An Analysis of Risk Factors of Recipient Site Temporary Effluvium After Follicular Unit Excision: A Single-Center Retrospective Study.

BACKGROUND: Temporary hair loss at the recipient site after hair restoration surgery is called shock loss (SL). This study analyzed the risk factors for SL among patients who received follicular unit excision. MATERIALS AND METHODS: This study included 621 patients (554 males and 67 females). Twenty-three patients had SL (9 males and 14 females with a mean age of 40.8 years). The prevalence of SL was analyzed in relation to sex, age, graft follicular units, cause of alopecia, diabetes mellitus, smoking, drinking alcohol, and local anesthesia agent. RESULTS: Sex was identified as a risk factor for SL (odds ratio [OR]: 30.18; 95% confidence interval [CI] 9.43-96.55; p<0.001). Among female patients, age was identified as a risk factor for SL (OR:1.07; 95% CI 1.00-1.15; p=0.039). Over 40 years, the female pattern hair loss group had a significantly higher risk for SL than a female cosmetic group younger than 39 years. CONCLUSION: Sex was the only risk factor found for SL in this study. In addition, age was identified as a risk factor for SL among female patients. We believe our results provide information and risk factors for SL, not only for hair transplant surgeons, but also patients who will receive follicular unit excision. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Treatment of Linear and Narrow Scar after Craniotomy Using the Follicular Unit Excision.

Background The scar alopecia after cranioplasty (SAC) may decrease the patient's quality of life. We have treated SAC using follicular unit extraction (FUE). The aim of this study was to discuss that efficacy of FUE and how much hair follicular unit (FU) should be transplanted intraoperatively for the treatment of SAC. Methods We treated 10 patients (4 men and 6 women) who had SAC using FUE. Results The average age, alopecia size, and intraoperative hair density on the graft area were 29.8 ± 12.1 years, 29.8 ± 44.5 cm 2 , and 34.6 ± 11.8 FU/cm 2 , respectively. One year postoperatively, the average hair survival rate on the graft area was 66.3 ± 6.1%. Hair appearance was rated as good in six, fair in three, and poor in one. Among patients whose 1-year postoperative hair density was ≥ 20 FU/cm 2 , five of six patients achieved good results. However, among patients whose 1-year postoperative hair density was < 20 FU/cm 2 , all four patients achieved fair or poor results. The postoperative hair density was significantly higher in patients whose 1-year postoperative hair density was ≥ 20 FU/cm 2 than in patients whose 1-year postoperative hair density was < 20 FU/cm 2 . The rate of achieving fair or poor results was significantly higher if the postoperative hair density was < 20 FU/cm 2 than if it was ≥ 20 FU/cm 2 ( p = 0.047). Conclusions FU excision is useful for the treatment of scar alopecia after craniotomy. Our results suggest that the 1-year postoperative hair density should exceed 20 FU/cm 2 to achieve good outcomes.

Characterization of human epithelial resident memory regulatory T cells.

Human resident memory regulatory T cells (Tregs) exist in the normal, noninflamed skin. Except one, all previous studies analyzed skin Tregs using full-thickness human skin. Considering that thick dermis contains more Tregs than thin epidermis, the current understanding of skin Tregs might be biased toward dermal Tregs. Therefore, we sought to determine the phenotype and function of human epidermal and epithelial Tregs. Human epidermis and epithelium were allowed to float on a medium without adding any exogenous cytokines and stimulations for two days and then emigrants from the explants were analyzed. Foxp3 was selectively expressed in CD4+CD103- T cells in the various human epithelia, as it is highly demethylated. CD4+CD103-Foxp3+ cells suppressed proliferation of other resident memory T cells. The generation and maintenance of epithelial Tregs were independent of hair density and Langerhans cells. Collectively, immune-suppressive CD4+CD103-Foxp3+ Tregs are present in the normal, noninflamed human epidermis and mucosal epithelia.

Revisiting the Experimental Methods for Human Skin T-Cell Analysis.

Tissue-resident memory T cells exist in both the epidermis and the dermis in human skin. To analyze these cells, the skin needs to be incubated with dispase II to separate the two layers, that is, the epidermis and the dermis. The next step varies among researchers; the subsequent enzymatic digestion of the two layers is popular, whereas the spontaneous migration method can also be done. Scraping of these layers to yield skin T cells may reduce antigen modulation. This study aimed to determine each method's limitations. Dispase II incubation itself cleaves T-cell antigens. Therefore, further enzymatic digestion with collagenases strongly cleaves antigens. The scraping method yields skin T cells that are affected by dispase II as it is. However, skin T-cell yield is low. The spontaneous migration method recovers and/or upregulates antigens with T-cell activation and loses ∼20% of T cells in the floating sheets. However, there was no prominent bias regarding CD103 expression between emigrants and the remaining T cells in the sheets. There were 104 and 105 CD3+ T cells per 1 cm2 of the epidermis and upper dermis, respectively. Collectively, each method has strengths and limitations to analyze both the epidermal and dermal T cells.

Tissue Expander-associated T Cells: Relevance to Breast Implant-associated Anaplastic Large-cell Lymphoma.

The generation of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is closely associated with textured implants. The phenotype of BIA-ALCL cells is well examined, but its cell of origin remains unknown. Here we investigate what types of T cells are recruited and differentiated in the surrounding capsules and tissues as a consequence of continuous contact with a textured surface. Methods: Capsule and pericapsule tissues were recovered from patients who had textured or smooth tissue expanders (TEs). These samples were enzymatically digested, and T cells in the samples were analyzed using flow cytometry. Peripheral blood mononuclear cells from the same donors were utilized as a control. Results: Effector memory CD4+ T cells predominantly infiltrated capsules and tissues without apparent differences between textured and smooth TEs. In these effector memory CD4+ T cells, CD4+ resident memory T cells were generated by smooth TEs but not by textured TEs. However, TNFRSF8/CD30 mRNA expression is higher in the CD69- effector memory CD4+ T cells than in the CD69+ ones. Conclusion: Textured and smooth TEs differentially recruit and/or differentiate T cells in situ.

Negative-pressure Wound Therapy for Sacral Pressure Ulcer in Gorham-Stout Disease.

Gorham-Stout disease (GSD) is a rare musculoskeletal disorder characterized by progressive bone resorption and overgrowth of lymphatic vessels. The mechanism of GSD is still largely unknown. Negative-pressure wound therapy (NPWT) is known to accelerate wound healing and is used worldwide. Herein, we report a successful treatment of a patient with GSD having a sacral pressure ulcer, using NPWT. An 18-year-old female GSD patient was referred to our department for treating a sacral wound. The wound was disinfected by pocket incision, cleansing, and administration of antibiotics; however, the lesion remain unhealed. Histopathology of the debrided sacral wound revealed fibrous granulation tissue, with no sign of lymphatic anomalies. NPWT was started with -75 mm Hg of pressure, and neither lymphorrhea nor growth of lymphangioma was noted. Negative pressure was gradually increased to -125 mm Hg. The ulcer size decreased to 2 × 2 cm2, which healed 3 months after hospital discharge, with no recurrence for 8 months. For progressive diseases such as GSD, NPWT may cause the regrowth of lymphangioma or other neoplasms due to an increase in vessel endothelial growth factor. NPWT appears to be one of the safest and most effective wound therapies even for this rare and difficult disease, provided the use of the following treatment protocol: Pathohistological assessment before application of NPWT, and negative pressure initially set at a low level; then, gradually increased, with careful observation to avoid lymphorrhea. When changing the foam dressing, careful checking is important to determine whether the wound is necrotic, or if there is tumor-like tissue accumulation rather than healthy granulation.

Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan.

BACKGROUND: Mastectomy is performed in female-to-male transsexual (FTM TS) patients as a surgical treatment to make a female thorax resemble a male thorax; however, no studies have examined the nipple-areolar complex (NAC) position in FTM TS patients after mastectomy. PATIENTS AND METHODS: The NAC position in 41 FTM TS patients before and after non-skin-excisional mastectomy was examined and compared with that in 50 age- and BMI-matched biologically male subjects as controls. The factors affecting the NAC position after the operation were also examined and verified by multiple regression analysis. RESULTS AND CONCLUSIONS: After non-skin-excisional mastectomy, the NAC in the FTM TS patients was positioned significantly more medially (horizontal NAC position ratio {('internipple distance'/'width of thorax') × 100} [HNPR]: preoperatively, 70.07% ± 4.19%; postoperatively, 63.28% ± 3.79%) and cranially (vertical NAC position ratio {('distance from sternal notch to nipple height'/'distance from sternal notch to umbilicus') × 100} [VNPR]: preoperatively, 43.87% ± 3.68%; postoperatively, 41.37% ± 3.15%). Postoperatively, the NAC in the FTM TS patients was located significantly more medially than that in the control subjects (HNPR: 63.28% ± 3.79% to 66.79% ± 4.82%), although the height of the NAC was the same. Multiple regression analysis revealed that the NAC position on breasts characterized by ptosis, a high projection, and lateral leaning (low skin elasticity and a substantial amount of skin between the nipples) tended to be positioned more medially after non-skin-excisional mastectomy. Laterally deviated eccentric circular type mastectomy may be a good option for FTM TS patients who have moderately sized breasts with such features. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Restoration of Bilateral Cranial Defects by Hybridization of Microvascular Free Flaps and Artificial Bones.

Although treatment methods for cranial reconstruction have significantly improved over the past decades, patients having potentially negative influences, such as a history of infection, epidural dead space, or inadequate scalp, remain at high risk of postoperative failure from implant infection and exposure necessitating removal. A 41-year-old male patient sustained severe craniofacial injuries in a traffic accident. Cranioplasty with titanium mesh implants failed due to implant infection, leading to implant removal and debridement. Following repeated local infections and a craniectomy, the patient developed large bilateral complex cranial defects. We then performed a multistage operation, consisting of vascularized free-flap transfers to cover the intracranial dead spaces, and bony reconstruction using hydroxyapatite implants, which achieved full restoration of the defects. We believe that this is the better operative plan for treatment of cranial defects in patients with high-risk factors.

An anatomic study of nipple position and areola size in Asian men.

BACKGROUND: In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men. OBJECTIVES: The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men. METHODS: Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI. RESULTS: Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI. CONCLUSIONS: Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.

Identification of the cause of severe skin infection by Fournier transform infrared spectroscopy: a case of Fournier's gangrene caused by fish bone.

Fournier's gangrene (FG) is an infrequent but highly lethal infection. Here we report a 74-year-old man who presented with genital swelling and severe malaise. Based on the physical and imaging examination results, the diagnosis of FG was confirmed. Intraoperative findings showed dirty necrosis of soft tissue, and a splinter-shaped foreign body was found in the perirectal region. The foreign body was thought to be the cause of the condition, and it was analyzed using Fourier transform infrared spectroscopy. We found that the foreign body was a mixture of calcium phosphate and protein, suggesting that the splinter was a bone. Moreover, during the medical interview, the patient mentioned about intake of fish around the time of onset of symptoms. Therefore, to confirm the results of the analysis, DNA was extracted from the foreign body, and genomic PCR with subsequent sequence analysis was performed. The DNA sequence was identical to that of Oncorhynchus kisutch, a salmon that is a very popular food in Japan. On the basis of these findings, we concluded that FG in this case was caused by the penetration into the rectum of an accidentally ingested fish bone. Although some cases of intra-abdominal abscess due to accidental ingestion of fish bone have been reported, FG caused by fish bone is extremely rare.

Muscular pedicled lateral chest composite flap-a new nonmicrosurgical option for forearm salvage.

SUMMARY: Posttraumatic upper or lower limb salvage is still challenging. Under difficult situations in which only one vessel supplies the hand or foot, free microvascular reconstruction might damage not only the transferred tissue but also the terminal hand or foot. Two cases of incomplete amputation of the unilateral forearm with large radius bone and soft tissue loss were reconstructed using a newly-refined pedicled osteomyocutaneous flap including vascularized rib, lateral part of the latissimus dorsi muscle, and skin as a lateral chest flap. After insetting of the flap, the transferred limb is fixed with a soft bandage, and the flap is divided no less than 4 weeks after the first operation. The flap completely survived, and bone union between the rib and radius was observed. Although our treatment needed a two-stage procedure, safe and secure reconstruction with an appropriate amount of tissue for salvage was accomplished.

Comparative study of different combinations of microvascular anastomosis types in a rat vasospasm model: versatility of end-to-side venous anastomosis in free tissue transfer for extremity reconstruction.

BACKGROUND: There have been many studies comparing the patency rates of end-to-end and end-to-side microvascular anastomoses in both arteries and veins. Most of them failed to demonstrate a significant difference. The purpose of this study was to compare three different combinations of microvascular anastomoses in a rat vasospasm model, and determine which type of anastomosis is the most tolerant to vasospasm. METHODS: Ninety Wistar rats were divided into three groups (n = 30 for each). In each group, a free pectoral skin flap was elevated and microsurgically transferred to the anterior cervical region. In group 1, end-to-end anastomoses were performed on both arteries and veins, in group 2 end-to-side anastomoses were performed on arteries and end-to-end anastomoses were performed on veins, and in group 3 end-to-end anastomoses were performed on arteries and end-to-side anastomoses were performed on veins. After revascularization, vasospasm was induced with topical epinephrine. Flap survival was assessed on day 3, and the success rates of the three groups were compared. RESULTS: The flap success rate was 73.3% (22 of 30) in group 1, 66.7% (20 of 30) in group 2, and 96.7% (29 of 30) in group 3. The differences between groups 1 and 3 and between groups 2 and 3 were statistically significant. Overall, venous thrombosis was much more frequent than arterial thrombosis. CONCLUSIONS: In a rat epinephrine-induced vasospasm model, venous thrombosis was much more frequent than arterial thrombosis. The type of arterial anastomosis did not affect the success rate, but end-to-side venous anastomosis had a higher success rate than end-to-end venous anastomosis.

Endoscopic and ultrasonic removal of a lipoma on the forehead with no facial scarring: practicality of patient's early return to work.

We used endoscopy and ultrasonic liposuction to remove lipomas from the forehead to facilitate early return to work. The tumours were approached through a pair of small remote scalp incisions behind the frontal hairline, which continued to subperiosteal dissection, thereby avoiding injury to the supraorbital or supratrochlear neurovascular bundles. The deep surfaces of the lipomas were identified easily through the periosteum by well-illuminated and magnified endoscopic views, and protruded through the periosteal incisions. An ultrasonic cannula was introduced to emulsify and aspirate the lipomas. Parts of the lipomas were extracted by forceps as solid specimens for histopathological evaluation. Preservation of the neurovascular bundles and complete resection of the tumours in the bloodless operative fields were confirmed by direct endoscopic monitoring. Of five patients treated, three returned to their jobs within two postoperative days, with no protective dressings on their faces. There have, to our knowledge, been few reports describing this combination of endoscopy and ultrasonic treatment of forehead lipomas.

Retrospective outcome analysis of temporalis muscle transfer for the treatment of paralytic lagophthalmos.

Temporalis muscle transfer for paralytic lagophthalmos, which was first proposed by Gillies and later developed by Andersen, has been one of the most common treatment modalities for paralytic lagophthalmos. However, there have been no scientific reports statistically analysing the efficacy of temporalis muscle transfer. We, therefore, retrospectively analysed the functional and aesthetic results of temporalis muscle transfer. Between 1994 and 2006, we carried out temporalis muscle transfer (the so-called Gillies-Andersen method) on 95 established facial paralysis patients. We sent a postal questionnaire to these patients and 47 of them responded. The functional and aesthetic results were analysed based on the patients' replies together with clinical records and photographs, and unfavourable factors of this procedure were investigated. After surgery, most ocular symptoms (mechanical irritation, dry eye, soreness, and discharge) improved significantly. Achievement rate of complete eye closure was 78.7%. A morphometric study revealed that possible unfavourable factors (old age, intracranial disease, use of dentures, etc.) did not affect the achievement rates of complete eye closure. Deformity of eyelid fissure due to undue tension of the temporal fascia fixation was found in nine patients (19.1%) and six of these patients underwent secondary revision. Unlike lid loading with a gold implant, the results of temporalis muscle transfer depend greatly on the surgeon's skill. However, if this procedure is performed properly, strong eye closure can be obtained. We, therefore, recommend temporalis muscle transfer as the preferred option for reconstruction of paralytic lagophthalmos.

Transconjunctival orbital fat repositioning for tear trough deformity in young Asians.

BACKGROUND: Tear trough deformity is a primary complaint in those who believe it causes an old and tired appearance. This deformity naturally increases with aging, but there are younger people that also complain about the appearance of their lower eyelid area. Recently, many authors have reported good results treating this deformity with transconjunctival orbital fat repositioning. Although Kawamoto has pointed out a possible need for a procedure modification in Asians with a brachycephalic face, thus far, there have been no reports evaluating such procedures in Asians. OBJECTIVE: In November 2004, to validate past clinical experiences, we planned a prospective study in young Japanese Asians to assess the efficacy of orbital fat repositioning for improvement of lower eyelid disfigurement. Our goal was to evaluate the viability of transconjunctival repositioning of orbital fat using a preseptal dissection and supraperiosteal pocket method. METHODS: The prospective study was performed in 20 Japanese patients younger than 40 years of age who were referred to our department over a 1-year period. These patients, in whom eyelid skin tightening was deemed unnecessary, underwent transconjunctival blepharoplasty. Using a transconjunctival incision, a preseptal dissection was performed, extending over the arcus marginalis. A supraperiosteal pocket was made below the orbicularis oculi muscle with blunt scissor dissection. The arcus marginalis was then released by cautery cutting. Both the orbital fat and orbital septum were anchored across the orbital rim with 5-0 polyglactin sutures. RESULTS: Results in 18 of 20 patients (90%) were rated as "excellent," the result for 1 patient (5%) was rated as "good," and the result for the 1 remaining patient was rated as "fair." No major eye or eyelid complications, such as lower eyelid retraction, ectropion, or diplopia, were observed. CONCLUSIONS: Transconjunctival orbital fat repositioning (incorporating preseptal dissection and supraperiosteal pockets) is an effective and safe method for relatively young Asians complaining of lower eyelid disfigurement.

Transzygomatic coronoidectomy as a treatment for pseudoankylosis of the mandible after transtemporal surgery.

Pseudoankylosis of the mandible after a transtemporal operation is rare. In patients with severely limited mouth opening, a transzygomatic approach is the approach of choice. We report a case of pseudoankylosis of the mandible that was successfully treated by transzygomatic coronoidectomy.

Temporary suspension of acute facial paralysis using the S-S Cable Suture (Medical U&A, Tokyo, Japan).

For a treatment of facial paralysis, suture suspension of soft tissue is considered effective due to its less invasiveness and relatively simple technique, with minimal bruising and rapid recovery. However, suture suspension effect may not last for a long period of time. We obtained good outcome with temporary static suture suspension in 5 cases of severe facial paralysis in the intervening period between the onset of paralysis and expected spontaneous recovery. We used the S-S Cable Suture (Medical U&A, Tokyo, Japan), which was based on the modification of previously established method using the Gore-Tex cable suture originally reported by Sasaki et al in 2002. Because of the ease of technique and relatively strong lifting capability of the malar pad, we recommend it as a useful procedure for a patient suffering acute facial paralysis with possible spontaneous recovery for an improved quality of life by the quick elimination of facial distortion.

Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for periorbital skin hyperpigmentation in Asians.

BACKGROUND: Periorbital skin hyperpigmentation, so-called dark circles, is of major concern for many people. However, only a few reports refer to the morbidity and treatment, and as far as the authors know, there are no reports of the condition in Asians. METHODS: A total of 18 Japanese patients underwent combined therapy using Q-switched ruby laser to eliminate dermal pigmentation following topical bleaching treatment with tretinoin aqueous gel and hydroquinone ointment performed initially (6 weeks) to reduce epidermal melanin. Both steps were repeated two to four times until physical clearance of the pigmentation was confirmed and patient satisfaction was achieved. Skin biopsy was performed at baseline in each patient and at the end of treatment in three patients, all with informed consent. Clinical and histologic appearances of periorbital hyperpigmentation were evaluated and rated as excellent, good, fair, poor, or default. RESULTS: Seven of 18 patients (38.9 percent) showed excellent clearing after treatment and eight (44.4 percent) were rated good. Only one (5.6 percent) was rated fair and none was rated poor. Postinflammatory hyperpigmentation was observed in only two patients (11.1 percent). Histologic examination showed obvious epidermal hyperpigmentation in 10 specimens. Dermal pigmentation was observed in all specimens but was not considered to be melanocytosis. Remarkable reduction of dermal pigmentation was observed in the biopsy specimens of three patients after treatment. CONCLUSION: The new treatment protocol combining Q-switched ruby laser and topical bleaching treatment using tretinoin and hydroquinone is considered effective for improvement of periorbital skin hyperpigmentation, with a low incidence of postinflammatory hyperpigmentation.

Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face.

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.