Initial report of extraperitoneal pedicle dissection in deep inferior epigastric perforator flap breast reconstruction using the da Vinci SP

The deep inferior epigastric perforator (DIEP) flap has been widely used for autologous breast reconstruction after mastectomy. In the conventional surgical method, a long incision is needed at the anterior fascia of the rectus abdominis muscle to obtain sufficient pedicle length; this may increase the risk of incisional hernia. To shorten the incision, several trials have investigated the use of endoscopic/robotic devices for pedicle harvest; however, making multiple additional incisions for port insertion and operating in the intraperitoneal field were inevitable. Here, we describe the first case, in which a DIEP free flap was successfully made using the da Vinci SP model. Our findings can help surgeons perform operations in smaller fields with a single port in the extraperitoneal space. Moreover, this method is expected to lead to fewer donor-related complications and faster healing.

Verrucous carcinoma arising from actinic keratosis: a case report

Verrucous carcinoma (VC) is a rare subtype of squamous cell carcinoma that commonly occurs in the oral cavity. However, VC of the facial skin is relatively rare. We report a case of a 91-year-old woman with VC of the facial skin in the left zygoma area. She was diagnosed with actinic keratosis (4 × 3 cm) of the same site approximately 12 years previously, but declined further treatment. The mass was excised with a minimum of 0.4 cm from gross margins with the result of free from tumor of all margins by frozen section, allowing for primary closure after skin undermining. Basal resection was performed in the preplatysmal plane. The diagnosis of VC was confirmed by histopathological examination. Postoperatively, the wound healed without incident and with no signs of facial nerve injury. To our knowledge, this is the first reported case of VC of facial skin arising from actinic keratosis.

Antibiotic use in nasal bone fracture: a single-center retrospective study

Background@#Prophylactic antibiotics are used to prevent surgical wound infection; however, proper indications must be followed with careful consideration of the risks and benefits, especially in clean or clean-contaminated wounds. Nasal bone fractures are the most common type of facial bone fracture. The most common method for treating nasal bone fracture is closed reduction, which is performed inside the nasal cavity without an incision. The purpose of this study was to determine the need for antibiotic use in the closed reduction of nasal bone fractures. @*Methods@#A retrospective study was conducted using data from the National Insurance Service Ilsan Hospital of the Republic of Korea between 2016 and 2018. The records of patients who underwent closed reduction of nasal bone fracture were reviewed and classified according to sex, age, comorbidities, perioperative antibiotic usage, postoperative complications, nasal packing, anesthesia type, surgeon’s specialty, and operation time. @*Results@#Among the 373 patients studied, the antibiotic prescription rate was 67.3%. Just 0.8% of patients were prescribed preoperative antibiotics only, 44.0% were prescribed postoperative antibiotics only, and 22.5% were prescribed both preoperative and postoperative antibiotics. There were no cases that satisfied the definition of “surgical site infection.” Furthermore, 2.1% of infection-related complications (e.g., mucosal swelling, synechia, and anosmia) occurred only in the antibiotic usage group. The use of nasal packing, anesthesia type, and surgeon’s specialty did not show any difference in infection-related complication rates. @*Conclusion@#According to the study findings, the routine use of perioperative antibiotics is not recommended in uncomplicated nasal bone fracture surgery.

Antibiotic use in nasal bone fracture: a nationwide population-based cohort study in Korea

Background@#Prophylactic antibiotics are commonly used in craniofacial surgeries. Despite the low risk of surgical site infection after nasal surgery, a lack of consensus regarding the use of antibiotic prophylaxis in the closed reduction of nasal bone fractures has led to inappropriate prescribing patterns. Through this study, we aimed to investigate the status of prophylactic antibiotic use in closed reductions of nasal bone fractures in Korea. @*Methods@#This retrospective cohort study was conducted using data from the National Health Insurance Service-National Sample Cohort of Korea from 2005 to 2015. We analyzed the medical records of patients who underwent closed reduction of nasal bone fractures. The sex, age, region of residence, comorbidities, and socioeconomic variables of the patients were collected from the database. Factors that affect the prescription of perioperative antibiotics were evaluated using multivariate logistic regression analysis. @*Results@#A total of 3,678 patients (mean± standard deviation of age, 28.7± 14.9 years; 2,850 men [77.5%]; 828 women [22.5%]) were included in this study. The rate of antibiotic prescription during the perioperative period was 51.4%. Approximately 68.8% of prescriptions were written for patients who had received general anesthesia. The odds of perioperative prophylactic antibiotic use were significantly higher in patients who received general anesthesia than who received local anesthesia (odds ratio, 1.59). No difference was found in terms of patient age and physician specialty. Second-generation cephalosporins were the most commonly prescribed antibiotic (45.3%), followed by third- and first-generation cephalosporins (20.3% and 18.8%, respectively). In contrast, lincomycin derivatives and aminoglycosides were not prescribed. @*Conclusion@#The findings of this study showed that there was a wide variety of perioperative antibiotic prescription patterns used in nasal bone surgeries. Evidence-based guidance regarding the prescribing of antimicrobial agents for the closed reduction of nasal bone fractures should be considered in future research.

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.

Primary extracranial meningioma presenting as a forehead mass

Meningioma originates from arachnoid cap cells and is the second most common intracranial tumor; however, it can also be found in an extracranial location. A very rare primary extracranial meningioma without the presence of an intracranial component has also been reported. Primary extracranial meningiomas have been found in the skin, scalp, middle ear, and nasal cavity. A computerized tomography or magnetic resonance imaging scan is necessary to determine the presence or absence of an intracranial meningioma, and a biopsy is essential for diagnosis. We report a case of primary extracranial meningioma located in the forehead skin of a 51-year-old male.

Effects of Human Adipose-Derived Stem Cells on the Survival of Rabbit Ear Composite Grafts

BACKGROUND: Composite grafts are frequently used for facial reconstruction. However, the unpredictability of the results and difficulties with large defects are disadvantages. Adipose-derived stem cells (ADSCs) express several cytokines, and increase the survival of random flaps and fat grafts owing to their angiogenic potential. METHODS: This study investigated composite graft survival after ADSC injection. Circular chondrocutaneous composite tissues, 2 cm in diameter, from 15 New Zealand white rabbits were used. Thirty ears were randomly divided into 3 groups. In the experimental groups (1 and 2), ADSCs were subcutaneously injected 7 days and immediately before the operation, respectively. Similarly, phosphate-buffered saline was injected in the control group just before surgery in the same manner as in group 2. In all groups, chondrocutaneous composite tissue was elevated, rotated 90 degrees, and repaired in its original position. Skin flow was assessed using laser Doppler 1, 3, 6, 9, and 12 days after surgery. At 1 and 12 days after surgery, the viable area was assessed using digital photography; the rabbits were euthanized, and immunohistochemical staining for CD31 was performed to assess neovascularization. RESULTS: The survival of composite grafts increased significantly with the injection of ADSCs (P<0.05). ADSC injection significantly improved neovascularization based on anti-CD31 immunohistochemical analysis and vascular endothelial growth factor expression (P<0.05) in both group 1 and group 2 compared to the control group. No statistically significant differences in graft survival, anti-CD31 neovascularization, or microcirculation were found between groups 1 and 2. CONCLUSIONS: Treatment with ADSCs improved the composite graft survival, as confirmed by the survival area and histological evaluation. The differences according to the injection timing were not significant.

Effects of Human Adipose-Derived Stem Cells on the Survival of Rabbit Ear Composite Grafts

BACKGROUND: Composite grafts are frequently used for facial reconstruction. However, the unpredictability of the results and difficulties with large defects are disadvantages. Adipose-derived stem cells (ADSCs) express several cytokines, and increase the survival of random flaps and fat grafts owing to their angiogenic potential. METHODS: This study investigated composite graft survival after ADSC injection. Circular chondrocutaneous composite tissues, 2 cm in diameter, from 15 New Zealand white rabbits were used. Thirty ears were randomly divided into 3 groups. In the experimental groups (1 and 2), ADSCs were subcutaneously injected 7 days and immediately before the operation, respectively. Similarly, phosphate-buffered saline was injected in the control group just before surgery in the same manner as in group 2. In all groups, chondrocutaneous composite tissue was elevated, rotated 90 degrees, and repaired in its original position. Skin flow was assessed using laser Doppler 1, 3, 6, 9, and 12 days after surgery. At 1 and 12 days after surgery, the viable area was assessed using digital photography; the rabbits were euthanized, and immunohistochemical staining for CD31 was performed to assess neovascularization. RESULTS: The survival of composite grafts increased significantly with the injection of ADSCs (P<0.05). ADSC injection significantly improved neovascularization based on anti-CD31 immunohistochemical analysis and vascular endothelial growth factor expression (P<0.05) in both group 1 and group 2 compared to the control group. No statistically significant differences in graft survival, anti-CD31 neovascularization, or microcirculation were found between groups 1 and 2. CONCLUSIONS: Treatment with ADSCs improved the composite graft survival, as confirmed by the survival area and histological evaluation. The differences according to the injection timing were not significant.

Functional Outcomes of Multiple Sural Nerve Grafts for Facial Nerve Defects after Tumor-Ablative Surgery

BACKGROUND: Functional restoration of the facial expression is necessary after facial nerve resection to treat head and neck tumors. This study was conducted to evaluate the functional outcomes of patients who underwent facial nerve cable grafting immediately after tumor resection. METHODS: Patients who underwent cable grafting from April 2007 to August 2011 were reviewed, in which a harvested branch of the sural nerve was grafted onto each facial nerve division. Twelve patients underwent facial nerve cable grafting after radical parotidectomy, total parotidectomy, or schwannoma resection, and the functional facial expression of each patient was evaluated using the Facial Nerve Grading Scale 2.0. The results were analyzed according to patient age, follow-up duration, and the use of postoperative radiation therapy. RESULTS: Among the 12 patients who were evaluated, the mean follow-up duration was 21.8 months, the mean age at the time of surgery was 42.8 years, and the mean facial expression score was 14.6 points, indicating moderate dysfunction. Facial expression scores were not influenced by age at the time of surgery, follow-up duration, or the use of postoperative radiation therapy. CONCLUSIONS: The results of this study indicate that facial nerve cable grafting using the sural nerve can restore facial expression. Although patients were provided with appropriate treatment, the survival rate for salivary gland cancer was poor. We conclude that immediate facial nerve reconstruction is a worthwhile procedure that improves quality of life by allowing the recovery of facial expression, even in patients who are older or may require radiation therapy.

Acceleration of Wound Healing Using Adipose-derived Stem Cell Therapy with Platelet Concentrates: Platelet-rich Plasma (PRP) vs. Platelet-rich Fibrin (PRF)

PURPOSE: Although platelet-rich plasma (PRP) potentiate the wound healing activity of adipose-derived stem cells (ADSCs), its effect cannot be sustained for a prolonged period of time due to short duration of action. This led us to design and produce platelet-rich fibrin (PRF), in an effort to develop a tool which lasts longer, and apply it on wound healing. METHODS: Two symmetrical skin defects were made on the back of seven nude mice. ADSCs were applied to each wound, combined with either PRP or PRF. The wound area was measured over 14 days. By day 16, the wound was harvested and histologic analysis was performed including counting of the blood vessel. RESULTS: The healing rate was more accelerated in PRP group in the first 5 days (p<0.05). However, PRF group surpassed PRP group after 6 days (p<0.05). The average number of blood vessels observed in the PRF group was 6.53 +/- 0.51, compared with 5.68 +/- 0.71 for the PRP group. CONCLUSION: PRF exerts a slow yet pervasive influence over the two-week course of the wound healing process. Thus, PRF is probably more beneficial for promoting the activity of ADSCs for a sustained period of time.

Experimental Hind Limb & Inguinal-Femur Osteocutaneous Flap Model in Rats for Composite Tissue Transplantation

PURPOSE: Composite tissue allotransplantation (CTA) is a newly raised field as a treatment of severe body disfigurements. But in the point that it is transplant of functional organ not vital organ, it has limitation of using immunosuppressant for lifetime. Therefore, recent studies on CTA are focused on the reduction of risk of immunosuppression by inducing immunotolerance, developing new regimen and so on. So, appropriate experimental models to solve the problems are needed. We have performed CTA experiment using hind limb of rats which is frequently used CTA animal model. There were many trials and errors when actually conducting experiment. Hence the authors are to state the experiences in our own experiments. METHODS: Total 13 Sprague Dawley rats (SD rats) were used. In 10 rats, hind limb allotransplantation were performed and in 3 rats, inguinal-femur osteocutanoeus flap operation were conducted. RESULTS: Out of total 13 rats, on the day of operation 4 rats died, and 1dayafter operation 2 rats died. The remainder 7 rats were euthanized on the 3rd day after operation. Autophagy occurred in 3 rats. The dead experimental models were experienced in the early stage of study. CONCLUSION: We could increase survival rate through appropriate anesthesia, maintaining body temperature, supplement of water and pain control.

Effect of Relaxin Expressing Adenovirus for Rat Skin Flap Viability

PURPOSE: Of various effects of relaxin, we assumed that anti-fibrotic effects, neovascularization effects and vasodilatation effects of relaxin might enhance the survival rate of skin flap. In the current study, we used adenovirus expressing relaxin genes to examine whether these genes could enhance the survival rate of a skin flap. METHODS: A total of 30 Sprangue-Dawley rats were divided into three groups: RLX group (10; relaxin virus injected group), CTR group (10; no gene coded virus injection group), and PBS group (10; PBS injected group). Each group was intradermally injected with the virus (107 PFU) and PBS 48 hours before and immediately before the flap elevation. A distally based flap 3 x 9 cm in size was elevated on the dorsal aspect of each rat. Following this, a flap was placed in the original location and then sutured using a #4-0 Nylon. A surviving area of the flap was measured and then compared on postoperative days 3, 7 and 10. Using a laser Doppler, the amount of blood flow was measured. On postoperative day 10, tissues were harvested for histologic examination and the number of blood vessels was counted. RESULTS: There was a significant increase in the area of the flap survival in the RLX group on postoperative days 3 and 7. The Doppler measurement also showed significantly increased blood flow immediately after the operation and on postoperative days 7 and 10. The number of blood vessels was significantly greater in the RLX group in the tissue harvested on postoperative day 10. The VEGF concentration was significantly higher in the RLX group than others in the tissues harvested on postoperative day 10. CONCLUSION: Following an analysis of the effects of relaxin-secreting adenovirus on the survival of a flap, the surviving area of the flap and the blood flow also increased. A histopathology also showed an increase in the number of blood vessels and the concentration of VEGF.