Takahiko Moriguchi’s research while affiliated with Okayama University and other places

In 1962, research and an article by Winter reported on the superior efficacy of moist wound dressings. The optimum wound environment to enhance wound healing is a balance of nutrition, hypoxia, and removal of debris in an occlusive moist environment. Today the principle of moist healing is generally accepted, and hundreds of dressings that help to create a moist wound environment have been developed. Seaman suggested the following six properties of an ideal dressing. (1) It maintains a moist wound environment. (2) It absorbs excess exudate. (3) It eliminates dead space. (4) It does not harm the wound. (5) It provides thermal insulation. (6) It provides a bacterial barrier. Modern wound dressings include polyethylene films, polyethylene foams, hydrocolloids, hydrofibers, hydropolymers, hydrogels, alginates and chitin. With the wide array of wound dressings available today, it can be a difficult task to select the appropriate dressing required for a particular wound. The selection should be based on the characteristics of the dressing materials, the degree of exudate, the potential of infection, the presence of necrotic tissue, hemorrhage, the condition of the surrounding skin and the needs of the patient. No single dressing is suitable for all types of wounds. Often a number of different types of dressings will be used during the healing process of a single wound.

Negative pressure wound therapy is a new wound management technique used in accelerated wound healing through which continuous negative pressure is delivered within a closed environment. This therapy is gaining popularity as an acute and chronic wound management technique. This report describes its application to the treatment of devastating pressure ulcers. We fixed polyurethane form dressings to wounds, using 12 Fr suction tubes and performed sealing with polyurethane film. The tubes were connected to a continuous suction apparatus (125 mmHg) or a chest drain (50 cm H2O). Remarkable progress in granulation tissue formation and the reduction of ulcer depth were achieved in all cases. The DESIGN-R score improved on treatment with negative pressure in all cases. The score especially decreased markedly for the element of inflammation/infection. No untoward serious complications resulted from this treatment. Low negative pressure with a chest drain was also effective. This technique is a simple and cost-effective method and is also applicable for home-care cases.

The aim of the current study was to examine the cartilage-specific binding property of polyarginine peptides (R4, 8, 12, and 16) and specifically to test octaarginine peptides for the optical imaging of articular cartilage in experimentally induced arthritis in mice. Four rhodamine-labeled polyarginine peptides each with a different-length arginine chain (R4, 8, 12, or 16) were injected into the knee joints of C57BL/6J mice (n=20). The joints were excised 1h later and the fluorescent signal intensity in cartilage cryosections was compared for the four peptides. To examine the substrate of R8 in cartilage, femoral condyles obtained from another set of mice were treated with chondroitinase ABC (Ch'ase ABC), keratanase or heparitinase then immersed in R8-rhodamine. Fluorescent signals were examined by fluorescent microscopy. Next, R8-rhodamine was injected into the right knee joints of three control and three collagen antibody-induced arthritis (CAIA) mice, and fluorescent intensity in normal and degenerative cartilage was semi-quantitatively analysed on the histological sections using image software. Finally, femoral condyles from normal mice (n=2) and CAIA mice (n=2) were immersed in R8-rhodamine and calcein, then imaged using optical projection tomography (OPT). Fluorescent signals were specifically detected in the cartilage pericellular matrix from the surface to the tide mark but were completely absent in the calcified layer or bone marrow. The number of arginine residues significantly influenced peptide accumulation in articular cartilage, with R8 accumulating the most. The fluorescent signal in the femoral condylar cartilage diminished when it was treated with Ch'ase ABC. R8 accumulation was significantly decreased in the degenerative cartilage of CAIA mice, and this was demonstrated both histologically and in three-dimensional (3D)-reconstruction image by OPT. R8 may be a useful new experimental probe for optical imaging of normal and arthritic articular cartilage.

In 1985, Mulliken described a new method for repairing bilateral cleft lip characteristics of the narrow philtral flap. The remaining premaxillary vermilion-mucosa is used for the mucosal side of the pre-maxilla, and the lateral labial elements are advanced medially as the buccal sulci are closed. The lateral mucosal flap forms the anterior wall of the central sulcus. The orbicular muscles are sutured throughout the vertical height of the lip. This primary lip repair is performed by 3 to 5 months of age. Then the dislocated alar cartilages are corrected through bilateral alar rim incisions and a nasal tip incision. This nasal deformity is corrected when the child is 8 to 9 months of age. In 1995, Mulliken reported that the correction of the nasal deformity had been simultaneously performed with the primary lip repair. Because we have not had positive proof that primary nasal repair prevents the typical nasal deformity of bilateral cleft lip in our cases, we do not dissect the alar cartilages during the primary lip repair. That is why we consider our procedure to be a modified Mulliken method for bilateral cleft lip repair. We report some merits and demerits of this modified Mulliken method. As for its merits, first, there is less tendency for the nasolabilal asymmetry caused by one-stage repair for bilateral cleft lip to occur with this method. Secondly, there are no color differences of the central lip because the vermilion of the prolabium is used for the mucosal side of the premaxilla. Third, the tension for the sutured line of the lip is decreased by the reconstructed muscle bundle of the orbicular oris muscle. We suspect that this results in an inconspicuous scar of the lip. Lastly, a deep oral vestibular can be made because the premaxillary vermilion-mucosa is used for the mucosal side of the premaxilla. Regarding the possible demerits of this method, first, it is difficult to perform a lip repair in one stage without active orthodontic therapy for the severe projection of the premaxilla and wide cleft of bilateral cleft lip patients. Secondly, congestion of the philtral flap is sometimes seen because a narrow philtral flap is created. Third, a horizontal scar is seen on the floor of the nostril. If the suture line is extended to the lateral side of the alar, there is a possibility that the lateral base of the alar will be flattened. To prevent this deformity, the incision line of the nostril is made up to the medial base of the alar. Lastly, open rhinoplasty will have to be performed at the age of five or six, because correction of the alar cartilage deformity cannot be performed at the time of primary lip repair.

Although melanocytic nevi are common skin lesions, they have very various clinical features from the small nevus which is called lentigo to the giant "bathing trunk" nevus. For the treatment of a benign melanocytic nevus, cosmetic improvement becomes the main purpose. There is disagreement as to the most appropriate treatment when removal is for cosmesis. Many surgical and non-surgical treatment modalities have been reported. Operative methods include surgical excision and primary closure, serial excision, local flaps, tissue expansion, dermabrasion, curettage, split-thickness or full-thickness skin grafts, artificial dermis grafts and cultured epithelial autografts. Non-surgical methods include laser treatment, electrodessication, cryotherapy and chemical peeling. Because the incidence of malignant melanoma from a small congenital melanocytic nevus is extremely rare, it is not necessary to offer the removal except when the purpose is to improve the patient and the familial psychological burden. But large congenital melanocytic nevi carry a high risk of malignancy before the age of ten years. Therefore, the current recommended treatment for these lesions is early and complete excision followed by reconstruction. Recently, the progress of laser treatment has been remarkable as new therapy.

A technique for unilateral cleft lip repair is described. This technique is an improvement on the Millard method that involves a small triangular flap. We changed the design of the C flap and shortened the incision to a columellar base. With this technique a good cleft-side philtrum ridge form can be created. We have also designed a C flap that is smaller than that used with the Millard method. Since the C flap subsides nearly completely into the nasal cavity, the postoperative scar is not visible from the front. Moreover, since an incision line which meets the cleft-side alar base may result in a conspicuous scar, it is not added. To properly reposition the alar base with its surrounding soft tissue, we have designed an incision line at the margin of the alar cartilage up along the limen nasi. With this incision, when upper movement is restricted, tension in the vertical direction is mitigated by adding a Z plasty to the upper end of the incision. We believe that correctness is most required in primary cleft lip repair in completing the form of a symmetrical alar base. For that purpose, it is certainly important to form a nasal floor. The nasal floor is formed using a cleft-side vermilion flap and an alar base flap, and the foundation of the nasal floor is produced by suturing the paranasal muscle to the columellar base.

Hemifacial microsomia is a complex craniofacial malformation. It is important to take care of both sides appearance and occlusion when treating hemifacial microsomia. The correction of facial asymmetry is still a challenging process that requires further development. Deficiencies of both the facial skeleton and the overlying soft tissue must be addressed to achieve the optimal aesthetic result. For soft tissue augmentation, various free flaps such as the deltopectoral flap, the groin flap, scapular and parascapular flaps, the superficial inferior epigastric flap, the deep inferior epigastric perforator flap and the paraumbilical perforator flap have been reported. From 1992 to 2004, ten patients with hemifacial microsomia underwent microsurgical correction of facial contour using free flap transfer. Four patients had previous facial skeletal correction using the mandibular gradual distraction technique or the free vascularized iliac bone transfer. Age at operation ranged from 9 to 22 years. We have used 5 groin flaps, 2 paraumbilical perforator flaps, 2 anterolateral thigh flaps and 1 rectus abdominis musculocutanedous flap. There were no flap losses and severe complications in this series. Correction of facial contour in hemifacial microsomia is possible using microsurgical free flap transfer. The groin dermal-fat flap is a persuasive flap especially in children and young women because the donor scar is in a concealed area.

A full thickness defect of the eyelid following resection of extensive eyelid neoplasms is difficult to reconstruct, because excellent functional and cosmetic results are demanded. When such an eyelid defect extends for less than 25 per cent of the horizontal dimension of the lid, the reconstruction can be accomplished by direct approximation. In larger defects, full thickness eyelid reconstruction necessitates a skin covering layer and a mucus lining layer. There are several options available for the reconstruction of the outer lamella of the upper eyelid. We usually use a local flap, such as an advancement flap or a subcutaneous pedicle flap based on the orbicularis oculi muscle, a median forehead flap or a Washio flap. For defects of the upper eyelid, a lower lid switch flap can also be used. The lining of the eyelid should be covered with hard palate mucosa, conchal cartilage, nasal chondromucosa or a tarsoconjunctival flap. The first option for reconstruction of a lower eyelid defect is a cheek rotation flap. For reconstruction of the lower eyelid, lateral orbital, nasolabial, median forehead, and Washio flaps are also valuable. When there is a massive defect that is involved in an adjacent facial lesion, a free flap, such as a radial forearm flap or a dorsalis pedis flap may be utilized. For the loss of total eyelids and orbital content, a free flap, such as a rectus abdominis musculocutaneous flap or a latissimus dorsi musculocutaneous flap can fill the large defect. In these cases, the eye socket is reconstructed with a full thickness skin graft as a second operation.

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.

Various techniques to resurface defects following the excision of sacral pressure ulcers have been reported. We have used gluteal perforator flaps to repair large sacral defects as our first choice. The gluteal perforator flap is nourished by the cutaneous perforators penetrating the gluteus maximus muscle. Among the many perforators which can been found throughout the gluteal region, the parasacral perforators originating from the lateral sacral artery and the internal pudendal artery are the most useful as the pedicle of this flap, because they are of large caliber and exist near the sacral defect. The advantages of gluteal perforator flaps are: 1.) the operative technique is comparatively easy, 2.) the flap has a reliable blood flow, 3.) the flap can be rotated widely without tension, 4.) an adjacent gluteal perforator flap can be used to treat future recurrent pressure ulcers, 5.) the histological structure of the flap resists external pressure, 6.) the gluteus maximus muscle can be preserved and 7.) the donor defect can be closed directly.