Batwing-shaped de-epithelialization technique: a case report

For women with extremely ptotic breasts, achieving optimal aesthetic outcomes with implant-based breast reconstruction following nipple-sparing mastectomy presents significant challenges. Traditional mastopexy designs may be considered; however, they often lead to nipple-areola complex necrosis due to inadequate blood supply. We propose a novel approach to breast reconstruction that involves skin de-epithelialization to minimize excess mastectomy skin flap, combined with simultaneous contralateral reduction mammoplasty. This technique effectively preserves circulation to the nipple-areola complex while delivering satisfying aesthetic results, offering a viable solution for managing the complexities associated with large, ptotic breasts in patients undergoing nipple-sparing mastectomy.

Demographic review of aesthetic surgery for patients with facial palsy

Background@#This study analyzed the demographic characteristics of patients with facial palsy who were treated using either dynamic or static procedures. This study aimed to compare the frequency of procedure implementation and age distribution between the two groups. @*Methods@#This study retrospectively analyzed the medical records of patients treated for facial palsy at a single institution from 2014 to 2022. Among cases included in our study, dynamic procedures involved cross-facial nerve graft and latissimus dorsi or gracilis muscle flap transfer. Static procedures included gold weight insertion, canthopexy, browlift, and thread lift/static slings. @*Results@#Among the 31 patients included in our study, eight (25.8%) incorporated dynamic techniques, and the average age of patients was 44.75 years (range, 24–68 years) with a male to female ratio of 1:4. The remaining 23 patients (74.2%) underwent a static procedure, of which the average age was 59.17 years (range, 23–81 years) which was statistically significantly higher than the average age of 44.75 of dynamic patients (p= 0.013). Regarding the timing of treatment after diagnosis, no patient underwent dynamic procedures more than 20 years after initial diagnosis. A greater diversity in the timing of treatment was observed in the static group. All patients who underwent dynamic procedures were treated using static procedures during the study period. @*Conclusion@#Because aesthetics-based static techniques are typically quick outpatient procedures that can be performed under local anesthesia, our study shows that these are often preferred treatments for all age groups, especially for debilitated or older patients. Further research is required to investigate the long-term functional outcomes of these surgical techniques in a wider population of patients.

Fabrication of 3D-Printed Implant for Two-Stage Ear Reconstruction Surgery and Its Clinical Application

Purpose@#Ear reconstruction is one of the most difficult areas in the field of reconstructive surgery. Due to limitations of the current practice, a novel method of auricular reconstruction is needed. Major advancements in three-dimensional (3D) printing technique have rendered the process of ear reconstruction more favorable. Herein, we present our experience in designing and clinically using 3D implants in both 1st and 2nd stage ear reconstruction surgery. @*Materials and Methods@#After obtaining 3D CT data from each patient, a 3D geometric ear model was created using mirroring and segmentation processes. The 3D-printed implant design resembles but does not exactly match the normal ear shape, and can be inserted in harmony with the currently used surgical technique. The 2nd stage implant was designed to minimize dead space and support the posterior ear helix. The 3D implants were finally fabricated with a 3D printing system and used in ear reconstruction surgery in our institute. @*Results@#The 3D implants were manufactured for application to the currently used two-stage technique while maintaining the shape of the patient’s normal ear. The implants were successfully used for ear reconstruction surgery in microtia patients. A few months later, the 2nd stage implant was used in the 2nd stage operation. @*Conclusion@#The authors were able to design, fabricate, and apply patient-specific 3D-printed ear implants for 1st and 2nd stage ear reconstruction surgeries. This design, combined with 3D bioprinting technique, may be a future alternative for ear reconstruction.

Methodology in Conventional Head and Neck Reconstruction Following Robotic Cancer Surgery:A Bridgehead Robotic Head and Neck Reconstruction

Purpose@#Robotic head and neck surgery is widespread nowadays. However, in the reconstruction field, the use of robotic operations is not. This article aimed to examine methodologies for conventional head and neck reconstruction after robotic tumor surgery in an effort to obtain further options for future reconstruction manipulations. @*Materials and Methods@#A retrospective review of all patients who received head and neck robot surgery and conventional reconstructive surgery between October 2016 and September 2021. @*Results@#In total, 53 cases were performed. 67.9% of the tumors were greater than 4 cm. Regarding defect size, 47.2% of the lesions were greater than 8 cm. In terms of TNM stage, stage 3 disease was recorded in 26.4% and stage 4 in 52.8%. To make a deep and narrow field wider, we changed the patient’s posture in pre-op field, additional dissection was done. We used radial forearm flap mostly (62.2%). @*Conclusion@#Conventional head and neck reconstruction after robotic ENT cancer surgery is possible. One key step is to secure additional space in the deep and narrow space left after robotic surgery. For this, we opted for a radial forearm flap mostly. This can be performed as a bridgehead to perform robotic head and neck reconstruction.

Perforating patterns of cutaneous perforator vessels in anterolateral thigh flaps for head and neck reconstruction and clinical outcomes

Background@#Anterolateral thigh (ALT) flaps are versatile soft tissue flaps that have become the standard soft-tissue flaps used for head and neck reconstruction. They provide a long vascular pedicle, constant vessel diameter, abundant soft tissue coverage, and minimal donor site morbidity. The ALT flap was initially designed on the basis of a septocutaneous (SC) perforator. However, more recent research has shown that a substantial number of ALT flaps are now based on musculocutaneous (MC) perforators, and the ratio between MC and SC perforators varies among studies. In this study, we analyzed the perforating pattern of ALT flaps along with their clinical outcomes during head and neck reconstruction in the Korean population. @*Methods@#From October 2016 to July 2020, 68 patients who had undergone an ALT flap procedure for head and neck reconstruction were enrolled retrospectively. The perforating pattern of the cutaneous perforator vessel (MC perforator/SC perforator/oblique branch), pedicle length, and flap size were analyzed intraoperatively. Patient demographics and flap necrosis rates were also calculated. @*Results@#The highest number of cutaneous perforator vessels supplying the ALT flap were the MC perforators (87%). The proportion of MC perforators was significantly higher than that of the SC perforators and oblique branches. Flap necrosis occurred in seven cases (11.86%); sex, hypertension, diabetes mellitus, coronary artery disease, perforator course, and history of radiotherapy did not significantly affect flap necrosis. @*Conclusion@#The ALT free flap procedure remains popular for reconstruction of the head and neck. In this study, we observed that the majority of cutaneous vessels supplying the flaps were MC perforators (87%). When using the MC perforator during flap elevation, careful dissection of the perforator is required to achieve successful ALT flaps because intramuscular dissection is difficult. Perforator pattern and history of radiotherapy did not affect flap necrosis.

Dystrophic Extra-Articular Soft Tissue Calcification after Burn Injury: A Case Study and Literature Review

Soft tissue calcifications after burn injuries are commonly found in the periarticular region. They can easily be found because they cause severe pain and distress to the patient. However, a long period is required to identify extra-articular soft tissue calcification after burn injuries because they have no specific symptoms. Herein, we present the case of a patient with dystrophic extra-articular soft tissue calcification after a burn injury. A 70-year-old woman developed a non-healing ulcer in the right lower leg area two months before presentation to the hospital. She had third-degree flame burns on the anteromedial tibial area of the right leg approximately 40 years prior, and there had been no particular problem. Examination revealed chronic ulcers, and a review of radiograph findings revealed irregular calcification. The wound was treated with wide excision with a skin graft, and it healed without complications. During follow-up one month later, no recurrence of the calcification or ulceration of the lesion was found.

Treatment strategy for skin and soft tissue infections caused by nontuberculous mycobacteria following various procedures

Background@#The early diagnosis and treatment of skin and soft tissue infections caused by nontuberculous mycobacteria (NTM) are important, especially as infections with rapidly growing mycobacteria (RGM) are rare and difficult to diagnose and treat. Recently, we identified 22 cases of NTM infections; in this study, we suggest treatment strategies by analyzing the demographic characteristics and treatment progress of these patients. @*Methods@#A retrospective study of patients with NTM infections from 2009 to 2019 was conducted. To identify NTM infections, acid-fast bacillus (AFB) staining, Gram staining, polymerase chain reaction (PCR), and cultures of mycobacteria were performed. Empirical treatment with a combination of antibiotics or surgery was performed; species identification and drug susceptibility tests were performed by the Korean National Tuberculosis Association. The final regimen was determined after obtaining the test results. @*Results@#The mean incubation time of NTM was 4.32±2.88 weeks. RGM were detected in mycobacterial cultures in 21 of the 22 NTM patients. The results of AFB staining were negative in all patients, although PCR was positive for NTM in one patient. Fourteen patients were hospitalized for treatment with intravenous antibiotics and surgery. Treatment with a combined regimen of oral antibiotics was maintained for a mean of 5.41±1.85 months. @*Conclusions@#The unusual clinical manifestations of skin and soft tissue infections caused by NTM make them difficult to diagnose. Suspicion of NTM based on clinical presentation and a detailed examination should be followed by proper treatment involving multiple antibiotics and surgery in these patients.

Diagnosis and treatment of positional plagiocephaly

Positional plagiocephaly is increasing in infants. Positional plagiocephaly is an asymmetric deformationof skull due to various reasons; first birth, assisted labor, multiple pregnancy, prematurity,congenital muscular torticollis and position of head. Positional plagiocephaly can mostly be diagnosedclinically and by physical examinations. The simplest way to assess the severity of plagiocephalyis to use a diagonal caliper during physical examination, which measures the differencebetween the diagonal lengths on each side of the head. Plagiocephaly can be treated surgically orconservatively. Positional plagiocephaly, which is not accompanied by craniosynostosis, is treatedconservatively. Conservative treatments involve a variety of treatments, such as change of positions,physiotherapy, massage therapy, and helmet therapy. Systematic approaches to clinical examination,diagnosis and treatment of positional plagiocephaly can be necessary and the age-appropriatetreatment is recommended for patients with positional plagiocephaly.

Effect of Relaxin Expression from an Alginate Gel-Encapsulated Adenovirus on Scar Remodeling in a Pig Model

PURPOSE: Relaxin (RLX) is a transforming growth factor-β1 (TGF-β1) antagonist that is believed to function as a potent collagen re-arranger and a major suppressor of extracellular matrix components. Adenoviruses (Ads) are accepted vectors for cancer gene therapy. However, repeated treatments of Ad are limited by short-term biological activity in vivo. The efficacy of sustained RLX expression to scar remodeling was assessed using an injectable alginate gel-matrix system. MATERIALS AND METHODS: Pig scar tissue was treated with relaxin-expressing Ad loaded in alginate gel (gel/Ad-RLX). Surface areas, color, and pliability of scars were compared, and various factors influencing scar formation and collagen arrangement were analyzed. RESULTS: Gel/Ad-RLX decreased scar size, color index, and pliability. Immunohistochemistry showed decreased levels of major extracellular matrix proteins in the gel/Ad-RLX-treated group. Furthermore, treatment with gel/Ad-RLX reduced expression of tissue inhibitor of metalloproteinase-1 and alpha-smooth muscle actin and markedly increased expression of matrix metalloproteinase-1 in pig scar tissues. Gel/Ad-RLX also significantly downregulated TGF-β1 and upregulated TGF-β3 mRNAs in pig scar tissues. CONCLUSION: These results support a prominent role for RLX in scar remodeling and suggest that gel/Ad-RLX may have therapeutic effects on scar formation.

Cryptotia recurrence lowering technique with additional acellular dermal matrix graft

BACKGROUND: Cryptotia is a congenital anomaly in which the upper part of the retroauricular sulcus is absent and buried underneath the temporal skin. Various surgical techniques have been reported for the correction of cryptotia following Kubo’s V-Y plasty in 1933. Conventional methods using a local skin flap, skin grafting, tissue expansion, Z-plasty, and any of these combined approaches can result in skin deficiency of the upper auricle. The aim of this study was to develop a new method that improves cosmetic results and has fewer complications. METHODS: This study involved four patients in whom five cryptotia deformities were corrected using V-Y plasty and Z-plasty. After elevation of the flap, acellular dermal matrix (ADM; MegaDerm) that was over 5 mm in thickness was applied to the cephalo-auricular angle and positioned to enhance the projection of the ear. Lastly, the flap was transposed to complete the repair. RESULTS: Between January 2014 and February 2018, cryptotia correction with ADM graft was performed in four patients. None of the patients developed a recurrence of cryptotia, and there were no postoperative complications such as wound infection, seroma formation, and dehiscence. In addition, the procedures resulted in a favorable cosmetic appearance. CONCLUSION: Based on these findings, i.e., no recurrence and a favorable cosmetic result, when using an ADM graft, it is suggested that this technique could be an alternative method of cryptotia correction. It could also lessen donor-site morbidity when compared to autologous cartilage grafting and be more cost-effective than using cartilage from a cadaver.

A Combination of Direct-to-Implant and Vertical Mastopexy Immediate Breast Reconstruction: A Case Report

Patients with large or ptotic breasts who undergo nipple-sparing mastectomy and direct-to-implant (DTI) reconstruction tend to exhibit poor esthetic outcomes. We present a combined vertical mastopexy-DTI technique that can be used to raise the nipple position and to improve esthetic outcomes. Using the combined vertical mastopexy-DTI technique, it is possible to save time and to increase patient satisfaction.

Forehead reconstruction with a custom-made three-dimensional titanium implant in a Parry-Romberg syndrome patient

Parry-Romberg syndrome is a rare neurocutaneous syndrome characterized by progressive shrinkage and degeneration of the tissues usually on only one side of the face. It is usually difficult to restore the facial contour due to skin tightness. In this case report, we report a forehead reconstruction with custom-made three-dimensional (3D) titanium implant of a Parry-Romberg syndrome patient who was treated with multiple fat grafts but had limited effect. A 36-year-old man presented with hemifacial atrophy. The disease progressed from 5 to 16 years old. The patient had alopecia on frontal scalp and received a surgery using tissue expander. The alopecia lesion was covered by expanded scalp flap done 22 years ago. Also, he was treated with fat grafts on depressed forehead 17 years ago. However, it did not work sufficiently, and there was noted depressed forehead. We planned to make 3D titanium implant to cover the depressed area (from the superior orbital rim to the vertex). During the operation, we confirmed that the custom-made 3D implant accurately fit for the depressed area without any dead spaces. Previously depressed forehead and glabella were elevated, and the forehead contour was improved cosmetically. A custom-made 3D titanium implant is widely used for skull reconstruction and bring good results. In our case, the depressed forehead of a Parry-Romberg syndrome patient was improved by a 3D titanium implant.

Effect of Relaxin Expressing Adenovirus on Scar Remodeling: A Preliminary Study

BACKGROUND: Relaxin is a transforming growth factor β1 antagonist. To determine the effects of relaxin on scar reduction, we investigated the scar remodeling process by injecting relaxin-expressing adenoviruses using a pig scar model. METHODS: Scars with full thickness were generated on the backs of Yorkshire pigs. Scars were divided into two groups (relaxin [RLX] and Control). Adenoviruses were injected into the RLX (expressing relaxin) and Control (not expressing relaxin) groups. Changes in the surface areas, color index and pliability of scars were compared. RESULTS: Fifty days after treatment, the surface areas of scars decreased, the color of scars was normalized, and the pliability of scars increased in RLX group. CONCLUSION: Relaxin-expressing adenoviruses improved the surface area, color, and pliability of scars. The mechanism of therapeutic effects on scar formation should be further investigated.

Reconstruction of Large Defects in the Perineal Area Using Multiple Perforator Flaps

BACKGROUND: Perineal defects are commonly encountered during the treatment of conditions such as malignancy, infectious disease, and trauma. Covering large defects in the perineal area is challenging due to its complicated anatomy and the need for functional preservation. METHODS: Fourteen patients who underwent reconstructive surgery with multiple perforator flaps for defects >100 cm2 in the perineal area were included in this retrospective cohort study. Characteristics of the perforator flap operation and postoperative outcomes were reviewed. RESULTS: Reconstruction was performed using 2 perforator flaps for 13 patients and 3 perforator flaps for 1 patient. Internal pudendal artery perforator flaps were mainly used for covering the defects. The average defect size was 176.3±61.8 cm2 and the average size of each flap was 95.7±31.9 cm2. Six patients had minor complications, such as wound dehiscence and partial necrosis of the flap margin, which were corrected with simple revision procedures. CONCLUSIONS: Multiple perforator flaps can be used to achieve successful reconstructions of large perineal defects that are difficult to reconstruct with other coverage methods.

Correction of Congenital Auricular Deformities Using the Ear-Molding Technique

BACKGROUND: Studies of the ear-molding technique have emphasized the importance of initiating molding early to achieve the best results. In the present study, we describe the immediate effects and long-term outcomes of this technique, focusing on children who were older than the ideal age of treatment initiation. METHODS: Patients who visited our institution from July 2014 to November 2015 were included. Medical charts were reviewed to collect data on demographics, the duration of treatment, the types of deformities, and the manner of recognition of the deformity and referral to our institution. Parents were surveyed to assess the degree of improvement, the level of procedural discomfort at the end of treatment, any changes in the shape of the molded auricle, and overall satisfaction 12 months after their last follow-up visits. RESULTS: A review of 28 ears in 18 patients was conducted, including the following types of deformities: constricted ear (64.2%), Stahl ear (21.4%), prominent ear (7.1%), and cryptotia (7.1%). The average score for the degree of improvement, rated on a 5-point scale (1, very poor; 5, excellent), was 3.5 at the end of treatment, with a score of 2.6 for procedural discomfort (1, very mild; 5, very severe). After 12 months, the shapes of all ears were well maintained. The average overall satisfaction score was 3.6 (1, very dissatisfied; 5, very satisfied). CONCLUSIONS: We had reasonable outcomes in older patients. After 1 year of follow-up, these outcomes were well maintained. Patients past the ideal age at presentation can still be candidates for the molding technique.

Skull Reconstruction with Custom Made Three-Dimensional Titanium Implant

BACKGROUND: Source material used to fill calvarial defects includes autologous bones and synthetic alternatives. While autologous bone is preferable to synthetic material, autologous reconstruction is not always feasible due to defect size, unacceptable donor-site morbidity, and other issues. Today, advanced three-dimensional (3D) printing techniques allow for fabrication of titanium implants customized to the exact need of individual patients with calvarial defects. In this report, we present three cases of calvarial reconstructions using 3D-printed porous titanium implants. METHODS: From 2013 through 2014, three calvarial defects were repaired using custommade 3D porous titanium implants. The defects were due either to traumatic subdural hematoma or to meningioma and were located in parieto-occipital, fronto-temporo-parietal, and parieto-temporal areas. The implants were prepared using individual 3D computed tomography (CT) data, Mimics software, and an electron beam melting machine. For each patient, several designs of the implant were evaluated against 3D-printed skull models. All three cases had a custom-made 3D porous titanium implant laid on the defect and rigid fixation was done with 8 mm screws. RESULTS: The custom-made 3D implants fit each patient's skull defect precisely without any dead space. The operative site healed without any specific complications. Postoperative CTs revealed the implants to be in correct position. CONCLUSION: An autologous graft is not a feasible option in the reconstruction of large calvarial defects. Ideally, synthetic materials for calvarial reconstruction should be easily applicable, durable, and strong. In these aspects, a 3D titanium implant can be an optimal source material in calvarial reconstruction.

Gene Therapy Using Hepatocyte Growth Factor Expressing Adenovirus Improves Skin Flap Survival in a Rat Model

Hepatocyte growth factor (HGF) is a potent angiogenic factor that can stimulate the production of blood vessels in ischemic tissue. We investigated whether gene therapy using HGF-expressing adenovirus could enhance skin flap survival. Sprague-Dawley rats were randomly divided into three groups. Rats were subdermally injected with HGF-expressing adenovirus (HGF virus group), recombinant HGF (rhHGF group), or phosphate buffered saline (PBS group) 2 days before and immediately after 3 x 9 cm caudal flap elevation. The survival area of the skin flap, the ratio of blood flow, CD31-positive vessels and, VEGF expression were examined. Skin flap viability was significantly increased in the HGF virus group compared to the rhHGF and PBS groups (71.4% +/- 5.9%, 63.8%+/- 6.4%, and 39.2% +/- 13.0%, respectively) (P = 0.025). Furthermore, the blood flow ratio was significantly increased in the HGF virus group. In the HGF virus group, the number of CD31-positive vessels and vascular endothelial growth factor (VEGF) expression were significantly increased. Gene therapy using HGF-expressing adenovirus increase VEGF expression, the number of viable capillaries, and blood flow to the flap, thereby improving skin flap survival.

Treatment of Ischial Pressure Sores with Both Profunda Femoris Artery Perforator Flaps and Muscle Flaps

BACKGROUND: Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischial pressure sores. METHODS: We retrospectively analyzed data from 14 patients (16 ischial sores) whose ischial defects had been reconstructed using both a profunda femoris artery perforator flap and a muscle flap between January 2006 and February 2014. We compared patient characteristics, operative procedure, and clinical course. RESULTS: All flaps survived the entire follow-up period. Seven patients (50%) had a history of surgery at the site of the ischial pressure sore. The mean age of the patients included was 52.8 years (range, 18-85 years). The mean follow-up period was 27.9 months (range, 3-57 months). In two patients, a biceps femoris muscle flap was used, while a gracilis muscle flap was used in the remaining patients. In four cases (25%), wound dehiscence occurred, but healed without further complication after resuturing. Additionally, congestion occurred in one case (6%), but resolved with conservative treatment. Among 16 cases, there was only one (6%) recurrence at 34 months. CONCLUSIONS: The combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Therefore, this may be used as an alternative treatment method for ischial pressure sores.

Correction of Dark Coloration of the Lower Eyelid Skin with Nanofat Grafting

BACKGROUND: A number of factors can cause dark circles around the eyes including excessive pigmentation, thin and translucent lower eyelid skin overlying the orbicularis oculi muscle, and shadowing due to skin laxity and tear trough. Autologous fat graft is an effective method for the treatment of lower lid dark circles, but irregularities caused by leaving visible lumps of the fat can occur. Tonnard et al. suggested 'nanofat' grafting and introduced its characteristics and clinical applications. The authors used their nanofat grafting to correct lower eyelid dark circles. METHODS: Nanofat grafting was performed in 19 patients for dark lower eyelids. The grafts were injected into subdermal layer using blunt cannula. Microfat grafting with nasojugal fold was performed to all the patients. Among them, 18 patients received transconjunctival fat removal at the same time. RESULTS: All the patients showed much improvement from preoperative dark coloration. There were no visible lumps of fat, contour irregularities, or fat necrosis. Postoperative edema and ecchymosis were minimal. CONCLUSIONS: Nanofat grafting methods provide a good alternative for correcting dark circles by augmenting thin skin with lower complications. This simple, cost effective procedure is suitable for correction of dark circles and various skin rejuvenation purposes.

Total Hairline Correction in Female Patient

BACKGROUND: The shape of the hairline and the ratio of the forehead to the face are both important factors for a balanced and attractive face. Because males primarily have a hairline with a rectangular or M shape (a frontotemporal-recessed shape), females with such shapes often have a strong masculine image and appear older. Follicular unit (FU) transplantation was used recently so that the forehead could be reduced naturally and effectively by changing the rectangular or M-shape hairline to a round-shape hairline, thus reducing the forehead. So the author is going to introduce a harmonious, balanced correction, named as total hairline correction that presents not only the frontal midpoint and fronto-temporal line, but also a temporal point, infra-temporal area, and/or sideburn. METHODS: Author studied 300 operation patients in last three years whose mean age was 29.3 years (range 19-57 years). RESULTS: The average reduced length was followed: frontal mid-point: 0.63 (0-1.5 cm), frontotemporal apex: 3.38 (1-4.5 cm), Rt 3.18 (1-4.5 cm) Lt, temporal point: 0.91 (0-3 cm) Rt, 0.88 (0-3 cm) Lt, infratemporal apex: 0.92 (0-1.5 cm) Rt, 0.93 (0-2 cm) Lt. CONCLUSIONS: In female patient with M shaped or rectangular hairline, total hairline correction which included not only mid-frontal area and fronto-temporal recession, but also temporal peak, infratemporal area and sideburn is better than simple correction of frontotemporal recess in reducing the facial area and maintaining the aesthetic facial balance.