In the initial phase of wound healing, endogenous fibrin clots are known to form a provisional matrix and to promote angiogenesis. Growth factors such as vascular endothelial growth factor (VEGF) increase in wounds to stimulate angiogenesis. However, it remains unknown whether VEGF is induced when fibrin is used as a dermal substrate for cultured skin substitutes. The authors investigated the effect of fibrin gel as a dermal substrate for a cultured skin substitute, using human keratinocytes and dermal fibroblasts. A collagen-cultured skin substitute was also examined for comparison. VEGF in the culture supernatant in both types was measured by enzyme-linked immunosorbent assay, and VEGF mRNA was determined semiquantitatively by reverse-transcriptase polymerase chain reaction after 2 days of incubation. Experiments were performed using 12 cultured skin substitutes: four for histologic examination before transplantation, four for VEGF assay in vitro, and four for the transplantation to athymic mice. Three independent experiments were performed for each step. VEGF concentration in the fibrin-cultured supernatant was 84.3 +/- 11.8 pg/ml, whereas it was 27.8 +/- 4.68 pg/ml in the case of the collagen substrate. The relative levels of VEGF mRNA were 1.088 +/- 0.100 and 0.698 +/- 0.226, respectively. In in vivo transplantation, the fibrin-type cultured skin substitute showed an excellent take on the wound bed, and a normally proliferating keratinocyte layer with emergence of vascular endothelial cells in the transplanted floor was seen 3 days after transplantation. Vascular endothelial cells, which were identified using alkaline phosphatase stain, were significantly increased in the fibrin-type cultured skin substitute. The use of fibrin as a dermal substrate for cultured skin substitute increases the secretion of VEGF, improves regeneration of mature epidermal structure after in vivo transplantation, and promotes the migration of vascular endothelial cells.
The internal jugular vein (IJV) is used as the optimal recipient for free-tissue transfer in reconstruction following modified radical neck dissection. Some reports documented rare cases of flap compromise following IJV thrombosis, but large sample studies are few. We present cases of emergent exploration and an analysis of factors to improve salvage rates of compromise due to IJV thrombosis. From a survey of 756 patients, four developed congestion due to IJV thrombosis and returned to the operating room. A restrospective analysis was made from the case records. This represents a rate of 0.5% for the entire series. Three flaps survived,and one failed. Detection of compromise ranged from 7-25 h postoperatively. All four IJVs recovered to provide adequate drainage after thrombectomy. While flap compromise following IJV thrombosis is rare, careful observation and early exploration are crucial for salvage, as in other microvascular venous crises.
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