Effect of Phorbol 12-Myristate 13-Acetate on the Differentiation of Adipose-Derived Stromal Cells from Different Subcutaneous Adipose Tissue Depots

Human adipose-tissue-derived stromal cells (hADSCs) are abundant in adipose tissue and can differentiate into multi-lineage cell types, including adipocytes, osteoblasts, and chondrocytes. In order to define the optimal harvest site of adipose tissue harvest site, we solated hADSCs from different subcutaneous sites (upper abdomen, lower abdomen, and thigh) and compared their proliferation and potential to differentiate into adipocytes and osteoblasts. In addition, this study examined the effect of phorbol 12-myristate 13-acetate (PMA), a protein kinase C (PKC) activator, on proliferation and differentiation of hADSCs to adipocytes or osteoblasts. hADSCs isolated from different subcutaneous depots have a similar growth rate. Fluorescence-activated cell sorting (FACS) analysis showed that the expression levels of CD73 and CD90 were similar between hADSCs from abdomen and thigh regions. However, the expression of CD105 was lower in hADSCs from the thigh than in those from the abdomen. Although the adipogenic differentiation potential of hADSCs from both tissue regions was similar, the osteogenic differentiation potential of hADSCs from the thigh was greater than that of hADSCs from the abdomen. Phorbol 12-myristate 13-acetate (PMA) treatment increased osteogenic differentiation and suppressed adipogenic differentiation of all hADSCs without affecting their growth rate and the treatment of Go6983, a general inhibitor of protein kinase C (PKC) blocked the PMA effect. These findings indicate that the thigh region might be a suitable source of hADSCs for bone regeneration and that the PKC signaling pathway may be involved in the adipogenic and osteogenic differentiation of hADSCs.

Supernumerary Nostril: A Case Report

PURPOSE: Supernumerary nostril, also known as triple nostril or accessory nostril, is one of the extremely rare congenital nasal deformities which includes an additional nostril. Since Lindsey reported the first case of a supernumerary nostril, only 34 cases of supernumerary nostril have been reported world widely. And there was no any domestic case. In the present case, we described a case of supernumerary nostril and reviewed all the literature cases of supernumerary nostril. METHODS: A 10-month-old female patient visited to the authors with an additional nostril located above her right nostril, which had been present since birth. Antenatal history was uneventful and the infant's birth was normal. On physical examination there were no other abnormalities and additional nostril was communicating with ipsilateral normal nasal cavity. We performed fistulectomy and local flap for the correction. RESULTS: After 7 months postoperatively, the patient was doing well. The functional outcome was excellent and the cosmetic result was satisfactory. During the long term follow-up for 8 years, there were no specific problems. CONCLUSION: In supernumerary nostril, preoperative evaluation of other abnormalities is very important and we advocate that corrective surgery can be performed at an early age for patient's psychosocial development.

Supernumerary Nostril: A Case Report

PURPOSE: Supernumerary nostril, also known as triple nostril or accessory nostril, is one of the extremely rare congenital nasal deformities which includes an additional nostril. Since Lindsey reported the first case of a supernumerary nostril, only 34 cases of supernumerary nostril have been reported world widely. And there was no any domestic case. In the present case, we described a case of supernumerary nostril and reviewed all the literature cases of supernumerary nostril. METHODS: A 10-month-old female patient visited to the authors with an additional nostril located above her right nostril, which had been present since birth. Antenatal history was uneventful and the infant's birth was normal. On physical examination there were no other abnormalities and additional nostril was communicating with ipsilateral normal nasal cavity. We performed fistulectomy and local flap for the correction. RESULTS: After 7 months postoperatively, the patient was doing well. The functional outcome was excellent and the cosmetic result was satisfactory. During the long term follow-up for 8 years, there were no specific problems. CONCLUSION: In supernumerary nostril, preoperative evaluation of other abnormalities is very important and we advocate that corrective surgery can be performed at an early age for patient's psychosocial development.

Herpes Simplex Virus Infection after Corrective Rhinoplasty through External Approach: Two Case Reports

PURPOSE: Eczema herpeticum, caused by herpes simplex virus, is an infectious disease involving skin and internal organs. Varieties of physiologic, psychosocial, or environmental stress reactivate reservoir virus which exists in the trigeminal nerve ganglia. Authors report rare cases of nasal eczema herpeticum following corrective rhinoplasty. METHODS: First case, 22-year-old female underwent corrective rhioplasty through an external approach in a local clinic. She developed progressive and painful erythema, nodules and vesicles on nose on the 9th day postoperatively. This unfamiliar lesion lead to a misdiagnosis as a bacterial infection, and had accelerated its progress to the trigeminal innervation of the nasal unit. Second case, a 23-year-old female underwent corrective rhinoplasty by external lateral osteotomy. Ten days after the surgery, disruption occurred on the external osteotomy site, and the ulceration gradually worsened. The surgeon misdiagnosed it as secondary bacterial infection and only an antibacterial agent was applied. RESULTS: Both cases were healed effectively without any complication with proper wound dressing and antiviral therapy, and show no sequelae during an 8-month follow-up period. CONCLUSION: Eczema herpeticum is rare in the field of plastic surgery, but it should be kept in mind that secondary bacterial infections may lead to serious complications such as full-thickness skin loss. Thus, acknowledgement of the patient's past history regarding perioral or intraoral lesion may provide the surgeon with the possible expectancy of eczema herpeticum. Thus, if anyone develops eczema herpeticum, following facial plastic surgery, early diagnosis and immediate proper antiviral therapy will allow fast recovery without serious complications.

Herpes Simplex Virus Infection after Corrective Rhinoplasty through External Approach: Two Case Reports

PURPOSE: Eczema herpeticum, caused by herpes simplex virus, is an infectious disease involving skin and internal organs. Varieties of physiologic, psychosocial, or environmental stress reactivate reservoir virus which exists in the trigeminal nerve ganglia. Authors report rare cases of nasal eczema herpeticum following corrective rhinoplasty. METHODS: First case, 22-year-old female underwent corrective rhioplasty through an external approach in a local clinic. She developed progressive and painful erythema, nodules and vesicles on nose on the 9th day postoperatively. This unfamiliar lesion lead to a misdiagnosis as a bacterial infection, and had accelerated its progress to the trigeminal innervation of the nasal unit. Second case, a 23-year-old female underwent corrective rhinoplasty by external lateral osteotomy. Ten days after the surgery, disruption occurred on the external osteotomy site, and the ulceration gradually worsened. The surgeon misdiagnosed it as secondary bacterial infection and only an antibacterial agent was applied. RESULTS: Both cases were healed effectively without any complication with proper wound dressing and antiviral therapy, and show no sequelae during an 8-month follow-up period. CONCLUSION: Eczema herpeticum is rare in the field of plastic surgery, but it should be kept in mind that secondary bacterial infections may lead to serious complications such as full-thickness skin loss. Thus, acknowledgement of the patient's past history regarding perioral or intraoral lesion may provide the surgeon with the possible expectancy of eczema herpeticum. Thus, if anyone develops eczema herpeticum, following facial plastic surgery, early diagnosis and immediate proper antiviral therapy will allow fast recovery without serious complications.

Recurrent Huge Benign Tumors in the Hands

PURPOSE: Huge benign tumors in the hands sometimes show aggressive nature clinically. We report the clinical features of patients with a large benign recurrent tumors in the hands. METHODS: We retrospectively reviewed 139 benign tumors in hands excised by the authors between January, 2006 and March, 2012. There were 4 cases of huge benign tumors in hands that recurred after total excision. RESULTS: The average initial tumor size was 5.3x3.3 cm and the average recurrent tumor size was 4.4x3.0 cm. The average period of recurrence from initial operation was 11.3 months. The pathologic findings involved one epidermal cyst, two fibromatosis, and one giant cell tumor of tendon sheath. Although radical removal of the tumors were successful, reoperation due to the tumor recurrence was required. CONCLUSION: Regardless of the tumor malignancy, a wide range of tumor resection and radiation therapy may be necessary in order to prevent the recurrence of tumors in the hand. Sufficient follow-up periods to determine recurrence were required.

Modified Seven-flap Web Plasty for Incomplete Syndactyly

PURPOSE: Incomplete syndactyly, due to either congenital or acquired, is uncommon. Many different surgical methods have been descirbed. We introduce the modification of seven flap-plasty for incomplete syndactyly and report functional improvement after correction by modified seven flap-plasty without skin graft. MATERIALS AND METHODS: Twelve patients with an incomplete syndactyly who underwent modified seven flap-plasty were analyzed. Age ranged from one to 40-year-old (average age 21). There were 8 males and 4 females, and the degree of syndactyly was near proximal interphalangeal joint. Two different operative methods were performed. Modification I modified two half-Z flaps in parallelogram shape, and modification II modified V flap of V-M flap in Y-V flap. Functional improvements was measured by maximal abduction distance and maximal abduction angle change. RESULTS: All cases were corrected by using the modified seven flap plasty. Flap tip necrosis was found in two cases of severe burn scar patients, but did not require additional surgery. There was no specific complications. Maximal abduction distance was increased in 6 mm, and maximal abduction angle was increased in 5.8degrees. CONCLUSION: Incomplete syndactyly near proximal interphalangeal joint was corrected by modified seven flap plasty and was able to get a satisfactory result.

Toe Tissue Transfer for Reconstruction of Damaged Digits due to Electrical Burns

BACKGROUND: Electrical burns are one of the most devastating types of injuries, and can be characterized by the conduction of electric current through the deeper soft tissue such as vessels, nerves, muscles, and bones. For that reason, the extent of an electric burn is very frequently underestimated on initial impression. METHODS: From July 1999 to June 2006, we performed 15 cases of toe tissue transfer for the reconstruction of finger defects caused by electrical burns. We performed preoperative range of motion exercise, early excision, and coverage of the digital defect with toe tissue transfer. RESULTS: We obtained satisfactory results in both functional and aesthetic aspects in all 15 cases without specific complications. Static two-point discrimination results in the transferred toe cases ranged from 8 to 11 mm, with an average of 9.5 mm. The mean range of motion of the transferred toe was 20degrees to 36degrees in the distal interphalangeal joint, 16degrees to 45degrees in the proximal interphalangeal joint, and 15degrees to 35degrees in the metacarpophalangeal joint. All of the patients were relatively satisfied with the function and appearance of their new digits. CONCLUSIONS: The strategic management of electrical injury to the hands can be both challenging and complex. Because the optimal surgical method is free tissue transfer, maintenance of vascular integrity among various physiological changes works as a determining factor for the postoperative outcome following the reconstruction.

Application of Lateral Osteotomy in Nasal Bone Fracture

PURPOSE: Who may dare to state that optimal choice of treating nasal bone fracture is closed reduction? Few decades of authors' experience in nasal bone fracture has lead to believe that more active and assertive approach in nasal bone fracture by performing simultaneous lateral osteotomy may be applied in proper indications to acquire more accurate reduction and cosmetically satisfying result. METHODS: From May 2008 to October 2009, among 241 nasal bone fracture patients, 20 patients underwent simultaneous lateral osteotomy with nasal bone fracture reduction. Followed by rigid septal correction, nasal cavity is packed to stabilize the fracture segment for safer osteotomy. Through intranasal incision, in selected cases of difficult reduction or for cosmetic purposes, various types of lateral osteotomy was performed corresponding to the fracture anatomy, conditions of the nasal cavity. Postoperative nasal packing was retained for one week and nasal dorsum splint for 3 weeks. RESULTS: Lateral osteotomy was utilized for difficult cases of closed reduction, for correction of wide nose, hump and deviation in 9, 5, 2, and 4 cases, respectively. Patient satisfaction was scaled 90% in satisfaction and moderate in 10% (2 cases), complaining of mild nasal tip deviation. Physicians detected 2 cases of apparent deformity with patient recognition; one patient with mild step deformity at the osteotomy site and the other patient with minimal implant mobility. CONCLUSION: By accompanying profound understanding of the fracture anatomy, more active and assertive approach in nasal fracture reduction can be coincide with simultaneous lateral osteotomy to reduce the rate of secondary deformity and to obtain more cosmetically satisfying result.

Calcified Lipoma of the Forehead

PURPOSE: Although lipoma is known as one of the most common soft tissue tumors, calcification in lipoma is very rare in its occurrence. This calcified lipoma has been reported by some as a result of regression of lipoma, but its genesis is not clearly known yet with various opinions being discussed regarding its possible metabolic relation to hypercalcemia or hyperphosphatemia to be considered as a regression phase of lipoma. The authors would like to present this unusual case of calcified lipoma. METHODS: A 50-year-old male patient visited our hospital with complaint of an enlarging mass on his right forehead which has been acknowledged for 5 years' period. On physical examination, a mass was observed on his forehead as palpable, non-tender, mobile and firm in its consistency. Ultra sonogram examination revealed a well-demarcated mass (1.92 cm) with central echoic zone at deep layer of forehead. Mass excision and biopsy were performed subsequently. RESULTS: According to the pathological report, the diagnosis confirmed the lipoma consisting of grown-up adipocyte and calcification. Neither growing lipoma nor relapse was observed for postoperative three years' follow-up of the patient. CONCLUSION: Now that the calcified lipoma was successfully removed and cured by a simple mass excision, authors hereby report the case of calcified lipoma on forehead.

Myositis Ossificans on the Nasal Dorsum: A Case Report

PURPOSE: Myositis ossificans is a benign condition of heterotopic bone formation that still requires more of its pathologic explanation. The lesions are localized predominantly to the high-risk sites of injury, involving flexor muscles of the upper limbs and thigh, but rarely in the head and neck area. METHODS: A case of a 44-year-old male patient presented with a palpable hard mass on nasal dorsum. The patient experienced a similar lesion on upper limb few years ago. On computed tomographic image, the lesion presented focal definite increase in opacity compatible to adjacent bone densitiy on nasal dorsum. RESULTS: The lesion was excised under open rhinoplasty incision. The pathologic report revealed focal bone formation and calcification within skeletal muscle. CONCLUSION: We describe a unique and only case of a myositis ossificans on nasal dorsum which is indifferent from previous concept.

Clinical Analysis of the Nasal Bone Fracture

PURPOSE: Nasal bone fracture is the most common facial fracture. Although nasal bone fractures are considered to be minor injuries, the incidence of post-traumatic nasal deformity remains high. This study is designed to support management and patient satisfaction by classifying the simple nasal bone fracture, and survey the care method and result, which is compared with other studies. METHODS: From May 2008 to April 2010, 334 patients with simple nasal bone fractures visited our hospital. The incidence, cause, types of nasal bone fracture, treatment, and complications are analyzed according to clinical examination, patient's record and radiographic images. RESULTS: The mean age of patients was 30 years old, with 74% of the patients having been male, and 26% were female. The highest incidence of this fracture was between late teens to late twenties. The causes of nasal bone fracture were the following: having slipped or fallen down(39%), violence(16%), sports accident(14%), traffic accident(11%), industrial accident(6%), and others(16%). Patient's radiographic images were analyzed by Stranc and Robertson classification, frontal impact plane I was 38%, plane II was 16%, plane III was 1%, lateral impact plane I was 21%, plane II was 21%, and plane III was 3%. On average, surgical treatment was performed 7.2 days after trauma under general anesthesia. Closed reduction of nasal bone fracture was performed in 99% of patients. In patients with septal injuries, septal management was performed in 76.7% of cases. Aesthetic surgery was done on same time in 24% of patients. There were some complications, such as residual nasal deformity(7.2%), nasal obstruction(0.9%) and hyposmia(0.3%). CONCLUSION: According to this study, nasal bone fractures occurred commonly in physically active age groups(age 15~29 years), as a result of having slipped or fallen down, at afternoon and at night time. And it could be treated successfully by closed reduction and septoplasty by 7 days after trauma.

Epidermal Inclusion Cyst after Fat Injection: A Case Report

Epidermal inclusion cysts are caused by an implantation of the epidermal elements. Primary or congenital epidermoid cysts are related to implantation of ectoderm at time of closure of the neural groove, or of other epithelial lines. Secondary or acquired epidermoid cysts are usually caused by post traumatic or iatrogenic inclusion of surface epithelium. We are reporting a case of secondary epidermoid inclusion cyst on left nasolabial fold after fat injection, which is extremely rare. A 57-year-old female patient presents with gradually progressive protruding palpable mass on left nasolabial fold. The patient had history of fat injection 1 year before, and mass was found under the previous fat injection site. There was no other history of trauma. The mass was excised and histological examination confirmed the diagnosis of an epidermoid cyst. Secondary epidermoid cysts are rare and occur mainly in the fingers, palms, and soles. The cause of secondary epidermoid cysts has been reported following trauma, radiotherapy, and after surgical procedures such as needle biopsy. During fat injection, needle injection may cause disruption of the epithelium and leading to the occurrence of this cyst. So. we suggest a careful procedure during fat injection.

Multiple Epidermal Inclusion Cysts in Previous Bone Graft Site of the Thumb: A Case Report

We report a 71-year-old male presenting with painful growing mass on his left thumb. The patient had received iliac bone graft on his left thumb 20 years ago, and removed all the grafted bone 8 years ago due to recurrent ulcer. Biopsy revealed multiple eidermal inclusion cysts on the dorsal surface of the bone graft site. Surgeon should be aware of epidermal inclusion cyst occurred at the previous bone graft site of the finger.

Microsurgical Training using Preserved Saphenous Vein

PURPOSE: Given that the critical nature of the microvascular anastomosis to what is often a long and difficult reconstructive operation, trainees need to have a high level of microsurgical competence before being allowed to perform microsurgery on patients. Some artificial substitutes and dead or live animal models have been used to improve manual dexterity under the operating microscope. Yet, most surgeons are not equipped with such models, so search for easy available and appropriate microsurgical practice model have been an issue. Umbilical artery, placental vessels and gastroepiploic arteries have been previously suggested as a microsurgical training model, which involves other surgical departments. The purpose of this article is to introduce that saphenous vein specimen obtained from varicose vein surgery is useful and has many advantages as training model for the practice of microvascular anastomosis. METHODS: The conventional technique using perforation/inversion method with a metallic stripper is widely performed for varicose vein patients. The stripper is inserted through disconnected safeno-femoral junction and retrieved at the knee or the medial side of ankle. The length of saphenous vein specimens removed is about that of one's leg and inversed from inside out. Obtained saphenous vein specimens are re-inversed and cleansed with normal saline, to be readily available for microsurgical practice. Preserved in a squeezed wet saline gauze and refrigerated, frozen or glycerated specimens were investigated into their comparative quality for microsurgical practice. RESULTS: Varicose vein surgery remains one of the common operations performed in the field of plastic surgery. Convenient informed consent regarding the vessel donation can be easily signed. The diameter of the obtained saphenous vein is as variable as 1.5 to 6mm, which is already stripped, and is in sufficient length corresponding to that of patient's leg. Vessels specimens were available for microsurgical practice within 1 week period when preserved with squeezed wet saline gauze, and the preservation period could be extended monthly by freezing it. CONCLUSION: Saphenous vein obtained from varicose vein patients provide with variable size of vessel lumen with sufficient length. The practice can be cost effective and does not require microsurgical laboratory. Additionally there is no need of involving other surgical departments in acquiring vessel specimens. Furthermore, simple preservation method of refrigerating for a week or freezing with squeezed wet saline gauze for a month period, allow the saphenous vein obtained after varicose vein surgery as an excellent model for the microsurgical practice.

A Case of Intramuscular Ectopic Lacrimal Gland Developing within Muller Muscle

Ectopic lacrimal gland is a rare clinical condition. Cases have been recorded in literature describing that ectopic lacrimal tissue has been found at varying sites in and around the eye. Before performing aesthetic blepharoplasty, however, it should be kept in mind that anomalous condition of the lacrimal complex can lead to alterations in ocular lubrication. A 54 year-old female presented with an aging eyelid, but accompanying no other ophthalmologic symptoms. While performing skin incision during blepharoplasty, the right upper lid was directly exposed with prolapsed orbital lobe of lacrimal gland, and diffuse infiltrating hyperplasia of ectopic lacrimal gland tissue in the M?ller muscle bulging out beneath the levator aponeurosis. The left upper lid also revealed ectopic lacrimal gland tissue beneath the aponeurosis. Carefully preserving the main lacrimal complex, ectopic lacrimal gland mass was excised. Histopathology revealed the tissue as lobules of lacrimal gland with some dilated ducts. The ectopic lacrimal gland tissue is a rare clinical entity, and the diagnosis is rarely made on physical bases alone. Therefore, we herein describe a unique clinical case of an ectopic lacrimal gland generated within the M?ller muscle. To our best knowledge, such a case has not yet been described in literature.