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Radiofrequency thermocoagulation trigeminal rhizotomy (RT-TR) through the foramen ovale is a minimally invasive treatment for trigeminal neuralgia. Navigation of magnetic resonance imaging (MRI) and CT fusion imaging is a well-established method for cannulation of the Gasserian ganglion. In this study, we use the inline measurements from fusion image to analyze the anatomical parameters between the actual and simulation trajectories and compare the short- and intermediate-term outcomes according to determinable factors.The study included thirty-six idiopathic neuralgia patients who had undergone RT-TR with MRI and CT fusion image as a primary modality or repeated procedures.Among thirty-six treated patients, the inline length of the trigeminal cistern was longer for the simulated trajectory (8.4 ± 2.4 versus 6.5 ± 2.8 mm; p0.05), and the predominant structure at risk extrapolated from the inline trajectory was the brainstem, which signified a more medially directed route, in contrast with the equal weighting of temporal lobe and brainstem for the actual trajectory. The preoperative visual analogue scale (VAS) was 9.3 ± 1.0, which decreased to 2.5 ± 2.6 and 2.9 ± 3.1 at first (mean, 3 months) and second (mean, 14 months) postoperative follow-up, respectively. The postoperative VAS scores at the two follow-ups were not statistically significant without a covariate analysis. After adjustment for covariate risk factors, the second follow-up sustained therapeutic benefit was evident in patients with no prior history of related treatment, an ablation temperature greater than 70 °C, and needle location within or adjacent to the trigeminal cistern.This preliminary study demonstrated that the needle location between cistern and ganglion also plays a significant role in better intermediate-term results.

Background Percutaneous radiofrequency trigeminal rhizotomy (RF-TR) is a well-established treatment for patients suffering from trigeminal neuralgia (TN) as a primary modality or for those refractory to medical treatment. However, few existing studies have identified intraoperative parameter or navigation technique that can be used to predict the rates of short-term or long-term pain relief. In this study, we analyzed patient characteristics, intraoperative parameters and technical factors, and postoperative changes in relation to immediate and long-term pain relief. Method This study included a total 252 patients in which 340 RF-TR were performed under the guidance of intraoperative computed tomography (iCT) alone or with magnetic resonance image (MRI) and iCT fusion imaging. Result The immediate pain relief of RF-TR with iCT alone and iCT with MR image guidance with or without cerebrospinal fluid (CSF) outflow were all above 90.4%. The 2-year pain relief rate of RF-TR using iCT alone and iCT with MR images guidance with or without CSF outflow were 47.8%, 39.8%, 71.7%, and 53.9% respectively. Significant factors for 2-year pain relief were CSF outflow, iCT with MR image fusion, non-recurrent TN, and presence of postoperative facial numbness. Conclusion This preliminary study demonstrated foramen ovale cannulation under the aid of iCT with MR image guidance could improve 2-year pain relief.

The benefits of diploidy are considered to involve masking partially recessive mutations and increasing genetic diversity. Here, we review new studies showing evidence for diverse allele-specific expression and epigenetic states in mammalian brain cells, which suggest that diploidy expands the landscape of gene regulatory and expression programs in cells. Allele-specific expression has been thought to be restricted to a few specific classes of genes. However, new studies show novel genomic imprinting effects that are brain-region-, cell-type- and age-dependent. In addition, novel forms of random monoallelic expression that impact many autosomal genes have been described in vitro and in vivo. We discuss the implications for understanding the benefits of diploidy, and the mechanisms shaping brain development, function, and disease.

Background Identification of small pulmonary nodules is challenging in a limited intrathoracic field during minimally invasive video‐assisted thoracoscopic surgery (VATS), and preoperative localization is required. Various techniques have been reported with some failure and complications. Here, we compare the feasibility and safety between electromagnetic navigation bronchoscopic marking and computed tomography (CT)‐guided percutaneous marking using indocyanine green (ICG) and iopamidol. Methods A total of 47 patients with small‐sized pulmonary nodules, scheduled to undergo video‐assisted thoracoscopic limited resection, were enrolled in this study. A mixture of diluted ICG and iopamidol was injected into the lung parenchyma as a marker, using CT‐guided percutaneous or electromagnetic navigation bronchoscopic injection techniques and the results were examined and compared. Results A total of 35 and 12 patients underwent preoperative marking by percutaneous injection and electromagnetic navigation bronchoscopic injection, respectively, in which a marker was detected in 33/35 (94.3%) and 12/12 (100%) patients. No combination of these procedures was performed in any patient. All markers were successfully detected in three patients who underwent injection marking at two different lesion sites. Pneumothorax occurred in five patients (14%) in the percutaneous marking group, which was relieved in all patients without the necessity for chest tube drainage. No other complication was observed in this study. Conclusions Electromagnetic navigation bronchoscopic injection techniques using indocyanine green fluorescence plus iopamidol are safe and effective, and comparable with CT‐guided localization. Furthermore, a bronchoscopic approach enables marking of multiple lesion areas without increasing patient risk, especially for puncture‐related pneumothorax. Key points Significant findings of the study Either computed tomography (CT)‐guided percutaneous or electromagnetic navigation bronchoscopic injection techniques can be used for preoperative marking of pulmonary nodules with indocyanine green (ICG) fluorescence. What this study adds Indocyanine green (ICG) is a safe and easily detectable fluorescent marker for video‐assisted thoracoscopic surgery (VATS).A bronchoscopic injection approach enables marking of multiple lesion areas without increasing the risk of pneumothorax., Computed tomography (CT)‐guided percutaneous or electromagnetic navigation bronchoscopic injection techniques can be used for preoperative marking of pulmonary nodules with indocyanine green (ICG) fluorescence. ICG is a safe and easily detectable fluorescent marker for video‐assisted thoracoscopic surgery (VATS). A bronchoscopic injection approach enables marking of multiple lesion areas without increasing the risk of pneumothorax.

A retrospective, population-based study.To identify factors affecting long-term mortality and medical resources use in disabled spinal cord injury (SCI) patients after syringomyelia diagnosis.A National Health Insurance Research Database containing 10,374 patients with SCI.Data recorded between 1997 and 2012 for 376 disabled SCI patients with syringomyelia and 376 characteristics-matched disabled SCI patients without syringomyelia were collected. The index date was the date of syringomyelia diagnosis. Cox proportional hazards regression model was used to investigate the factors affecting 10-year mortality in these patients. Medical resources use was compared for 1 year before and after index date.The survival rate at 10-year follow-up after syringomyelia diagnosis was estimated at 68.6%. The 10-year survival rate was comparable between the two groups. Age ≥ 60 (adjusted hazard ratios (aHR) 4.21, 95% confidence interval (CI) 2.97 to 5.96) and 30 years (aHR 0.25, 95% CI 0.10 to 0.62), spinal cord or spinal canal operations within 1 year after the index date (aHR 1.84, 95% CI 1.19 to 2.84), history of pneumonia (aHR 1.55, 95% CI 1.07 to 2.26), and history of coronary heart disease (CHD) (aHR 1.85, 95% CI 1.18 to 2.89) were significantly associated with long-term mortality. Outpatient prescription costs were higher during 1 year after the diagnosis than those of 1 year before the diagnosis.Age, spinal operations, history of pneumonia, and history of CHD are associated with 10-year mortality in disabled SCI patients with syringomyelia.

The ATP-binding cassette transporter ABCG2 is expressed in the interfollicular epidermis and mediates the side-population phenotype in skin cells. However, the role of ABCG2 in skin is unclear. Increased expression levels of ABCG2 were found at the basal layer of transitional epidermis adjacent to cutaneous wounds in human patients, indicating that ABCG2 may be involved in regulating the wound healing process. To investigate the role of ABCG2 in cutaneous wound healing, full-thickness skin wounds were created in ABCG2 knockout (ABCG2-KO) and wild-type mice. The healing process was analysed and revealed that ABCG2 deficiency in skin results in delays in wound closure and impairments in re-epithelialization, as evidenced by reductions in both suprabasal differentiation and in p63-expressing keratinocytes migrating from transitional epidermis to epithelial tongues. The reduction in p63-expressing cells may be due to elevated levels of reactive oxygen species in ABCG2-KO epidermis, which can cause DNA damage and lead to proliferation arrest. To determine whether ABCG2 deficiency affects the potency of epidermal stem/progenitor cells (EPCs), transplantation studies were carried out, which demonstrated that ABCG2-KO EPCs display higher levels of γH2AX and lose the capacity to differentiate into suprabasal keratinocytes. A competitive repopulation assay confirmed that ABCG2 expression is critical for the proper expansion and differentiation of EPCs in cutaneous wounds. As EPCs are known to contribute to the healing of larger wounds, the current findings imply a functional role for ABCG2 in the expansion and differentiation of p63-expressing EPCs. Thus, ABCG2 deficiency in skin impairs re-epithelialization in cutaneous wound healing.

The pain of acute compression fracture in the lumbar spine may be refractory to conservative treatment, and surgery is not an optimal choice for the elderly or infirm individuals. Moreover, even vertebroplasty can cause many side effects such as chemical leak, adjacent segment instability, and residual pain. Percutaneous dorsal root ganglion block (PDRGB) possibly is an alternative therapeutic option. In this study, we evaluated the efficacy of pain relief and the rate of adjacent level compression fracture in patients with acute compression fracture of the lumbar spine.We retrospectively reviewed 40 patients with lumbar compression fracture from 2013 to 2015. The patients were treated with navigation-assisted CT-guided PDRGB with steroid at the pathological level and at the adjacent level above and below. Therapeutic response was evaluated using the Numerical Rating Scale (NRS); and an optimal, acceptable, and unfavorable outcome were analyzed.Among the 40 patients treated, initial pain relief on the first day was dramatic, and the average NRS did not change significantly up to the first-year follow-up. The highest percentage of a good outcome, at 90% (37.5% with an optimal outcome, 52.5% with an acceptable outcome), was reported at 1 week postoperatively. The percentage of optimal outcomes increased even at the 1-year follow-up. No adjacent compression fracture was found in the group treated with PDRGB alone at the 1-year follow-up.PDRGB is a simple, safe, and minimally invasive procedure that showed immediate and prolonged improvement of pain in lumbar osteoporotic compression fracture patients who failed conservative treatment or had residual pain after vertebroplasty. However, continuous medication for osteoporosis was still required.

Summary Interactions between genetic and epigenetic effects shape brain function, behavior, and the risk for mental illness. Random X inactivation and genomic imprinting are epigenetic allelic effects that are well known to influence genetic architecture and disease risk. Less is known about the nature, prevalence, and conservation of other potential epigenetic allelic effects in vivo in the mouse and primate brain. Here we devise genomics, in situ hybridization, and mouse genetics strategies to uncover diverse allelic effects in the brain that are not caused by imprinting or genetic variation. We found allelic effects that are developmental stage and cell type specific, that are prevalent in the neonatal brain, and that cause mosaics of monoallelic brain cells that differentially express wild-type and mutant alleles for heterozygous mutations. Finally, we show that diverse non-genetic allelic effects that impact mental illness risk genes exist in the macaque and human brain. Our findings have potential implications for mammalian brain genetics. Video Abstract

Introduction Perforator flap transfer has the benefits of minimal donor site morbidity and customization in design. This study reports on the proximal lateral leg perforator (PLLP) flap transfer for head and neck reconstruction. Materials and Methods From January 2000 through December 2009, 18 patients underwent head and neck reconstruction with the PLLP flap, including 16 males and 2 females ranging in age between 32 and 80 years old. The mean follow-up time was 9.8 months. Results Mother vessels of PLLP flaps can arise 77.8% (14/18) from the peroneal system, 11.1% (2/18) from the posterior tibial system, or 11.1% (2/18) from the common popliteal system. The skin dimension ranges from 4 cm × 7 cm to 6.5 cm × 18 cm. The mean of the perforator size is 1.96 mm (1.5 mm to 2.3 mm). The mean of the pedicle length is 6.96 cm (4.5 cm to 10 cm). All flaps survived completely except one flap that had partial necrosis. Conclusions The PLLP flap for head and neck reconstruction offers versatility in design, diverse tissues for composition, a two-team approach, and negligible donor site morbidity, and it spares major vessels. The unpredictable pedicle length and the feasibility for microvascular anastomosis in the perforator level can be adapted with further experience and refining techniques.

Background: The standardized mortality rate of type 2 diabetes is higher in Taiwan than that in other developed countries. In Taiwan, the diabetes mortality rate in Chiayi County is the highest nationwide. Purpose: This study was designed to explore the health status (to measure six physiological indicators), the health-related behaviors, and the associated factors among type 2 diabetes sufferers living in rural communities. Methods: Researchers used a cross-sectional, correlation design and conducted the study at nine local health districts in Chiayi County, Taiwan. A total of 387 participants previously diagnosed with type 2 diabetes were randomly selected and invited to join in the program. Results: Fifty-nine percent of participants were women; their mean age was 68.7 years, and their mean duration with diabetes was 7.9 years. Most were treated at local health centers and took oral medications (90.7%). More than 40% did not exercise regularly and 33.9% did not practice diet control. Results found a higher percentage of abnormal health indicators in terms of participant body mass index, waist circumference, HbA1C, and peripheral neurovascular function. After controlling for potential confounding factors, researchers found smaller waist circumference, participating in community support groups, better foot self-care capability, and frequent exercise to be associated with better health indicators. Diabetes duration, lower education, and being of male gender were found to be negatively associated with health status. Conclusions/Implications for Practice: This study found that rural residents with diabetes do not adequately control their diabetes and exhibit inadequate health-related behavior. Joining community support groups, increasing exercise frequencies, and improving foot self-care capabilities should be employed in nursing strategies and health policies for diabetes control-especially for those who have less formal education or are male.

Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 to 25 percent of transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the timing of occurrence of flap compromise following free tissue transfer, and its correlation with salvage outcome.Between January of 2002 and June of 2003, 1142 free flap procedures were performed and 113 flaps (9.9 percent) received re-exploration due to compromise. All patients were cared for in the microsurgical intensive care unit for 5 days. Through a retrospective review, timing of presentation of compromise was identified and correlated with salvage outcome.Seventy-two flaps (63.7 percent) were completely salvaged and 23 (20.4 percent) were partially salvaged. Eighteen flaps (15.9 percent) failed completely. Ninety-three flaps (82.3 percent) presented with circulatory compromise within 24 hours; 108 (95.6 percent) presented with circulatory compromise within 72 hours, and 92 flaps (85.2 percent) were salvaged within this period. One out of the three flaps presenting with compromise 1 week postoperatively was salvaged. Flaps presenting with compromise upon admission to the microsurgical intensive care unit had significantly lower complete salvage rates as compared with those without immediate abnormal signs (40.9 percent versus 69.2 percent, p = 0.01).The time of presentation of flap compromise is a significant predictor of flap salvage outcome. Intensive flap monitoring at a special microsurgical intensive care unit by well-trained nurses and surgeons allows for early detection of vascular compromise, which leads to better outcomes.

Background The radial forearm flap has been a workhorse flap for soft-tissue or coverage reconstruction in the head and neck area. Although it has several major advantages, it requires sacrifice of the radial artery. In this article, the authors present their modification of harvesting a forearm flap based on a large septocutaneous branch of the radial artery in the proximal forearm with or without sacrificing the main radial artery. They name it the proximal radial forearm flap. Methods From September of 2003 to March of 2004, a total of 14 free proximal radial forearm flaps were used for head and neck reconstruction in 12 patients. There was one female patient and 11 male patients. Their ages ranged from 32 to 85 years. The skin flap size ranged from 2.0 x 6.0 cm to 4.5 x 18 cm. Results All free proximal radial forearm flap reconstructions had immediate success. There were one delayed flap loss caused by wound infection and one death attributable to advanced medical disease. Six flaps were harvested with preservation of the radial artery trunk. Six of the eight radial arteries that were killed during flap harvest were repaired with a short segment (3 to 4 cm) of vein graft. The average diameter and length of the septocutaneous vessel of the proximal radial forearm flap was 0.73 mm and 3.3 cm, respectively. Two flaps were harvested in conjunction with the conventional free radial forearm flaps. Nine donor sites were closed primarily and five donor sites required skin grafts. Conclusions The proximal radial forearm flap can be used successfully in head and neck reconstruction with the advantages of moving the donor site to the proximal forearm for better scar concealment and possible preservation of the radial artery trunk. The disadvantages of this flap are short pedicle length and small pedicle diameter when the radial artery is to be preserved.

Background Massive defects of the head and neck regions after resection of advanced carcinoma often require two flaps for optimal reconstruction. This study focuses on the selection of proper recipient vessels. Methods A total of 262 free-flap transfers were performed in 130 patients using the two-flap approach (one patient received two flaps twice). Results For microvascular anastomosis of inner flaps (intraoral lining-bone reconstruction flaps), the ipsilateral facial artery was used in 56 flaps (42.8 percent), the ipsilateral superior thyroid artery was used in 49 flaps (37.4 percent), and a branch of the internal jugular vein was used as recipient vein in 101 flaps (77.1 percent). For external flaps (soft-tissue-external skin reconstruction flaps), the ipsilateral superior thyroid artery was used in 59 flaps (50.4 percent) and the transverse cervical artery was used in 19 flaps (16.2 percent). In 14 patients the inner flaps provided distal run-off for external flap revascularization. Only seven flaps required vein grafts; they were all used for external face reconstruction (2.8 percent). There were six total (2.3 percent) and 12 partial (4.6 percent) flap failures. Conclusions Recipient vessel selection and preparation in primary head and neck cancer reconstruction requiring two simultaneous flaps should take into consideration (1) avoidance of unnecessary destruction during tumor ablations and preservation of as many neck vessels as possible, (2) length and diameter match between flap pedicles and recipient vessels to avoid vein grafts, and (3) possible need of another free-flap reconstruction for flap failure, complication, recurrence, or secondary primary cancers. The previously radiated or operated neck does not preclude the use of recipient vessels from that side. Distal run-off of the inner flap for external flap revascularization should be avoided if possible. Once those principles are observed, two-flap reconstruction for primary cancer presents no more difficulties than single-flap reconstruction.

Cotreatment with regulatory T cells (T(reg)) and conventional allogeneic bone marrow transplantation (BMT) successfully induced durable chimerism and tolerance to nonvascularized skin allografts without cytoreductive conditioning in mice. We sought to determine whether T(reg) treatment combined with vascularized BMT (VBMT) could create mixed chimerism and induce tolerance to vascularized composite allografts (VCAs) without cytoreductive conditioning in rats.Recipient Lewis rats treated (day 0) with or without naturally sorted T(reg) (3 × 10(6)) from Lewis rat spleen and lymph nodes received costimulation blockade (anti-CD154 monoclonal antibody, days 0 and 1 and CTLA-4 immunoglobin, days 2, 4, and 6), rapamycin (days -1, 0, and 2), and concurrent transplantation of fully mismatched allogeneic donor VCAs (day 0) from the Brown Norway rat hindlimb containing VBMT. The mixed chimerism level was assessed monthly using flow cytometry. Survival of VCAs and occurrence of graft-versus-host disease were assessed clinically and histologically.The combination of T(reg) and VBMT treatment led to long-term multilineage hematopoietic mixed chimerism (12-18%) and long-term donor-specific tolerance to VCAs (89% acceptance rate). Neither stable mixed chimerism nor VCA acceptance was observed in recipients without T(reg) treatment. Graft-versus-host disease did not occur in the VBMT recipients.Cotreatment with T(reg) and VBMT created stable mixed chimerism and induced long-term donor-specific tolerance to VCAs without requiring cytoreductive conditioning. This noncytoreductive T(reg)-VBMT protocol has potential for clinical application in VCAs.

With the development of modern microsurgical reconstruction, there are several alternative methods for the complicated head and neck defect or injured extremity. The double-paddled flap, double flaps, and double flap with vascular flow-through linkage are good tools for extensive wide, composite, and three-dimensional defects. When faced with a difficult reconstruction, the expense, morbidity of the donor site, and operative time must be taken into consideration. Compared with other combined composite flaps and other methods, the chimeric flap has many advantages including: easy three-dimensional insetting, acceptable aesthetic appearance, reduced donor site morbidity, design with the least effort and operation time, and one pair of recipient vessel. The disadvantages of the chimeric flaps include: the variation of perforators, the requirement of a learning curve, and, sometimes, the need for a second venous drainage or shifting to double flaps. Overall, in selected cases, the chimeric flap is a good option for the reconstruction of extensive, composite, and three-dimensional defects.

Although postoperative radiotherapy has proved effective in improving local control and survival in patients with head and neck cancers, its complications, especially mandibular osteoradionecrosis, reduce the quality of life. Mandibular surgery before the radiotherapy adds an additional risk factor for osteoradionecrosis. This study reviews patients in Chang Gung Memorial Hospital, Taipei, Taiwan, over a 10-year period, who underwent intraoral cancer resection followed by postoperative radiotherapy and thereafter developed osteoradionecrosis of the mandible. A total of 24 men and three women with a mean age of 49.9 years were identified and included in the study. In 10 cases, tumor resection was performed with a marginal mandibulectomy; in eight cases, tumor resection was performed after mandibular osteotomy; and in three cases, a segmental mandibulectomy was performed, and the defect was reconstructed with a fibula osteoseptocutaneous flap. In six cases, tumor excisions were performed without interfering with the mandibular continuity. Patients received postoperative external beam radiotherapy into the primary site and the neck, with a mean dose (+/-SD) of 5900 +/- 1300 cGy in an average of 35 fractions during an average of 6.5 weeks. The average elapsed time between the end of radiation therapy and clinical diagnosis of osteoradionecrosis of the mandible was 11.2 months (range, 2 to 36 months). The time elapse between the end of the radiation therapy and the diagnosis of osteoradionecrosis was influenced by initial treatment (Kruskal-Wallis test: n = 27, chi-square = 12.884, p < 0.005), and this period was shorter if the mandibular osteotomy or marginal mandibulectomy was performed (the two lowest mean ranks in the test). However, if the initial surgery resulted in a segmental mandibulectomy reconstructed with a fibula osteoseptocutaneous flap, onset of the osteoradionecrosis was relatively late (Kruskal-Wallis test: n = 21, chi-square = 7.731, p = 0.052). After resection of osteoradionecrotic bone and surrounding soft tissue, 22 patients underwent reconstructive procedures with a fibula osteoseptocutaneous flap, and five patients underwent reconstructive procedures with an inferior genicular artery osteoperiosteal cutaneous flap. One fibula osteoseptocutaneous flap showed total failure and another showed a 25 percent skin loss; both were revised with pedicled flaps. The skin paddle of an inferior genicular artery flap was replaced with an anterolateral thigh flap because of anatomic variation of the skin vessel. Once the diagnosis of osteoradionecrosis is established, replacement of the dead bone and surrounding tissue with a vascularized free bone flap is inevitable, and a composite osteocutaneous free flap is a good option.

Repairing full-thickness cheek defects involving the oral commissure in the head and neck regions after tumor resection is a challenge for reconstructive surgeons. First, they are usually relatively large defects. Second, the axes of the cheek and intraoral lining are different from each other. Third, the shape and volume of the defect and the oral sphincter should be considered individually. Lateral femoral circumflex perforator flaps with at least two independent cutaneous perforators are suitable for reconstruction of such a defect in one stage. In this study, between January and December of 1999, a total of nine patients underwent reconstruction with chimeric lateral femoral circumflex perforator flaps immediately after resection of their oral cancers. The average age of the patients was 61 years (range, 42 to 74 years). The oral lining defects were between 5 x 5 cm and 6 x 12 cm in size, whereas the cheek defects were between 5 x 6 and 8 x 12 cm. Fifteen flaps were supplied by one perforator, and three flaps were supplied by two perforators. There were nine single arterial anastomoses, eight single venous anastomoses, and one double venous anastomosis. There were no total flap failures. One case of postoperative venous congestion was successfully treated by a second venous anastomosis. The average duration of hospitalization was 31.8 days (range, 18 to 49 days). The median follow-up time was 8.6 months, and all patients were alive at the time of evaluation. Six of nine patients had satisfactory or good contours of the cheek. Five of nine patients had normal deglutition. Six of nine patients had adequate oral continence. Compared with other free flaps, use of the combined (chimeric) lateral femoral circumflex perforator flaps for the reconstruction of cheek through-and-through defects involving the oral commissure has several advantages: (1) easy three-dimensional insetting, (2) a unique character suitable for the requirements of the oral lining and cheek skin to achieve good aesthetic appearance, (3) functional preservation of the oral sphincter and the resistance of gravity by use of the tensor fasciae latae, (4) minimal donor-site morbidity, (5) economic design, and (6) no need for microsurgical fabrication, because major vascular branches such as the transverse branch, the ascending branch, and the feeding branch to the rectus femoris muscle are not sacrificed in the procedure. The disadvantages of these flaps include (1) the complicated anatomy of the perforators, (2) the learning-curve requirement for their use, and (3) the occasional need for secondary venous drainage and shifts to double flaps. Although there are some difficulties, it was concluded that use of the chimeric lateral femoral circumflex perforator flaps in the selected cases is one of the good options available for the reconstruction of cheek through-and-through defects involving the oral commissure.

Extensive composite defects of the oromandibular area are usually created after the surgical treatment of T3 and T4 cancers, requiring complex reconstructive plastic surgical procedures. The preferred treatment method for this type of defect is reconstruction with two free flaps. The use of the vascularized fibula osteoseptocutaneous flap for the bone and inner lining defect is well known and accepted. Among the flaps that can be used for the outer lining and soft-tissue reconstruction, the two most commonly used have been the forearm flap and the rectus abdominis myocutaneous flap. However, these flaps have some disadvantages that restrict their use for this purpose. The forearm flap is usually too thin to cover the fibular bone and reconstruction plate, and the rectus abdominis myocutaneous flap can cause a subclinical reduction in abdominal strength. Both radial forearm and rectus abdominis myocutaneous flaps are difficult to harvest during tumor excision. Because of these drawbacks, over the past several years the authors have preferred to use the anterolateral thigh flap for outer face, neck, and submandibular region reconstructions. From October of 1998 to June of 2000, 22 extensive composite mandibular defect reconstructions using the free anterolateral thigh flap, combined with the vascularized free fibula osteoseptocutaneous flap, were performed at the Chang Gung Memorial Hospital. Complete flap survival was 90.9 percent (40 of 44 flaps). Complete loss was seen in an anterolateral thigh flap, which was then reconstructed with a pectoralis major myocutaneous pedicled flap (2.3 percent). There were five venous problems: three in osteoseptocutaneous free fibula flaps, the other two in anterolateral thigh flaps; all were revised immediately. However, the skin islands of two osteoseptocutaneous free fibula flaps and one anterolateral thigh flap developed partial necrosis (6.8 percent). The other complications were compartment syndrome in the leg in one patient, external carotid artery rupture in one patient, three donor-site infections in two patients, three neck wound infections, and one myocardial insufficiency; all were treated properly. Thirteen patients underwent revision procedures 6 months after the first operation. These procedures included debulking of the flap or revision of the mouth angle or both. Trismus or intraoral contraction was noted in none of these patients. In conclusion, the free anterolateral thigh flap combined with the vascularized fibula osteoseptocutaneous flap seems to be a good choice in the reconstruction of the extensive composite defects of the oromandibular region aesthetically and functionally.

Reconstruction of bilateral extensive composite mandibular defects afterosteoradionecrosis with two fibular osteoseptocutaneous free flaps.

A case of primary cardiac leiomyoma arising from the infundibulum of the right ventricle of a 24-year-old woman is presented. The mass protruded into the cavity of the right ventricle and caused severe right ventricular outflow tract obstruction. We resected the tumor under cardiopulmonary bypass successfully, and confirmed it histologically to be a benign leiomyoma. To the authors' knowledge, this is the first case report of a primary cardiac leiomyoma in an adult woman.

A clinically applicable tolerance induction regimen that removes the requirement for lifelong immunosuppression would benefit recipients of vascularized composite allotransplantation (VCA). We characterized the immunomodulatory properties of syngeneic (derived from the recipient strain) adipocyte-derived stem cells (ADSCs) and investigated their potential to induce VCA tolerance in rats.ADSCs were isolated from Lewis (LEW, RT1A(l)) rats; their immunomodulatory properties were evaluated by means of mixed lymphocyte reactions in vitro and VCAs in vivo across a full major histocompatibility complex mismatch with the use of Brown-Norway (BN, RT1A(n)) donor rats. Two control and four experimental groups were designed to evaluate treatment effects of ADSCs and transient immunosuppressants (anti-lymphocyte globulin, cyclosporine) with or without low-dose (200 cGy) total body irradiation. Flow cytometry was performed to quantify levels of circulating CD4(+)CD25(+)FoxP3(+) regulatory T cells (Tregs).Cultured syngeneic ADSCs exhibited CD90.1(+)CD29(+)CD73(+)CD45(-)CD79a(-)CD11b/c(-) phenotype and the plasticity to differentiate to adipocytes and osteocytes. ADSCs dramatically suppressed proliferation of LEW splenocytes against BN antigen and mitogen, respectively, in a dose-dependent fashion, culminating in abrogation of allo- and mitogen-stimulated proliferation at the highest concentration tested. Accordingly, one infusion of syngeneic ADSCs markedly prolonged VCA survival in LEW recipients treated with transient immunosuppression; of these, 66% developed tolerance. Total body irradiation provided no additional VCA survival benefit. An important role for Tregs in tolerance induction/maintenance was suggested in vivo and in vitro.Treatment comprising syngeneic ADSCs and transient immunosuppression (i) increased levels of circulating Tregs and (ii) induced tolerance in 66% of recipients of major histocompatibility complex-mismatched VCAs.

Although vascularized composite allografts (VCAs) have been performed clinically for a variety of indications, potential complications from long-term immunosuppression and graft-versus-host disease remain important barriers to widespread applications. Recently it has been demonstrated that VCAs incorporating a vascularized long bone in a rat model provide concurrent vascularized bone marrow transplantation that, itself, functions to establish hematopoietic chimerism and donor-specific tolerance following non-myeloablative conditioning of recipients. Advances such as this, which aim to improve the safety profile of tolerance induction, will help usher in an era of wider clinical VCA application for nonlife-saving reconstructions.

This paper is a report of a study examining the diabetes control and foot self-care capability in farmers and fishermen following introduction of a multi-stage, multi-disciplinary team and community-based small group health promotion programme.Improving the control of diabetes is a critical issue in Taiwan because mortality rates are increasing dramatically, particularly in rural populations.A quasi-experimental research design was deployed from January to December 2009. A total of 387 participants living in nine rural districts with previous diagnoses of type-2 diabetes were randomly selected. Three hundred and twenty-three completed the 3-stage programme, including health assessment, health promotion education and individually tailored telephone counselling and evaluation over a 1-year period.Most of the participants were fishermen or farmers who had6 years of education (79%) and were elders (68·9 ± 9·5 years). Most of the physiological variables and foot self-care capabilities showed statistically significant improvement after the programme. Furthermore, 37 participants with severe high risk of diabetic foot accepted additional referral treatments, and their peripheral nerve and vascular functions improved.The research outcomes support the value of community-based health promotion programmes in rural areas, incorporating a multidisciplinary health team and culturally competent materials to help the elder rural inhabitants with diabetes enjoy better health and quality of life.

Summary Background Osteocutaneous flaps are one of the best options for one-stage mandible reconstruction. However, the challenge remains to achieve optimal functional and cosmetic results. A new novel approach involving the preoperative prefabrication of a reconstructive plate through a calcium-sulphate three-dimensional (3D) model facilitates the contouring of vascularised bone grafts. We herein report our preparations and results using this technique. Methods A total of 17 mandibular defects were reconstructed by this novel approach. A calcium-sulphate 3D model was constructed from computed tomography (CT) data. After the oncologist designed the cut line on the model, the mandibular arc was ground to the neo-mandible shape, which consisted of several linear planes according to the osteotomy of the bone graft. The reconstruction plate was shaped to fit this. After tumour resection, the prefabricated plate was placed to the remaining mandible and revealed the defect to be reconstructed, just as a mould. Rubber sticks were used as a template to shape the bone graft. The preoperative information, and functional and aesthetic results were retrospectively analysed. Results As many as 12 fibular and 5 scapular flaps were applied. Postoperative complications included two salivary fistulae, one abscess and one partial skin loss, all of which were resolved after conservative treatment. Postoperatively, all patients could speak clearly, 12 had a normal diet and 12 had excellent cosmetic results. Conclusions This is the first report using models made by calcium-sulphate. The largest advantage of this model is that the neo-mandible shape can be demonstrated preoperatively. The refinement of mandible reconstruction after tumour ablative surgery can be achieved with a prefabricated plate through the use of a calcium-sulphate 3D model. It enables more accurate, faster and simplified fabrication of reconstruction plates, thus leading to satisfactory functional and cosmetic results.

Summary Second cancers following head and neck cancer (HNC) most often involve the esophagus and lung, yet the actual magnitude of impact of second primary esophageal or lung cancer on survival of HNC patients has not been well established, particularly by a large-scale epidemiological study. To provide a quantitative estimate of the survival impact, we conducted a population-based study including 63,720 cases of HNC subsets, of which 3658 developed at least one second primary malignancy, 253 had a second esophageal cancer and 388 had a second lung cancer. A Cox proportional hazards model which included age at initial cancer diagnosis and gender were employed to compare the survival rates between patients with different types of second cancers. Our results showed that the second esophageal or lung cancer contributed to a poorer outcome than the other types of second cancer, regardless of the index tumor site (all Ps ⩽ 0.019). The overall median survival was 0.76 ± 0.04 and 0.72 ± 0.08 years for second esophageal and lung cancers, respectively. Compared to those without second cancers, the patients with second esophageal or lung cancer were associated with a significant reduction in survival, with an estimated 31–105% excess risk of death according to the site of the primary index tumor. In conclusion, the second esophageal and lung cancers have a significantly negative impact on the survival of HNC patients, thereby calling for a more effective program for surveillance and chemoprevention for these two sites.

Although many large series of free tissue transfers for head and neck reconstruction have been reported in adults, there are few studies in paediatric patients. Seventy-three free tissue transfers for reconstruction of various defects of the head and neck were performed in 72 paediatric patients between January 1990 and September 2002, at our centre. The average age at the time of reconstruction was 11.8 years (range: 2 to 17 years). Thirty-eight patients were girls and 34 were boys. There were 19 tumour resection defects, 18 congenital oro-nasal fistula defects (cleft palate), 11 posttraumatic defects, nine corrosive pharyngo-oesophageal injuries, eight burn contractures, six hemifacial atrophies and microsomia, and one facial paralysis. Thirty-nine fasciocutaneous flaps, 16 osteoseptocutaneous flaps, 10 muscle or myocutaneous flaps, and eight jejunal flaps were transferred. The mean operative time was 8 h 20 min. All flaps survived, except one partial necrosis, with 98.6% success rate. Five patients (6.8%) required re-exploration. There were two venous and three arterial thromboses. All five flaps were successfully salvaged. The average hospital stay was 18 days. This study confirmed free tissue transfer as a safe, reliable, cost- and time-effective method for the reconstruction of various head and neck defects in children.

Head and neck tumors often require radiotherapy as part of the treatment protocol. Although it improves the survival rate in cancer patients, it may cause osteoradionecrosis, especially in the mandible and maxilla. Twelve patients with osteoradionecrosis of the maxilla were treated with microsurgical free tissue transplantations between April of 1996 and August of 2002. There were 10 male and two female patients, with a mean age of 60.2 years. The mean radiotherapy dose was 6674 cGy. The radiation dose could not be traced in three patients because radiotherapy was performed elsewhere. Radical sequestrectomy, soft-tissue debridement, and pathologic proof of no tumor recurrence were performed before microsurgical reconstruction. Free flaps used included the following: anterolateral thigh (n = 7), radial forearm (n = 2), rectus femoris musculocutaneous (n = 2), and supracondylar chimeric (n = 1) flaps. All flaps survived completely and reconstruction succeeded. During a mean 25-month follow-up period, ectropion, plate exposure, and mild infection were encountered in three patients and treated successfully. Radical debridement and obliteration of dead space with well-vascularized tissue are essential for successful treatment of maxillary osteoradionecrosis. The anterolateral thigh flap is most versatile for almost all types of soft-tissue defect reconstruction in the head and neck region.

Breast reconstruction offers not only physical but also psychological rehabilitation. Autologous tissue transfer is a good option for breast reconstruction. The purpose of this study was to investigate the success rate, complications, and cosmetic outcomes following use of a muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction.Between August 1999 and February 2001, 15 consecutive patients underwent breast reconstruction using a muscle-sparing free TRAM flap after a mastectomy. Ten patients received mastectomies and immediately underwent breast reconstruction using muscle-sparing free TRAM flaps at Chang Gung Memorial Hospital. The remaining 5 patients first received a modified radical mastectomy and then underwent breast reconstruction.The mean age of patients was 43.9 (range, 32 to 50) years. Ten patients (67%) underwent immediate reconstructions, and 5 (23%) underwent delayed reconstructions. The overall success rate was 93.3%. Postoperative complications included 1 abdominal seroma and 1 small area of breast fat necrosis. Six of 10 patients with immediate reconstruction underwent both adjuvant chemotherapy and hormone therapy, while 3 patients received only chemotherapy. None of these adjuvant therapies were delayed by the reconstructive surgery. At a mean follow-up of 26.7 months, no local recurrence had been found, and 93% of patients were satisfied with the esthetic results.A muscle-sparing free TRAM flap is a good option for breast reconstruction. Both the success rate and patient satisfaction are high. The subsequent adjuvant therapy need not be delayed following immediate reconstruction.

Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 x 2 cm to 26 x 5 cm (mean, 19.7 x 3.3 cm). The size of flaps ranged from 11 x 5 cm to 26 x 8 cm (mean, 21.3 x 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split-thickness skin graft in two cases. At a mean follow-up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one-stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor-site morbidity.

BackgroundAntioxidants have been shown to enhance the proliferation of adipose-derived mesenchymal stem cells (ADMSCs)in vitro, although the detailed mechanism(s) and potential side effects are not fully understood.In this study, human ADMSCs cultured in ImF-A medium supplemented with antioxidants (N-acetyl-l-cysteine and ascorbic acid-2-phosphate) and fibroblast growth factor 2 (FGF-2) were compared with ADMSCs cultured with FGF-2 alone (ImF) or with FGF-2 under 5% pO2conditions (ImF-H).ResultsDuring log-phase growth, exposure to ImF-A resulted in a higher percentage of ADMSCs in the S phase of the cell cycle and a smaller percentage in G0/G1 phase. This resulted in a significantly reduced cell-doubling time and increased number of cells in the antioxidant-supplemented cultures compared with those supplemented with FGF-2 alone, an approximately 225% higher cell density after 7 days. Western blotting showed that the levels of the CDK inhibitors p21 and p27 decreased after ImF-A treatment, whereas CDK2, CDK4, and CDC2 levels clearly increased. In addition, ImF-A resulted in significant reduction in the expression of CD29, CD90, and CD105, whereas relative telomere length, osteogenesis, adipogenesis, and chondrogenesis were enhanced. The results were similar for ADMSCs treated with antioxidants and those under hypoxic conditions.ConclusionAntioxidant treatment promotes entry of ADMSCs into the S phase by suppressing cyclin-dependent kinase inhibitors and results in rapid cell proliferation similar to that observed under hypoxic conditions.