Is the retroauricular region a suitable donor site for full-thickness skin grafting in the era of mask wearing?

Background@#During the coronavirus disease 2019 (COVID-19) pandemic, the everyday use of face masks massively increased to prevent the spread of infection. Many people complain of ear pain and erosion when wearing a mask for extended periods of time. If prolonged mask usage is uncomfortable for ordinary people, a question arises—how much more inconvenient must mask wearing be for patients with a full-thickness skin graft (FTSG) donor site in the retroauricular region? Herein, we evaluated complications related to face mask use in 27 patients with a retroauricular FTSG donor site, with the goal of clarifying whether the retroauricular region is still an appropriate FTSG donor site in the context of the COVID-19 pandemic. @*Methods@#Complications in 27 patients treated by FTSGs harvested from the retroauricular region from 2019 to 2021 were investigated. A questionnaire comparing the normal and the operated sides was administered. Pain, itching, soreness, deformity, and symmetry were further investigated. @*Results@#Pain and itching were the only observed complications. The operated side was slightly more painful than the normal side in four patients (14.8%), and four patients (14.8%) reported itching on the operated side. However, all patients who experienced complications stated that the pain or itching did not interfere with mask wearing. Most symptomatic patients were older than 60 years of age (23.8%, p=0.185) and wore masks for longer periods of time (28.5%, p=0.326). @*Conclusion@#Few retroauricular donor site-related complications occurred, and none of these complications caused inconvenience in daily life. Therefore, in the COVID-19 pandemic, the use of the retroauricular region as an FTSG donor site remains appropriate.

Reconstruction of a small defect of the lower vermilion adjacent to white roll using a modified O-Z flap

Reconstruction of lip defects is important because the lips play an important role in maintaining aesthetic facial balance, facial expressions, and speech. There are various methods of lip reconstruction such as primary repair, skin grafting, and utilization of local and free flaps. It is important to select a proper reconstruction method according to the size and location of lip defect. Failure to select an appropriate method may result in distortion, color mismatch, sensory loss, and aesthetic imbalance. Herein we present a case of successful aesthetic reconstruction of the lower vermilion. We removed a venous malformation, which was limited to the lower vermilion and adjacent to the white roll, and repaired the defect using the modified O-Z flap.

Experimentally induced fat embolism syndrome: shift from obstruction to toxic effects

Background@#Two hypothetical mechanisms have been proposed for fat embolism syndrome: mechanical obstruction and biochemical reactions. However, it has not been proven whether these mechanisms are correlated. This study aimed to demonstrate the relationship between these two hypothetical mechanisms by observing biochemical and histological changes in animals. @*Methods@#After a preliminary study, 700 mg/kg of triolein was injected via the ear vein into 25 rabbits and hemodynamic changes in triglycerides, lipases, free fatty acids, and albumin over time were observed. Necropsies were immediately conducted on all experimental animals, and the lungs were examined histologically. @*Results@#Eight rabbits died within 1 hour after the injection due to mechanical obstruction. Six rabbits died 7–60 hours after the injection due to diffuse hemorrhage of the lung induced by the toxic biochemical reactions of free fatty acids. Histological examinations of the lungs of the surviving rabbits showed petechiae on the surfaces and evidence of recovery from hemorrhage. Blood levels of free fatty acids increased immediately after the injection of triolein. @*Conclusions@#This study revealed that fat emboli primarily injure the lung via mechanical obstruction. The fat is hydrolyzed into fatty acids and causes secondary damage via biochemical reactions. The present study sheds light on the pathophysiology of fat embolism syndrome, with possible implications for its management and prevention.

Predictive factors of drainage volume and drain duration after the inframammary approach to nipple-areolar-complex sparing mastectomy and implant-based breast reconstruction

Background@#The placement of a closed suction drain is indispensable for preventing serious infections; however, closed suction drains are inevitably accompanied by increases in local infections, pain, and length of hospital stay, and delays in breast cancer treatment including postoperative chemotherapy and radiotherapy. We analyzed predictive factors of total drainage volume and duration. @*Methods@#Among patients who were diagnosed with primary breast cancer between January 2016 and December 2017, we retrospectively analyzed those who underwent immediate implant-based breast reconstruction. Factors that could affect the total volume and duration of drainage, including lipo-prostaglandin E1 use, preoperative chemotherapy, resected breast issue weight, age, body mass index (BMI), serum white blood cell count, erythrocyte sedimentation rate, and C-reactive protein (CRP) level, were analyzed. @*Results@#The mean volume and duration of drainage were 1,213.6 mL and 14.8 days respectively. BMI and CRP on postoperative day (POD) 1 were correlated with the total drainage volume. Age, BMI, and resected breast tissue weight were correlated with the drainage duration. Multiple regression analysis showed that CRP level on POD 1, age, and resected breast tissue weight significantly affected the drainage duration. Multiple regression analysis also showed that the total drainage volume was significantly affected by BMI and CRP level on POD 1. @*Conclusions@#The factors found to affect the duration of drainage in patients undergoing implant-based breast reconstruction were CRP on POD 1, age, resected breast tissue weight, and BMI. The CRP level on POD 1 and BMI influenced the total volume of drainage.

Reconstruction of a small defect of the lower vermilion adjacent to white roll using a modified O-Z flap

Reconstruction of lip defects is important because the lips play an important role in maintaining aesthetic facial balance, facial expressions, and speech. There are various methods of lip reconstruction such as primary repair, skin grafting, and utilization of local and free flaps. It is important to select a proper reconstruction method according to the size and location of lip defect. Failure to select an appropriate method may result in distortion, color mismatch, sensory loss, and aesthetic imbalance. Herein we present a case of successful aesthetic reconstruction of the lower vermilion. We removed a venous malformation, which was limited to the lower vermilion and adjacent to the white roll, and repaired the defect using the modified O-Z flap.

Experimentally induced fat embolism syndrome: shift from obstruction to toxic effects

Background@#Two hypothetical mechanisms have been proposed for fat embolism syndrome: mechanical obstruction and biochemical reactions. However, it has not been proven whether these mechanisms are correlated. This study aimed to demonstrate the relationship between these two hypothetical mechanisms by observing biochemical and histological changes in animals. @*Methods@#After a preliminary study, 700 mg/kg of triolein was injected via the ear vein into 25 rabbits and hemodynamic changes in triglycerides, lipases, free fatty acids, and albumin over time were observed. Necropsies were immediately conducted on all experimental animals, and the lungs were examined histologically. @*Results@#Eight rabbits died within 1 hour after the injection due to mechanical obstruction. Six rabbits died 7–60 hours after the injection due to diffuse hemorrhage of the lung induced by the toxic biochemical reactions of free fatty acids. Histological examinations of the lungs of the surviving rabbits showed petechiae on the surfaces and evidence of recovery from hemorrhage. Blood levels of free fatty acids increased immediately after the injection of triolein. @*Conclusions@#This study revealed that fat emboli primarily injure the lung via mechanical obstruction. The fat is hydrolyzed into fatty acids and causes secondary damage via biochemical reactions. The present study sheds light on the pathophysiology of fat embolism syndrome, with possible implications for its management and prevention.

Retrospective review of 108 breast reconstructions using the round block technique after breast-conserving surgery: Indications, complications, and outcomes

Background@#Several oncoplastic approaches have been implemented in recent years to enhance cosmetic results and to reduce complications. The round block technique is a volume displacement technique for breast reconstruction after breast-conserving surgery (BCS). However, its indications are currently limited according to tumor location, and its cosmetic results and complications have not been clearly established. We hypothesized that the round block technique could produce favorable cosmetic results without major complications regardless of tumor location or nipple-tumor distance, below a certain resected tumor volume and tumor-breast volume ratio. @*Methods@#All breast reconstructions using the round block technique after BCS were included in this analysis. Patients’ data were reviewed retrospectively to investigate complications during follow-up, and clinical photos were used to evaluate cosmetic results. The relationships of tumor location, nipple-tumor distance, tumor volume, and the tumor-breast volume ratio with cosmetic results were investigated. @*Results@#In total, 108 breasts were reconstructed. The mean resected tumor volume was 30.2±15.0 mL. The cosmetic score was 4.5±0.6 out of 5. Tumor location, nipple-tumor distance, tumor volume, tumor-breast volume ratio, radiotherapy, and chemotherapy had no significant effects on cosmetic results or complications. There were no major complications requiring reoperation. @*Conclusions@#Breast reconstruction using the round block technique after BCS can lead to good cosmetic results without major complications regardless of the tumor location, nipple-tumor distance, radiotherapy, or chemotherapy. Below the maximum tumor volume (79.2 mL) and the maximum tumor-breast volume ratio (14%), favorable results were consistently obtained.

Oncoplastic breast reduction using the short scar periareolar inferior pedicle reduction technique

After a partial mastectomy, large or ptotic breasts can be reconstructed using breast reduction techniques. Wise-pattern reduction is typically used to remove masses in any quadrant of the breast, but this technique leaves a large inverted T-shaped scar. Instead, the short scar periareolar inferior pedicle reduction (SPAIR) technique involves a periareolar line and does not result in a scar along the inframammary fold (IMF). A 49-year-old patient with macromastia and severely ptotic breasts was diagnosed with invasive cancer of the left breast. Her large breasts caused pain in her back, shoulders, and neck. She also expressed concern about postsurgical scarring along the IMF. In light of this concern, we chose the SPAIR technique, and we designed and performed the procedure as described by Hammond. During surgery, we removed 36 g of breast tumor and 380 g of breast parenchyma from the left breast. To establish symmetry, we also removed 410 g of tissue from the right breast. Postoperatively, the patient reported satisfaction regarding the reduction mammaplasty and, in particular, noted decreased back, shoulder, and neck pain. In summary, we used the SPAIR technique to achieve oncologic and aesthetic success in a patient with macromastia and a tumor located lateral to the nipple-areolar complex.

Malignant Hepatic Solitary Fibrous Tumor

Hepatic solitary fibrous tumors (SFTs) are mostly benign and rare because of information regarding the clinical symptoms, treatment, and prognosis of their malignant forms is currently lacking. A literature review concerning malignant SFTs revealed that there were a few cases where patients experienced abdominal right upper quadrant (RUQ) pain as their first clinical symptom, and metastases were found after being diagnosed with hepatic SFT. Here, we report a patient who was previously healthy without any clinical symptoms such as RUQ pain or weight loss, but had the appearance of a metastatic mass as the first clinical presentation before a primary hepatic SFT was detected.

Factors affecting mastectomy specimen density in direct-to-implant breast reconstruction

BACKGROUND: Direct-to-implant breast reconstruction following nipple-sparing mastectomy is becoming increasingly common. The weight of the breast specimen informs implant selection. However, specimens of the same weight may have different volume. Therefore, identifying the factors affecting the density of breast specimens may facilitate the selection of implants with an appropriate volume. METHODS: From December 2015 to May 2018, 108 patients underwent direct-to-implant reconstruction following nipple-sparing mastectomy. The weight of the breast specimens was measured using an electronic scale in the operating room. Furthermore, the volume of specimens was measured using the water displacement technique. Multiple regression analysis was performed on factors that can affect breast density, such as menopause, neoadjuvant chemotherapy (CTx), age, body mass index, and diabetes mellitus. RESULTS: The average density of breast specimens in patients older than 50 years (n=36) was 0.96±0.04 g/mL, which was significantly lower than the 1.01±0.08 g/mL observed in patients younger than 50 years (n=72) (P=0.007). The mean density of breast specimens in patients who underwent neoadjuvant CTx (n=25) was 0.96±0.06 g/mL, which was significantly lower than the value of 1.00±0.08 g/mL in those who did not (n=83). CONCLUSIONS: It is advisable to select an implant slightly larger than the mastectomy specimen weight in patients older than 50 years or in those who have undergone neoadjuvant CTx.

Metformin Ameliorates Lipotoxic β-Cell Dysfunction through a Concentration-Dependent Dual Mechanism of Action

BACKGROUND: Chronic exposure to elevated levels of free fatty acids contributes to pancreatic β-cell dysfunction. Although it is well known that metformin induces cellular energy depletion and a concomitant activation of AMP-activated protein kinase (AMPK) through inhibition of the respiratory chain, previous studies have shown inconsistent results with regard to the action of metformin on pancreatic β-cells. We therefore examined the effects of metformin on pancreatic β-cells under lipotoxic stress.METHODS: NIT-1 cells and mouse islets were exposed to palmitate and treated with 0.05 and 0.5 mM metformin. Cell viability, glucose-stimulated insulin secretion, cellular adenosine triphosphate, reactive oxygen species (ROS) levels and Rho kinase (ROCK) activities were measured. The phosphorylation of AMPK was evaluated by Western blot analysis and mRNA levels of endoplasmic reticulum (ER) stress markers and NADPH oxidase (NOX) were measured by real-time quantitative polymerase chain reaction analysis.RESULTS: We found that metformin has protective effects on palmitate-induced β-cell dysfunction. Metformin at a concentration of 0.05 mM inhibits NOX and suppresses the palmitate-induced elevation of ER stress markers and ROS levels in a AMPK-independent manner, whereas 0.5 mM metformin inhibits ROCK activity and activates AMPK.CONCLUSION: This study suggests that the action of metformin on β-cell lipotoxicity was implemented by different molecular pathways depending on its concentration. Metformin at a usual therapeutic dose is supposed to alleviate lipotoxic β-cell dysfunction through inhibition of oxidative stress and ER stress.

Treatment of post-traumatic chin deformities using bilateral botulinum toxin injections

Post-traumatic hematoma formation is a common complication of contusion. If the hematoma is large enough to aspirate or drain, it can be treated quickly and appropriately. However, if the hematoma is small or concealed by local swelling, it may be overlooked and left untreated. In most cases, a hematoma will resolve following conservative treatment; however, associated infection or muscle fibrosis can occur. Herein, we present the case of a patient with a chin deformity caused by a post-traumatic hematoma. The deformity was treated using botulinum toxin and triamcinolone acetonide injections as minimally invasive treatments. The course of treatment was good.

Correlation between dermal thickness and scar formation in female patients after thyroidectomy

BACKGROUND: Minimizing scarring has long been a challenge in plastic surgery. Factors affecting scar formation are well known, but the effect of some patient-specific factors such as dermal thickness remains unverified. Management of factors predictive of scarring can improve postoperative patient satisfaction and scar treatment. METHODS: For 3 years, we used ultrasonography to measure dermal thickness in female patients who had undergone thyroidectomy for cancer at our hospital. We confirmed the influence of dermal thickness on hypertrophic scar formation and the Patient and Observer Scar Assessment Scale scar score 6 months after surgery. RESULTS: There was a positive correlation between dermal thickness and scar score (p < 0.05), and dermal thickness appears to be a cause of hypertrophic scar formation (p < 0.05). CONCLUSION: Thick dermis was found to cause poor scar formation and hypertrophic scarring. Prediction of factors that can influence scar formation can be used to educate patients before surgery and can help in scar management and improvement in patient satisfaction.

Modified Anterior Craniofacial Osteotomy Using Partial Nasal Bone Division and Reconstruction in Frontoethmoidal Sinus Meningioma

Typical transcranial approaches are insufficient for adequate visualization and resection of skull base tumors. Different approaches with multiple modifications have been attempted. Here, we describe a new approach for a lesion that is central and hard to treat by conventional craniotomy and successful reconstruction with calvarial bone graft and titanium mesh plate. A 69-year-old female patient presented with recurrent meningioma. The tumor had invaded the frontal lobe, right supraorbital rim, and ethmoidal bone. We performed a modified anterior craniofacial approach that fully exposed the tumor and invaded bone. In consideration of the patient's age and cosmetic result, the tumor and invaded bone was resected and the defect area was reconstructed with titanium mesh and calvarial bone graft. At 6 months postoperative the patient had no complications and was satisfied with the esthetic result. We report this case to demonstrate the successful approach and reconstruction using this technique.

Modified Anterior Craniofacial Osteotomy Using Partial Nasal Bone Division and Reconstruction in Frontoethmoidal Sinus Meningioma

Typical transcranial approaches are insufficient for adequate visualization and resection of skull base tumors. Different approaches with multiple modifications have been attempted. Here, we describe a new approach for a lesion that is central and hard to treat by conventional craniotomy and successful reconstruction with calvarial bone graft and titanium mesh plate. A 69-year-old female patient presented with recurrent meningioma. The tumor had invaded the frontal lobe, right supraorbital rim, and ethmoidal bone. We performed a modified anterior craniofacial approach that fully exposed the tumor and invaded bone. In consideration of the patient's age and cosmetic result, the tumor and invaded bone was resected and the defect area was reconstructed with titanium mesh and calvarial bone graft. At 6 months postoperative the patient had no complications and was satisfied with the esthetic result. We report this case to demonstrate the successful approach and reconstruction using this technique.

Reduction of Nasal Bone Fracture using Ultrasound Imaging during Surgery

BACKGROUND: Most nasal bone fractures are corrected using non-invasive methods. Often, patients are dissatisfied with surgical outcomes following such closed approach. In this study, we compare surgical outcomes following blind closed reduction to that of ultrasound-guided reduction. METHODS: A single-institutional prospective study was performed for all nasal fracture patients (n=28) presenting between May 2013 and November 2013. Upon research consent, patients were randomly assigned to either the control group (n=14, blind reduction) or the experimental group (n=14, ultrasound-guided reduction). Surgical outcomes were evaluated using preoperative and 3-month postoperative X-ray images by two independent surgeons. Patient satisfaction was evaluated using a questionnaire survey. RESULTS: The experimental group consisted of 4 patients with Plane I fracture and 10 patients with Plane II fracture. The control group consisted of 3 patients with Plane I fracture and 11 patients with Plane II fracture. The mean surgical outcomes score and the mean patient dissatisfaction score were found not to differ between the experimental and the control group in Plane I fracture (p=0.755, 0.578, respectively). In a subgroup analysis consisting of Plane II fractures only, surgeons graded outcomes for ultrasound-guided reduction higher than that for the control group (p=0.007). Likewise, among the Plane II fracture patients, those who underwent ultrasound-guided reduction were less dissatisfied than those who underwent blind reduction (p=0.043). CONCLUSION: Our study result suggests that ultrasound-guided closed reduction is superior to blind closed reduction in those patients with Plane II nasal fractures.

Anti-tuberculosis Treatment-Induced Insulin Autoimmune Syndrome / 이화의대지

Insulin autoimmune syndrome, a rare cause of endogenous hyperinsulinemic hypoglycemia, is characterized by insulin autoantibody, hyperinsulinemia and fasting hypoglycemia. It is well known that drugs containing a sulfhydryl group such as methimazole or α-mercaptopropionyl glycine can induce insulin autoimmune syndrome. However, insulin autoimmune syndrome caused by anti-tuberculosis treatment is very rare. We report a case of insulin autoimmune syndrome after anti-tuberculosis treatment with a review of the relevant literature.

Taxonomic Position and Species Identity of the Cultivated Yeongji 'Ganoderma lucidum' in Korea

Ganoderma lucidum has a long history of use as a traditional medicine in Asian countries. However, the taxonomy of Ganoderma species remains controversial, since they were initially classified on the basis of their morphological characteristics. Recently, it was proposed that G. lucidum from China be renamed as G. sichuanense or G. lingzhi. In the present study, phylogenetic analysis using the internal transcribed spacer region rDNA sequences of the Ganoderma species indicated that all strains of the Korean 'G. lucidum' clustered into one group together with G. sichuanense and G. lingzhi from China. However, strains from Europe and North American, which were regarded as true G. lucidum, were positioned in a clearly different group. In addition, the average size of the basidiospores from the Korean cultivated Yeongji strains was similar to that of G. lingzhi. Based on these results, we propose that the Korean cultivated Yeongji strains of 'G. lucidum' should be renamed as G. lingzhi.

Multiple Endocrine Neoplasia Type 1 Presenting with an Invasive Giant Prolactinoma / 대한내과학회지

Pituitary tumors occur in 15-50% of patients with multiple endocrine neoplasia of type 1 (MEN1). To the best of our knowledge, no MEN1 case in which the initial lesion was an invasive giant prolactinoma has been reported from Korea. We describe a patient in whom a skull-base tumor involved the sellar and parasellar spaces. A 49 year-old female presented with headache and diplopia. The tumor was ultimately identified as a giant prolactinoma; the serum prolactin concentration increased from 155.6 ng/mL to 3,234.3 ng/mL after cranial irradiation. She was evaluated in terms of incidental hypercalcemia and was found to have parathyroid hyperplasia. Genetic analysis revealed a missense mutation in the MEN1 gene (c.643G>A, p.Val215Met). Two years of treatment with a dopamine agonist reduced, but did not normalize, the serum prolactin concentration. We highlight the aggressive behavior of the giant skull-base tumor, and the diagnostic delay caused by a high-dose hook effect of the MEN1-related prolactinoma.

Comparison of the Viability of Cryopreserved Fat Tissue in Accordance with the Thawing Temperature

BACKGROUND: Adipose tissue damage of cryopreserved fat after autologous fat transfer is inevitable in several processes of re-transplantation. This study aims to compare and analyze the survivability of adipocytes after thawing fat cryopreserved at -20degrees C by using thawing methods used in clinics. METHODS: The survival rates of adipocytes in the following thawing groups were measured: natural thawing at 25degrees C for 15 minutes; natural thawing at 25degrees C for 5 minutes, followed by rapid thawing at 37degrees C in a water bath for 5 minutes; and rapid thawing at 37degrees C for 10 minutes in a water bath. The survival rates of adipocytes were assessed by measuring the volume of the fat layer in the top layers separated after centrifugation, counting the number of live adipocytes after staining with trypan blue, and measuring the activity of mitochondria in the adipocytes. RESULTS: In the group with rapid thawing for 10 minutes in a water bath, it was observed that the cell count of live adipocytes and the activity of the adipocyte mitochondria were significantly higher than in the other two groups (P<0.05). The volume of the fat layer separated by centrifugation was also measured to be higher, which was, however, not statistically significant. CONCLUSIONS: It was shown that the survival rate of adipocytes was higher when the frozen fat tissue was thawed rapidly at 37degrees C. It can thus be concluded that if fats thawed with this method are re-transplanted, the survival rate of cryopreserved fats in transplantation will be improved, and thus, the effect of autologous fat transfer will increase.