical significance. CB-MSC may influence wound healing by TGF-β.

Silk fibroin (SF) is a natural, degradable, fibrous protein that is biocompatible, is easily processed, and possesses unique mechanical properties. Another natural material, wool keratose (WK), is a soluble derivative of wool keratin, containing amino acid sequences that induce cell adhesion. Here, we blended SF and WK to improve the poor electrospinability of WK and increase the adhesiveness of SF. We hypothesized that microwave-induced argon plasma treatment would improve chondrogenic cell growth and cartilage-specific extracellular matrix formation on a three-dimensional SF/WK scaffold. After argon plasma treatment, static water contact angle measurement revealed increased hydrophilicity of the SF/WK scaffold, and scanning electron microscopy showed that treated SF/WK scaffolds had deeper and more cylindrical pores than nontreated scaffolds. Attachment and proliferation of neonatal human knee articular chondrocytes on treated SF/WK scaffolds increased significantly, followed by increased glycosaminoglycan synthesis. Our results suggest that microwave-induced, plasma-treated SF/WK scaffolds have potential in cartilage tissue engineering.

We have introduced a less invasive, simple, and effective method for zygomatic fractures using percutaneous reduction with a Steinmann pin (S-pin) and temporary external suspension with a Kirschner wire (K-wire).For 2 years, 51 patients underwent first percutaneous reductions and then fixations, which is a method that we developed. After the S-pin no. 1 was percutaneously inserted at the most prominent point of the zygoma, closed reduction was first attempted using lever movement and temporary external suspension with a K-wire. If required, 1-site rigid fixation was performed on the zygomaticomaxillary buttresses via gingivobuccal incisions. Only 13 patients received K-wire suspensions and 38 patients received K-wire suspensions and lateral buttress fixations. We evaluated the postoperative result in 4 aspects (flattening, symmetry, scar, and paresthesia) using the 4-point visual analog score after at least 6 months.The mean maintenance period of the S-pin and K-wire was 12.3 days, and the mean operation time was 33 minutes. No serious complications, such as infections or external wire instability, were observed. Excellent or good results were achieved in more than 95% of patients in all 4 aspects mentioned.We believe that our method, which is the first percutaneous reduction using S-pin and temporary external suspensions with a K-wire with or without a lateral buttress rigid fixation, is a simple and effective method for noncomminuted zygomatic fractures.

To objectively describe skin color, the Commission International d'Eclairage (CIE) L*a*b* color coordinates and melanin and erythema indexes are used. However, it was difficult to understand the relationship among these parameters and to convert them into each other. We introduced a new technique to measure L*a*b* color coordinates and the melanin and erythema indexes at the same time. We analyzed the skin color of normal Asians using this method.The skin color of the forehead, cheek, upper inner arm, dorsum of hand, and anterior chest of 148 volunteers was measured using a spectrophotometer. Using a computer analysis program, L*a*b* values and the melanin and erythema indexes were presented at the same time. The averages of these data were shown according to gender, age, body parts, and correlations among the melanin and erythema indexes and L*a*b* color coordinates, and then they were analyzed.The averages of the melanin and erythema indexes of 148 participants were 1.10 +/- 0.29 and 1.29 +/- 0.38, respectively. The averages of the L*, a*, and b* values were 64.15 +/- 4.86, 8.96 +/- 2.65, and 18.34 +/- 2.39, respectively. The melanin and erythema indexes were higher in males than in females. While the correlation of the melanin index with the L* value was negative, it was positively correlated with the a* and b* values. While the erythema index showed a weak correlation with the b* value, its correlation was negative with the L* value and positive with the a* value.Our method of skin color measurement is useful. We consider the data of this study valuable basic data for the evaluation of colors of pigmental skin diseases and scars in the future.

As the survival rate of tongue cancer has increased, longer-term results of tongue reconstruction are also being considered. The aim of this study was to report the long-term outcomes of total glossectomy.Of 14 patients who underwent total glossectomy, 11 were reconstructed with the rectus abdominis musculocutaneous free flap and 3 with the anterolateral thigh free flap. We reviewed survival rate, swallowing capacity, speech intelligibility, and volume reduction in flaps. Swallowing capacity and speech intelligibility were evaluated by visual analog scale scores (7 points) at 1 to 7 years after surgery, and changes in neotongue volume were examined by dividing volume into 4 stages.The 5-year disease-specific survival rate was 71%. Almost all patients were able to eat a soft diet and resume verbal communication. However, a sufficient volume of the reconstructed tongue was decreased over the course of time. Volume change was more definitive in the cases using the anterolateral thigh free flap than the rectus abdominis musculocutaneous free flap. Neotongue volume was also correlated with swallowing capacity and speech intelligibility.In total tongue reconstruction, wide and thick flaps such as the rectus abdominis musculocutaneous flap had better outcomes. Overcorrection with a sufficient flap volume is recommended for adequate oral intake owing to volume loss caused by radiation therapy, and functional muscle transfer should also be considered to prevent muscle atrophy. Lastly, static suspension procedures are emphasized to prevent airway aspiration for larynx preservation.

PURPOSE There have been numerous attempts to use pharyngoesophageal reconstruction to restore swallowing function. Much controversy exist over reconstruction after total or partial pharyngectomy, and there is also debate over whether to continue with the reconstructive procedure with a narrow strip of remnant mucosa or complete it after total pharyngectomy. We analyzed the utility of omega-shaped radial forearm free flap (RFFF) using the narrow remnant posterior pharyngeal wall. METHODS Patients in group 1 (n = 12) had a narrow remnant pharyngeal wall with a width of less than 3 cm. Those in group 2 (n = 35) had a remnant pharynx with a width larger than 3 cm. The incidence of fistula, stricture, and swallowing difficulty were evaluated. Swallowing difficulty was graded using a 7-point visual analog scale. All circumferential hypopharyngeal reconstruction with tubed RFFF, pectoralis major flap, and jejunal free flap were also compared with group 1. RESULTS All flaps survived, and 1 fistula (8%) was detected in group 1. Compared with tubed RFFF (46%) and tubed pectoralis major flap (57%), this is a relatively low rate of fistula formation. In group 1, normal diet was possible in 92% of patients, but 1 patient can tolerate a liquid diet only. In group 2, normal diet was possible in 80% of patients. As for swallowing difficulty, the median visual analog scale score for both groups 1 and 2 was 6 points. When comparing different flaps, stricture and fistula rate was 0 and 8% in group 1, 15 and 46% in tubed RFFF, 43 and 57% in tubed pectoralis major flap, and 33 and 5% in jejunal flap, respectively. CONCLUSIONS We performed all surgeries taking care not to transgress the wide excision principle with the remnant hypopharyngeal wall. For remnant lesions greater than 3 cm, patch-type RFFF was performed, whereas for those less than 3 cm, omega-shaped RFFF was done. We achieved fairly good results in both groups without total resection of the narrow remnant hypopharyngeal wall.

Background. Moderate resection of the soft palate results in suboptimal outcomes in terms of postoperative velopharyngeal function. We propose the radial forearm tenocutaneous free flap incorporating the palmaris longus tendon for reconstruction of the levator sling in these cases. Methods. Twenty-six patients underwent reconstruction with this method. Group I defect involved up to one-fourth of the soft palate. Group II defect involved up to one-half of the soft palate whether or not including the uvula. Group III defect involved more than three-fourths of the soft palate. Postoperative function was assessed by means of speech intelligibility, swallowing performance, nasalance score, and nasoendoscopy. Results. Groups I and II showed normal results for speech intelligibility and swallowing function at 44 months. In group III, both parameters proved to be suboptimal. Conclusions. Moderate-sized soft palatal resection cases (group II) benefited most from this particular method of dynamic reconstruction using the radial forearm tenocutaneous free flap. © 2009 Wiley Periodicals, Inc. Head Neck, 2009

Radiotherapy is a crucial part in the treatment of cancer; however, it may cause adverse effects to normal tissue such as radiation-induced ulcer and osteoradionecrosis. The few cases of conservative management that were reported had a limited value and unsatisfactory results. The most reliable method to treat sacral radiation ulcer and osteoradionecrosis is a wide excision of the affected tissue, followed by coverage with well-vascularised tissue. Musculocutaneous free flaps and local gluteus maximus musculocutaneous flaps have been used; however, there were many drawbacks such as dissection of recipient vessel in the previously radiated area and donor-site morbidity. During a 4-year time period at our institute, we found favourable clinical results using gluteal artery perforator procedure for radiation-induced ulcers and osteoradionecrosis of the sacral area. The 10 patients, who were treated with gluteal artery perforator flaps, had chronic non-healing radiation ulcers or bone exposure of the sacrum. Intra-operatively, massive debridement of bone and soft tissue was performed, while the well-vascularised skin with only a colour change was preserved. The flap was designed to include two or more perforators using Doppler flowmetry and the perforators were preserved with surrounding subcutaneous tissue during the flap elevation. The mean post-operative follow-up period was 25.7 months. As regards the surgery, there was one major complication (of partial flap loss) and three minor complications (of wound dehiscence). In the patient with partial flap loss due to infection and a floating flap, the contralateral superior gluteal artery perforator flap was used to treat complications. Other complications were conservatively treated and well healed. Gluteal perforator flaps are a valuable alternative in treating sacral radiation ulcers and osteoradionecrosis. Sufficient excision of devitalised tissue is a crucial procedure to achieve optimal results.

The treatment of oropharyngeal squamous cell carcinoma (OSCC) remains controversial. This study reviews the authors' experience of treating OSCC, evaluates the oncologic outcome and assesses the factors affecting local/regional recurrence. A retrospective analysis of 110 consecutive OSCC patients treated primarily by surgery and/or postoperative radiotherapy was carried out. 82% of patients had advanced disease (stage III or IV). The 5-year overall survival and disease specific survival rates (DSSR) were 58% and 65%, respectively. The DSSR of the soft palate or posterior pharyngeal wall, tonsillar area, and base of tongue were 80%, 62%, and 51%, respectively (P

The ischial area is by far the most common site for pressure sores in wheelchair-bound paraplegic patients, because most of the pressure of the body is exerted on this area in the seated position. Even after a series of successful pressure sore treatments, the site is very prone to relapse from the simplest everyday tasks. Therefore, it is crucial to preserve the main pedicle during primary surgery. Several surgical procedures, such as myocutaneous flap and perforator flap, have been introduced for the treatment of pressure sores. During a 4-year time period at our institute, we found favourable clinical results using the inferior gluteal artery perforator (IGAP) procedure for ischial sore treatment. A total of 23 patients (20 males and three females) received IGAP flap surgery in our hospital from January 2003 to January 2007. Surgery was performed on the same site again in 10 (43%) patients who had originally relapsed after undergoing the conventional method of pressure sore surgery. The average age of patients was 47.4 years (range 26-71 years). Most of the patients were paraplegic (16 cases, 70%) and others were either quadriplegic (four cases, 17%) or ambulatory (three cases, 13%). Based on hospital records and clinical photographs, we attempted to assess the feasibility and practicability of the IGAP flap procedure through comparative analysis of several parameters including the size of the defective area, treatment modalities, relapses, complications, and postoperative treatments. The average follow-up duration for 23 subjects was 25.4 months (range 5-42 months). All flaps survived without major complications. Partial flap necrosis developed in one case but secondary healing was achieved and the final outcome was not impaired. Most of the cases healed well during the follow-up period. Postoperative complications such as wound dehiscence and fistula developed in some subjects, but all healed well with a secondary treatment. A total of five cases relapsed after surgery due to tissue deficit and these were treated with bursectomy and muscle transposition flap to fill the dead space. We propose that the IGAP flap should be considered a viable alternative to other methods of ischial pressure sore surgery owing to its many advantages, which include the ability to preserve peripheral muscle tissue, the variability of flap designs, relatively good durability, and the low donor site morbidity rate.

We developed a three-dimensional organotypic multicellular spheroid scar model to mimic the microenvironment of human keloid tissues. Keloid tissues were cultured for 7 days. Changes in total cellularity and apoptotic index in the primary keloid spheroid cultures were evaluated histologically and with a TUNEL assay, respectively. The expression profiles of transforming growth factor-b (TGF-b), collagen I, collagen III, elastin, fibronectin, matrix metalloproteinase-2, and matrix metalloproteinase-9 were examined with immunohistochemistry. In addition, these expression profiles were investigated after treating primary keloid spheroids with triamcinolone acetonide. Cell viability and morphology of ex vivo cultured keloid spheroids were maintained, and the apoptotic index did not increase for up to 1 week in culture. Keloid spheroids cultivated ex vivo retained the major characteristics of keloids, such as high levels of collagen I and TGF-bexpression for up to 7 days. The biological activity of keloids responding to TGF-b was also maintained during ex vivo culture. Moreover, ex vivo triamcinolone acetonide treatment of cultivated keloidspheroidssignificantlyredu cedcollagenI, collagen III, elastin, andfibronectin expression levels, in accordance with clinical observations. The three-dimensional organotypic multicellular spheroid keloid culture will allow investigators to study keloid pathogenesis and test potential keloid therapeutic agents.

Purpose There are currently no consistently effective treatments for the excessive collagen produced by keloid fibroblasts. Previously, we reported that heat shock protein 70 (Hsp70) is up-regulated in keloid fibroblasts and keloid tissue. We, therefore, investigated whether Hsp70 is related to excessive collagen production in keloid fibroblasts. Materials and Methods We inhibited Hsp70 in keloid fibroblasts by RNA interference and examined the resulting collagen expression. Thus, we selected small interfering RNAs (siRNAs) specific for human Hsp70, transfected them into keloid fibroblasts, and evaluated the resulting phenotypes and protein production using real-time polymerase chain reaction (PCR), Western blot, and a collagen assay. Results The siRNAs dramatically suppressed Hsp70 mRNA expression, resulting in a decrease in collagen production in the keloid fibroblasts compared with controls. The siRNAs did not influence the viability of the keloid fibroblasts. Conclusion Hsp70 overexpression likely plays an important role in the excessive collagen production by keloid fibroblasts. RNA interference has therapeutic potential for the treatment of keloids.

The reconstruction of the posterior heel including a wide defect of the Achilles tendon is difficult as a result of complicated infection, deficient soft tissue for coverage, and functional aspects and defects of the tendon itself. As a single-stage procedure, various methods of tendon transfer and tendon graft have been reported along with details of local flaps or island flaps for coverage. With advances in microsurgical techniques and subsequent refinements, several free composite flaps, including tendon, fascia, or nerve, have been used to reconstruct large defects in this area without further damaging the traumatized leg. The authors report such a single-stage reconstruction of a composite Achilles tendon defect using the extensor digitorum longus tendon of the second to fourth toe in combination with a dorsalis pedis flap innervated by the superficial peroneal nerve. The follow-up of this case has proved a satisfactory outcome to date.

Hepatocyte growth factor (HGF) is a potent angiogenic factor that can stimulate the production of blood vessels in ischemic tissue. We investigated whether gene therapy using HGF-expressing adenovirus could enhance skin flap survival. Sprague-Dawley rats were randomly divided into three groups. Rats were subdermally injected with HGF-expressing adenovirus (HGF virus group), recombinant HGF (rhHGF group), or phosphate buffered saline (PBS group) 2 days before and immediately after 3 × 9 cm caudal flap elevation. The survival area of the skin flap, the ratio of blood flow, CD31-positive vessels and, VEGF expression were examined. Skin flap viability was significantly increased in the HGF virus group compared to the rhHGF and PBS groups (71.4% ± 5.9%, 63.8%± 6.4%, and 39.2% ± 13.0%, respectively) (P = 0.025). Furthermore, the blood flow ratio was significantly increased in the HGF virus group. In the HGF virus group, the number of CD31-positive vessels and vascular endothelial growth factor (VEGF) expression were significantly increased. Gene therapy using HGF-expressing adenovirus increase VEGF expression, the number of viable capillaries, and blood flow to the flap, thereby improving skin flap survival. Graphical Abstract Keywords: Hepatocyte Growth Factor, Adenovirus, Gene Therapy, Skin Flap INTRODUCTION The creation of a skin flap is a simple and reproducible method for skin defect reconstruction. However, ischemic necrosis due to insufficient local blood supply is a serious complication of this procedure. Insufficient arterial blood supply and inadequate venous drainage are frequent occurrences and can result in skin flap death, especially in the distal portion where the blood flow is most likely to fail. Various surgical and non-surgical techniques have been devised to increase flap perfusion, thereby reducing the risk of ischemia. Among these, many reports have focused on increasing the local blood supply through inducing angiogenesis by means of growth factors such as vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), or platelet derived growth factor (PDGF) (1, 2, 3, 4, 5, 6, 7, 8). Hepatocyte growth factor (HGF) is a pleiotropic growth factor with an apparent molecular weight of 80 kDa that is capable of inducing cellular proliferation, migration, and invasiveness (9). One of the important activities of HGF is to stimulate angiogenesis of various types of cells. HGF is a potent angiogenic factor and can act on endothelial cells directly or indirectly to induce angiogenesis (10, 11, 12). Moreover, HGF stimulates the production of functional vessels in the ischemic zone by promoting the migration of vascular smooth muscle cells as well as endothelial proliferation (13). HGF has been reported to stimulate angiogenesis in rabbit, rat, and mouse ischemic hindlimb models of diabetes and high concentration lipoprotein (14, 15, 16, 17). In addition, HGF has been reported to have more potent angiogenic activity than VEGF and FGF in vitro (2). Because of its potential angiogenic benefits, several studies have investigated whether HGF can increase skin flap perfusion (18). Although skin flap neovascularization can possibly be improved by HGF, its use in a clinical setting is hampered by this protein's short half-life, poor bioavailability, and the consequent need for frequent administration to sustain long-lasting effects. For HGF to be applied clinically, an efficient drug-delivery system or alternative ways to realize the pharmacological effects of this growth factor need to be developed (19). Recent studies have shown that therapeutic angiogenesis induced by gene therapy can result in a more sustained and efficient therapeutic outcomes. Angiogenic growth factors have been evaluated in this context, and therapeutic angiogenesis using angiogenic growth factor therapy has been reported to have beneficial effects in human patients with critical limb ischemia and myocardial ischemia (2, 12, 20, 21). Of the various gene delivery systems developed for therapeutic angiogenesis, adenoviruses have been widely used because of their ability to transfer relatively large genes. Therapeutic angiogenesis by gene delivery has been used to enhance the survival of skin flaps. Inadequate perfusion, which is the most common cause of distal flap necrosis, could potentially be avoided by administering HGF to the skin flap. We therefore developed an HGF-expressing adenovirus and introduced this adenovirus into ischemic skin flaps to investigate the ability of subdermal HGF-expressing adenovirus gene therapy to augment blood perfusion and flap survival in a rat skin flap model.

In terms of wound healing, there are fundamental intrinsic and extrinsic differences between fetuses (scar-free healing) and adults. The fetus exhibits less typical inflammatory response (signifiquently neutropenic) with an underdeveloped self-nonself immunologic identity and a lack of cellular immunity. The recruitment of inflammatory cells to a wound may play an important role in the resulting cellular processes and ultimately affect the quality of the healing response. Foreign bodies can act as a source of infection and immunologic reactions. In contrast, there have been few studies of the wound healing of fetus with foreign bodies, where in adults, wounds are healed by tissue regeneration rather than capsule formation and a foreign body reaction. In this study, the wound healing process in an adult rabbit and fetus group, in which either silicone or a sponge was inserted in the uterus, were compared. All specimens showed capsule formation with fibroblast, collagen deposition, neovascularization, and infiltration of inflammatory cells. However, the fetal specimen exhibited mainly acute inflammatory responses and the capsule contained less fibroblasts and collagen deposition. In addition, myofibroblast expression, which mediates wound contracture, was lower in the fetal specimen. These findings were common with cotton implants, which were expected to induce a severe inflammatory response. The inflammatory response induced by foreign materials in fetal tissue showed similar response with that of incisional wound healing. This study may provide a basis for the use of implants such as silicone in future fetal surgery.

Keloids are pathologic proliferations of the dermal layer of the skin resulting from excessive collagen production and deposition. Hepatocyte growth factor (HGF) increases the expression of matrix metalloproteinase (MMP)-1 and suppresses collagen synthesis to modulate extracellular matrix turnover. To investigate the anti-fibrotic effects of HGF, we examine the mRNA expression of collagen types I and III and matrix metalloproteinase (MMP-1, MMP-3) on human dermal fibroblast (HDF) cell lines and keloid fibroblasts (KFs, n = 5) after adding various amount of HGF protein. We also evaluated the enzymatic activity of MMP-2, MMP-9 by zymograghy. In HDFs treated with TGF-β1 and HGF protein simultaneously, both type I and III collagen mRNA expression significantly decreased (P < 0.05). Expression of MMP-1, MMP-3 mRNA also decreased. However, the mRNA expression of MMP-1, MMP-3 significantly increased in KFs with increasing amount of HGF in dose dependent manner (P < 0.05). The enzymatic activities of MMP-2 increased with increasing HGF protein in a dose-dependent manner. However, the enzymatic activity of MMP-9 did not change. These results suggest that the anti-fibrotic effects of HGF may have therapeutic effects on keloids by reversing pathologic fibrosis.

Objectives Although the incidence of infected sternotomy wounds after median sternotomy for cardiovascular surgery is relatively low (0.5% to 5%), it is associated with significant morbidity and a long period of treatment. Today, muscle flaps, such as the pectoralis major or the rectus abdominis, are widely accepted as a mainstay of reconstructive options. Each method carries unavoidable limitations and setbacks of its own. To overcome the disadvantages of the pectoralis muscle and rectus abdominis muscle flaps, we designed and performed a pectoralis major–rectus abdominis muscle bipedicled flap for the coverage of sternal defects. Methods The pectoralis major–rectus abdominis bipedicled flap was elevated as a single unit, preserving the thoracoepigastric fascia in continuity with the rectus muscle and its anterior fascia. The method was used in 27 patients with postoperative mediastinitis during a 5-year period. Results The bipedicled flap could fill the defect with sufficient volume, not only in the upper two thirds but also in the lower one third of the sternum. Recurrent uncontrolled infection developed in 11% of all cases, and upper abdominal fascial attenuation was observed in 1 patient. There were no surgical intervention–related complications or deaths. Conclusions We conclude that pectoralis major–rectus abdominis bipedicled flap is a practical and efficacious method in the reconstruction of the anterior chest wall defect caused by poststernotomy mediastinitis. It not only provides sufficient volume to fill the entire mediastinum but also affords resolution of the infected wound with favorable outcomes comparable with those of other methods.