The Effect of Botulinum Toxin A on the NADPH Oxidase System and Ischemia-Reperfusion Injury.

BACKGROUND: Despite the increasing popularity of various materials for ischemia-reperfusion (I/R) injury mitigation, research on botulinum toxin type A (BoNTA) remains limited. This study assesses BoNTA's efficacy in protecting flaps from I/R injury by inhibiting the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system and reducing reactive oxygen species (ROS) production. METHODS: Seventy-six Sprague-Dawley rats were studied. We examined the effects of BoNTA on superoxide production in four rats using a lucigenin-enhanced chemiluminescence assay (LECL). Another group of 60 rats had their superficial inferior epigastric artery (SIEA) flaps treated with either BoNTA or saline and clamped for 0, 1, and 4 hours before reperfusion. Flap survival and histological outcomes were assessed five days post-operation. ROS production in SIEA flaps and femoral vessels was analyzed in 12 additional rats, post-I/R injury. RESULTS: The LECL results showed that the BoNTA group had significantly lower superoxide production compared to controls, with notable reductions at 4 hours. While no significant differences were noted at the 0 and 1-hour marks, the 4-hour mark showed significant protective effects in BoNTA-treated groups. The survival rate was 90% for BoNTA-treated rats versus 60% for controls ( P = 0.028). Significant reductions in ROS were also observed in the 4-hour I/R group. CONCLUSIONS: BoNTA effectively protects against I/R injury by inhibiting the NADPH oxidase system and reducing ROS levels. These results support further investigation into the specific mechanisms of NADPH oxidase inhibition by BoNTA and its potential clinical applications, given its safety profile. CLINICAL RELEVANCE STATEMENT: The findings from the present study are expected to provide a basis for clinical studies regarding this use of BoNTA.

Improvement in Biocompatibility and Biointegration of Human Acellular Dermal Matrix through Vacuum Plasma Surface Treatment.

Efforts are ongoing to enhance the functionality of human acellular dermal matrices (hADMs), which are extensively utilized in reconstructive surgeries. Among these efforts, plasma treatments, particularly vacuum plasma treatments, have recently emerged in the medical field. This study aims to investigate the efficacy of a vacuum plasma treatment in enhancing the biocompatibility and biointegration of hADMs. Utilizing a plasma activator (ACTILINK reborn, Plasmapp Co., Ltd., Daejeon, Republic of Korea), hADMs were treated and evaluated through in vitro and in vivo analyses. Hydrophilicity changes were gauged by the blood absorption times, while SEM imaging was used to analyze physical surface deformation. Protein adsorption was measured with fluorescently labeled bovine serum albumin and fibronectin. For the in vivo study, mice were implanted with plasma-treated and untreated hADMs, and the post-implantation effects were analyzed through histological and immunofluorescence microscopy. The plasma-treated hADMs demonstrated a significantly enhanced hydrophilicity compared to the untreated samples. SEM imaging confirmed the maintenance of the microroughness after the treatment. The treated hADMs showed a significant reduction in fibronectin adsorption, a critical factor for cellular adhesion. In vivo, the plasma-treated hADMs exhibited reduced capsule formation and enhanced fibroblast infiltration, indicating improved biocompatibility and integration. These findings highlight the potential of a plasma treatment to enhance the performance of hADMs in clinical settings, offering a promising avenue for improving reconstructive surgery outcomes.

Malignant triton tumor in the abdominal wall: A case report.

BACKGROUND: Malignant triton tumors (MTTs) comprise a subgroup of malignant peripheral nerve sheath tumors (MPNSTs) that exhibits rhabdomyosarcomatous differentiation and follow an aggressive course. MTTs are primarily located along peripheral nerves. Cases of MTTs in the abdominal wall have not been reported. MTT has a poorer prognosis than classic MPNSTs, and accurate diagnosis necessitates a keen understanding of the clinical history and knowledge of its differential diagnosis intricacies. Treatment for MTTs mirrors that for MPNSTs and is predominantly surgical. CASE SUMMARY: A 49-year-old woman presented with a subcutaneous mass in her lower abdominal wall and a pre-existing surgical scar that had grown slowly over 3-4 months before the consultation. She had previously undergone radical hysterectomy and concurrent chemo-radiotherapy for cervical cancer approximately 5 years prior to the consultation. Abdominal computed tomography (CT) showed a 1.3 cm midline mass in the lower abdomen with infiltration into the rectus abdominis muscle. There was no sign of metastasis (T1N0M0). An incisional biopsy identified sporadic MTT of the lower abdomen. A comprehensive surgical excision with a 3 cm margin inclusive of the peritoneum was executed. Subsequently, the general surgeon utilized an approach akin to the open peritoneal onlay mesh technique. The patient underwent additional treatment with an excision shaped as a mini-abdominoplasty for the skin defect. No complications arose, and annual follow-up CTs did not show signs of recurrence or metastasis. CONCLUSION: An abdominal MTT was efficaciously treated with extensive excision and abdominal wall reconstruction, eliminating the need for postoperative radiotherapy.

The Effect of Botulinum Toxin A on NADPH oxidase system and Ischemia Reperfusion Injury.

BACKGROUND: While studies aimed at overcoming ischemia-reperfusion (IR) injury using various materials are becoming popular, studies using botulinum toxin type A (BoNTA) are still limited. This study tested the hypotheses that BoNTA can protect flaps from IR injury by inhibiting the NADPH oxidase system and suppressing ROS (reactive oxygen species) production. MATERIAL AND METHODS: The subjects were Sprague-Dawley rats (n = 76). In 4 rats, the effects of different dose of BoNTA on superoxide production was evaluated through lucigenin enhanced chemiluminescence assay (LECL) using SD rats' thoracic aorta ring. In 60 SD rats, The BoNTA and normal saline-pretreated superficial inferior epigastric artery (SIEA) flaps were clamped for 0, 1, and 4 hours, and reperfused. On the 5th day after the opeartion, well-maintained flaps were grossly inspected, survival rates were analyzed, and histological analysis was also performed. In 12 rats, after making IR injury through the same model, SIEA flap segments and femoral vessels were obtained, and ROS production was evaluated through LECL and dihydroethidium (DHE) staining. RESULTS: In LECL, the experimental group produced a smaller amount of superoxide than the control group through NADPH oxidase inhibition (p < .05). There was no significant difference between the experimental and control group in the 0, and 1 hour IR groups, but the experimental group (90%) showed a higher survival rate than the control group (60%) in the 4 hours IR group (p = .028). In the measurement of ROS production through LECL and DHE staining, there was no significant difference in the 0, and 1 hour IR groups, but a significant difference was shown in the 4 hours IR group in both the SIEA flaps and femoral vessels (p < .05). SUMMARY: This study verified hypothesis that BoNTA can protect flaps from IR injury by inhibiting the NADPH oxidase system and suppressing ROS production. Based on this research model, future research should be expanded into studies on subtypes or subunits of NADPH oxidase, and the findings from the present study are expected to contribute and lead to clinical studies on BoNTA, which has already been proven to be clinically safe.

Tailored versus conventional surgical debridement in complex facial lacerations in emergency department: A retrospective study.

Surgical debridement is an essential step in treating complex facial lacerations (CFL). As the CFL severity increases, conventional surgical debridement (CSD) of wound edges becomes difficult and may be insufficient. Because the severity and shape of each CFL vary, it is necessary to tailor the customized pre-excisional design, that is, tailored surgical debridement (TSD), for each case before performing surgical debridement. The use of TSD can enable effective debridement of CFL with higher severity. This study aimed to compare the cosmetic outcomes and complication incidence of CSD versus TSD according to CFL severity. In this retrospective observational study, eligible patients with CFL who visited the emergency department between August 2020 and December 2021 were examined. CFL severity was graded as Grades I and II. The outcomes of CSD and TSD were compared using the scar cosmesis assessment and rating (SCAR) scale, wherein a good cosmetic outcome was defined as a SCAR score of ≤ 2. The percentage of good cosmetic outcomes between the 2 groups was compared. The SCAR score and percentage of good cosmetic outcomes between the 2 groups were compared overall and by severity. For analyzing complication incidence, asymmetry, infection, and dehiscence incidence were compared. In total, 252 patients were enrolled [121 (48.0%) CSD and 131 (52.0%) TSD]. The median SCAR scores were 3 (1-5) and 1 (0-2) in all enrolled patients (P < .001), 2 (0-4), and 1 (0-1) in Grade I patients (P < .01), and 5 (4-6) and 1 (1-2) in Grade II patients (P < .001) in the CSD and TSD groups, respectively. The percentage of good cosmetic outcomes was 46.3% and 84.0% overall (P < .001), 59.6% and 85.0% in Grade I patients (P < .01), and 9.4% and 83.5% in Grade II patients (P < .001) in the CSD and TSD groups, respectively. The incidence of complications was significantly higher in the CSD group than in the TSD group, but this was limited to asymmetry. No significant difference was noted in infection or dehiscence. Compared with CSD, TSD can lead to an objectively good cosmetic prognosis at higher CFL severity and can reduce facial asymmetry occurrence.

Reconstruction of complex knee wounds with a distally based gracilis flap and gastrocnemius myocutaneous flap: A case report.

A gastrocnemius muscle flap is a versatile option for covering the proximal one-third of the lower leg and around the knee. On the other hand, it is of limited use in patients with short gastrocnemius muscle or insufficient volume. The authors present a case in which a knee soft tissue defect occurred in a very thin patient and was reconstructed using a gastrocnemius myocutaneous flap and a distally based gracilis flap as a supplementary flap.

Designing with relaxed skin tension line in perforator-based island flap for sacral sore reconstruction: A STROBE-compliant observational study.

Many various types of operative techniques have been performed used to treat make-up for sacral defects. Perforator-based flaps with flap transposition, but achieving an optimal flap design and tension-free flap closure without skeletonizing the perforator requires a great deal of clinical experience. In this study, we demonstrate perforator selection based on considerations of the relaxed skin tension line (RSTL), which has proven to be a suitable method of achieving an efficient flap design that enables primary closure. Twenty-five perforator-based flap procedures were performed on 25 patients at a single institution from February 2018 to January 2021. The medical records of patients were retrospectively reviewed. Twenty-three flaps survived completely. Two flaps developed partial tip necrosis but recovered after secondary healing, and 1 patient developed temporary congestion, which resolved spontaneously. No recipient or donor site recurrence or dehiscence was identified during follow-up. We report our clinical experiences of perforator-based flap use in the sacral region. When selecting an appropriate perforating vessel, 2 important points should be considered, that is, a flap long axis parallel to RSTLs and defect shape. According to the method presented in this paper, perforator-based flaps can be transposed safely and easily with few complications and serve as useful practice models to cover sacral defects.

Comparison of the outcomes of nasal bone reduction using serial imaging.

BACKGROUND: Nasal bone fractures are frequently encountered in clinical practice. Although fracture reduction is simple and correction requires a short operative time, low patient satisfaction and relatively high complication rates remain issues for many surgeons. These challenges may result from inaccuracies in fracture recognition and assessment or inappropriate surgical planning. Findings from immediate postoperative computed tomography (CT) scans and those performed at 4 to 6 weeks postoperatively were compared to evaluate the accuracy and outcomes of nasal fracture reduction. METHODS: This retrospective study included patients diagnosed with nasal bone fractures at our department who underwent closed reduction surgery. Patients who did not undergo additional CT scans were excluded from the study. Clinical examinations, patient records, and radiographic images were evaluated in 20 patients with nasal bone fractures. RESULTS: CT findings from immediately after surgery and a 1month follow-up were compared in 20 patients. Satisfactory nasal projection and aesthetically acceptable results were observed in patients with accurate correction or mild overcorrection, while undercorrection was associated with unfavorable results. CONCLUSION: Closed reduction surgery for correcting nasal bone fractures usually provides acceptable outcomes with relatively few complications. If available, immediate postoperative CT scans are recommended to guide surgeons in the choice of whether to perform secondary adjustments if the initial results are unsatisfactory. Based on photogrammetric data, nasal bone reduction with accurate correction or mild overcorrection achieved acceptable and stable outcomes at 1 month postoperatively. Therefore, when upward dislocation is observed on postoperative CT, one can simply observe without a subsequent intervention.

Facial Contouring Surgery Using Facelift Approach.

BACKGROUND: In Asian women who undergo facelift surgery, satisfying results are achieved for facial rhytides, but there have been complaints concerning malar prominence and mandible angle region postoperatively. Anatomically, compared with the Caucasians, the Asians have a thick skin and a wide and short facial geometry. The Asians generally have a protruded zygoma and prominent mandible angles; accordingly, their bony contouring surgery that is the base frame in facelift must be considered. The authors aimed to investigate the effects of performing facial contouring surgery and facelift simultaneously to achieve oval facial contour and youthful face. METHODS: The authors assessed 21 Asian women who simultaneously underwent facial contouring surgery with facelift between March 2014 and March 2018. The clinical results were assessed based on preoperative and postoperative photographs and the global aesthetic improvement scale score. RESULTS: Surgery was successful in all patients. Postoperatively, improvements in facial rhytides and appropriate facial contour were achieved. All patients were satisfied with the outcomes. Some patients experienced short-term complication; however, these complications improved. Serious long-term complications were not noted. CONCLUSIONS: Highly satisfying outcomes can be achieved with combined facial contouring surgery and facelift for Asian women with a wide face.

Implant Delivery Technique for Prepectoral Reconstruction after Endoscopic-assisted Nipple-sparing Mastectomy.

Prepectoral breast reconstruction through a small axillary incision during endoscopic-assisted nipple-sparing mastectomy or robotic nipple-sparing mastectomy is difficult. Cases involving implants covered with an acellular dermal matrix (ADM) are particularly difficult. Therefore, a new delivery technique for ADM-covered implants is needed. The ADM pocket for complete coverage of the implant is made with double-crossed ADMs. The pocket end is open and sutured at the funnel entry. After insetting the ADM pocket at the mastectomy site through an axillary incision, the implant is delivered from a funnel to the ADM pocket by squeezing. Prepectoral breast reconstruction with the new delivery technique for implants covered with ADM pockets proved easy and safe. Our new implant delivery technique could be a good option for prepectoral breast reconstruction after minimal breast surgery.

The three-point crossover technique for immediate reconstruction of the umbilicus.

The umbilicus is an important aesthetic component of the abdomen; therefore, its absence is both cosmetically and psychologically distressing to the patient. However, loss of the umbilicus during abdominal surgical procedures is often unavoidable. Umbilical reconstruction is aimed at obtaining a natural, three-dimensional appearance. We propose a simple method for immediate umbilical reconstruction with good long-term results. This technique was used successfully on a patient who underwent tumor excision. A 49-year-old woman presented with a large mass, measuring 5.8×4.0 cm, on her umbilicus. The mass, an epidermal cyst, developed after laparoscopic uterine myomectomy 5 years earlier. Complete excision of the mass resulted in a large defect, and immediate umbilical reconstruction was planned. Our procedure involved apposing and anchoring two opposing flaps onto the abdominal wall, so that the umbilicus would retain its depth over a long period of time. Negative-pressure wound therapy was applied for 72 hours as a mild compressive dressing. No complications were encountered. The healing process was uneventful and the aesthetic outcome was pleasing; a natural-appearing navel was created. The patient was satisfied with the end result. This technique provides a permanent and sufficient depression for the umbilicus.

Availability and Safety of Osteotomy in Esthetic Rhinoplasty of East Asian Patients.

OBJECTIVE: East Asians usually have short and flat noses and broad nasal bones. Therefore, rhinoplasty with dorsal augmentation and nasal osteotomy is often required. However, many surgeons are wary of performing nasal osteotomy in conjunction with augmentation with silicone. The authors sought to evaluate the availability and safety of osteotomy in esthetic rhinoplasty of East Asian patients. METHODS: In a clinical study, a retrospective chart review was performed for 227 patients who had undergone nasal osteotomy (paramedian oblique osteotomy plus percutaneous lateral osteotomy) and dorsal augmentation with silicone. Patient satisfaction after surgery was evaluated by the Rhinoplasty Outcome Evaluation test. In addition, a cadaveric study was conducted in which 5 fresh cadavers received different osteotomies on each side of the nose (right side: paramedian oblique and percutaneous lateral osteotomy; left side: medial oblique and intranasal continuous lateral osteotomy). RESULTS: In the clinical study, patients were satisfied with the outcome after esthetic rhinoplasty with nasal osteotomy (paramedian oblique osteotomy plus percutaneous lateral osteotomy) and augmentation with silicone. The results revealed a low complication rate. The average Rhinoplasty Outcome Evaluation test score significantly increased (P < 0.001), with 91.2% of patients scoring their postoperative result better than "good." In the cadaveric study, stability was greater when paramedian oblique and percutaneous lateral osteotomy was performed. CONCLUSIONS: Paramedian oblique and percutaneous lateral osteotomy is effective for reducing broad nasal bones, thus providing a stable framework and a reliable method for achieving a good outcome when augmentation with silicone is performed simultaneously.

Eccrine Spiradenoma of the Scalp.

Eccrine spiradenoma is an uncommon benign adnexal tumor originating from the eccrine sweat gland. We diagnosed a eccrine spiradenoma on a 55-year-old man with histopathologic confirmation upon biopsy followed by complete resection, who had visited our clinic with a chief complain of occipital scalp mass. The solitary eccrine spiradenoma occurring in the scalp is rarely to be seen and should be considered as a differential diagnosis for a solitary cystic mass of the scalp.

A New Technique for Conchal Cartilage Harvest.

The goal of auricular cartilage harvest is to obtain a sufficient amount for reconstruction and to minimize the change in ear shape. The cartilage can be harvested by a posterior or anterior approach, and each method has advantages and disadvantages. The posterior approach presents the advantage of scar concealment, but there are limits to the amount of cymba cartilage that may be harvested. In contrast, the anterior approach may cause a noticeable scar. However, as cartilage is collected, the anterior approach provides a view that facilitates the preservation ear structure. In addition, it is possible to obtain a greater amount of cartilage. From January 2014 to December 2015, we harvested auricular cartilage graft material in 17 patients. To prevent the development of trapdoor scars or linear scar contracture, short incisions were made on the superior border of the cymba and cavum. Two small and narrow incisions were made, resulting in suboptimal exposure of the surgical site, which heightens the potential for damaging the cartilage when using existing tools. To minimize this, the authors used a newly invented ball-type elevator. All patients recovered without complications after surgery and reported satisfaction with the shape of the ear.

Reduction of the Isolated Anterior Wall of the Maxillary Sinus Fracture with Double Urinary Balloon Catheters and Fibrin Glue.

BACKGROUND: Conservative treatment is performed for isolated anterior wall of the maxillary sinus fractures, in many cases when the fracture is clinically not severe and asymptomatic. Despite the absence of symptoms, complications such as sinusitis, rhinitis, and chronic purulent secretion may develop; therefore, successful reduction is required. We attempted to reduce the risk of complications using an alternative technique: reduction of the fracture with two urinary balloon catheters inserted through the maxillary ostium and fixation using fibrin glue, which minimizes the damage to the bony fragments and sinus mucosa. METHODS: In this study, 38 patients who were diagnosed with an isolated anterior wall of the maxillary sinus fracture at our hospital between January 2014 and January 2017 were enrolled. The fracture site was exposed via the Caldwell-Luc approach followed by reduction through the insertion of two urinary balloon catheters using a nasal endoscope and fixation with fibrin glue. The sex, cause of fracture, physical examination, and presence of complications were examined and patient's medical records and facial bone computed tomography scans were analyzed. RESULTS: Radiological evaluation showed that there was no evidence of collapsed reduction fragments. Although some patients had remaining symptoms of hypoesthesia (15%; 3 patients), there were no complications such as infection, rhinitis, sinusitis, and chronic purulent secretion at the surgical site. CONCLUSION: In this study, we present an alternative surgical technique using two urinary balloon catheters and fibrin glue for the successful reconstruction of an isolated anterior wall of the maxillary sinus fracture. This technique enables precise restoration with a reduced risk of complications.

Fixation of fractured inferior orbital wall using fibrin glue in inferior blowout fracture surgery.

The objectives of surgical treatment for orbital fracture are to return soft tissue to its original position as well as reduce and fix the bone fragments properly. Reduction of the orbital bone through a subciliary or conjunctival incision and reduction using a urinary balloon catheter were simultaneously performed on 53 patients between 2010 and 2013. Fibrin glue was used to attach the reduced bone fragments. These patients had less than 2 cm(2) of bone defect and showed diplopia, eye movement limitation, and enophthalmos. Diplopia, eye movement limitation, and enophthalmos were each reduced to 3/32, 2/25, and 2/48, respectively. There were no adverse effects, such as infection or hematoma, and because implants were not used, there was no possibility of its extrusion or foreign body reaction. The operation time decreased compared with when using an implant, and the bone fragments remained in a fixed position even after removing the urinary balloon catheter. Therefore, the use of fibrin glue proved to be effective in orbital floor fractures.

Inferior Blow-Out Fracture Reduction Using Two Urinary Balloon Catheters.

BACKGROUND: The reduction of orbital blowout fracture primarily aims to normalize the extra-ocular movement by returning the herniated orbital soft tissue into the original position, and to prevent enophthalmos by normalizing the orbital cavity volume. We introduce a balloon catheter-assisted orbital floor reduction technique. METHODS: A retrospective review was performed for all patients with orbital floor fracture who underwent the technique described in the main body of this text. Medical records were reviewed for demographic data, clinical presentation and course, degree of enophthalmos, intraorbital volume on computed tomography scan, and postoperative outcomes. The enophthalmos and intraorbital volume of the injured site were compared to the uninjured eye and orbit. RESULTS: The review identified 14 patients (11 male, 3 female). The mean preoperative difference in en-exopthalmos was 2.13 mm, while the mean orbital volume was 116%. The mean postoperative difference in en-exophthalmos had improved to 0.61 mm with a mean orbital volume of 101.85%. At the time of catheter removal at 10 days, three patients experienced diplopia (n=1), extra-ocular movement disorder (1), or enophthalmos (1). All of these had resolved by the 6-month follow-up visit. CONCLUSION: Balloon catheter-assisted reduction of the orbital floor fractures was associated with improvements in intraorbital volume and enopthalmos in the 14 patients. Notable complications included diplopia, enophthalmos, and limited extra-ocular movement, all of which were transient in the early postoperative period and had resolved by 6-month follow up.

Reconstruction techniques for tissue defects formed after preauricular sinus excision.

BACKGROUND: Preauricular sinuses are congenital abnormalities caused by a failure of fusion of the primitive tubercles from which the pinna is formed. When persistent or recurring inflammation occurs, surgical excision of the infected tissue should be considered. Preauricular defects inevitably occur as a result of excisions and are often difficult to resolve with a simple suture; a more effective reconstruction technique is required for treating these defects. METHODS: After total excision of a preauricular sinus, the defect was closed by a plastic surgeon. Based on the depth of the defect and the degree of tension when apposing the wound margins, the surgeon determined whether to use primary closure or a posterior auricular flap. RESULTS: A total of 28 cases were examined. In 5 cases, including 2 reoperations for dehiscence after primary repair, reconstruction was performed using posterior auricular transposition flaps. In 16 cases of primary closure, the defects were closed using simple sutures, and in 7 cases, closure was performed after wide undermining. CONCLUSIONS: If a preauricular defect is limited to the subcutaneous layer and the margins can be easily approximated, primary closure by only simple suturing may be used to perform the repair. If the defect is deep enough to expose the perichondrium or if there is tension when apposing the wound margins, wide undermining should be performed before primary closure. If the extent of the excision exposes cartilage, the procedure follows dehiscence of the primary repair, or the tissue is not sufficiently healthy, the surgeon should use a posterior auricular flap.