Lower auricular malformations: their representation, correction, and embryologic correlation

Seventy-seven lower auricular malformations in 74 patients treated during the last 6 years were analyzed. Sixty cases (77.9 percent) were of malformations involving the earlobe; 54 cases involved the earlobe alone, and 6 cases were of complex deformities involving the earlobe and adjacent helix and/or tragus. Cleft earlobe was the most common lower auricular malformation (49 cases, 63.6 percent); four subtypes and their corrective methods are described. Cases of complex earlobe malformations, corrected by fabricated costal cartilage and expanded skin flap, are presented. A question mark ear (5 cases, 6.5 percent), a malformation with an ectopic anthelical fold (5 cases, 6.5 percent), and a malformation with a lower conchal stria (5 cases, 6.5 percent) are considered to be major lower auricular malformations. An attempt has been made to correlate the presented malformations with the embryologic-fetal development of the auricle. It is suggested that "clefting" ear malformations such as the cleft earlobe, the question mark ear, and the ectopic anthelical fold deformity may provide clues to understanding the embryologic-fetal development of the human auricle. It appears that hillocks 1 and 6 produce the earlobe and that hillock 4 or 5 produces the anthelix or helix.     

透明质酸在间充质干细胞向软骨细胞分化中的应用

随着组织工程学的发展,利用间充质干细胞(mesenchymal stem cells,MSCs)定向分化为软骨细胞,用于治疗骨性关节炎、关节创伤等因素造成的软骨缺损的研究方兴未艾。透明质酸(hyaluronic acid,HA) 是一种酸性多糖类生物大分子,亦是软骨基质的主要成分之一。由于其优良的生物相容性、可降解等特性,HA已成为优良的天然生物材料,其作为支架材料应用于软骨缺损修复已有一段历史。近年来又发现,HA除作为载体支架材料外,还可作为调节因子应用于MSCs向软骨细胞分化。以下将对近年来利用HA应用于MSCs向软骨细胞分化的研究进行总结,旨在为以MSCs为基础的组织工程化软骨的临床应用奠定基础。     

Correction of congenital microtia using the tissue expander

We attempted auricular reconstruction using Radovan-type inflatable silicone expanders in six children and one adult, with the complete hypoplastic, the conchal remnant, and constricted type of microtia. Ear frameworks, including the helix, anthelix, concha, and tragus, were prepared using autologous rib cartilage. Based on the surface area of the normal adult auricle, the silicone expander was tentatively shaped and sized into a rotated semiellipse and expanded with 70 cc saline. Auricular reconstruction on the framework was completed at the time of insertion in four of the seven patients, requiring no elevation of the ear. The reconstructed auricle was satisfactory in both color and texture and had nearly normal sensation. Mild complications were noted in three of the seven patients. However, no resorption of the inserted rib cartilage has been observed 14 months to 2 years and 5 months after the operation. Slight shrinkage of the expanded skin was noted in each patient.     

The Turkish delight: a pliable graft for rhinoplasty

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.     

The crumpled-ear deformity.

The common characteristics of the crumpled-ear deformity, the steps for surgical correction, and the authors' experience are described in this article. Commonly, the ear has a folded-over appearance; a normal length and width when unfurled; and wrinkling of the skin and cartilage of the helical rim, scapha, antihelix, and concha. Principles of correction of this deformity include (1) superficial scoring of the concave segments of the cartilage to open the wrinkled segments, (2) creating the antihelical fold by a mattress-suture technique, (3) repositioning of the helical rim, and (4) repositioning of the prominent ear lobe, if present. A total of 12 crumpled ears were evaluated in six patients, three of whom underwent surgery during their teenage years. No complications have been observed. A new classification of an ear deformity has been proposed based on morphology that to the authors' knowledge has not been described in the literature. Identification of the common features of the deformity allows for precise correction using already well-defined techniques.     

Onlay cartilage graft of the alar lateral crus for cleft lip nasal deformities

The onlay cartilage grafting technique is described for treatment of unilateral or bilateral cleft lip nasal deformities. The alar cartilage is exposed through rim and intercartilagenous incisions. The cephalic half of the alar cartilage is excised, similar to the technique of traditional tip rhinoplasty. The harvested cartilage is applied to the intact caudal cartilage in layered fashion and secured with absorbable sutures. If necessary, successive layers may be added. These grafts provide a sturdy, yet delicate framework for a more normal appearing alar rim. We have performed this procedure on 16 patients, ages 10 to 41. Follow-up intervals range from 13 to 40 months, with a mean of 19 months. Results have been rated good-to-excellent by patients and surgeons. There has been no recurrence of the deformity. The only complication has been one nasal vestibule synechia.     

Conchal cartilage and composite grafts for correction of lower lid retraction

Lower eyelid retraction may be due to vertical deficiency of the anterior lamella, supporting cartilage, or posterior lamella. We have used autologous cartilage grafts from the conchal bowl for reconstruction of the central lamella, reestablishing and augmenting support of the lower lid. The positioning of the graft is dependent on the specific anatomic deficiency, and the etiology of the lid retraction must be carefully evaluated. In patients with posterior lamella deficiency, the contracted lower lid retractors and conjunctiva are released and the graft is placed facing the bulbar conjunctiva and is allowed to reepithelialize. In patients in whom there is an associated skin deficiency, composite auricular grafts are used. We present our experience in 33 patients with lower lid retraction. Twenty-three patients required placement of a cartilage graft only, while 10 patients had an associated skin deficiency requiring placement of composite cartilage. In nine patients the cartilage graft was seated against the bulbar conjunctiva and allowed to reepithelialize. Reepithelialization was complete within 3 1/2 weeks in all but two of these patients. This technique has provided stable lid support in all 33 patients.     

An improved technique for creation of the inframammary fold in silicone implant breast reconstruction.

A "lipo-fascial" flap is described for creation of the inframammary fold in patients undergoing breast reconstruction with silicone implants. We have employed this technique in 13 patients. The fold has been enhanced in all cases, and we have not encountered any significant complications. This technique is a useful adjunct to breast reconstruction with a silicone implant, and we recommend that it be considered in appropriate patients.     

Otoplasty: the experience of 100 consecutive patients

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results.The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears.The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.     

The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty.

Anterior riberation methods of otoplasty have been criticized because of the risk of anterior hematoma that can cause anterior skin necrosis, scarring, and even cartilage destruction caused by infection. As a result, cartilage-sparing otoplasty such as the Mustardé and Furnas types has been increasingly popular. However, postauricular suture extrusion may result, and recurrence rates of up to 25 percent have been recorded. In this study, cartilage-sparing otoplasty is refined by the addition of a postauricular fascial flap to reduce suture extrusion and recurrence rates. Fifty-one patients underwent otoplasty (45 bilateral, six unilateral). This technique involves the elevation of a fascial flap from the postauricular region. A new antihelical fold is then created by Mustardé sutures, and the conchal bowl is rotated by Furnas-type concha-mastoid sutures. The fascial flap is then advanced to cover the sutures with a supplementary vascularized layer to prevent suture extrusion. In addition, the advancement of the flap acts as a postauricular support to prevent recurrence. A natural-looking antihelical fold and helical rim is created by this technique. There were no hematomas. There was recurrence in eight ears (8 percent) in six patients. Two patients requested further surgery. No patients developed suture extrusion or granuloma. This is a simple and intrinsically safe procedure and does not cause irreparable complications such as anterior scarring or skin necrosis. The postauricular fascial flap seems to prevent suture extrusion. It may also help to reduce recurrence rates to acceptable levels.     

Proteomics makes progress in cartilage and arthritis research

Understanding biology at the systems level is a powerful method for discovery of previously unrecognized molecular pathways and mechanisms in human disease. The application of proteomics to arthritis research has lagged behind many other clinical targets, partly due to the unique biochemical properties of cartilage and associated biological fluids such as synovial fluid. In recent years, however, proteomic-based studies in cartilage and arthritis research have risen sharply and have started to make a significant impact on our understanding of joint disease, including the discovery of new and promising biomarkers of cartilage degeneration, a hallmark of arthritis. In this review we will make the case for the ongoing proteomic analysis of cartilage and other tissues affected by joint disease, overview some of the core proteomic techniques and discuss how the challenge of cartilage proteomics has been met through technical innovation. The major outcomes and information obtained from recent proteomic analysis of synovial fluid, cartilage and chondrocytes will also be described. In addition, we present some novel insights into post-translational regulation of cartilage proteins, through proteomic identification of proteolytic fragments in mouse cartilage extracts and explant culture media. We conclude with our prediction of how emerging proteomic technologies that have yet to be applied in arthritis research are likely to contribute further important information.     

How best to preserve and reveal the structural intricacies of cartilaginous tissue

No single processing technique is capable of optimally preserving each and all of the structural entities of cartilaginous tissue. Hence, the choice of methodology must necessarily be governed by the nature of the component that is targeted for analysis, for example, fibrillar collagens or proteoglycans within the extracellular matrix, or the chondrocytes themselves.This article affords an insight into the pitfalls that are to be encountered when implementing the available techniques and how best to circumvent them.Adult articular cartilage is taken as a representative pars pro toto of the different bodily types. In mammals, this layer of tissue is a component of the synovial joints, wherein it fulfills crucial and diverse biomechanical functions. The biomechanical functions of articular cartilage have their structural and molecular correlates. During the natural course of postnatal development and after the onset of pathological disease processes, such as osteoarthritis, the tissue undergoes structural changes which are intimately reflected in biomechanical modulations. The fine structural intricacies that subserve the changes in tissue function can be accurately assessed only if they are faithfully preserved at the molecular level. For this reason, a careful consideration of the tissue-processing technique is indispensable. Since, as aforementioned, no single methodological tool is capable of optimally preserving all constituents, the approach must be pre-selected with a targeted structure in view. Guidance in this choice is offered.     

Folds and activities of peptidoglycan amidases

Bacterial peptidoglycan amidases are a large and diverse group of enzymes. During the last few years, genomic sequence information has accumulated to an extent such that lists of proven or predicted peptidoglycan amidases can now be expected to be fairly complete. Moreover, representative crystal structures for most groups of phylogenetically related peptidoglycan amidases have been solved. Here, sequence and structural information is combined with published biochemical findings to demonstrate that (a) peptidoglycan amidases have evolved for almost every bond that occurs in peptidoglycan, (b) there are enzymes that share the fold, yet cleave different bonds and (c) there are enzymes that have entirely different folds and must have evolved independently, and yet cleave the same peptide bond. It is shown that despite these complications, some rules can be deduced from the available biochemical and structural information that can be useful to predict the specificity of hypothetical peptidoglycan hydrolases, for which only sequence information is available.     

Chondrogenesis and developments in our understanding

Conditions affecting cartilage through damage or age-related degeneration pose significant challenges to individual patients and their healthcare systems. The disease burden will rise in the future as life expectancy increases. This has resulted in vigorous efforts to develop novel therapies to meet current and future needs. Due to the limited regenerative capacity of cartilage, in vitro tissue engineering techniques have emerged as the favoured technique by which to develop replacements. Tissue engineering is mainly concerned with developing cartilage replacements in the form of chondrocyte suspensions and three-dimensional scaffolds seeded with chondrocytes. One major limiting factor in the development of clinically useful cartilage constructs is our understanding of the process by which cartilage is formed, chondrogenesis. For example, techniques of culturing chondrocytes in vitro have been used for decades, resulting in chondrocyte-like cells which produce an extracellular matrix of similar composition to native cartilage, but with inferior physical properties. It has now been realised that one aspect of chondrogenesis which had been ignored was the physical context in which cartilage exists in vivo. This has resulted in the development of bioreactor systems which aim to introduce various physical stresses to engineered cartilage in a controlled environment. This has resulted in some improvements in the quality of tissue engineered cartilage. This is but one example of how the knowledge of chondrogenesis has been translated into research practice. This paper aims to review what is currently known about the process of chondrogenesis and discusses how this knowledge can be applied to tissue engineering.     

84 例基于三脚架结构改建的鼻尖综合整形术的临床总结

目的:总结基于鼻翼软骨三脚架结构的改建技术在鼻尖综合整形术中的应用经验。方法:从2012年09月到2015年02月间,共84例求美者在我院进行初次鼻尖综合整形术。3例为男性,81例为女性。年龄20-45岁,平均年龄31.7岁。其中鼻头肥大伴鼻背低平65例,行鼻翼软骨缝合+鼻翼软骨切除+鼻假体+自体软骨帽状移植术;鼻头肥大、鼻背低平伴鼻小柱短小19例,行自体软骨鼻小柱支撑+鼻翼软骨切除+鼻翼软骨缝合+鼻假体植入+自体软骨帽状移植术。结果:84例求美者术后随访1个月-2年,除1例病例鼻头过于肥大,鼻尖形态改善不明显以外,其余求美者鼻额角及鼻尖角度及均较术前有明显改善,鼻小柱短小组的鼻小柱长度也较术前有明显改善。所有病例切口瘢痕均不明显,无明显并发症出现。结论:针对不同鼻翼软骨发育条件下的病人,个性化的应用鼻翼软骨三脚架结构改建的鼻尖综合整形术具有较好的临床效果,须根据不同病人特点选用。     

Partial 4q trisomy. Apropos of 3 cases.

Three observations of partial trisomy 4q are reported: the first due to a familial translocation the second to a de nove translocation, the third to a "mirror" duplication. The very characteristic phenotype is compared to that of 4 other patients already reported in the literature. The most evocatory symptoms include: absent or poorly indicated nose bridge; pursed lips; shortness of the philtrum; and constant existence of a fold on the antitragus continuing the anthelix reachinghe insertion of the pinna.     

Quantitative trait locus mapping in natural populations: progress, caveats and future directions

Over the last 15 years quantitative trait locus (QTL) mapping has become a popular method for understanding the genetic basis of continuous variation in a variety of systems. For example, the technique is now an integral tool in medical genetics, livestock production, plant breeding and population genetics of model organisms. Ten years ago, it was suggested that the method could be used to understand continuous variation in natural populations. In this review I: (i) clarify what is meant by natural population in the QTL context, (ii) discuss whether evolutionary biologists have successfully mapped QTL in natural populations, (iii) highlight some of the questions that have been addressed by QTL mapping in natural populations, (iv) describe how QTL mapping can be conducted in unmanipulated natural populations, (v) highlight some of the limitations of QTL mapping and (vi) try to predict some future directions for QTL mapping in natural populations.     

Stem cells for osteoarticular and vascular tissue engineering

Tissue damages or loss of organs often result in structural and metabolic changes that can cause serious complications. The therapeutic objective of tissue engineering (TE) is to recreate, regenerate or restore function of damaged tissue. TE is based on the coalescence of three components: a scaffold or matrix from natural or synthetic origin biodegradable or not, reparative cells and signals (hypoxia, mechanical stress, morphogens…). Articular cartilage, bone and blood vessels are tissues for which TE has progressed significantly, from basic research to clinical trials. If biomaterials must exhibit different properties depending on the tissue to regenerate, the cellular component of TE is mostly represented by stem cells notably adult mesenchymal stem cells harvested from bone marrow or adipose tissue. In recent years, progress has been made in our understanding of the biological mechanisms that govern stem cell differentiation and in the development of materials with controlled physicochemical and biological properties. However, many technological barriers and regulations concerns have to be overcome before tissue engineering enters into the therapeutic arsenal of regenerative medicine. This review aims at highlighting the progress in the use of stem cells for engineering osteoarticular and vascular tissues.     

Cartilage repair: surgical techniques and tissue engineering using polysaccharide- and collagen-based biomaterials

Lesions of articular cartilage have a large variety of causes among which traumatic damage, osteoarthritis and osteochondritis dissecans are the most frequent. Replacement of articular defects in joints has assumed greater importance in recent years. This interest results in large part because cartilage defects cannot adequately heal themselves. Many techniques have been suggested over the last 30 years, but none allows the regeneration of the damaged cartilage, i.e. its replacement by a strictly identical tissue. In the first generation of techniques, relief of pain was the main concern, which could be provided by techniques in which cartilage was replaced by fibrocartilage. Disappointing results led investigators to focus on more appropriate bioregenerative approaches using transplantation of autologous cells into the lesion. Unfortunately, none of these approaches has provided a perfect final solution to the problem. The latest generation of techniques, currently in the developmental or preclinical stages, involve biomaterials for the repair of chondral or osteochondral lesions. Many of these scaffolds are designed to be seeded with chondrocytes or progenitor cells. Among natural and synthetic polymers, collagen- and polysaccharide-based biomaterials have been extensively used. For both these supports, studies have shown that chondrocytes maintain their phenotype when cultured in three dimensions. In both types of culture, a glycosaminoglycan-rich deposit is formed on the surface and in the inner region of the cultured cartilage, and type II collagen synthesis is also observed. Dynamic conditions can also improve the composition of such three-dimensional constructs. Many improvements are still required, however, in a number of key aspects that so far have received only scant attention. These aspects include: adhesion/integration of the graft with the adjacent native cartilage, cell-seeding with genetically-modified cell populations, biomaterials that can be implanted without open joint surgery and combined therapies, aimed at disease modification, pain relief and reduction of inflammation.