VGG19 demonstrates the highest accuracy rate in a nine-class wound classification task among various deep learning networks: a pilot study.

BACKGROUND: Current literature suggests relatively low accuracy of multi-class wound classification tasks using deep learning networks. Solutions are needed to address the increasing diagnostic burden of wounds on wound care professionals and to aid non-wound care professionals in wound management. OBJECTIVE: To develop a reliable, accurate 9-class classification system to aid wound care professionals and perhaps eventually, patients and non-wound care professionals, in managing wounds. METHODS: A total of 8173 training data images and 904 test data images were classified into 9 categories: operation wound, laceration, abrasion, skin defect, infected wound, necrosis, diabetic foot ulcer, chronic ulcer, and wound dehiscence. Six deep learning networks, based on VGG16, VGG19, EfficientNet-B0, EfficientNet-B5, RepVGG-A0, and RepVGG-B0, were established, trained, and tested on the same images. For each network the accuracy rate, defined as the sum of true positive and true negative values divided by the total number, was analyzed. RESULTS: The overall accuracy varied from 74.0% to 82.4%. Of all the networks, VGG19 achieved the highest accuracy, at 82.4%. This result is comparable to those reported in previous studies. CONCLUSION: These findings indicate the potential for VGG19 to be the basis for a more comprehensive and detailed AI-based wound diagnostic system. Eventually, such systems also may aid patients and non-wound care professionals in diagnosing and treating wounds.

Lymphatic complex transfer as combined lymph vessel and node transfer for advanced stage upper extremity lymphedema.

OBJECTIVE: Lymphedema, especially in the advanced stage, is a growing challenge in extremity reconstruction, with few applicable surgical methods. Despite its importance, no consensus has been reached regarding a single surgical method yet. Herein, the authors introduce a novel concept of lymphatic reconstruction yielding promising results. METHODS: We included 37 patients with advanced-stage upper extremity lymphedema who underwent lymphatic complex transfers, consisting of both lymph vessel and node transfers, from 2015 to 2020. We compared the preoperative and postoperative (last visit) mean circumferences and volume ratios between the affected and unaffected limbs. Changes in the Lymphedema Life Impact Scale scores and complications were also investigated. RESULTS: The circumference ratio (affected to unaffected limbs) improved at all measuring points (P < .05), while the volume ratio showed a decrease from 1.54 to 1.39 (P < .001). The mean Lymphedema Life Impact Scale decreased from 48.1 ± 15.2 to 33.4 ± 13.8 (P < .05). No donor site morbidities, including iatrogenic lymphedema or any other major complications, were observed. CONCLUSIONS: A new technique for lymphatic reconstruction, lymphatic complex transfer, may be useful in cases of advanced stage lymphedema because of its effectiveness and the low possibility of donor site lymphedema.

Comparing Complications of Biologic and Synthetic Mesh in Breast Reconstruction: A Systematic Review and Network Meta-Analysis.

Background In breast reconstruction, synthetic meshes are frequently used to replace acellular dermal matrix (ADM), since ADM is expensive and often leads to complications. However, there is limited evidence that compares the types of substitutes. This study aimed to compare complications between materials via a network meta-analysis. Methods We systematically reviewed studies reporting any type of complication from 2010 to 2021. The primary outcomes were the proportion of infection, seroma, major complications, or contracture. We classified the intervention into four categories: ADM, absorbable mesh, nonabsorbable mesh, and nothing used. We then performed a network meta-analysis between these categories and estimated the odds ratio with random-effect models. Results Of 603 searched studies through the PubMed, MEDLINE, and Embase databases, following their review by two independent reviewers, 61 studies were included for full-text reading, of which 17 studies were finally included. There was a low risk of bias in the included studies, but only an indirect comparison between absorbable and non-absorbable mesh was possible. Infection was more frequent in ADM but not in the two synthetic mesh groups, namely the absorbable or nonabsorbable types, compared with the nonmesh group. The proportion of seroma in the synthetic mesh group was lower (odds ratio was 0.2 for the absorbable and 0.1 for the nonabsorbable mesh group) than in the ADM group. Proportions of major complications and contractures did not significantly differ between groups. Conclusion Compared with ADM, synthetic meshes have low infection and seroma rates. However, more studies concerning aesthetic outcomes and direct comparisons are needed.

Epidemiological characteristics and importance of lobulation of giant epidermal cysts: An 18-year retrospective review of 19 cases.

Giant epidermal cysts, which have a diameter of ≥5 cm, have rarely been reported. Giant epidermal cysts that have multiple lobules are referred to as multilocular giant epidermal cysts. This study aims to establish the epidemiological characteristics and statistically determine the significance of lobulation in giant epidermal cysts. Data on 19 patients who developed giant epidermal cysts between January 2003 and February 2021 were retrospectively reviewed. Patients were divided into 2 groups based on the presence of septa and the differences in characteristics were analyzed. Among the 19 patients, 16 (84.2%) were male, and the mean age was 57.7 ±â€…10.6 years. The mean patient-reported tumor duration was 14.8 ±â€…12.5 years. Seven (36.8%) patients had multilocular giant epidermal cysts, whereas 12 (63.2%) had unilocular giant epidermal cysts. Compared with unilocular giant epidermal cysts, multilocular giant epidermal cysts had a significantly larger mean diameter (6.0 ±â€…0.7 vs 8.2 ±â€…1.8 cm, P = .02) and estimated volume (91.8 ±â€…43.3 vs 250.0 ±â€…157.0 mL, P = .02). Giant epidermal cysts have distinctive epidemiologic characteristics with predominance among males, those in their 50s, and a long tumor duration. Multilocular giant epidermal cysts are significantly larger in diameter and volume than unilocular ones.

Current Status of Experimental Animal Skin Flap Models: Ischemic Preconditioning and Molecular Factors.

Skin flaps are necessary in plastic and reconstructive surgery for the removal of skin cancer, wounds, and ulcers. A skin flap is a portion of skin with its own blood supply that is partially separated from its original position and moved from one place to another. The use of skin flaps is often accompanied by cell necrosis or apoptosis due to ischemia-reperfusion (I/R) injury. Proinflammatory cytokines, such as nuclear factor kappa B (NF-κB), inhibitor of kappa B (IκB), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and oxygen free radicals are known causative agents of cell necrosis and apoptosis. To prevent I/R injury, many investigators have suggested the inhibition of proinflammatory cytokines, stem-cell therapies, and drug-based therapies. Ischemic preconditioning (IPC) is a strategy used to prevent I/R injury. IPC is an experimental technique that uses short-term repetition of occlusion and reperfusion to adapt the area to the loss of blood supply. IPC can prevent I/R injury by inhibiting proinflammatory cytokine activity. Various stem cell applications have been studied to facilitate flap survival and promote angiogenesis and vascularization in animal models. The possibility of constructing tissue engineered flaps has also been investigated. Although numerous animal studies have been published, clinical data with regard to IPC in flap reconstruction have never been reported. In this study, we present various experimental skin flap methods, IPC methods, and methods utilizing molecular factors associated with IPC.

Establishment and characterization of two human cutaneous angiosarcoma cell lines, KU-CAS3 and KU-CAS5.

BACKGROUND: Cutaneous angiosarcoma (CAS) is a rare but fatal cancer. Established CAS cell lines are necessary for the investigation of their properties and treatment options. METHODS: Two cell lines, KU-CAS3 and KU-CAS5, were established from human angiosarcoma specimens obtained from the scalp. Flow cytometric assay, tube formation assay, low-density lipoprotein (LDL) uptake assay, immunofluorescence analysis, real-time PCR, tumorigenesis assay, and STR analysis were conducted. RESULTS: The cells showed endothelial cell properties, based on the cobblestone appearance upon reaching confluence, CD31 positivity, tube-formation activity, active uptake of acetylated LDL, and vWF expression. The two cell lines expressed relatively high levels of adrenergic ß2 receptor, and the VEGF1 and VEGF2 receptors. In the in vivo study, the growing neoplasms, confirmed as CAS, were identified as subcutaneous dark papules. KU-CAS cell lines were considered authentic based on STR profiling. CONCLUSIONS: KU-CAS3 and KU-CAS5 are the first human CAS cell lines having tumorigenic potential in vivo.

Chemical Sterilization of Lipoplasty Cannula and Nontuberculous Mycobacteria Disinfection: An Experimental Study.

BACKGROUND: Nontuberculous mycobacteria are commonly found pathogens; however, skin and soft tissue infections due to nontuberculous mycobacteria are often associated with surgical procedures, particularly after lipoplasty. Although nontuberculous mycobacteria are resistant to some chemical disinfectants, glutaraldehyde, peracetic acid, povidone iodine, alcohol, and chlorine are still used for the sterilization of medical instruments. This study investigated the efficacy of various disinfectants in a fatty environment with adipose and a bloody environment without adipose. In addition, this study was also used to identify the most effective disinfectant against nontuberculous mycobacteria. METHODS: Three nontuberculous mycobacteria (Mycobacterium avium, M. abscessus, and M. fortuitum), pathogens frequently found in skin and soft tissue infections, were used. Seven chemical disinfectants were tested in both fatty and bloody environments. The disinfectants used were considered to have a sterilization effect when the log10 reduction factor exceeded 5. RESULTS: Most disinfectants had some sterilizing effects against nontuberculous mycobacteria; however, glutaraldehyde was the most effective against all 3. Chlorhexidine and povidone iodine also displayed sterilizing effects. Of the disinfectants tested, only alkyldiaminoethylglycine hydrochloride showed a diminished effect with statistical significance, specifically against M. fortuitum in a fatty environment, whereas it had effective results in a bloody environment. CONCLUSIONS: Glutaraldehyde showed the greatest sterilizing effect on nontuberculous mycobacteria with a log10 reduction factor >5 in both fatty and bloody environments. However, some chemical disinfectants did not show sufficient sterilizing effects in a fatty environment and, therefore, should be used with caution for the sterilization of nontuberculous mycobacteria. LEVEL OF EVIDENCE: Level II.

Vascularized lymph node transfer for surgical treatments of upper versus lower extremity lymphedema.

OBJECTIVE: The purpose of this study was to compare clinical outcomes after vascularized lymph node transfer (VLNT) for the treatment of lymphedema performed on the upper and lower extremities. METHODS: Between April 2015 and January 2020, 71 patients with advanced-stage lymphedema, categorized as International Society of Lymphology late stage 2 or 3, who underwent VLNT in upper and lower extremities were included in this study. Thirty-seven and 34 patients underwent VLNT in upper and lower extremities, respectively. The circumference of the affected and unaffected extremities was measured at baseline, follow-up visits, and at the last visit. The circumference was measured in six places on the extremities, and the circumference and volume percent differences between the affected and unaffected extremities were calculated. First, we compared preoperative and postoperative extremity circumferences in the overall, upper, and lower extremity groups. Second, we compared circumference and volume percent differences between the affected and unaffected extremities calculated at the last visit to identify the degree of improvement by VLNT in the upper and lower extremity groups. RESULTS: The results of the comparative analysis between the preoperative and postoperative extremity circumferences showed that all postoperative extremity circumferences measured at the last visit were decreased compared with the preoperative values in the overall, upper, and lower extremity groups. In the upper extremity group, the circumference percent difference measured at the elbow was 23.1% before surgery and decreased to 13.4% at the last visit (P < .001). In the lower extremity group, the circumference percent difference measured at the knee was 24.4% before surgery and decreased to 17.4% at the last visit (P = .003). In the results of comparative analysis between the upper and lower extremity groups, there was a statistically significant difference in the postoperative circumference percent differences at the elbow/knee calculated at the last visit (P = .048). Similarly, there were statistically significant differences in circumference percent differences in two of six measurement sites at the last visit between the upper and lower extremity groups. However, there was no statistically significant difference in the volume percent difference calculated at the last visit between the upper and lower extremity groups. CONCLUSIONS: These results demonstrate that VLNT may be effective in treating patients with advanced-stage lymphedema. However, patients with upper extremity lymphedema demonstrate superior outcomes compared with those with lower extremity lymphedema.

Overcome the barriers of the skin: exosome therapy.

Exosomes are nano-sized cargos with a lipid bilayer structure carrying diverse biomolecules including lipids, proteins, and nucleic acids. These small vesicles are secreted by most types of cells to communicate with each other. Since exosomes circulate through bodily fluids, they can transfer information not only to local cells but also to remote cells. Therefore, exosomes are considered potential biomarkers for various treatments. Recently, studies have shown the efficacy of exosomes in skin defects such as aging, atopic dermatitis, and wounds. Also, exosomes are being studied to be used as ingredients in commercialized skin treatment products. In this review, we discussed the need for exosomes in skin therapy together with the current challenges. Moreover, the functional roles of exosomes in terms of skin treatment and regeneration are overviewed. Finally, we highlighted the major limitations and the future perspective in exosome engineering.

Surgical Correction of Upper Eyelid Ectropion Presenting Dry Eye Symptoms.

BACKGROUND: Upper eyelid ectropion occurs as a post-blepharoplasty complication or involution change, and it causes dry eye symptoms that cannot be resolved with conservative management. OBJECTIVES: The aim of this study is to describe the authors' surgical technique of anatomical correction of upper eyelid ectropion, including tarsal scoring incision. METHODS: The technique involves the following 4 steps: (1) adhesiolysis at the preaponeurotic layer; (2) undermining and redraping of the pretarsal flap in a pretarsal plane; (3) optional, partial thickness tarsal scoring incision over the central two-thirds; and (4) downward repositioning of the pretarsal flap and lower fixation to the tarsus. Outcomes were assessed based on the position of eyelid margin and the improvement of the dry eye symptoms. RESULTS: A retrospective review of 54 cases of patients who underwent ectropion correction, including tarsal scoring incision, was performed. The eyelid margin was well positioned in 51 patients (94.4%). Of the 32 patients involved in the study assessed with the 7-point Patient Global Impression of Improvement, 29 (90.6%) reported the resolution of dry eye symptoms. Furthermore, in the 22 patients assessed with the Ocular Surface Disease Index, the mean score significantly decreased from 43.2 ±â€…24.1 before surgery to 29.8 ±â€…23.3 (P = 0.006) after surgery. CONCLUSIONS: The combination of partial-thickness tarsal plate scoring and lower flap redraping surgical techniques resolved the upper eyelid ectropion, reducing the dry eye symptoms.

Aesthetic Comparison of Abdominal Donor Site Scar Between Absorbable Dermal Staple and Subcutaneous Suture after Autologous Breast Reconstruction: A Prospective Randomized Controlled, Double-Blinded Study.

BACKGROUND: Abdominal tissue transfer has become the most commonly used tool for breast reconstruction. However, a secondary operator is often responsible for donor closure, which leaves dissatisfaction to patients due to inconsistent donor scars. Now, an absorbable dermal stapler is popularized worldwide and currently used for wound closure in many surgical fields. In this study, we aim to evaluate the abdominal donor site scar in using an absorbable dermal staple compared to a conventional suture. METHODS: This is a prospective, randomized controlled and double-blinded study. Between January 2018 and April 2019, a total of 30 patients who underwent breast reconstruction using abdominal flap were included. Donor sites were divided into equal halves, and the each dermal layer was sutured with either dermal staples or traditional suturing, respectively. At 1, 3 and 6 months after operation, the scar was evaluated by two blinded plastic surgeons by using the modified Manchester scar scale (MSS). RESULTS: An averaged sum of modified MSS was lower for the side sutured with a dermal stapler at the first month (11.76 ± 2.12 vs. 12.28 ± 2.03, p = 0.097), third month (12.17 ± 1.86 vs. 12.62 ± 2.31, p = 0.301) and sixth month (11.28 ± 2.63 vs. 12.14 ± 2.76, p = 0.051). Also, the dermal stapler side scored significantly higher for patient satisfaction than did the suture side (4.03 ± 0.98 vs 3.66 ± 0.97, p < 0.05). CONCLUSION: The objective outcome of the scar closed by an absorbable dermal stapler was not statistically superior to conventional suturing. (p > 0.05) In the subjective outcome, however, it showed a significantly higher patients' satisfaction (p < 0.05). LEVEL OF EVIDENCE III: 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 .

Clinical Experience with Treatment of Aquafilling Filler-Associated Complications: A Retrospective Study of 146 Cases.

BACKGROUND: Aquafilling filler is used for breast and buttock augmentation, which are the most commonly performed cosmetic surgery procedures. However, complications after using Aquafilling filler for breast augmentation have been reported, and there are concerns regarding its use in large areas, such as the buttocks. We provide our experience with complications after breast augmentation and buttock augmentation using Aquafilling filler. METHODS: This observational cohort study analyzed the data of 399 patients treated for filler-related complications at our institutes from September 2015 to November 2019. Of these patients, 146 underwent surgery to remove Aquafilling filler from the breast or buttock. RESULTS: The mean time between Aquafilling filler use and complication onset was 38.5 ± 10.2 months. The average amount of filler material removed from one side of the breast or buttock was 285.5 ± 95.8 mL (range 150-750 mL). The most common complications were induration and masses (83.6%), followed by pain (52.1%), firmness (24.7%), asymmetry (10.3%), migration (8.2%), mastitis (6.8%), dimpling (6.2%), fever (3.4%), and sepsis (n = 1). After treatment, there was no recurrence of infection, and the patient satisfaction level based on the visual analogue scale was 8.0 ± 0.9. CONCLUSIONS: Although Aquafilling filler is easily injectable and has long-term clinical effects, complications can occur. Furthermore, there are concerns regarding its toxicity and influence on the surrounding tissues. Hence, further research studies on Aquafilling filler and evidence regarding its long-term safety are needed. 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 .

Use of a biopsy punch for end-to-side anastomosis in free-tissue transfer.

Background: In end-to-side vessel-anastomoses, a side fenestration should be made by a slit incision or partial excision of the vessel wall. However, a slit incision might restrict blood flow across the anastomosis, and a partial vessel wall excision using micro-scissors may be time-consuming and result in irregular edges, which may weaken the vessel wall and cause flow disturbances. We used a biopsy punch for end-to-side anastomosis, and obtained satisfactory results.Methods: Between September 2015 and August 2017, 27 end-to-side anastomoses using punch biopsies were performed. Two vessel clamps were applied to the recipient vessel proximal and distal to the point planned for the side anastomosis. The flap side vessel size was measured, and an appropriately sized punch was selected. The clamped recipient vessel was supported by a wooden tongue depressor and the punch was applied to the vessel wall. An end-to-side anastomosis was performed in the usual manner, and immediate patency was tested with a refill test.Results: The vessel patency rate was 96 percent. The mean arteriotomy or venotomy time was 65 s and entire anastomosis procedure time was 1065 s. Both the vessel preparation and the micro-anastomosis procedure times were shorter than those of the conventional procedure group with statistical significance. (p < .05) There was only one case of venous failure by deep vein thrombosis - and it was resolved with thrombectomy and re-anastomosis.Conclusion: Use of a biopsy punch in end-to-side anastomosis can offer a uniform circular edge and reduce operating time.

Ophthalmoplegia with skin necrosis after a hyaluronic acid filler injection.

Hyaluronic acid filler injection is commonly used for aesthetic purposes. However, many clinicians neglect the possibility of developing vascular occlusion and its devastating sequelae. Besides visual loss after iatrogenic ophthalmic artery occlusion, ophthalmoplegia without blindness is rare but may occur. Here, we report a 23-year-old woman with ptosis, lateral deviation of the right eye, and skin necrosis after hyaluronic acid filler injection. After hyaluronidase injection and steroid pulse therapy, ptosis and eye movement were completely restored. Skin necrosis was treated with a human epithelial growth factor ointment, followed by Nd:YAG laser. Complete healing with minimal scar was achieved.

Use of a multilayered acellular dermal substitute with simultaneous full-thickness skin graft for the one-stage coverage of nasal skin defects.

BACKGROUND: Nasal skin defect closures are challenging because the nose is a complex anatomic structure with several subunits, and the nasal tip and ala represent particularly difficult subunits to reconstruct. The traditional full-thickness skin graft (FTSG) is an easy and well-established method, but often results in undesirable outcomes in terms of the nasal contour caused by a lack of dermal tissue. AIMS: The purpose of the study is to report the outcomes of the simultaneous application of the acellular dermal substitute (Matriderm® ) with FTSG in the treatment of nasal skin defects. PATIENTS/METHODS: Five patients with various nasal skin defects were treated with multilayered Matriderm grafts followed by FTSGs harvested from the pre- or postauricular region. Graft survival, scar quality, and patient satisfaction were evaluated and compared with 10 patients treated with conventional FTSGs. RESULTS: One-stage Matriderm-aided FTSGs were well-taken in all cases. Scar quality in the Matriderm group (8.0 ± 1.9) was statistically superior to that in the FTSG only group (10.8 ± 1.7). The Matriderm-aided graft was also superior in patient satisfaction. CONCLUSIONS: The multilayered application of Matriderm in combination with FTSG is a reliable method for covering nasal skin defects, especially in the thick skin zone of the tip and ala.

Dual vascular free transverse rectus abdominis myocutaneous flap for hemifacial reconstruction in a vessel-depleted neck.

Cutaneous squamous cell carcinoma (SCC) is the second most common skin malignancy. This report describes the case of an unusual extensive SCC involving the whole hemiface, which required reconstruction with a combination of a dual vascular free transverse rectus abdominis muscle (TRAM) flap and a skin graft. A 79-year-old woman visited our hospital with multiple large ulcerated erythematous patches on her right hemiface, including the parieto-temporal scalp, bulbar and palpebral conjunctiva, cheek, and lip. A preliminary multifocal biopsy was performed in order to determine the resection margin, and the lesion was resected en bloc. Orbital exenteration was also performed. A free TRAM flap was harvested with preserved bilateral pedicles and was anastomosed with a single superior thyroidal vessel. The entire TRAM flap survived. The final pathological examination of the resected specimen confirmed that there was no regional nodal metastasis, perineural invasion, or lymphovascular involvement. The patient was observed for 6 months, and there was no evidence of local recurrence. Usage of a TRAM flap is appropriate for hemifacial reconstruction because the skin of the abdomen matches the color and pliability of the face. Furthermore, we found that the independent attachment of two extra-flap anastomoses to a single recipient vessel can safely result in survival of the flap.

The Outcome of Early Ablative Fractional Laser Treatment for Thyroidectomy Scars.

BACKGROUND AND OBJECTIVES: Ablative fractional laser (AFL) systems are commonly used to treat various scars, and recent research has indicated that early treatment with AFL may have a preventive effect on scars. This study was designed to evaluate the efficacy of early treatment with a 10,600 nm carbon dioxide (CO2 ) AFL on thyroidectomy scars and compare it to late (conventional) treatment for the same and untreated controls. STUDY DESIGN/MATERIALS AND METHODS: We performed a prospective, evaluator-blinded, split-scar study on fresh thyroidectomy scars between July 2014 and July 2017. Scars were divided into two equal portions. Early AFL treatment had begun 1 month after surgery; five sessions on the right half of the scar was performed at 1-month intervals. Late AFL treatment followed for 1 month after the final early treatment session on the left half of the scar at the same interval. The scars were evaluated at 6 and 11 months postoperatively using scar analysis scales and patient questionnaires. RESULTS: Twenty-four out of 28 patients completed the study. The mean decrease in Vancouver Scar Scale (VSS) scores was significantly higher for the early treated right halves of the scars both at the 6th month (vs. untreated controls) and at the 11th month (vs. late treated controls). The VSS subset analysis showed that the early treated sides had significantly greater improvement in pliability and height than the control sides at each point of evaluation. CONCLUSIONS: Early postoperative AFL treatment is safe and effective in improving linear surgical scars, such as thyroidectomy scars, and may be a promising option for scar prevention. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Immediate Reconstruction of Amputated Ear With Fascia Flap.

BACKGROUND: Various surgical methods have been used for reconstruction of an amputated ear, including microsurgical replantation and delayed reconstruction using synthetic material or autologous rib cartilage. The authors share our experience of immediate reconstruction using amputated cartilage and discuss the advantages compared to other techniques of reconstruction. MATERIALS AND METHODS: The authors retrospectively reviewed the medical records of 3 patients who underwent immediate reconstruction of amputated ear by a single operator. In the cases, the amputees were washed; the skin and cartilage were separated. The ear cartilage was fixed to its original position with non-absorbable suture. Regional fascia flap was elevated and covered the ear cartilage. The amputee skin was redraped to cover the fascia flap. Several months after the operation, photographic assessment was done. RESULTS: All 3 cases showed well-defined convolution, tolerable skin color, and patient satisfaction without any major complications. A patient showed mild temporal incision site alopecia. CONCLUSION: The above immediate reconstruction method can achieve reliable and favorable result with minimal complications.

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.

Protective Effect of Botulinum Toxin against Ultraviolet-Induced Skin Pigmentation.

BACKGROUND: Hyperpigmentation following ultraviolet irradiation has cosmetic concerns. Botulinum toxin type A can favorably affect skin pigmentation. However, the mechanism of skin pigmentation is unclear. METHODS: In vitro, human epidermal melanocytes were co-cultured with human keratinocytes. After cells were treated with botulinum toxin type A, cell morphology, proliferation, and dendricity were analyzed, and immunofluorescence, tyrosinase activity, and melanin contents were determined. To evaluate the effect of botulinum toxin type A on ultraviolet B-irradiated mouse skin, ultraviolet B alone was applied to one side of the back of each mouse as a control, whereas ultraviolet B plus injection of botulinum toxin type A was applied to the contralateral side. Skin pigmentation, histology, and the number of dihydroxyphenylalanine-positive melanocytes were evaluated. The L* colorimeter value was measured. Enzyme-linked immunosorbent assay determinations of basic fibroblast growth factor, interleukin-1 alpha, and prostaglandin E2 were performed. RESULTS: Immunohistochemical staining revealed botulinum toxin type A in the cytoplasm of melanocytes and in the positive control. In vitro, melanocyte dendricity and melanin contents were decreased slightly but significantly (p < 0.05) after botulinum toxin type A treatment. In vivo, botulinum toxin type A suppressed skin pigmentation. The number of dihydroxyphenylalanine-positive melanocytes was also significantly lower than in the control side. Tyrosinase activity and melanin content were also significantly reduced (p < 0.05). Botulinum toxin type A also significantly reduced the amounts of basic fibroblast growth factor, interleukin-1 alpha, and prostaglandin E2 (all p < 0.05). CONCLUSION: Botulinum toxin type A can suppress epidermal melanogenesis through both direct and indirect mechanisms.