Following nerve injury, Schwann cells ( SC ) play a crucial role in peripheralnerve regeneration by providing a pathway for regenerating axons and by replacing myelin, which is indispensable for nerve function. Even though cell therapy using SC seems to be effective and promising for the treatment of nerve injuries, there are several drawbacks: a healthy peripheral nerve must be sacrificed, the harvesting and expansion to obtain a sufficient number of cells present significant technical difficulties, and considerable time is required for the entire process.
　In recent years, adipose tissue has been identified as possessing a population of multipotent stem cells ( adipose-derived stem cells: ADSC ), which can differentiate not only to mesenchymal cells but also to a Schwann cell phenotype. Adipose tissue is recognized as having the potential to benefit the treatment of peripheral nerve injuries. However, there is no common consensus about how to use these cells for clinical applications. The mechanisms involved and the level of transdifferentiation needed to form SC are not known.
　This article will focuses on the need to abtain a better understanding of stem cells in tissue repair and on the recent advances in the use of ADSC for peripheral nerve regeneration, with specific attention to the clinical potential of ADSC in nerve repair strategies.

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　Tissue expansion allows highly esthetic reconstruction by the use of expanded adjacent tissue to reconstruct a defect after excision of tumors and scar. We retrospectively reviewed data on 49 expanded flap reconstructions performed in 39 patients during the period 2006 - 2013.
　Location, disease, reconstruction methods, and complications were collected. A total of 39 patients ( mean age of 32 years ) underwent reconstruction by insertion of a tissue expander in the trunk ( n = 15 ), the head and neck ( n = 7 ), and the back ( n = 4 ). The indications for tissue expansion were breast reconstruction ( n = 14 ), scar ( n = 12 ), and giant nevi ( n = 7 ). Complications included extrusion in 5 patients infection in 2, poor fixation of the port in 2, and impairment of the port in 1. Our modifications were: healthy skin incision, pocket dissections larger than the expander size, slow expansion to avoid exposure, another incision in the nevi, and reliable fixation of the port to avoid its migration.

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　The standard therapies for venous ulcers and venous insufficiency consist of compression bandages and surgical operations, respectively. However, these procedures are frequently unsuccessful for the closing of venous ulcers. Negative-pressure wound therapy promotes healing by applying compression at subatmospheric pressure to the wound. Here, we discuss the indications of negative-pressure wound therapy for venous ulcers.
　The treatment course was as follows: the wounds were surgically debrided, and the patients underwent negative-pressure wound therapy for three weeks. Then, the patients underwent skin grafting. Complete healing of the venous ulcers was observed within two weeks after the skin graft in most cases.
　Venous leg ulcers affect a significant proportion of the population. The most popular treatment used for their management is compression bandage therapy; however, is frequently unsuccessful in healing venous leg ulcers. Therefore, adjunctive treatment for local wound care should be considered in such patients. According to our experience, venous leg ulcers developed healthy granulation tissue because of negative-pressure wound therapy. All wounds were then successfully closed using skin grafts. Negative-pressure wound therapy can be an effective adjunctive treatment option for severe venous leg ulcers.

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　We often use pedicled flaps for the reconstruction of extremities following resection of sarcoma and sometimes use free flaps. We compare pedicled-flap cases and free-flap ones by measuring the tumor size and defect size, among others. Thereafter, we discuss the indication of free flaps in these reconstructions.
　Sixteen free flaps and 29 pedicled flaps were performed. The regions of free flaps included 5 legs and 5 thighs. The regions of pedicled flaps included 14 thighs and 7 upper arms. Free flaps included 11 latissimus dorsi flaps and 2 vascularized fibula flaps. Pedicled flaps included 12 gastrocnemius muscle flaps and 8 rectus abdominis muscle flaps. The diameters of bone sarcoma for free flaps were larger than for pedicled ones. The sizes of skin defects for free flaps were also larger than for pedicled ones.
　The indications for free flaps could be inaccessible defects by pedicled flaps, major tissue defects, and the usage of vascularized fibula flaps, among others.

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　In patients with critical limb ischemia ( CLI ) who have an intractable ulcer of the lower limbs, there is a higher level of need for an amputation due to severe infection after revascularization. Three out of the thirteen patients with CLI ended up with major amputations in the past five years. A comparative study was performed between these patients and those who were cured by only minor amputations. Patient factors in the comparative study included age, sex, medical history of diabetes and chronic kidney disease, diabetes medication, history of lower limb amputation on the other side, complement-reactive protein ( CRP ) levels before and after revascularization and in the early period after local surgery, and serum albumin ( Alb ) before local surgery. The patient risk factors of major amputation were late diabetic nephropathy, history of lower limb amputation on the other side and under-nutrition. There was a possibility of major amputations if patients had high CRP levels early after they completed local surgeries compared with those after revascularization. Perioperative CRP levels may be one of the indicators to use in order to avoid major amputations.

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Satoshi Tsukushi, Yoshihiro Nishida
Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine → Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine

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