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.

Customized Reconstruction of Lower Eyelid Defects.

BACKGROUND: A lower eyelid defect is a loss of skin, muscle, and underlying structures that can occur due to trauma, malignant or benign tumors, burns, or other causes. The conventional surgical treatment of lower lid defects has several limitations, including visible scarring, narrowing of the eye, and ectropion. Here, we combined the use of a customized mid-face lift with a free mucochondral graft to overcome the disadvantages of existing methods. METHODS: Forty patients underwent reconstructive surgery using a customized mid-face lift with or without a free mucochondral graft for a lower lid defect between April 2013 and October 2020. Patients were discharged shortly after surgery and were expected to visit the outpatient clinic periodically for 12 months. RESULTS: The causes of lower eyelid defects were malignancy, trauma, foreign body granuloma, and other causes. Four patients reported complications, including 2 cases of chemosis, 1 case of a hematoma, and 1 case of corneal abrasion, who reportedly performed well after 2 weeks of conservative therapy. No patient required revision during the average follow-up period. CONCLUSIONS: Customized reconstruction demonstrated a better aesthetic reconstruction of the lower eyelid. This method represents a good option for reconstructing lower lid defects.

Effects of Midcheek Lift According to Dissection Plane and Range: An Anatomical Study.

BACKGROUND: Midcheek lift has been performed for cosmetic or reconstructive surgery of the lower eyelid. For midcheek lift through the subciliary incision, preperiosteal and subperiosteal dissections are the most often implemented, with good clinical outcomes. However, a comparative assessment of the effects of these 2 methods had not been conducted. OBJECTIVES: In this study we compared the effects of midcheek lift according to preperiosteal or subperiosteal plane and range of midfacial dissection. METHODS: Forty hemifaces of 20 fresh cadavers were dissected. One side of the hemiface underwent preperiosteal dissection, and the other side underwent subperiosteal dissection. After dissections of 5, 10, 15, 20, and 30 mm and all of the midcheek area from the inferior orbital rim, the length of the elevated lid-cheek junction was measured by placing upward traction on the lateral portion of the lower lid. RESULTS: In both methods, the length of the midcheek lift increased as the dissection progressed, and the length of the lift on the lateral side was greater than that on the medial side. The length of the pulled skin in the preperiosteal group was the greatest in most cases. However, in the full dissection cases, the midcheek lift length was not statistically different between the 2 surgical methods, especially on the lateral side. CONCLUSIONS: Flap elevation in lower blepharoplasty surgery can be predicted based on the surgical method and dissection range. Implementing a surgical plan that takes this into account can enhance both reconstruction and aesthetic surgery outcomes in the midcheek area.

Introduction of Deep Learning-Based Infrared Image Analysis to Marginal Reflex Distance1 Measurement Method to Simultaneously Capture Images and Compute Results: Clinical Validation Study.

Marginal reflex distance1 (MRD1) is a crucial clinical tool used to evaluate the position of the eyelid margin in relation to the cornea. Traditionally, this assessment has been conducted manually by plastic surgeons, ophthalmologists, or trained technicians. However, with the advancements in artificial intelligence (AI) technology, there is a growing interest in the development of automated systems capable of accurately measuring MRD1. In this context, we introduce novel MRD1 measurement methods based on deep learning algorithms that can simultaneously capture images and compute the results. This prospective observational study involved 154 eyes of 77 patients aged over 18 years who visited Chungnam National University Hospital between 1 January 2023 and 29 July 2023. We collected four different MRD1 datasets from patients using three distinct measurement methods, each tailored to the individual patient. The mean MRD1 values, measured through the manual method using a penlight, the deep learning method, ImageJ analysis from RGB eye images, and ImageJ analysis from IR eye images in 56 eyes of 28 patients, were 2.64 ± 1.04 mm, 2.85 ± 1.07 mm, 2.78 ± 1.08 mm, and 3.07 ± 0.95 mm, respectively. Notably, the strongest agreement was observed between MRD1_deep learning (DL) and MRD1_IR (0.822, p < 0.01). In a Bland-Altman plot, the smallest difference was observed between MRD1_DL and MRD1_IR ImageJ, with a mean difference of 0.0611 and ΔLOA (limits of agreement) of 2.5162, which was the smallest among all of the groups. In conclusion, this novel MRD1 measurement method, based on an IR camera and deep learning, demonstrates statistical significance and can be readily applied in clinical settings.

Smartphone-Based LiDAR Application for Easy and Accurate Wound Size Measurement.

The accurate assessment of wound size is a critical step in advanced wound care management. This study aims to introduce and validate a Light Detection and Ranging (LiDAR) technique for measuring wound size. Twenty-eight wounds treated from December 2022 to April 2023 at the Chungnam National University Hospital were analyzed. All the wounds were measured using three techniques: conventional ruler methods, the LiDAR technique, and ImageJ analysis. Correlation analysis, linear regression, and Bland-Altman plot analysis were performed to validate the accuracy of the novel method. The measurement results (mean ± standard deviation) obtained using the ruler method, LiDAR technique, and ImageJ analysis were 112.99 ± 110.07 cm2, 73.59 ± 72.97 cm2, and 74.29 ± 72.15 cm2, respectively. The Pearson correlation coefficient was higher for the LiDAR application (0.995) than for the conventional ruler methods (mean difference, -5.0000 cm2), as was the degree of agreement (mean difference, 38.6933 cm2). Wound size measurement using LiDAR is a simple and reliable method that will enable practitioners to conveniently assess wounds with a flattened and irregular shape with higher accuracy. However, non-flattened wounds cannot be assessed owing to the technical limitations of LiDAR.

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.

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.

Efficacy and safety of stromal vascular fraction on scar revision surgery: a prospective study.

BACKGROUND: Cell-based therapies are popular in the field of reconstructive surgery. The stromal vascular fraction (SVF), comprised of mature adipocytes or blood, reportedly has a regenerative effect; however the mechanism remains unclear. This study aimed to prove the viability and effectiveness of using SVF in scar treatment. METHODS: This prospective double-blind study involved 20 patients who visited an outpatient clinic for 2 years, from July 2016 to July 2018, and underwent scar revision for traumatic or surgical scars. After scar revision surgery performed by a single surgeon, patient scars were divided into experimental and control sides. The subcutaneous layer of the experimental and control sides were injected with 0.1 mL/cm of SVF and normal saline, respectively. Each side was evaluated using the Patient and Observer Scar Assessment Scale (POSAS) before and six months after the surgery. RESULTS: Of the 20 patients who underwent scar revision surgery and SVF treatment, 4 dropped out for personal reasons. In 11 of 12 POSAS items, the experimental side showed significant improvements compared to the control side. CONCLUSIONS: Although more research is needed, autologous SVF is a valuable source of regenerative medicine that can be swiftly and inexpensively prepared from human fat tissue.

Levator Extension Method for Correcting Double Eyelids in Elderly Asian Patients: A Reliable and Flexible Blepharoplasty Technique.

Background: Conventional tarsal fixation techniques for creating a static double-eyelid fold frequently result in a nonmobile overdepression of the fold, which is particularly pronounced in elderly patients. Objectives: We propose a novel surgical approach aimed at achieving better results with fewer complications. This approach involves imitating the natural double-fold physiology by employing a turn-over flap of the orbital outer septum and carefully managing the pretarsal soft tissue to create a double fold. Methods: A total of 503 patients underwent double-eyelid surgery, involving a turn-over flap of the outer orbital septum and pretarsal soft-tissue management. The orbital septum was exposed and transversely opened superior to the incision margin and the pretarsal soft issue was removed as necessary. Turn-over flaps were trimmed and attached to the dermis and orbicularis oculi muscle of the lower flap. Patient follow-up occurred for 2 to 7 years (mean, 3.8 years). Results: This surgical method achieves a double fold with shallow or moderate depth, creating a natural-appearing fold line. Of the 503 patients, 94% of respondents provided a satisfaction score of 4 and 5 points; 20 people provided a score of 3 points; 10 were dissatisfied. A review of the patient chart showed that there were no specific complications in >94% (473) of patients. Conclusions: We proposed a double-eyelid surgery technique using the outer septum to control the depth and pretarsal soft-tissue management to minimize resistance in the creation of the double eyelid. Our method showed a high patient satisfaction rate and fewer complications in elderly Asians.

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.

Effects of Ti-doping amount and annealing temperature on electrochromic performance of sol-gel derived WO3.

Fine control of structural and morphological features in electrochromic materials is of paramount importance for realizing practical electrochromic devices (ECDs), which can dynamically adjust indoor light and temperature of buildings. To this end, herein we investigate impacts of two variants such as Ti-doping amount and the annealing temperature on physical and chemical properties of sol-gel derived electrochromic WO3 films. We use a wide range of titanium coupling agents (TCAs) as Ti-dopants ranging from 0 wt% to 20 wt% and vary the annealing temperature between 200 °C and 400 °C with 50 °C interval. Both variants greatly influence the physical properties of the resulting WO3 films, resulting in different crystallinities and morphologies. Through complementary analytical techniques, we find that the WO3 film featuring an amorphous phase with nano-porous morphology enhances the electrochemical and electrochromic performances. The specific TCA used in this study helps stabilize the amorphous WO3 structure and generate the nano-pores during the following thermal treatment via its thermal decomposition. As a result, the WO3 film having an optimal 8 wt% TCA annealed at 300 °C shows a high optical density of 73.78% in visible light (400-780 nm), rapid switching speed (t c = 5.12 s and t b = 4.74 s), and high coloration efficiency of 52.58 cm2 C-1 along with a superior cyclic stability. Thus, understanding a structure-property relationship is of paramount importance in engineering the advanced electrochromic WO3 for use in practical ECDs and other optoelectronic applications.

Aesthetic Removal of Foreign Body Granulomas of Forehead Via Pretrichial Approach.

ABSTRACT: In the field of plastic surgery, various filler types have been developed, which are widely used for cosmetic or reconstruction purposes. However, unregulated substances often injected by unlicensed practitioners may cause difficult-to-treat side effects, such as foreign body granulomas. Since the forehead is an exposed area and the lesions are likely extensive, complete surgical removal with inconspicuous scar can be difficult. In addition, pharmacological treatments, such as steroids, have only a temporary effect. The authors report successful cases of foreign body removal combined with subcutaneous forehead lift via a pretrichial approach for cosmetic satisfaction.Ten patients who had received illegal filler injections that resulted in chronic granulomas on the forehead were studied. The granulomas were confirmed using sonography, and simultaneous foreign body removal and subcutaneous forehead lifts using pretrichial incisions were planned. For the surgical method, the forehead flap was carefully elevated to a uniform thickness in the subcutaneous plane via a pretrichial incision, and the foreign body was removed, paying attention to the forehead contour and nerve damage; excess skin was excised from the top of the flap to tighten the remaining skin on the forehead.None of the patients developed complications, such as skin necrosis, infection, hematoma, or wound dehiscence, during the follow-up period. The functional and aesthetic outcomes were satisfactory in all the patients.The subcutaneous forehead lift via a pretrichial incision seems to facilitate foreign body removal and improve the forehead deformity by tightening the remaining skin.

Reconstruction of Sacral Pressure Ulcer Using a Modified Parasacral Perforator-Based Flap (Maple Leaf Design): An Easier Method for Beginners.

Background. Many different operative options have been used to cover sacral defects. Perforator flap enables wide defect reconstruction with long pedicle and a large arc of rotation while preserving gluteus maximus muscle, but the risk of vessel injury can jeopardize flap survival. Perforator-based flap, the flap transposed without skeletonization of the perforator, requires much experience to be perfect in flap design to achieve tension-free closure. Methods. Fourteen modified parasacral perforator-based flap procedures were carried out on 14 patients. The records of patients at Chungnam National University Hospital from February 2017 to January 2020 were retrospectively reviewed. Results. All 14 flaps survived completely. One patient developed localized hematoma, and another presented with latent seroma. No donor or recipient site dehiscence or recurrence occurred during follow-up. Conclusion. We present our experience of a parasacral perforator-based flap with modified design of bilobed flaps. It could be performed easily and safely with less wound dehiscence and serve as a good practice model for young surgeons to cover small to moderately sized defects.

Reconstruction of the Lower Leg With Percutaneous Aponeurotomy and Lipofilling: A Case Report.

Soft tissue loss in the lower leg presents a challenge for reconstructive surgeons. When a defect is large, free flap transfer provides a well-established method, but local flaps are more convenient for small to moderately sized soft tissue defects. When a defect is very small, even local flaps are too invasive, leave additional scar, and cause bulky flaps. We present our case aiming to underline the usefulness of percutaneous aponeurotomy and lipofilling in a small lower leg defect with several advantages.

The Efficacy of Hyaluronidase in Early Surgery of Nasal Bone Fracture.

A nasal bone fracture is one of the most common facial injuries and is often treated by closed reduction. Typically, 2 to 3 weeks are needed for patients to return to daily life because the operation is performed after swelling around the fracture site is reduced. This study aimed to investigate that hyaluronidase injection could reduce swelling, perform early operation and return to daily life accelerated.From January 2017 to December 2017, 181 patients with nasal bone fracture were analyzed. 60 patients underwent hyaluronidase injection and massage to reduce edema, then performed surgery within 2 to 4 days. The remaining patients were treated conservatively (massage alone); they then underwent surgery. Ultrasonography was used to measure changes in skin thickness, and the treatment duration, outcome, and patient satisfaction were compared.The duration from injury to surgery was short in the early operation group, and the period of recovery and return to ordinary life was significantly shorter than in the conventional group. The difference in skin thickness after hyaluronidase injection and massage was 0.8 mm in the early operation group; there was no significant difference in the conventional group. There was no statistically significant difference in satisfaction between the 2 groups, but the mean satisfaction was higher in the early operation group.In patients with nasal bone fracture after facial trauma, hyaluronidase injection, and massage led to reduced edema. This might improve patient satisfaction by allowing earlier operation and earlier return to daily life.

Open reduction of zygoma fractures with the extended transconjunctival approach and T-bar screw reduction.

BACKGROUND: Zygomaticomaxillary complex (ZMC) fractures mostly occur in the form of tripod fractures. The surgical field is accessed using a combination of three classic approaches. However, the subciliary incision may have unfavorable aesthetic results. Herein, the authors report the advantages of the extended transconjunctival approach (ETA) combined with T-bar screw reduction in minimizing scarring and complications for the treatment of ZMC fractures. METHODS: A total of 26 patients underwent ZMC reduction through the ETA and intraoral approach. A skin incision measuring roughly 5 to 8 mm in length was placed following the lateral canthal skin crease. After releasing the inferior crus of the lateral canthal tendon for canthotomy, the medial periosteum of the lateral orbital rim was preserved for canthal reattachment. A limited subperiosteal dissection and partial relaxing incision of the orbicularis oculi were performed to expose the fracture line of the inferior orbital rim and zygomaticofrontal suture. Reduction was performed using a T-bar screw through the transconjunctival incision and an elevator through the intraoral incision. RESULTS: The aesthetic and functional results were excellent. Successful reduction was achieved and the skin incision was less than 8 mm in 20 cases (76.9%). Only six patients had an additional skin incision (less than 5 mm) to achieve reduction. No cases of ectropion, entropion, or excessive scarring were noted. CONCLUSIONS: The ETA using a T-bar screw is a useful method for maximizing aesthetic results in ZMC fractures, with the advantages of minimal scarring, faster recovery, and maintenance of pretarsal fullness.

Bilateral interdigitated Pacman flap for round and oval facial defects.

BACKGROUND: Skin texture and color are important considerations during the reconstruction of facial defects, and anatomical borders should be preserved. Therefore, a local flap is a better option. In these cases, the authors repaired facial defects using a bilateral interdigitated VY flap. OBJECTIVE: We aim to present a modified bilateral Pacman flap technique for the reconstruction of round and oval facial defects. MATERIALS AND METHODS: We performed a retrospective chart review of 25 patients (26 cases) who underwent bilateral interdigitated Pacman flap repair of round and oval facial defects after Mohs surgery for skin cancer from January 2012 to December 2017. The defect sizes ranged from 0.7 to 8.4 cm2 (mean 3.1 cm2). RESULTS: All defects were covered successfully and the flaps survived in all cases. One patient had partial flap necrosis that resolved spontaneously. No flap contraction, distortion, or severe scar formation was observed in any patient during the 12-month follow-up period. CONCLUSION: The bilateral interdigitated Pacman flap can cover round and oval facial defects without distortion or central dog-ear deformity. This method is a useful option for facial restoration in selected cases.

Proper Choice of Vessels for Supermicrosurgery Training: An Experimental Animal study.

BACKGROUND: Reconstruction using supermicrosurgery, a technique of microneurovascular anastomosis for smaller vessels (< 0.8 mm), has become popular. Experimental animal studies for supermicrosurgery training have been reported; however, there have been few studies performed according to vessel diameter and pedicle length. In this study, the external diameters of four vessels (femoral, superficial epigastric, axillary, and common thoracic) and pedicle length of two flaps (superficial epigastric and common thoracic-long thoracic) were measured. METHODS: The inguinal and pectoral regions of Sprague-Dawley rats (n = 19) were dissected anatomically, and the external diameters of the four vessels were measured (right and left, artery and vein measured separately). After elevating the superficial epigastric and common thoracic-long thoracic flaps, the pedicle length of the flaps was also measured. RESULTS: Among the 16 vessels examined, the external diameters of 11 and 5 vessels were above and below 0.8 mm, respectively. The external diameters of the superficial epigastric vessel and common thoracic vessel (both arteries and veins) were below 0.8 mm. The external diameters of the femoral and axillary vessels (veins) were above 0.8 mm. The length of the common thoracic-long thoracic pedicle was approximately10 mm longer than that of the superficial epigastric pedicle. CONCLUSIONS: The external diameters of the superficial epigastric vessel and common thoracic vessel are small enough for supermicrosurgery training. The pedicle lengths of both the superficial epigastric and common thoracic-long thoracic flaps are sufficient to perform free flap experiments. Supermicrosurgical free flaps using these two vessels and a study of the physiology and pharmacology of the flaps will likely be possible in the future.

Comparison of Postoperative Outcomes Between Monitored Anesthesia Care and General Anesthesia in Closed Reduction of Nasal Fracture.

Fracture of nasal bone is among the most common facial bone fractures. Reduction of nasal bone fracture is able to be performed under local or general anesthesia. The aim of this study is to compare monitored anesthetic care (MAC) and general anesthesia (GA) based on intraoperative vital signs, and the adverse effects after closed reduction of nasal bone fractures.The authors performed a retrospective study of 45 patients who underwent a closed reduction of nasal bone fracture between January 1, 2016 and December 31, 2016. Patients are divided into an MAC group (n = 17) or GA group (n = 28). A sore throat, postoperative pain scores, nausea, vomiting, hospital stay, operation time, and the result of surgery are compared between the groups. All the patients have interviewed their satisfaction of aesthetic and functional outcome.The operation time and hospital stay were lower in the MAC group. There is no difference in a sore throat, postoperative pain score, and the result of surgery significantly. In the MAC and GA groups, there was no statistically significant difference in the postoperative cosmetic and functional satisfaction scores.Closed reduction of nasal bone fracture using MAC is as safe and efficient as GA. However, MAC anesthesia may not be feasible if airway discomfort due to bleeding is expected, or fracture is severe and multiple manipulations are required. Therefore, MAC is considered to be a good alternative when patients undergoing short-term or small operations do not prefer general anesthesia.