Recurrent delayed hypersensitivity reaction to a hyaluronic acid soft-tissue filler following COVID-19 vaccination: a case report

Hyaluronic acid soft-tissue fillers are the second most widely used injectable agents in cosmetic surgery. During the coronavirus disease 2019 (COVID-19) pandemic, a few cases of delayed hypersensitivity reactions to hyaluronic acid filler injections have been reported following COVID-19 infection or vaccination against the virus. A 61-year-old woman visited the emergency room with swelling and redness on the entire face that started on the nasolabial area. She had received hyaluronic acid filler injections in her nasolabial area 8 months previously and had completed the primary series of vaccinations and received a booster dose of the mRNA Pfizer-BioNTech COVID-19 vaccine 1 month before the swelling episode. A corticosteroid was added to the antibiotic regimen because of the nonsignificant effect of the antibiotics. The symptoms then resolved, and corticosteroid use was tapered over the course of 2 weeks. Four months later, swelling and redness recurred on both nasolabial folds and chin, but the symptoms were more localized than before. The renewed symptoms regressed with surgical drainage and corticosteroid and antibiotic treatment. This study discusses this extremely rare case of a recurrent delayed hypersensitivity reaction to a hyaluronic acid soft-tissue filler following COVID-19 vaccination.

De-epithelialized dermal flap for nipple reconstruction: A modified star flap

BACKGROUND: Multiple approaches for nipple reconstruction exist, and none is considered superior to all others. The star flap is one of the most popular methods for nipple reconstruction, but gradual height loss is a major concern. We present a new modification of the star flap that incorporates a de-epithelialized dermal flap, along with the associated surgical results. METHODS: We reviewed the medical records of patients who underwent nipple reconstruction using the modified star flap method. The design was different from the conventional star flap in that the lateral wings were changed into a trapezoidal shape and de-epithelialized dermal flaps were added. The patients were followed up at 2, 4, 6, and 12 months postoperatively, and nipple height was measured. The postoperative nipple height achieved using the modified method was compared with that obtained using the traditional method. RESULTS: From February 2013 to June 2017, 32 patients received surgery using the modified star flap, and 18 patients who underwent nipple reconstruction before 2013 comprised the conventional method group. All patients had undergone breast reconstruction with an abdominal tissue-based flap. The mean follow-up period was 14.4 months in the modified method group and 17.3 months in the conventional method group. The mean maintenance of projection at 12 months postoperatively was 56.28%±18.58% in the modified method group, and 44.23%±14.15% in the conventional method group. This difference was statistically significant (P<0.05). CONCLUSIONS: The modified method using a de-epithelialized dermal flap provides reliable maintenance of projection in patients who have undergone abdominal tissue-based breast reconstruction.

Mandibular reconstruction using customized three-dimensional titanium implant

Mandibular defects lead to severe deformation and functional deficiency. Vascularized osteocutaneous tissue has been widely used to reconstruct the mandible. However, it is technically challenging to shape this type of grafts in such a manner that they resemble the configuration of the mandible. A 48-year-old female patient who underwent anterolateral thigh (ALT) flap coverage after a tongue cancer excision was diagnosed with a tumor recurrence during the follow-up. A wide excision mandibulectomy and mandibular reconstruction with an ALT flap and a titanium implant were performed. The prefabricated titanium implant was fixed to the condyle. Then, an ALT flap was harvested from the ipsilateral thigh and anastomosed. After confirming that the circulation of the flap was intact, the implant was fixed to the parasymphysis. On the radiograph taken after the surgery, the prosthesis was well positioned and overall facial shape was acceptable. There was no postoperative complication during the follow-up period, 1 year and 2 months. The prefabricated implant allows the restoration of facial symmetry without harvesting autologous bone and it is a safe and effective surgical option for mandibular reconstruction.

Lymphatic vessel mapping in the upper extremities of a healthy Korean population

BACKGROUND: Intraoperative indocyanine green (ICG) lymphography can effectively detect functioning lymph vessels in edematous limbs. However, it is sometimes difficult to clearly identify their course in later-stage edematous limbs. For this reason, many surgeons rely on experience when they decide where to make the skin incision to locate the lymphatic vessels. The purpose of this study was to elucidate lymphatic vessel flow patterns in healthy upper extremities in a Korean population and to use these findings as a reference for lymphedema treatment. METHODS: ICG fluorescence lymphography was performed by injecting 1 mL of ICG into the second web space of the hand. After 4 hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera, and the lymphatic vessels were marked. Three landmarks were designated: the radial styloid process, the mid-portion of the cubital fossa, and the lower border of the deltopectoral groove. A straight line connecting the points was drawn, and the distance between the connected lines and the marked lymphatic vessels was measured at 8 points. RESULTS: There were 30 healthy upper extremities (15 right and 15 left). The average course of the main lymph vessels passed 26.0±11.6 mm dorsal to the styloid process, 5.7±40.7 mm medial to the mid-cubital fossa, and 31.3±26.1 mm medial to the three-quarters point of the upper landmark line. CONCLUSIONS: The main functioning lymphatic vessel follows the course of the cephalic vein at the forearm level, crosses the mid-cubital point, and travels medially toward the mid-axilla.

Footplate Incision in Rhinoplasty: an Update

BACKGROUND: In 2004, we reported on 110 consecutive Asian rhinoplasty patients who were treated with the addition of a footplate incision to obtain a greater aesthetic satisfaction. We continue to perform the reported technique with several modifications, and we still think that this method contributes to Asian rhinoplasty. METHODS: A footplate incision was made along the caudal border of the footplate of the medial crura onto the floor of the nasal vestibule. This incision can be made alone or in combination with either endonasal or open rhinoplasty. It enables surgeons to achieve a further tip projection since the pressure of the skin flap is reduced on the tip. In this study, we emphasize a couple of recent changes that we made to our procedure after publication of the prior article. First, we excised the dog-ear that appeared at the caudal end of the extended footplate incision. After making the new tip, a dog ear can be seen at the posterior end of the footplate incision. Second, an inferior columellar dissection was also extended to achieve an additional tip projection and to improve the columello-labial angle. RESULTS: This study included 85 consecutive patients who underwent an aesthetic rhinoplasty using footplate incision techniques between August of 2010 and May of 2013. A total of 43 patients had an adequate follow-up time of over 12 months. The majority of the patients (40/43 cases) were satisfied with the results. CONCLUSIONS: The authors believe that a footplate incision in aesthetic rhinoplasty is safe and can reliably achieve better results for Asian patients.

Revision of a Widened Scar Using Dermal Splinting Technique

BACKGROUND: Scar revision is a fundamental technique in the field of plastic and reconstructive surgery. Methods using local flaps, such as a Z-plasty, W-plasty, or geometric broken-line closure, have been used for scar revision. Widening of scars is a frustrating event that most plastic surgeons have encountered. Several therapeutic modalities have been proposed, but frequently, the result is disappointing. We describe our experience with the use of a dermal splinting technique for scar revision. METHODS: We propose a technique by which tension on the wound is applied by tough scar tissue instead of the suture line, thereby reducing the incidence of postoperative widening. This technique was used to treat 21 nonburn scars that had widened:5 scars were facial (3 patients), 8 were on the extremities (6 patients), and 8 were on the torso (5 patients). All scars were at least 4 months old. The operations were performed between January 2003 and December 2012; follow-up was 9 to 24 months. RESULTS: Only one scar widened during the follow-up period. Overall, satisfaction with scar appearance and surgery was assessed with a visual analog scale (VAS). Mean patient satisfaction was 8.1 +/- 0.5. CONCLUSIONS: We recommend this technique in dealing with widened scars in highly tensile areas during revision surgery.

Effects of the Diabetic Condition on Grafted Fat Survival: An Experimental Study Using Streptozotocin-Induced Diabetic Rats

BACKGROUND: Autologous fat grafts have been widely used for cosmetic purposes and for soft tissue contour reconstruction. Because diabetes mellitus is one of the major chronic diseases in nearly every country, the requirement for fat grafts in diabetes patients is expected to increase continuously. However, the circulation complications of diabetes are serious and have been shown to involve microvascular problems, impairing ischemia-driven neovascularization in particular. After injection, revascularization is vital to the survival of the grafted fat. In this study, the authors attempted to determine whether the diabetic condition inhibits the survival of injected fat due to impaired neovascularization. METHODS: The rat scalp was used for testing fat graft survival. Forty-four seven-week-old male Sprague-Dawley rats were allocated to a diabetic group or a control group. 1.0 mL of processed fat was injected subcutaneously into the scalp of each rat. The effect of diabetes was evaluated by calculating the volume and the weight of the grafted fat and by histologically analyzing the fat sections. RESULTS: The surviving fat graft volume and weight were considerably smaller in the diabetic group than in the control group (P<0.05), and histological evaluations showed less vascularity, and more cysts, vacuoles, and fibrosis in the diabetic group (P<0.05). Cellular integrity and inflammation were not considerably different in the two groups. CONCLUSIONS: As the final outcome, we found that the presence of diabetes might impair the survival and the quality of fat grafts, as evidenced by lower fat graft weights and volumes and poor histologic graft quality.

Modified Direct W-incision with Silicone Sheet to Minimize Operation Scar in Reconstruction of Mild to Moderate Symptomatic Medial Orbital Wall Fracture

BACKGROUND: For reconstruction of the mild to moderate medial orbital wall fractures, various surgical approaches have been used. Prior existing W-shaped incision was a direct local approach through a 3 cm incision on the superior medial orbital area with a titanium mesh implant. In this study, the authors modified W-shaped incision and reconstructed the defect with silastic sheet to improve the result and the postoperative scar. METHODS: This study included 20 patients who had mild to moderate size of medial wall defect and therefore relatively suitable for reconstruction with silastic sheets from July, 2009 to December, 2011. A modified W-shaped skin incision approximately 1.2 to 1.5 cm in length was made along the superior medial orbital rim from approximately 1 cm medial to the medial canthus to the lower border of the medial eyebrow. The angles of the limbs of the W ranged from 150 to 160 degrees. RESULTS: By using soft flexible silastic sheet, the authors reduced the incision from 3 to 1.5 cm, and by widening the angle of the W limbs, scars were more effectively hided in the relaxed skin tension line. Scar assessment was done with modified patient and observer scar assessment scale and mean score from patients was 2.08 and mean score from observers was 2.12. CONCLUSION: Although this method will not be suitable for every case, it can be a consistent method to obtain the surgical goal in treatment of mild to moderate blowout fractures of the medial orbital wall.

Reconstruction of Unexpected Huge Chest Wall Defect after Recurrent Breast Cancer Excision Using a TRAM Flap Combined with Partial Latissimus Dorsi Muscle Flap

No abstract available.

Fixation of Nasal Bone Fracture with Carved Merocel(R)

PURPOSE: In most cases of nasal bone fracture, closed reduction with internal or external splint fixation approach is selected. However, because of indiscriminate insertion of the internal splint without considering of anatomical difference or deformity, insufficient fixation happens frequently that need additional fixation. Therefore, we suggest a new method for providing adequate support in reduced nasal bone by carving Merocel(R) that is fixed for the anatomical structure. METHODS: Closed reduction and internal fixation with carved Merocel(R) was performed in 15 nasal bone fracture patients from March, 2010 to July, 2010. Each patient was evaluated by physical examination, facial photographic check, simple X-ray, and computerized tomography. On the first day post-operation, location of packing and amount of reduction were checked by follow up X-ray and computerized tomography. In addition, patients' symptoms were evaluated. During the 3-month post-op follow up at out-patient clinic, operator, 2 doctors in training and one assistant performed the objective evaluations by physical examination on nasal dorsal hump, nasal deviation, nasal depression, nasal breath difficulty, and nasal airway obstruction. A survey of subjective patients' satisfaction in 4-stages was also performed. RESULTS: The results of follow-up computerized tomography of the 15 patients revealed that 11 patients had good reduced state. Three patients with combined maxillary frontal process fracture had over reductions. A survey performed on the first day post-operation showed that 14 of 15 patients answered that their current symptoms were more than tolerable. At the 3-month follow-up physical exam, one case had a dorsal hump. However, there were no nasal deviations, nasal depressions, nasal breath difficulties, or nasal airway obstructions. Twelve of the 15 patients answered more than moderate on the 3-month survey. CONCLUSION: Intranasal packing after carving the Merocel(R) considering anatomical structure is a new effective method to promote proper-reduction, maintain stability, and minimize patients' symptoms by addition of a simple procedure.