Immunogenicity of botulinum toxin

Botulinum toxin treatment is the most common non-surgical cosmetic treatment. Although there are many available treatments using botulinum toxin, their effects are temporary and repeated injections are required. These frequent injections can trigger an immunological response. In addition, botulinum toxin acts as an antigen in the body; thus, its effect disappears progressively due to this immunological reaction, which may cause treatment failure. Active botulinum toxin consists of a core neurotoxin and complexing proteins, the exact effects of which remain unclear. However, the complexing proteins are closely related to the immune response and the formation of neutralizing antibodies. Since neutralizing antibodies can lead to treatment failure, their formation should be prevented. Furthermore, various methods of detecting neutralizing antibodies have been used to predict treatment failure.

A rare case report of neonatal calcinosis cutis induced by distant and delayed extravasation of intravenous calcium gluconate

A 3,480 g male neonate showed tachypnea symptom with a serum ionized calcium level of 0.66 mmol/L by routine clinical analysis. He was injected calcium gluconate intravenously through femoral vein catheter to treat the hypocalcemia. On second day after the injection, he started to show erythema in the flank area. The lesion became firm and changed into whitish crust consist of small crystals. Abdominal X-ray and ultrasonography showed the accumulation of calcium deposit in the subcutaneous layer of the lesion. Surgical debridement was performed to remove the crust with calcium deposit and acellular fish skin graft rich in omega-3 (Kerecis) was applied to the defect site for secondary intention of the defect wound. After 2 months, the skin and soft tissue defect were fully covered with healthy normal skin without depression or contracture. This report is a first case of iatrogenic calcinosis cutis without extravasation symptom.

A split-face study evaluating the efficacy of a topical antioxidant cream containing tocotrienol after 1064-nm picosecond Nd:YAG laser treatment for environment-induced skin pigmentation

Background@#This study aimed to evaluate the efficacy and safety of a topical antioxidant cream containing tocotrienol after 1064-nm picosecond neodymium-doped yttrium aluminum garnet (Nd:YAG) laser treatment for environment-induced skin pigmentation. @*Methods@#A split-face study was conducted between December 2020 and March 2021 in 26 patients (25 women and one man) who were treated with a 1064-nm picosecond Nd:YAG laser. On the right side of the face, an antioxidant cream containing tocotrienol was applied after picosecond laser treatment, and on the left side, only picosecond laser treatment was performed. We compared the right and left sides of the face at 4 weeks after laser treatment using an automatic skin analysis device to investigate skin pigmentation. The melasma severity scores of the two sides were evaluated before and 4 weeks after picosecond laser treatment. @*Results@#The skin pigmentation score showed a significant difference between pretreatment and 4 weeks after picosecond laser treatment on both sides of the face (P0.05). @*Conclusions@#Our results show that, for the treatment of environment-induced skin pigmentation, the application of a tocotrienol-containing antioxidant cream after 1064-nm picosecond laser treatment can provide good results without any complications.

Removal of a red tattoo on the lips using a 532-nm picosecond laser

Tattoos, which people choose to have performed for various reasons, can have multiple colors, ranging from conventional black to red, yellow, blue, and others. As tattoos have become increasingly popular, the need for tattoo removal has also grown, and the most commonly used method for removal is a laser. However, the extent to which various types of lasers remove different tattoo pigments is clearly important. Although extensive research has been done on black tattoos, red tattoos have not been adequately studied, and there are few case reports on red tattoos. We present a case of effective removal of a red tattoo from the lips using a picosecond laser.

A split-face study evaluating the efficacy of a topical antioxidant cream containing tocotrienol after 1064-nm picosecond Nd:YAG laser treatment for environment-induced skin pigmentation

Background@#This study aimed to evaluate the efficacy and safety of a topical antioxidant cream containing tocotrienol after 1064-nm picosecond neodymium-doped yttrium aluminum garnet (Nd:YAG) laser treatment for environment-induced skin pigmentation. @*Methods@#A split-face study was conducted between December 2020 and March 2021 in 26 patients (25 women and one man) who were treated with a 1064-nm picosecond Nd:YAG laser. On the right side of the face, an antioxidant cream containing tocotrienol was applied after picosecond laser treatment, and on the left side, only picosecond laser treatment was performed. We compared the right and left sides of the face at 4 weeks after laser treatment using an automatic skin analysis device to investigate skin pigmentation. The melasma severity scores of the two sides were evaluated before and 4 weeks after picosecond laser treatment. @*Results@#The skin pigmentation score showed a significant difference between pretreatment and 4 weeks after picosecond laser treatment on both sides of the face (P0.05). @*Conclusions@#Our results show that, for the treatment of environment-induced skin pigmentation, the application of a tocotrienol-containing antioxidant cream after 1064-nm picosecond laser treatment can provide good results without any complications.

Removal of a red tattoo on the lips using a 532-nm picosecond laser

Tattoos, which people choose to have performed for various reasons, can have multiple colors, ranging from conventional black to red, yellow, blue, and others. As tattoos have become increasingly popular, the need for tattoo removal has also grown, and the most commonly used method for removal is a laser. However, the extent to which various types of lasers remove different tattoo pigments is clearly important. Although extensive research has been done on black tattoos, red tattoos have not been adequately studied, and there are few case reports on red tattoos. We present a case of effective removal of a red tattoo from the lips using a picosecond laser.

Reduction of Radiation Exposure by Modifying Imaging Manner and Fluoroscopic Settings during Percutaneous Pedicle Screw Insertion

Objective@#: Percutaneous pedicle screw (PPS) fixation is a needle based procedure that requires fluoroscopic image guidance. Consequently, radiation exposure is inevitable for patients, surgeons, and operation room staff. We hypothesize that reducing the production of radiation emission will result in reduced radiation exposure for everyone in the operation room. Research was performed to evaluate reduction of radiation exposure by modifying imaging manner and mode of radiation source. @*Methods@#: A total of 170 patients (680 screws) who underwent fusion surgery with PPS fixation from September 2019 to March 2020 were analyzed in this study. Personal dosimeters (Polimaster Ltd.) were worn at the collar outside a lead apron to measure radiation exposure. Patients were assigned to four groups based on imaging manner of fluoroscopy and radiation modification (pulse mode with reduced dose) : continuous use without radiation modification (group 1, n=34), intermittent use without radiation modification (group 2, n=54), continuous use with radiation modification (group 3, n=26), and intermittent use with radiation modification (group 4, n=56). Post hoc Tukey Honest significant difference test was used for individual comparisons of radiation exposure/screw and fluoroscopic time/screw. @*Results@#: The average radiation exposure/screw was 71.45±45.75 μSv/screw for group 1, 18.77±11.51 μSv/screw for group 2, 19.58±7.00 μSv/screw for group 3, and 4.26±2.89 μSv/screw for group 4. By changing imaging manner from continuous multiple shot to intermittent single shot, 73.7% radiation reduction was achieved in the no radiation modification groups (groups 1, 2), and 78.2% radiation reduction was achieved in the radiation modification groups (groups 3, 4). Radiation source modification from continuous mode with standard dose to pulse mode with reduced dose resulted in 72.6% radiation reduction in continuous imaging groups (groups 1, 3) and 77.3% radiation reduction in intermittent imaging groups (groups 2, 4). The average radiation exposure/screw was reduced 94.1% by changing imaging manner and modifying radiation source from continuous imaging with standard fluoroscopy setting (group 1) to intermittent imaging with modified fluoroscopy setting (group 4). A total of 680 screws were reviewed postoperatively, and 99.3% (675) were evaluated as pedicle breach grade 0 (<2 mm). @*Conclusion@#: The average radiation exposure/screw for a spinal surgeon can be reduced 94.1% by changing imaging manner and modifying radiation source from real-time imaging with standard dose to intermittent imaging with modified dose. These modifications can be instantly applied to any procedure using fluoroscopic guidance and may reduce the overall radiation exposure of spine surgeons.

Feasibility of Posterior Cervical Foraminotomy for Adjacent Segmental Disease after Anterior Cervical Fusion

Objective@#: The aim of this study is to evaluate the feasibility of posterior cervical foraminotomy (PCF) for adjacent segmental disease (ASD) after anterior cervical fusion (ACF). As ACF is accepted as the standard treatment for cervical spondylosis, many studies have been conducted to evaluate the efficacy of various surgical techniques to overcome symptomatic ASD after the previous surgery. Herein, PCF was performed for the treatment of symptomatic ASD and the feasibility of the surgery was evaluated. @*Methods@#: Forty nine patients who underwent PCF due to symptomatic ASD from August 2008 to November 2017 were identified. For demographic and perioperative data, the sex, age, types of previous surgery, ASD levels, operation times, and bleeding amount were recorded. The clinical outcome was assessed using the visual analogue scale for the neck and arm, the modified Odom’s criteria as well as neck disability index. Radiologic evaluations were performed by measuring disc softness, disc height, the cervical 2–7 sagittal vertical axis, cervical cobb angle, and facet violation. @*Results@#: Thirty-seven patients were enrolled in this study. The patients were divided into two groups based on the location of the pathology; paracentral (group P) or foramina (group F). Both groups showed significant clinical improvement (p0.05). @*Conclusion@#: PCF showed satisfactory clinical and radiologic outcomes for both paracentral and foraminal pathologies of ASD after ACF. Complications related to anterior revision were also avoided. PCF can be considered a feasible and safe surgical option for ASD after ACF.

Validation of the optimal scaffold pore size of nasal implants using the 3-dimensional culture technique

Background@#To produce patient-specific nasal implants, it is necessary to harvest and grow autologous cartilage. It is crucial to the proliferation and growth of these cells for scaffolds similar to the extracellular matrix to be prepared. The pore size of the scaffold is critical to cell growth and interaction. Thus, the goal of this study was to determine the optimal pore size for the growth of chondrocytes and fibroblasts. @*Methods@#Porous disc-shaped scaffolds with 100-, 200-, 300-, and 400-µm pores were produced using polycaprolactone (PCL). Chondrocytes and fibroblasts were cultured after seeding the scaffolds with these cells, and morphologic evaluation was performed on days 2, 14, 28, and 56 after cell seeding. On each of those days, the number of viable cells was evaluated quantitatively using an MTT assay. @*Results@#The number of cells had moderately increased by day 28. This increase was noteworthy for the 300- and 400-µm pore sizes for fibroblasts; otherwise, no remarkable difference was observed at any size except the 100-µm pore size for chondrocytes. By day 56, the number of cells was observed to increase with pore size, and the number of chondrocytes had markedly increased at the 400-µm pore size. The findings of the morphologic evaluation were consistent with those of the quantitative evaluation. @*Conclusions@#Experiments using disc-type PCL scaffolds showed (via both morphologic and quantitative analysis) that chondrocytes and fibroblasts proliferated most extensively at the 400-µm pore size in 56 days of culture.

Comparative study of the prevention of seroma formation in immediate breast reconstruction with latissimus dorsi myocutaneous flaps

Background@#Latissimus dorsi (LD) flaps are often used in breast reconstruction procedures, but seroma formation is a frequent complication. To decrease the incidence of seroma formation, fibrin sealants and/or quilting sutures have been proposed, with controversial results. The primary objective of this study was to assess the effectiveness of the Harmonic scalpel in association with Tisseel and three-point deep dermal sutures in reducing the incidence of this complication. @*Methods@#A retrospective study was conducted of 108 patients undergoing immediate unilateral breast reconstruction with LD flaps over a 3-year period (2016–2018) by a single surgeon. In the experimental group, 37 patients underwent the procedure with a Harmonic scalpel and three-point deep dermal sutures (a modified version of quilting sutures), and the other 71 received conventional electrocautery. Fibrin sealant was applied to the donor site of all patents to reduce seroma formation. @*Results@#Statistically significant differences in the incidence of seroma were found between the two groups. There was a lower incidence of seroma formation in the group of patients treated with a Harmonic scalpel and three-point deep dermal sutures than in the other group. The total drainage amount and drain removal date between the two groups were not significantly different. @*Conclusions@#Within the limitations of this study, we suggest that Harmonic scalpel use can be a good choice among the many ways to reduce seroma formation following LD flap procedures, and that this technique will be very helpful for patients.

Correlation between Chronic Ankle Instability and Center of Pressure Using Pedobrarograph / 대한족부족관절학회지

PURPOSE: Chronic ankle instability is a very common abnormality of the ankle, but there is still controversy regarding its evaluation criteria. The stress view has difficulties in reflecting the patient's symptoms and treatment progress. Therefore, this study examined the relationship between the center of pressure (COP) measured by a pedobarograph and the symptoms of the patient.MATERIALS AND METHODS: Thirty patients with chronic ankle instability from February to August 2018 were included. Each patient was surveyed with the foot and ankle outcome score (FAOS). The COP was measured with a foot pressure scanner, and the travel distance and ellipse area of the COP were calculated. Each patient was measured on one foot and on two feet with his or her eyes closed and open. The relationship between the COP measurement and FAOS score was analyzed using the Pearson correlation coefficient.RESULTS: The participants were consisted of 21 male and nine female, with a mean age of 30 years, mean weight of 72 kg, and mean foot size of 259 mm. With the eyes open, the correlation coefficient between the FAOS and travel distance of the affected side was −0.394 (p<0.05) and that between the FAOS and the ellipse area of the affected side was −0.425 (p<0.05). On the other hand, no significant correlations were found between the travel distance and ellipse area of the affected side when patients closed their eyes.CONCLUSION: Measurement of the COP using foot pressure scanner could evaluate objectively patients with chronic ankle instability, with measurements in patients with their eyes open being more significant. Based on the findings of this study, an analysis of the COP with the patients with their eyes open and standing on one foot may help determine the management strategy and assess the progress of the patients.

A novel photonumeric hand grading scale for hand rejuvenation

BACKGROUND: Few scales are currently available to evaluate changes in hand volume. We aimed to develop a hand grading scale for quantitative assessments of dorsal hand volume with additional consideration of changes in skin texture; to validate and prove the precision and reproducibility of the new scale; and to demonstrate the presence of clinically significant differences between grades on the scale. METHODS: Five experienced plastic surgeons developed the Hand Volume Rating Scale (HVRS) and rated 91 images. Another five plastic surgeons validated the scale using 50 randomly selected images. Intra- and inter-rater agreement was calculated using the weighted kappa statistic and intraclass correlation coefficients (ICCs). Paired images were also evaluated to verify whether the scale reflected clinical differences. RESULTS: The intra-rater agreement was 0.95 (95% confidence interval, 0.922–0.974). The interrater ICCs were excellent (first rating, 0.94; second rating, 0.94). Image pairs that differed by 1, 2, and 3 grades were considered to contain clinically relevant differences in 80%, 100%, and 100% of cases, respectively, while 84% of image pairs of the same grade were found not to show clinically relevant differences. This confirmed that the scale of the HVRS corresponded to clinically relevant distinctions. CONCLUSIONS: The scale was proven to be precise, reproducible, and reflective of clinical differences.

Approach for naso-orbito-ethmoidal fracture

The purpose of this study is to discuss several approaches to addressing naso-orbito-ethmoidal (NOE) fracture. Orbital fracture, especially infraorbital fracture, can be treated through the transconjunctival approach easily. However, in more severe cases, for example, fracture extending to the medial orbital wall or zygomatico-frontal suture line, only transconjunctival incision is insufficient to secure good surgical field. And, it also has risk of tearing the conjunctiva, which could injure the lacrimal duct. Also, in most complex types of facial fracture such as NOE fracture or panfacial fracture, destruction of the structure often occurs, for example, trap-door deformity; a fracture of orbital floor where the inferiorly displaced blowout facture recoils to its original position, or vertical folding deformity; fractured fragments are displaced under the other fragments, causing multiple-packed layers of bone.

A 30-year neglected foreign body mimicking a maxillary fracture

A-50-year-old male patient presented with complaint of tenderness on the left malar area after traffic accident. Our first impression on him was zygomatic fracture, we did radiologic work-up and physical examination on him. But, on the computed tomography scan, there was no fracture or discontinuity on his facial bone. The computed tomography scan was revealed a 4-cm long foreign body in left maxillary sinus with a large amount of fluid collection. After thorough history taking from him, we reveal the patient had a history of trauma 30 years back on the left zygomatic area with a chopstick. The foreign body was removed via transoral approach with the endoscopic assist. There was no complication after operation.

A prospective, comparative evaluation of axillary hair removal with an 808-nm diode laser at different fluences

BACKGROUND: Diode lasers are the gold standard for removing unwanted hair. Lowering the energy should result in less pain and could theoretically affect therapeutic efficacy. This study evaluated the efficacy of an 808-nm diode laser at different fluences for permanent axillary hair removal in Korean women. METHODS: Twenty-four Korean women were divided into two groups. Each patient received laser treatment at both axillae, which were divided into upper and lower parts. Each part received different fluence from an HR808 prototype diode at 1-month intervals: 8, 10, 12, and 14 J/cm². Hair count and thickness were recorded at each follow-up visit and at a 3-month follow-up after the final laser treatment by photography and using a folliscope. At the final visit, pain and patient satisfaction were surveyed. Three plastic surgeons assessed the results on photographs. RESULTS: The mean hair follicle density reduction was 62.18%, 65.28%, 73.08%, and 78.29% on the right upper side, right lower side, left upper side, and left lower side, respectively. The mean hair follicle thickness reduction was 45%, 48%, 54%, and 59% on the right upper side, right lower side, left upper side, and left lower side, respectively. In the plastic surgeons' assessment, the left upper and lower sides scored 2.71. The right upper and lower sides scored 2.38 and 2.04, respectively. CONCLUSIONS: High-fluence (14 J/cm²) treatment with an HR 808 prototype diode laser efficiently removed unwanted hair. No significant difference in comfort was reported compared to the low-fluence mode (8–10 J/cm²).

Usefulness of Optical Coherence Tomography in the Preoperative Assessment of Nail Deformities

Secondary nail deformities are often seen at some time after fingertip and nail bed injuries. A proper evaluation of the fingernail enables appropriate diagnosis and treatment, especially in patients who need surgical management. To date, ultrasound and magnetic resonance imaging are the only diagnostic tools that most surgeons use in cases of nail deformities. Herein, we report the case of a patient with a nail deformity who underwent successful correction based on the preoperative use of real-time optical coherence tomography.

The Characteristics and Safety of Previous Fillers in Secondary Rhinoplasty

BACKGROUND: Filler injection into the soft tissue of the nose is a useful technique for rhinoplasty. The individual characteristics of fillers determine which is best suited for a patient's specific circumstances. The objective of this study was to identify the characteristics of various fillers and to determine which fillers should be used for primary rhinoplasty in order to yield optimal long-term results. METHODS: Excluding patients treated with hyaluronic acid fillers, we reviewed 17 patients who underwent surgical rhinoplasty due to dissatisfaction with an injection using a different filler. After removing the previously injected filler, rhinoplasty was performed as part of the same procedure using a silicone or Surgiform® prosthesis. RESULTS: Various previous fillers were used in the cohort. During the process of filler removal, skin perforation occurred in 2 cases and infection was observed in 1 case. In the other cases, rhinoplasty using a prosthesis was performed at the time of filler removal and no complications were observed. CONCLUSIONS: We found that if surrounding tissue had been maintained stably, a simultaneous secondary operation using implants produced ideal results in most cases without any complications, despite the presence of residual remnant filler material.

Restoration of an Upper Lip Affected by Necrotizing Ulcerative Stomatitis Using Bilateral Cheek Advancement with a Crescentic Perialar Excision

Necrotizing ulcerative stomatitis (NUS) refers to ulceration of the oral mucosa that precedes rapid orofacial soft- and hard-tissue destruction. NUS on the upper lip is considered a reconstructive challenge because of the functional importance and complex multidimensional structure of the facial units that are involved, and is most commonly found in developing countries. Therefore, few studies have been conducted on NUS. Moreover, reconstruction options vary from local regional flaps to free-tissue transfers. We report a very interesting case in which we performed regional flap surgery using bilateral cheek advancement in a patient with NUS. A 75-year-old woman with a history of diabetes mellitus and hypertension, but no other immunological diseases, presented with skin necrosis on the upper lip. At presentation, necrotic tissue covered the upper lip and philtrum, but it had not invaded the nose or lower lip. After debridement of the necrotic tissue, approximately 70% of the upper lip was missing. We therefore designed a bilateral cheek advancement and rotation flap, in which the flap was sutured in 3 layers. There was no need to perform additional procedures, as the flap healed well and showed no other complications or recurrence. The patient exhibited good voluntary muscle control and oral competence while eating and drinking, and she was also very satisfied with the cosmetic results. Thus, regional flap surgery using a simple advancement flap may result in good recovery of both functional and aesthetic units in patients with NUS.

Changes in Implant Thickness after Rhinoplasty Using Surgiform

BACKGROUND: Gore-Tex implants started out as a product with the distinct advantage of producing a natural nose shape, but using Gore-Tex, it is difficult to predict the height of the nose after rhinoplasty because Gore-Tex contracts over time, making the nose shrink. However, Surgiform, a new form of expanded polytetrafluoroethylene (ePTFE) implant, enables prediction of the height of the nose after rhinoplasty because the implant does not change in thickness even after many years. Thus, we investigated whether changes in implant thickness occurred after rhinoplasty using Surgiform implants. METHODS: This study enrolled 12 patients who had Surgiform nasal implants removed for any reason after receiving rhinoplasty in 2007 or later. After the Surgiform implants were removed, we measured the thickness of the central part of the implants using calipers. RESULTS: At the time of the initial operation, the mean implant thickness was 4.48±0.30 mm at the supra-tip. At the time of implant removal, the mean thickness was 4.32±0.29 mm. The implants maintained 96.5% of their initial thickness. There was a negligible reduction in the Surgiform implants' thickness over time. CONCLUSIONS: Surgiform implants maintained their shape after rhinoplasty, making it possible to predict the height of the nose. Thus, Surgiform is more useful for nasal implants than other ePTFE implants.

The Efficacy of a Q-Switched 694-nm Ruby Fractional Laser for Treating Acquired Bilateral Nevus of Ota-Like Macules

BACKGROUND: Acquired bilateral nevus of Ota-like macules (ABNOM) are a common form of hyperpigmentation in Asian populations, characterized by brownish-blue or slate-gray pigmentation in the bilateral malar regions. The purpose of this study was to evaluate the efficacy and complications of a Q-switched (QS) fractional ruby laser in the treatment of ABNOM. METHODS: Forty-four patients with ABNOM treated with a QS fractional ruby laser from January 2014 to February 2016 were enrolled in this study. Patients received up to 10 treatment sessions, at intervals ranging from 3 to 4 weeks. An automatic skin diagnosis system was used before and after laser treatment to evaluate the efficacy of the laser treatment. To evaluate the complications of the laser treatment, a retrospective chart review was conducted. RESULTS: Forty-one patients were female, and 3 were male. The mean age of the patients was 47.2 years, and the mean follow-up period was 14 months. The median skin pigmentation score was 5 (interquartile range [IQR], 5–6) before laser treatment and 3 (IQR, 3–4) after laser treatment. A statistically significant difference (P < 0.01) was found in the skin pigmentation score before and after laser treatment. CONCLUSIONS: This study suggests that, although multiple sessions are required, QS ruby fractional lasers can be considered an effective and less invasive form of treatment of ABNOM.