Adipose Derived Stromal Vascular Fraction and Mesenchymal Stem Cells Improve Angiogenesis in a Rat Hindlimb Ischaemia Model

OBJECTIVE

This study aimed to investigate the effect of human adipose tissue derived stromal vascular fraction (AD-SVF) and mesenchymal stem cells (AD-MSCs) on blood flow recovery and neovascularisation in a rat hindlimb ischaemia model.

METHODS

SVF was isolated using an automated centrifugal system, and AD-MSCs were obtained from adherent cultures of SVF cells. Rats were divided into four groups of six rats each: non-ischaemia (Group 1); saline treated ischaemia (Group 2); SVF treated ischaemia (Group 3); and AD-MSC treated ischaemia (Group 4). Unilateral hindlimb ischaemia was induced in Sprague-Dawley rats via femoral artery ligation. Saline, SVF, or AD-MSCs were injected intramuscularly into the adductor muscle intra-operatively. Cell viability was calculated as the percentage of live cells relative to total cell number. Blood flow improvement, muscle fibre injury, and angiogenic properties were validated using thermal imaging and histological assessment.

RESULTS

The viabilities of SVF and AD-MSCs were 83.3% and 96.7%, respectively. Group 1 exhibited no significant temperature difference between hindlimbs, indicating a lack of blood flow changes. The temperature gradient gradually decreased in SVF and AD-MSC treated rats compared with saline treated rats. In addition, only normal muscle fibres with peripherally located nuclei were observed in Group 1. Groups 3 and 4 exhibited significantly fewer centrally located nuclei, indicating less muscle damage compared with Group 2. Regarding angiogenic properties, CD31 staining of endothelial cells showed similar patterns among all groups, whereas expression of vascular endothelial growth factor, as a crucial angiogenesis factor, was enhanced in the SVF and AD-MSC treated groups.

CONCLUSION

SVF and AD-MSCs improved blood flow and neovascularisation in a rat hindlimb ischaemia model, suggesting their potential ability to promote angiogenesis. Further extensive research is warranted to explore their potential applications in the treatment of severe lower extremity arterial disease.

Revisiting bilateral bony orbital volumes comparison using 3D reconstruction in Korean adults: a reference study for orbital wall reconstruction, 3D printing, and navigation by mirroring

BACKGROUND

Orbital wall fractures can result in changes to the bony orbital volume and soft tissue. Restoring the bony orbital and intraconal fat volumes is crucial to prevent posttraumatic enophthalmos and hypoglobus. We aimed to establish an evidence-based medical reference point for "mirroring" in orbital wall reconstruction, which incorporates three-dimensional (3D)-printing and navigation-assisted surgery, by comparing bilateral bony orbital volumes.

METHODS

We retrospectively analyzed the data obtained from 100 Korean adults who did not have orbital wall fractures, categorized by age groups. The AVIEW Research software (Coreline Soft Inc., Seoul, South Korea) was used to generate 3D reformations of the bony orbital cavity, and bony orbital volumes were automatically calculated after selecting the region of interest on consecutive computed tomography slices.

RESULTS

The mean left and right orbital volume of males in their 20 s was 24.67 ± 2.58 mL and 24.70 ± 2.59 mL, respectively, with no significant difference in size (p = 0.98) and Pearson's correlation coefficient of 0.977 (p < 0.001). No significant differences were found in orbital volumes in other age groups without fractures or in patients with nasal bone fractures (p = 0.84, Pearson's correlation coefficient 0.970, p < 0.001). The interclass correlation coefficients (2,1) for inter- and intrarater reliability were 0.97 (p < 0.001) and 0.99 (p < 0.001), respectively.

CONCLUSIONS

No significant differences were found in the bilateral bony orbital volumes among males of any age. Thus, the uninjured orbit can be used as a volumetric reference point for the contralateral injured orbit during orbital wall reconstruction.

Mastectomy Skin Flap Stability Prediction Using Indocyanine Green Angiography: A Randomized Prospective Trial

BACKGROUND

The first step in successful breast reconstruction is obtaining a stable skin flap. Indocyanine green (ICG) angiography has recently been studied for its value and usefulness in predicting the stability of skin flaps; however, relevant prospective studies of its clinical efficacy are limited.

OBJECTIVES

The aim of this study was to prospectively investigate the clinical impact on breast reconstruction outcomes of the intraoperative use of ICG angiography.

METHODS

Between March and December 2021, 64 patients who underwent immediate breast reconstruction at the authors' institution were prospectively enrolled. They were classified into an experimental group (n = 39; undergoing ICG angiography) and a control group (n = 25; undergoing gross inspection alone). In the absence of viable skin, debridement was performed at the surgeon's discretion. Skin complications were categorized as skin necrosis (the transition of the skin flap to full-thickness necrosis) or skin erosion (a skin flap that did not deteriorate or become necrotic but lacked intactness).

RESULTS

The 2 groups were matched in terms of basic demographic characteristics and incision line necrosis ratio (P = .354). However, intraoperative debridement was significantly more frequent in the experimental group (51.3% vs 48.0%, P = .006). The authors additionally classified skin flap necrosis into partial- and full-thickness necrosis, with a higher predominance of partial-thickness necrosis in the experimental vs control group (82.8% vs 55.6%; P = .043).

CONCLUSIONS

Intraoperative ICG angiography does not directly minimize skin erosion or necrosis. However, compared to gross examination alone, it enables surgeons to perform a more active debridement during surgery, thereby contributing to a lower incidence of advanced skin necrosis. In breast reconstruction, ICG angiography may be useful for assessing the viability of the postmastectomy skin flap and could contribute to successful reconstruction.

LEVEL OF EVIDENCE

4.

Mapping the Anatomical Distribution of MRI-Identified Locoregional Recurrence following Robotic-Assisted Laparoscopic Prostatectomy for Prostate Adenocarcinoma

PURPOSE/OBJECTIVE(S)

The pattern of locoregional recurrence specifically after robotic-assisted laparoscopic prostatectomy (RALP) for prostate adenocarcinoma is still unknown. In this study, we reviewed pelvic magnetic resonance images (MRI) after postoperative biochemical recurrence (BCR) and drew a map of locoregional recurrence to support evidence of determining the optimal target volume of salvage radiotherapy in a post-RALP BCR scenario.

MATERIALS/METHODS

We have retrospectively searched 7,583 prostate adenocarcinoma patients who have received RALP in our institution between January 2010 and December 2021, and found a pool of highly selected patients with gross tumor recurrence confirmed by post-BCR pelvic MRIs and did not have other histories of malignancy. BCR was defined as the serum PSA more or equal to 0.2 ng/mL, or three consecutive increases. Patients with serum PSA nadir more or equal to 0.2 ng/mL on the 90th postoperative day (POD 90) were excluded to guarantee successful tumor removal. We have reviewed serum PSA levels using R codes, MRI and pathological reports using Excel, and descriptive statistics using SPSS 25. The gross lesions were contoured on the correlating MRIs using MIM Maestro 7.1. The RT structure DICOM files were merged into a map using MATLAB 2022b. In addition, we have conducted Fisher exacted test, Mann-Whitney U test, and logistic regression to identify risk factors for regional recurrence.

RESULTS

A total of 173 patients were identified with locoregional recurrence from post-BCR pelvic MRIs, and 139 (80.3%) patients were in the high-risk group or very-high-risk group according to the NCCN guidelines: 57 (32.9%) patients with histological grade group 5, 50 (28.9%) patients with initial PSA over 20 ng/mL, 114 (65.9%) patients with extracapsular extension, 55 (31.8%) patients with seminal vesicle invasion, and 15 (9%) patients with pN1. The median follow-up was 4.7 (IQR 2.8-6.9) years for pelvic MRIs and 5.8 (IQR 4.0-8.6) years for serum PSA. The BCF survival was median of 10.7 (IQR 4.6-19.1) months, and the locoregional recurrence-free survival was median of 24.6 (IQR 9.7-49.4) months for this subgroup of patients. At first locoregional recurrence, 148 (85.5%) patients were local only, 20 (11.6%) patients were regional only, and 5 (2.9%) patients were both local and regional. Out of the 25 patients with regional recurrence, the incidence of gross tumor recurrence differed by nodal sites: 3 (12%) in perirectal space, 5 (20%) in internal iliac, 7 (28%) in obturator, 13 (52%) in external iliac, and 6 (24%) in common iliac lymph nodes.

CONCLUSION

We have found 173 patients and were able to map reliable gross tumor recurrence sites after RALP and confirmed by pelvic MRIs following BCR. The map supports evidence of using the existing consensus pelvic clinical target volume of salvage radiotherapy, in a post-RALP BCR scenario.

Comparison of Early Outcomes of Stereotactic Accelerated Partial Breast Irradiation vs. Volumetric Modulated Arc Therapy-Based FAST-FORWARD Whole Breast Irradiation for Breast Cancer

PURPOSE/OBJECTIVE(S)

Despite evidence supporting APBI from 8 published prospective randomized trials enrolling over 10,000 women, the uptake of APBI in clinical practice is surprisingly low. This is being exacerbated by a new, convenient, and safe shortened WBI schedule. Here, we report the dosimetric and early outcome analyses of the first >1000 patients treated at our institution since the first adoption of stereotactic APBI and the ultra-hypofractionated WBI regimen.

MATERIALS/METHODS

From 2016 to 2022, 801 women with breast cancers in the suitable or cautionary categories according to the ASTRO APBI consensus panel guidelines, received 30 Gy in 5 fractions (92%) either using a robotic stereotactic radiation system (83%) or stereotactic volumetric-based arc therapy (VMAT, 17%). Between 2020 and 2022, 468 women, who were not candidates for APBI and not undergoing any regional irradiation received 26 Gy in 5 fractions using VMAT to the whole breast with the addition of cardiac sparing technique in left-sided breast cancer patients. Tumor bed boosts were delivered in 99% of FF-WBI patients. We evaluated dose-volume histogram parameters for target volumes and organs-at-risk and radiation-related toxicities during RT or within 6 months after the end of RT.

RESULTS

Target volume coverage was acceptable in both groups, with mean 96% of the target volumes receiving 95% of the prescribed doses and 0 cm3 within target volumes exceeding 105% of the prescribed doses. S-APBI resulted in small, but statistically significant, reductions in the radiation dose delivered to the ipsilateral breast, contralateral breast, lungs, heart, and coronary artery compared with FF-WBI. Comparing WBI to APBI, the mean contralateral breast dose, ipsilateral lung V20 Gy, mean contralateral lung dose, and mean heart dose, were reduced by 89%, 78%, 73%, and 29%, respectively. With median follow-up periods of 32 months for s-APBI and 19 months for FF-WBI, acute toxicity was assessable in all patients. The risks of any grade acute toxicity were 21% for s-APBI and 25% for FF-WBI (p = .117). Among them, grade 2 rates were 1.3% in both groups and no severe toxicity has been reported.

CONCLUSION

We found s-APBI and VMAT-based FF WBI were associated with favorable dosimetric and acute toxicity profiles. However, considering significantly less irradiated volume in the breast, lungs, and heart, APBI with advanced available technique options should be considered over any WBI-based approach for patients at low risk for local recurrence.

Beneficial Role of Multi-Disciplinary Treatment for Anaplastic Thyroid Cancer with Initial Distant Metastasis

PURPOSE/OBJECTIVE(S)

Anaplastic thyroid cancer (ATC) is a rare, highly aggressive tumor, with median survival around 5 months. Approximately half of the ATC patients presents with distant metastases at diagnosis, showing even more devastating prognosis, yet no outcome analysis had been reported. In this study, we aim to evaluate the clinical outcome of M1 ATC patients, and to define the group of patients who would benefit from local treatment based on multi-disciplinary approach.

MATERIALS/METHODS

A total of 133 histology-confirmed ATC patients underwent protocol-based multidisciplinary treatment including surgery and chemoradiotherapy (CRT) between May 2016 and January 2022. Patients received intensity-modulated radiotherapy of 30 fractions concurrently with paclitaxel on days 1, 8 and 15 every 4 weeks, and lenvatinib was added upon progression. After 18 fractions of CRT, interim response analysis using modified RECIST was conducted for adaptive treatment planning. We reviewed 58 patients with distant metastasis at diagnosis (stage IVC). Overall survival (OS) and progression-free survival (PFS) were measured from the day of diagnosis.

RESULTS

Most common metastatic site was lung (91.4%), followed by bone (31.0%) and brain (5.2%). Lenvatinib was added for 35 patients after any sign of progression. Fourteen patients received upfront surgery (16 debulking and 5 total) followed by adjuvant CRT in 16 patients. Thirty-one patients received upfront CRT with 2 patients receiving total resection after sufficient down-staging. Six (10%) patients could not complete radiotherapy but continued receiving systemic treatment. The median follow-up was 5.9 months. The median and 1-year OS were 6.2 months and 20.5%, and PFS were 3.7 months and 3.5%. Total RT dose over 60 Gy significantly improved median OS (7.5 vs 4.1 months, p = 0.012) and median PFS (4.4 vs 3.0, p = 0.010). Patients with less than 10 initial metastatic tumors showed better median OS (9.1 vs 4.6 months, p = 0.002) but not PFS (5.1 vs 3.6, p = 0.485). At interim analysis, early response (CR, PR and SD) of primary tumor was not associated with survival, while progression of distant metastases showed significantly worse median OS (9.8 vs 4.6 months, p = 0.001). More than 10 metastatic tumors (HR 2.73, 95% CI 1.32-5.66) and stable metastasis at interim analysis (HR 2.39, 95% CI 1.04-5.48) remained as significant factor in the multivariable cox regression analysis. Median OS and PFS of patients with less than 10 metastases showing no progression at interim analysis were 9.1 months, and 5.1 months.

CONCLUSION

Local treatment combined with chemotherapy for M1 ATC patients showed outcome comparable to those of non-metastatic ATC results. Active local treatment should be considered especially for patients with less than 10 metastases, and patients without distant progression in early response evaluation.

Assessment of diagnostic accuracy and complication rates of CT-guided percutaneous core-needle biopsy for lung lesion: difference between solid and sub-solid nodules based on propensity score matching analysis

AIM

To compare the success and complication rates of computed tomography (CT)-guided percutaneous core-needle biopsy (PCNB) based on the density of lung nodules, using propensity score matching (PSM).

MATERIALS AND METHODS

This single-centre retrospective study included 1,312 PCNB cases of lung lesions, including solid (n=1,120), part-solid (n=115), and non-solid nodules (n=77), that were detected between March 2013 and March 2021. The diagnostic accuracy and complication rates of pneumothorax and pulmonary haemorrhage were analysed before PSM. To perform PSM, part-solid and non-solid nodules were combined and newly defined as sub-solid nodules. The diagnostic accuracy and complication rates of pneumothorax and pulmonary haemorrhage were then compared between solid and sub-solid nodules after PSM.

RESULTS

Among the 1,312 included cases, the success rate and incidence of pneumothorax after CT-guided PCNB for solid, part-solid, and non-solid nodules were not statistically different (p=0.080 and 0.410). However, the rates of overall pulmonary haemorrhage showed statistical differences (p<0.001), particularly between solid and part-solid nodules (p<0.001) and between solid and non-solid nodules (p<0.001). After PSM, the incidence rates of overall pulmonary haemorrhage in solid and sub-solid nodules were 8.9% (17/192) and 29.7% (44/182), respectively, showing a statistically significant difference (p<0.001).

CONCLUSION

There is increased risk of haemorrhage in CT-guided needle biopsy of sub-solid nodules compared to solid nodules. Increased emphasis should be placed on the risk of pulmonary haemorrhage when consenting these patients.

Effect of a Team Approach to Pressure Injury Management over 5 Years in a Tertiary Hospital

OBJECTIVE

The authors' facility established a novel integrated wound care team (IWCT), which included the implementation of a strict treatment algorithm by the patients' attending providers and a specialized wound care team led by a plastic surgeon. Investigators then retrospectively analyzed clinical outcomes of pressure injury (PI) management by the IWCT over 5 years.

METHODS

The authors performed a retrospective chart review and periodic statistical analysis of the data for all patients with PI referred to the IWCT in the authors' center from May 2015 to April 2019. Data including patients' demographic information, first and last consultation dates, referring department, PI stage, site of PI, and Braden Scale scores were collected and analyzed.

RESULTS

Patients (N = 15,556) did not differ significantly in age, sex, or Braden Scale score. A preimplementation/postimplementation analysis of PI data before and after establishing the IWCT showed that the incidence of stage 3 or 4 PIs had significantly decreased during the study period (19.1% vs 15.2%, P < .05). Conversely, the incidence of stage 1 PIs significantly increased in the same period (38.0% vs 57.4%, P < .05). The proportion of completely healed PIs also increased, and the median treatment period was significantly shortened (P < .05).

CONCLUSIONS

Implementation of the IWCT in a tertiary hospital setting led to a significant increase in early-stage PI detection and a decrease in severe PIs.

Prior activation of social work team process by pre-admission one-click automatic referral system

Background

Coronary artery disease (CAD) is the leading global cause of mortality. Coronary angiography (CAG) is often performed for CAD patients, and the mean length of stay (LoS) is 4 d. Requests to the social work team (SWT) are often delayed until just before discharge, causing unnecessarily prolonged LoS and reduced chances of obtaining financial support. If the SWT’s support system is activated beforehand for scheduled CAGs, the LoS would be shorter and patients would be relieved of emotional and financial burdens.

Methods

Collaborating with the cardiology and medical informatics departments, a one-click automatic referral system (OARS) was set up (January-May 2021). When cardiologists scheduled a CAG in the outpatient department, an OARS cue popped automatically for the medical aid recipients. The cardiologists could also activate the pre-admission OARS for other patients when necessary. Subsequently, the SWT responded on that day to discuss initiating the financial support process with the candidates. The rate of cardiologists’ pre-admission referral to SWT, decision-making time on financial support provision, and proportion of patients receiving financial support were compared before and after initiating OARS.

Results

After initiating pre-admission OARS, the rate of cardiologists’ pre-admission referral to SWT increased from 17.8% (18/101: mean age, 64.6±12.0 y; 32 females; January-December 2020) to 59.1% (55/93: mean age, 64.0±11.8 y; 29 females; June-December 2021) (p &lt; 0.001). Although the decision-making time to provide financial support did not change significantly (8.4±11.1 vs. 4.7±11.6 d; p = 0.96), the proportion of patients receiving financial support increased (45.5% [46/101] vs. 60.2% [56/93]; p = 0.045).

Conclusions

By enhancing the cardiologists’ pre-admission referral to SWT and success rate of receiving financial support, the proactive strategy of pre-admission OARS benefits CAD patients scheduled for CAG.

Key messages

• By building a proactive referral strategy of pre-admission OARS, more CAD patients scheduled for CAG could obtain timely financial support and be relieved both emotionally and financially by the SWT.

• This pre-admission OARS might be incorporated for more disease entities for patients in need.

Efficacy of split-thickness skin graft combined with novel sheet-type reprocessed micronized acellular dermal matrix

BACKGROUND

Autologous split-thickness skin grafts (STSGs) remain the mainstay for treatment of large skin defects. Despite its many advantages, there exist critical disadvantages such as unfavorable scar and graft contracture. In addition, it cannot be used when structures such as tendons and bones are exposed. To overcome these limitations, acellular dermal matrix (ADM) is widely used with STSG. CGDerm Matrix^®, which was recently developed, is a novel reprocessed micronized ADM (RMADM). In this study, outcomes of the combined application of RMADM and STSG on full-thickness wounds were analyzed.

METHODS

Forty-one patients with full-thickness skin defects due to trauma, scar contracture release, and diabetic foot ulcers, who underwent STSGs, from January 2021 to July 2021, were retrospectively reviewed. The primary outcome of interest was skin loss rate, which was measured 14 days after surgery.

RESULTS

The most common cause of skin defect was trauma (36 patients), diabetic foot (2 patients), scar contracture release (2 patients), and malignancy (1 patient). The average defect size was 109.6 cm² (range, 8-450 cm²). The average skin loss rate was 9.1%, showing a graft take rate of > 90%.

CONCLUSION

The use of combined RMADM and STSG in full-thickness wound reconstruction provides stable and acceptable outcomes. The newly developed ADM can be a promising option in wound reconstruction.

Clinical use of perioperative magnetic resonance imaging-based breast volumetric analysis in final implant volume prediction for two-stage breast reconstruction

Purpose

Breast volume is an important factor in breast reconstruction; however, the surgeon is expected to deliver the volume expectation with his aesthetic inspiration. Therefore, objective volumetry must be developed. This study aimed to conduct an MRI-based breast volumetric analysis. With periodic analysis of 2-stage breast reconstruction, we suggest the possibility of clinical use of breast volumetry in implant volume prediction.

Methods

This retrospective study included 140 patients who underwent unilateral 2-stage breast reconstruction (tissue expander followed by implant insertion) between January 1, 2017 and December 31, 2019. The MRI image was converted into a 3-dimensional image with a reconstruction program (A-VIEW, Coreline Soft). MRI image was obtained before the surgery and then at 1, 3, 6, 12, and 24 months postoperatively. The volume was automatically calculated.

Results

Compared with the preoperative volume, maximized volume and differences were noted at 1 month and minimized at 1 year. The correlation between MRI-based preoperative breast volumetry and the mastectomy specimen volume was 0.611. Volume difference between the MRI-based preoperative state and the implant volume showed a minimal difference at 1 year. The final implant size prediction formula was calculated using the 1-year postoperative volume (P < 0.001, R² = 0.594).

Conclusion

To avoid breast reconstruction based solely on the surgeon’s subjective assessment, MRI-based breast volumetry could be a useful method to develop more scientific and objective breast reconstruction planning. We suggest a volume prediction formula that describes the relationship between the postoperative breast volume and the final breast implant size.

Impact of establishing a level-1 trauma center for lower extremity trauma: a 4-year experience

Purpose

A multidisciplinary approach is essential for trauma patients’ treatment, particularly for cases with open lower extremity fractures, which are considered major traumas requiring a comprehensive approach. Recently, the social demand for severe-trauma centers has increased. This study analyzed the clinical impact of establishing a trauma center for the treatment of open lower extremity fractures.

Methods

A retrospective chart review was conducted for trauma patients admitted to our hospital. Patients were classified into two groups: before (January 2014–December 2015, 178 patients) and after establishment of a Level-1 trauma center (January 2017–December 2018, 125 patients). We included patients with open fracture below the knee level and Gustilo type II/III, but excluded those with life-threatening trauma that affected the treatment choice.

Results

Total 273 patient were included in this study, initial infection was significantly more common and external fixator application significantly less in post-center establishment group. The time to emergency operation decreased significantly from 13.89 ± 17.48 to 11.65 ± 19.33 h post-center setup. By multivariate analysis, the decreased primary amputation and increased limb salvage was attributed to establishment of the trauma center.

Conclusion

With the establishment of the Level-1 trauma center, limbs of patients with open lower extremity fractures could be salvaged, and the need for primary amputation was decreased. Early control of initial open wound infection and minimizing external fixator use allowed early soft tissue reconstruction. The existence of the center ensured a shorter interval to emergency operation and facilitated interdepartmental cooperation, which promoted active limb salvage and contributed to patients’ quality of life.

Impact of perioperative vasopressors on lower extremity free flap reconstruction

PURPOSE

Free tissue transfer is a treatment option for soft tissue defects of the lower extremity. For a successful outcome, it is necessary to evaluate the vessel condition and blood flow patency. The administration of a vasopressor could impact the survival rate of free tissue transfer; however, there is a lack of studies on vasopressor use and lower extremity reconstruction. This study aimed to investigate the relationship between the use of a vasopressor and outcomes of free tissue transfer in lower extremity reconstruction.

METHODS

This retrospective, observational study was conducted between March 2010 and February 2019. Data were divided into intraoperative and postoperative variables according to the administration time. Data on patient demographics, risk factors, details of reconstruction, flap outcomes, and duration of intensive care unit (ICU) stay were obtained. Binary logistic regression models were computed to determine the association between flap outcome and vasopressor administration.

RESULTS

Of the 338 patients, 186 were administered a vasopressor. Intraoperative and postoperative vasopressor use was not related to the overall complication rate (odds ratio, 1.547; 95% confidence interval, 0.830-2.882; p = .169). Low-intraoperative levels of hemoglobin were associated with the overall complication rate. Postoperative vasopressor administration was associated with prolonged ICU stay.

CONCLUSION

Our results showed that the intraoperative and postoperative use of vasopressors was not significantly associated with the success rate of free flaps. Future studies investigating the relationship between the dose, type, and duration of vasopressors and the complication rate following free tissue transfer are warranted.

Factors affecting the outcome of lower extremity osteomyelitis treated with microvascular free flaps: an analysis of 65 patients

Background

Free flaps have been a useful modality in the management of lower extremity osteomyelitis particularly in limb salvage. This study aimed to determine the factors affecting the outcome of free flap reconstruction in the treatment of osteomyelitis.

Methods

This retrospective study assessed 65 osteomyelitis patients treated with free flap transfer from 2015 to 2020. The treatment outcomes were evaluated in terms of the flap survival rate, recurrence rate of osteomyelitis, and amputation rate. The correlation between outcomes and comorbidities, causes of osteomyelitis, and treatment modalities was analyzed. The following factors were considered: smoking, peripheral artery occlusive disease, renal disease, diabetic foot ulcer, flap types, using antibiotic beads, and negative pressure wound therapy.

Result

Among the 65 patients, 21 had a severe peripheral arterial occlusive disease. Osteomyelitis developed from diabetic foot ulcers in 28 patients. Total flap failure was noted in six patients, and osteomyelitis recurrence was noted in eight patients, for which two patients underwent amputation surgery during the follow-up period. Only end-stage renal disease had a significant correlation with the recurrence rate (odds ratio = 16.5, p = 0.011). There was no significant relationship between outcomes and the other factors.

Conclusion

This study showed that free flaps could be safely used for the treatment of osteomyelitis in patients with comorbidities and those who had osteomyelitis developing from diabetic foot ulcers. However, care should be taken in patients diagnosed with end-stage renal disease.

Ready-to-Use Micronized Human Acellular Dermal Matrix to Accelerate Wound Healing in Diabetic Foot Ulcers: A Prospective Randomized Pilot Study

OBJECTIVE

To examine and report clinical outcomes of a ready-to-use micronized dermal matrix for diabetic foot ulcers (DFUs) and compare it to treatment with conventional negative-pressure wound therapy (NPWT) only.

METHODS

The researchers randomly allocated 30 DFUs Wagner grade 2 or higher from 30 adult patients into two groups. The control group (n = 15) was treated with conventional NPWT, and the experimental group (n = 15) was treated with micronized dermal matrix and NPWT. The researchers evaluated the following outcomes: granulation tissue formation, proportion of patients with closed or granulated wounds at 42 and 120 days, achievement of complete wound healing in the 6 months of follow-up, and intervals from enrollment to final surgical procedures.

RESULTS

All 15 wounds treated with the micronized matrix showed healthy granulation tissue without noticeable complications during follow-up. At 42 days, 46.7% of wounds in the experimental group had closed compared with 28.6% in the conventional NPWT group (P = .007). At 120 days, 86.7% of the experimental group had completely closed wounds, compared with 57.1% in the conventional therapy group (P = .040). During the 6-month follow-up period, 93.3% of the experimental group achieved complete wound healing compared with 85.7% of the conventional therapy group (P = .468).

CONCLUSIONS

The healing outcomes for DFUs in the experimental group were superior when micronized matrix treatment was combined with NPWT.

Role of plastic surgeons in the trauma center: national level I trauma center startup experience in South Korea

Although it is well recognized that other surgical specialties perform various procedures related to trauma care, there is a lack of analyses focusing on the role of plastic surgical management in trauma centers. This retrospective study was designed to investigate the scope of plastic surgery services in acute trauma care, using clinical data obtained from a single, regional, level I trauma center.This study included patients who presented to a single, regional, level I trauma center between March 1, 2016 and February 28, 2018. Patients with acute trauma to the facial soft tissue and skeleton, soft tissue of the upper and lower limbs, trunk and perineum, and other areas requiring plastic surgical procedures were included in the analysis. Cases requiring consultation for the correction of posttraumatic deformity or secondary deformity and trauma sequelae, such as scars, were excluded. Data on patients' demographics and detailed surgical procedures were acquired from electronic medical records. The reviewed cases were categorized by the primary anatomical region requiring surgery and the primary procedure performed.A total of 1544 patients underwent surgery, and 2217 procedures were recorded during the 2-year study period. In 2016, 1062 procedures on 690 patients, and, in 2017, 1155 procedures on 787 patients were registered. The average age of the patients who underwent plastic surgical procedure due to a trauma-related cause was 38.4 years (range, 2 days to 91 years), and 1148 patients (77.7%) were male. The head and neck region was the most commonly observed anatomical area that was operated on. The facial bone requiring the largest degree of surgical intervention was the mandible, followed by the zygomatic bone, nasal bones, orbital floor, and maxilla. Microsurgical procedures, such as flap surgery and microsurgery, were performed in 121 cases. The most commonly elevated free flap was the ALT flap (n = 69).Plastic surgeons play various roles in level I trauma centers, such as in the management of facial injury, performing limb-saving free tissue transfers, and complex wound reconstruction with flaps or skin grafts. Thus, plastic surgeons are an essential part of trauma centers.

The Effects of Subcutaneously Injected Novel Biphasic Cross-Linked Hyaluronic Acid Filler: In Vivo Study

BACKGROUND

Biphasic hyaluronic acid (HA) fillers have been used extensively to improve facial skin. However, in some cases, the skin surface is irregular because of the premature loss of HA solution. We propose a new biphasic filler (G-filler) to overcome this problem by using small particles of HA hydrogel instead of HA solution, which can provide a smooth skin surface and good durability.

METHOD

We evaluated the rheologic properties of G-filler and its physiologic effects after subcutaneous injection in a mouse model by histologic analysis.

RESULTS

The G-filler showed a similar elastic modulus (G') and complex viscosity (η*) as the conventional biphasic filler, but had a higher viscous modulus (G″) than the conventional monophasic filler. The highest material elasticity (tan δ) value and the lowest percentage elasticity value indicate the rheologic properties of G-filler are closer to those of liquids. After subcutaneous injection of G-filler, collagen content (~ 2-fold) and elastin fibers (~ 6.5-fold) were significantly increased at 12 weeks compared to those of the saline group. Fibronectin (~ 2.6-fold) and the laminin-immunolabeled cell number (~ 6-fold) were also significantly increased at 12 weeks. Significant increases in the CD31-immunoreactive cell numbers of the G-filler groups were observed at 2, 6, and 12 weeks (~ 3.7-fold) compared to those of the saline groups. There were no significant differences between the G-filler and saline groups in patterns of skin thickness and inflammatory cell numbers around loading sites.

CONCLUSION

These findings demonstrate that the injection of a new biphasic filler with improved rheologic properties can effectively stimulate extracellular matrix production and angiogenesis without safety concerns.

NO LEVEL ASSIGNED

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 .

What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction?

Background

The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction.

Methods

A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient’s demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results.

Results

The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival.

Conclusions

Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.

Multivariate analysis of early surgical management factors affecting posttraumatic penoscrotal avulsion injury: a level I trauma center study

Background

To conduct an accurate evaluation of patients presenting with posttraumatic penoscrotal injuries, and to formulate a treatment algorithm based on this assessment.

Methods

We conducted a retrospective chart review study. Patients with penoscrotal defects admitted to our level I trauma center from 2017 to 2019 were evaluated. The Braden scale score was used for wound evaluation and the Korean patient classification system (KPCS) was used for assessment of severity. Univariate and multivariate analyses were performed for potential risk factors associated with early surgical management.

Results

In total, there were 58 male patients, and the average Braden scale score was 12.08 ± 2.54, with the scrotum (36.20%), and the penile shaft (32.76%) being popular sites for injuries. The wounds requiring surgical treatment were 20.68% (n = 12), with local flaps (33.33%) being most commonly used. The significant predictors of advanced wounds which required surgical treatment were old age (p = 0.026, odds ratio [OR] 8.238), orthopedic combined injuries (p = 0.044, OR 1.088), intubation (p = 0.018, OR 9.625), restraint (p = 0.036, OR 0.157) and blood transfusion (p < 0.001, OR 2.462).

Conclusion

In multiple trauma patients, penoscrotal defects caused by high-speed trauma are an important matter of concern. Specifically, patients with combined skeletal injuries or requiring respiratory care were prone to advanced wounds. We proposed a five-category algorithm to manage such patients, which included severity of the patient’s condition, respiration, hemodynamic status, comorbidity, and immobilization. Additionally, inter-departmental cooperation and active intervention by plastic surgeons is needed for the comprehensive treatment of such injuries.

Trial registration This study was performed in line with the principles of the Declaration of Helsinki. The study and all its protocols were approved by the institutional review board of Ajou Medical Center (approval no. AJIRB-MED-MDB-17-254). The need for informed consent was waived by the institutional review board of our hospital due to the retrospective design of the study.

Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases

BACKGROUND

Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia.

METHODS

Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected.

RESULTS

Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications.

CONCLUSION

The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.

Transformation of Malignant Melanoma From Giant Nevus in Infantile Penis

Background: Malignant melanoma is the most serious type of skin cancer, and its incidence rate increases with age. Malignant melanoma in infants has been rarely reported in the literature. Herein, we report a case of malignant transformation of a nodular lesion found in the penis of a patient with a giant congenital nevus.

Case presentation: A 1-month-old male patient was admitted due to the presence of a giant congenital nevus involving the lower abdomen, bilateral inguinal areas, genitals, and left thigh and knee. Six months later, nodules measuring 1 cm in diameter protruding from the genital area were noted, and a part of the nodule was removed via elliptical excision with the patient under general anesthesia. Gross examination showed an edematous lesion similar to a neurofibroma and with unclear boundaries. Biopsy revealed a malignant melanoma, with a Breslow thickness of at least 3 mm, and absence of lymphovascular invasion; the biopsy confirmed incomplete excision. The patient was scheduled for radical resection, but reconstruction was not performed following surgical resection due to the guardian's refusal. Hence, the patient only received an adjuvant medical treatment and eventually died.

Conclusion: We reported a rare case of an infant with a malignant melanoma in the penis. Congenital malignant melanoma rarely occurs in infants; however, due to its fatal consequences, follow-up should be performed to assess for malignant changes.

In Vitro Analysis of Histology, Mechanics, and Safety of Radiation-free Pre-hydrated Human Acellular Dermal Matrix

Purpose

Acellular dermal matrix (ADM) supports tissue expanders or implants in implant-based breast reconstruction. The characteristics of ADM tissue are defined by the manufacturing procedure, such as decellularization, preservation, and sterilization, and are directly related to clinical outcomes. This study aimed to compare the properties of a new pre-hydrated-ADM (H-ADM-low) obtained using a decellularization reagent reduction process with a low concentration of detergent with those of radiation-sterilized H-ADM and freeze-dried ADM (FD-ADM).

Methods

ADMs were evaluated in terms of structure, mechanical quality, and cytotoxicity using histochemical staining, tensile strength testing, and in vitro cell viability analysis.

Results

The tissue structure of H-ADM-low (CGDERM ONE-STEP) was similar to that of native skin despite complete decellularization. By contrast, in FD-ADM, the tissue structure was damaged by the freeze-drying process, and radiation-sterilized H-ADM showed a compact fibrillar arrangement. Furthermore, matrix components such as collagen and elastin were preserved in H-ADM-low, whereas a loss of elastin fibers with fragmented distribution was observed in radiation-sterilized H-ADMs. H-ADM-low's tensile strength (58.84 MPa) was significantly greater than that of FD-ADM (38.60 MPa) and comparable with that of radiation-sterilized H-ADMs. The residual detergent content in H-ADM-low (47.45 mg/L) was 2.67-fold lower than that of H-ADM decellularized with a conventional detergent concentration (126.99 mg/mL), and this finding was consistent with the cell viability results (90.7% and 70.7%, respectively), indicating that H-ADM-low has very low cytotoxicity.

Conclusions

H-ADM-low produced through aseptic processes retains the original tissue structure, demonstrates excellent mechanical properties, and does not affect cell viability. Therefore, this newer H-ADM is suitable for use in implant-based breast reconstruction.

Risk Assessment of Recurrence and Autoimmune Disorders in Kikuchi Disease

Purpose

Kikuchi disease (KD) is typically a benign disease. Recent studies reporting recurrence or serious cases suggest a possible association of KD with systemic autoimmune disorders. We performed a long-term analysis of the characteristics of KD in patients of all ages and assessed KD recurrence or progress to systemic autoimmune disorders.

Patients and Methods

Electronic medical records of patients diagnosed with KD between April 1995 and May 2017 were reviewed for clinical and laboratory manifestations.

Results

In total, 480 patients were confirmed to have KD based on histopathology findings. The mean age at KD diagnosis was 24.4 years. Recurrence occurred in 11.3% of patients; 2.7% developed autoimmune diseases after KD diagnosis. Patients who experienced recurrence had more extranodal symptoms, lymphopenia, and a longer lymphopenia-recovery duration. Patients who developed autoimmune diseases after KD were more likely to have extranodal symptoms, KD recurrence, and anti-nuclear antibody positivity.

Conclusion

KD patients with risk factors need to be followed-up for KD recurrence and the development of systemic autoimmune diseases.

Factors affecting the dormancy and germination of bleeding heart [Lamprocapnos spectabilis (L.) Fukuhara] seeds

Information on the optimal conditions to promote the germination of Lamprocapnos spectabilis (L.) Fukuhara seeds is limited; consequently, this study was conducted to establish the requirements to break seed dormancy and promote germination. The selected seeds had morphophysiological dormancy and had not begun embryo development. To study the dormancy breaking and embryo development processes, seeds were subjected to constant or changing temperature treatments during moist stratification. High temperature and humidity resulted in vigorous embryo growth, with the longest embryos occurring after 1 month of incubation at 20 °C. At 4 °C, the seeds required incubation period of at least 3 months to germinate. Embryo growth and germination were higher with changing high and low temperatures than under a constant temperature, and changing temperatures also considerably changed the endogenous hormone levels, embryo development and germination. Bioactive gibberellin (GA) content was higher in seeds incubated at 20 °C for 1 month, then at 4 °C for 2 months. The content of endogenous abscisic acid in seeds subjected to the same treatment decreased by 97.6% compared with that of the untreated seeds. Embryo growth and seed germination require changing high and low temperatures; however, exogenous GA₃ could substitute for high temperatures, as it also causes accelerated germination. In this study, the seeds of L. spectabilis were identified as an intermediate simple type, a sub-level of morphophysiologically dormant seeds.

Efficacy and safety of transarterial chemoembolisation with cone-beam CT in patients with hepatocellular carcinoma within the Milan criteria: a retrospective cohort study

AIM

To compare the therapeutic efficacy and safety of transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC) within the Milan criteria with or without the use of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients with HCC within the Milan criteria who underwent conventional angiography-guided TACE (Angio-TACE group: 58 patients from January 2010 to December 2011) were compared with those who underwent CBCT-guided TACE (CBCT-TACE group: 55 patients from January 2013 to December 2014). Local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were compared. Adverse events after TACE were also investigated.

RESULTS

Baseline characteristics were balanced between the two groups. LPFS was significantly longer in the CBCT-TACE group than in the Angio-TACE group (median: not reached for 36 versus 19.2 months, respectively; Log-rank p=0.029). In multivariable Cox regression analysis, CBCT guidance had a significantly lower risk of local progression or death (adjusted hazard ratio: 0.585; 95% confidence interval, 0.344-0.995; p=0.048); however, there was no significant difference in PFS (3-year PFS: 15.9% versus 26.8%, respectively; p=0.122) or OS (3-year OS: 85% versus 88.2%, respectively; p=0.761) between the Angio-TACE and CBCT-TACE groups. Post-embolisation syndrome occurred significantly less frequently in the CBCT-TACE group (p=0.002).

CONCLUSION

CBCT-guided TACE could improve local tumour control for HCC within Milan criteria and showed fewer cases of post-embolisation syndrome.

Abstract OT2-04-02: A phase 3 study of post-lumpectomy radiotherapy to whole breast + regional lymph nodes vs whole breast alone for patients with pN1 breast cancer treated with taxane-based chemotherapy (KROG 1701): Trial in progress

Background

In patients with early stage breast cancer, regional nodal irradiation (RNI) is added to whole breast irradiation (WBI) in order to control microscopic regional disease and to prevent systemic spread of cancer. According to recent randomized trials (MA.20 and EORTC 22922-10925), prophylactic RNI was associated with improvement in disease-free survival (DFS) in the patients with high-risk node negative or pN1 breast cancer. However, systemic agents now known to improve loco-regional control, such as taxane or endocrine therapy, were prescribed to a small percentage of patients in the studies. The benefit of RNI found in the previous studies might be attributed to incorporation of less effective systemic treatments. The impact of prophylactic RNI in pN1 breast cancer should be evaluated in the patients receiving modern systemic treatment. The current study was conducted to compare the effect of post-lumpectomy WBI vs WBI plus RNI on DFS in pN1 breast cancer patients who received adjuvant taxane-based chemotherapy.

Methods

This study is a multicenter, phase 3, randomized controlled non-inferiority trial (NCT03269981). Eligibility criteria are ≥ 20 years female; pathologically proven invasive carcinoma of the breast; one to three positive axillary lymph nodes (pN1) in pathologic specimen; receiving breast-conserving surgery followed by taxane-based chemotherapy; having adjuvant endocrine therapy or anti-HER2 treatment according to molecular subtype of tumor. Patients are randomly assigned in a 1:1 ratio to receive WBI or WBI plus RNI. Patient randomization was stratified by molecular subtype of tumor (i.e. luminal A/luminal B/luminal HER2/HER2-enriched/triple-negative) and methods of axillary management (i.e. sentinel lymph node biopsy/axillary lymph node dissection). The primary outcome is DFS. The secondary outcomes include DFS according to molecular subtype, treatment-related toxicity, and patient's quality of life per EORTC QLQ-C30 and QLQ-BR23. Patients will be followed for survival and disease recurrence for seven years. A total of 1,926 patients are planned to be enrolled, with recruitment initiated in April 2017. As of June 2018, a total of 236 patients were enrolled.

Acknowledgement

This study was supported by a grant from the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (grant number: HA17C0043010018).

Citation Format: Kim H, Park W, Choi DH, Ahn SJ, Kim SS, Kim ES, Lee JH, Lee KC, Kim JH, Lee H-S, Kim JH, Kim MY, Park HJ, Kim K, Song SH, Kwon J, Lee IJ, Kim TH, Kim TG, Chang AR, Cho O, Jeong BK, Ha B, Lee J, Ki Y. A phase 3 study of post-lumpectomy radiotherapy to whole breast + regional lymph nodes vs whole breast alone for patients with pN1 breast cancer treated with taxane-based chemotherapy (KROG 1701): Trial in progress [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-02.

Analysis of prognostic factors affecting poor outcomes in 41 cases of Fournier gangrene

Purpose

We present our experience involving the management of this disease, identifying prognostic factors affecting treatment outcomes.

Methods

The patients treated for Fournier gangrene at our institution were retrospectively reviewed. Data collected included demographics, extent of soft tissue necrosis, predisposing factors, etiological factors, laboratory values, and treatment outcomes. The severity index and score were calculated. Multivariate regression analysis was used to determine the association between potential predictors and clinical outcomes.

Results

A total of 41 patients (male:female = 33:8) were studied. The mean age was 54.4 years (range, 24-79 years). The most common predisposing factor was diabetes mellitus (n = 19, 46.3%). Sixteen patients (39.0%) were current smokers. Seven patients had chronic kidney disease. The most frequent etiology was urogenital lesion (41.5%). The mortality rate was 22.0% (n = 9). Multivariate regression analyses showed that extension of necrosis beyond perineal/inguinal area and pre-existing chronic kidney disease were significant and independent predictors of mortality. Extension of necrosis beyond perineal/inguinal area was a significant predictor of increased duration in the intensive care unit and hospital stay. In addition, pre-existing chronic kidney disease was a significant predictor of flap reconstruction in the wound.

Conclusion

Fournier gangrene with extensive soft tissue necrosis and pre-existing chronic kidney disease was associated with poor prognosis and complexity of patient management. Early recognition of dissemination and premorbid renal function is essential to reduce mortality and establish a management plan for this disease.

Effect of the Bowl Structure in an Automated Cell-Isolation Device on Stromal Vascular Fraction's Isolation Yield

The enzymatic digestion of lipoaspirate is used to isolate the heterogeneous stromal vascular fraction (SVF) that contains the adipose-derived stromal cells (ASCs). Several automated SVF isolation systems are used to operate standard technical procedures and avoid human errors. However, the yield of isolated cells and the residual collagenase activities of the SVF samples obtained from automated systems are not satisfactory compared to those from manual isolation methods. In this study, we evaluated the efficiency and the reliability of a new automated SVF isolation system in which the bowl was designed in the shape of a radial protrusion at each angle (a top-type bowl). The viability and yield of cells and the residual collagenase activities of SVFs obtained in a top-type bowl were compared with the SVFs obtained in a conventional bowl. We achieved a significantly higher yield of cells and decreased residual collagenase activity in the SVFs obtained from a top-type bowl (18.0 × 105 cells/mL of fat) compared to a conventional bowl (2.3 × 105 cells/mL). There was no significant difference in the cell viability between the two groups. These results suggest that the automated SVF isolation system with an improved bowl structure will potentially yield higher numbers of nucleated cells and decreased residual collagenase activity compared to conventional automated systems in cell-based clinical trials.

Solitary mastocytoma presenting at birth

Mastocytosis is a rare disease which occurs in both children and adults, and it can manifest as a solitary or multiple skin lesions. Both can cause cutaneous or systemic symptoms. Because of the heterogeneity of clinical presentation of mastocytosis and its rare prevalence, it can be hard to suspect the mastocytosis at the first time. Most solitary mastocytomas are about 1-5 cm in diameter and have features of brownish-yellow, minimally elevated plaques with a smooth shiny surface. This article presents a case of solitary mastocytoma which occurred in neonate and that we treated through surgical excision. In histopathological examination, it consisted of c-kit-positive mast cells. Although pediatric cutaneous mastocytosis might regress spontaneously, clinicians should keep in mind that it could be associated with systemic mastocytosis which involves hematopoietic system.

Iodine insertion and dispersion of refractive index in organic single crystal semiconductor

Insertion of halogens such as bromine or iodine affects the electronic polarizability of ions and the local field inside the medium, and thus modifies the refractive index. Acquiring precise knowledge of the dispersion of refractive index and ultimately tailoring conventional semiconductors for wide-range refractive index control have been a vital issue to resolve before realizing advanced organic optoelectronic devices. In this report, dispersions of the refractive index of a single crystal tetramethyltetraselenafulvalene [C₁₀H₁₂Se₄] (TMTSF) are thoroughly studied from broadband interference modulations of photoluminescence (PL) spectra at various temperatures and doping levels. A large enhancement of the refractive index, more than 20% of the intrinsic value, is achieved with inclusion of a small composition of iodide ions, while the structural and optical properties remain mostly intact. Nearly temperature independent dispersion of the refractive index suggests that, unlike most polymers in which the thermal expansion coefficient dominates over the change of polarizability with temperature, the latter enhances significantly and may become more or less comparable to the thermal expansion coefficient given by 1.71 × 10⁻⁴/K, when single crystal TMTSF is doped by iodine.

Reduction of Closed Frontal Sinus Fractures through Suprabrow Approach

Background

The traditional approach for reduction of frontal sinus fractures is coronal incision. Inherent complications of the coronal approach include long scar, hair loss, and long operation time. We describe a simple approach for the reduction of frontal sinus anterior wall fractures using a suprabrow incision that is commonly used for brow lift.

Methods

From March 2007 to October 2016, the authors identified patients with anterior wall frontal sinus fractures treated by open reduction through a suprabrow incision. Only cases with photographic/radiographic documentation and a minimum follow-up of 6 months were included. The incision line was designed to be at the upper margin of the eyebrow. Medical records and radiographic data were retrospectively reviewed. Surgical outcomes, cosmetic results, and complication were assessed. The patient scale of the patient and observer scar assessment scale was used to assess patient satisfaction for incisional scar at the 6-month follow-up.

Results

Thirty-one patients underwent fracture reduction through a suprabrow approach during the study period, with a mean follow-up of 41 months. No patients showed any recurrent displacement, eyebrow asymmetry, or infection during follow-up. Thirteen patients reported their forehead paresthesia postoperatively, and 12 of them had preoperative symptom. One patient complained of incisional scar and underwent scar revision. All patients were satisfied with their eyebrow and forehead contour.

Conclusion

The suprabrow approach allowed for an accurate reduction of the fractures in the anterior wall frontal sinus by providing direct visualization of the fracture. This transcutaneous approach can effectively restore forehead contour with acceptable postoperative complications and patient satisfaction.

Effectiveness of Acellular Dermal Matrix on Autologous Split-Thickness Skin Graft in Treatment of Deep Tissue Defect: Esthetic Subjective and Objective Evaluation

BACKGROUND

A split-thickness skin graft (STSG) is performed to cover a large full-thickness skin defect. Esthetic and functional deficits can result, and many studies have sought to overcome them. This study compared the effectiveness of the acellular dermal matrix (ADM) graft and STSG concerning esthetic and functional effectiveness of ADM on scar quality.

METHODS

Of the patients who underwent anterolateral thigh free flap from 2011 to 2015, patients who received skin graft only (n = 10) or skin graft with ADM (n = 20) for coverage of the donor site were enrolled. In all cases, autologous STSG was performed with 1:1.5 meshed 0.008-0.010-inch-thick skin. In the skin graft with ADM group, 0.008-0.013-inch-thick meshed ADM (CGderm^®; CGBio, Inc., Seungnam, Korea) was co-grafted. Negative-pressure wound therapy (CuraVAC^®; CGBio, Inc., Seungnam, Korea) was applied to both groups in continuous mode at -120 mmHg. We investigate early outcomes (skin loss rate, duration of negative-pressure wound therapy, days to removal of stitches, days to achieve complete healing, and complications) and late outcomes in terms of scar quality (vascularity, pigmentation, pliability and height) and graft-related symptoms (itching sensation and pain). Assessments used the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale. Skin fold was measured to evaluate the elasticity of scar tissue.

RESULTS

In the Vancouver Scar Scale, vascularity subscore (p = 0.003) and total score (p = 0.016) were significantly lower in the skin graft with ADM group. In Patient and Observer Scar Assessment Scale, the pain (p = 0.037) and stiffness subscores (p = 0.002), and total score (p = 0.017) were significantly lower in the skin graft with ADM group.

CONCLUSIONS

Skin graft with ADM results in better scar quality in objective and subjective aspects.

LEVEL OF EVIDENCE IV

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Free-Flap Transfer for Coverage of Transmetatarsal Amputation Stump to Preserve Residual Foot Length

Surgical management of soft-tissue defects of the forefoot and midfoot caused by trauma or diabetic complications can be challenging because locoregional tissue is insufficient to provide adequate flap. This deficiency necessitates higher-level amputations, such as Chopart or even transtibial amputation, resulting in far more debilitating functional outcomes than are seen with partial foot amputation. The purpose of this study was to examine the surgical outcomes after transmetatarsal amputation and a free-flap transfer to preserve foot length. This prospective case series was conducted from January 2011 to December 2015 at the Department of Plastic and Reconstructive Surgery at our institute. A total of 16 patients (11 men and 5 women) were enrolled in this study, all of whom were candidates for higher-level amputation because of inadequate soft-tissue coverage after debridement. Each patient underwent transmetatarsal amputation and reconstruction of the amputation stump using free-flap transfers to preserve foot length. Preoperative and postoperative data were collected to evaluate the postoperative outcomes. All 16 free-flap transfers were successful, with no major complications. In 2 cases, partial flap necrosis required additional skin grafting. The mean follow-up period was 24.3 months (range = 7-55 months). Flap coverage was stable, and all the patients were comfortable with their prostheses at long-term follow-up. Use of a free flap to reconstruct a transmetatarsal amputation stump provided stable coverage, preserved maximal foot length, and resulted in good functional outcomes.

Change of Facial Asymmetry in Patients With Congenital Muscular Torticollis After Surgical Release

BACKGROUND

A number of studies have shown that facial asymmetry improves in congenital muscular torticollis (CMT) patients after surgical release. This study confirmed the improvement in facial asymmetry, and analyzed factors that affect the change of facial asymmetry in CMT patients after surgical release by using objective and quantitative methods.

METHODS

Facial asymmetry was analyzed in 60 CMT patients who underwent surgical release before 10 years of age. Horizontal and lower facial asymmetry angles (HFAA and LFAA) in the clinical photograph were used to measure facial asymmetry. Postoperative improvements in HFAA and LFAA were evaluated in each age group, after grouping the patients by age. Patients were divided into 2 groups according to the postoperative head tilt and functional deficit. Postoperative improvements in HFAA and LFAA were compared between 2 groups. The relationships between postoperative improvements in HFAA and LFAA and independent variables (age, follow-up period, preoperative HFAA or LFAA, postoperative head tilt, and postoperative functional deficit) were analyzed.

RESULTS

Mean age at operation was 34.8 months (range, 6-120 mo). Horizontal facial asymmetry angle was improved significantly postoperatively in groups <5 years of age. Lower facial asymmetry angle was improved significantly postoperatively in all age groups. No significant difference was found in the postoperative improvements in HFAA and LFAA between 2 groups according to the postoperative head tilt and functional deficit. In the correlation analysis, postoperative improvements in HFAA and LFAA were proportional to the follow-up period (r = 0.256, P = 0.048) and preoperative HFAA or LFAA (r = 0.600, P < 0.001).

CONCLUSIONS

Facial asymmetry in CMT patients can be improved in part if surgical release is performed before 10 years of age and the possibility of improvement may be different according to the area of the face. After surgical release, facial asymmetry will improve over a long period of time, and patients with more severe facial asymmetry have a better remodeling potential to achieve facial symmetry.

Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions

In our hospital, an adverse event reporting system was initiated that alerts the plastic surgery department immediately after suspecting contrast media extravasation injury. This system is particularly important for a large volume of extravasation during power injector use. Between March 2011 and May 2015, a retrospective chart review was performed on all patients experiencing contrast media extravasation while being treated at our hospital. Immediate treatment by squeezing with multiple slit incisions was conducted for a portion of these patients. Eighty cases of extravasation were reported from approximately 218 000 computed tomography scans. The expected extravasation volume was larger than 50 ml, or severe pressure was felt on the affected limb in 23 patients. They were treated with multiple slit incisions followed by squeezing. Oedema of the affected limb disappeared after 1-2 hours after treatment, and the skin incisions healed within a week. We propose a set of guidelines for the initial management of contrast media extravasation injuries for a timely intervention. For large-volume extravasation cases, immediate management with multiple slit incisions is safe and effective in reducing the swelling quickly, preventing patient discomfort and decreasing skin and soft tissue problems.

Knee and Ankle Reconstruction With Reverse Anterolateral Thigh and Free Anterolateral Thigh Flap From One Donor Site

Traditionally, the anterolateral thigh (ALT) free flap is used in distal lower extremity reconstruction. Reverse ALT flap has become one of the most popular choices for knee joint soft tissue defects. A 53-year-old man sustained a degloving injury in the right lateral side of the lower extremity from the lateral malleolar area to the knee joint area. The contamination was severe, necessitating serial debridement and negative pressure wound therapy. After 4 weeks, no more soft tissue necrosis was evident. No more microorganism growth was confirmed by swab culture. ALT free flap using proximal perforator was planned for lateral malleolar area reconstruction and reverse ALT flap using distal perforator was planned to cover knee joint after confirming the pedicle length was sufficient for simultaneous knee and lateral malleolar area reconstruction.

Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection

Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.

Factors affecting clinical outcomes after treatment of extra-articular open tibial fractures

BACKGROUND

Tibial fractures are the most common long bone fracture and are often associated with severe soft tissue and bone defects. The objectives of our study were to describe the management and clinical results of patients with extra-articular open tibial fractures and to identify factors associated with a poor functional outcome.

METHODS

This study included 82 adults available for follow-up for over 1 year after surgery. According to the AO Foundation/Orthopedic Trauma Association fracture classification, 26 fractures were type 41 A, 34 were type 42, and 22 were type 43 A. In accordance with the Gustilo-Anderson classification system, 31 were type I, 19 were type II, and 32 were type III. Initial nerve injury was confirmed in 18 cases.

RESULTS

Definitive fixation occurred at a mean of 6.73 days (range, 0-16 days) after the injury. Soft tissue reconstruction was as follows: primary closure with debridement, 50 patients; split-thickness skin graft, 5; perforator based rotational flaps, 10; and free flaps, 17. Complications occurred in 29 cases (35.4%): superficial infection, 5 patients; deep infection, 3; primary suture site skin necrosis, 7; partial flap necrosis, 4; malalignment, 7; joint stiffness, 2; and hardware breakage, 1. Thirty additional operations (36.6%) were performed during the hospital stay. Mean bone union time was 20.4 weeks (range, 13-63 weeks) and the mean Lower Extremity Functional Scale score (LEFS) was 70.93 (range, 36-79). Multiple linear regression analysis indicated that skin defect size (p = 0.002), and occurrence of complications (p < 0.001) correlated with the LEFS score.

CONCLUSION

Functional outcome after treatment of extra-articular open tibial fractures was influenced by the skin defect size and the presence of any complications. This suggests that good clinical results can be expected if complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation.

A Surgical Technique for Congenital Preauricular Sinus

BACKGROUND

Preauricular sinuses represent a common congenital abnormality in children. Classically, a preauricular sinus manifests as a small opening, usually near the anterior limb of ascending helix. The difficulty in the surgical treatment of preauricular sinus is the high recurrence rate. The aim of this article is to review the outcomes of preauricular sinus and to introduce our surgical technique and its prognosis.

METHODS

A single-institutional retrospective review was performed for all patients who had undergone excision of congenital periauricular sinus between October 2007 and April 2014. Medical records were reviewed for demographic information, wound complication, and recurrence rate. The sinus tract was visualized with the aid of preoperative dye instillation and intraoperative probe insertion. The skin next to the sinus opening was incised elliptically, and the tract itself was dissected medially to the end of the sinus tract and posteriorly to the cartilage of the ascending helix.

RESULTS

The review identified 44 patients for a total of 57 preauricular sinus tracts. The mean age at time of operation was 16.3 years with a range from 9 months to 65 years. Unilateral preauricular sinus tract was present in 31 patients (11 right and 20 left preauricular tract), and 13 patients had bilateral sinus tract. None of the patients had experienced wound issues postoperative, and there were no recurrent sinus tract formation or infection.

CONCLUSION

Using a combination of dye instillation, probe insertion, and modified dissection, we were able to achieve a recurrence free series of preauricular sinus tract excision among a heterogenous group of patients. A large patient series is necessary to replicate the results of this study.

Improvement of Congenital Muscular Torticollis with Mild Symptoms in Non-Treated Adult after Simple Surgical Myotomy of Sternocleidomastoid Muscle under Local Anesthesia

In adult congenital muscular torticollis (CMT) patients, physical therapy is not as effective because the development of sternocleidomastoid muscle (SCM) muscle is complete. While surgical release can address CMT in adult patients, the risk of general anesthesia and visible postoperative scar is a concern, expecially in patients with mild symptoms. In this paper, we report our experience in treating such patients with minimal-incision myotomy under local anesthesia. A review was performed for all adult patients who had undergone the simple myotomy procedure. Surgical indication was reserved for patients with mild fibrotic band in the SCM muscle with minimal lengthdiscrepancybetween the muscles. All patients had recognizable head tiltand palpation of fibrotic band on affected side of the neck. Surgical details are described in the main body of text. Three female patients had undergone the procedure. Torticollis was resolve in all patients with complete restoration of ranage of motion. There were no postoperative complications, and patient satisfaction was high. We have reported three cases of mild CMT in adult female patients, who had undergone minimal-incision myotomy under local anesthesia. Outcomes were satisafactory with no morbidity to report. With careful patient selection, this method offers an alternate treatment option for adult CMT patients with mild symptoms.

A bifractal nature of reticular patterns induced by oxygen plasma on polymer films

Plasma etching was demonstrated to be a promising tool for generating self-organized nano-patterns on various commercial films. Unfortunately, dynamic scaling approach toward fundamental understanding of the formation and growth of the plasma-induced nano-structure has not always been straightforward. The temporal evolution of self-aligned nano-patterns may often evolve with an additional scale-invariance, which leads to breakdown of the well-established dynamic scaling law. The concept of a bifractal interface is successfully applied to reticular patterns induced by oxygen plasma on the surface of polymer films. The reticular pattern, composed of nano-size self-aligned protuberances and underlying structure, develops two types of anomalous dynamic scaling characterized by super-roughening and intrinsic anomalous scaling, respectively. The diffusion and aggregation of short-cleaved chains under the plasma environment are responsible for the regular distribution of the nano-size protuberances. Remarkably, it is uncovered that the dynamic roughening of the underlying structure is governed by a relaxation mechanism described by the Edwards-Wilkinson universality class with a conservative noise. The evidence for the basic phase, characterized by the negative roughness and growth exponents, has been elusive since its first theoretical consideration more than two decades ago.

Molecular classification of basal cell carcinoma of skin by gene expression profiling

Non-melanoma skin cancers (NMSC) including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are more common kinds of skin cancer. Although these tumors share common pathological and clinical features, their similarity and heterogeneity at molecular levels are not fully elaborated yet. Here, by performing comparative analysis of gene expression profiling of BCC, SCC, and normal skin tissues, we could classify the BCC into three subtypes of classical, SCC-like, and normal-like BCCs. Functional enrichment and pathway analyses revealed the molecular characteristics of each subtype. The classical BCC showed the enriched expression and transcription signature with the activation of Wnt and Hedgehog signaling pathways, which were well known key features of BCC. By contrast, the SCC-like BCC was enriched with immune-response genes and oxidative stress-related genes. Network analysis revealed the PLAU/PLAUR as a key regulator of SCC-like BCC. The normal-like BCC showed prominent activation of metabolic processes particularly the fatty acid metabolism. The existence of these molecular subtypes could be validated in an independent dataset, which demonstrated the three subgroups of BCC with distinct functional enrichment. In conclusion, we suggest a novel molecular classification of BCC providing insights on the heterogeneous progression of BCC.

Significance of osteoporosis in facial bone density using computed tomography

OBJECTIVES

The objectives of this study were to compare the variations of bone density in the midfacial bones as measured by computed tomography (CT) scans between the osteoporosis and control groups and to evaluate the regions that facial trauma and iatrogenic problem often occur in the midface.

METHODS

The 96 patients who underwent both osteomeatal unit CT scans and dual-energy x-ray absorptiometry at our hospital were included in this study retrospectively. Seven skeletal regions were chosen for evaluation: group A (orbital floor, nasal bone), group B (zygomaticomaxillary suture, zygomatic arch, zygomaticofrontal suture), and group C (anterior wall of the maxillary sinus, maxillary process). Forty-seven patients were in the osteoporosis group, and 49 patients were in the control group. On a PACS (picture archiving communication system), the region of interest was analyzed, and the Hounsfield units were measured.

RESULTS

There was a significant difference in the mean bone density of the midfacial bones between the osteoporosis group and the control group (P < 0.01). For both groups, each of comparison of the 7 skeletal regions was greater as group A < group B < group C in this order (P < 0.01).

CONCLUSIONS

We can see the independent effects of osteoporosis on the midfacial bones using CT scans. Estimated Hounsfield unit through CT scan is able to explain osteoporosis, which may be useful in the clinical fields in the future.

A Feasibility Study of a Tilted Head Position in Helical Tomotherapy for Fractionated Stereotactic Radiotherapy of Intracranial Malignancies

Herein, we evaluated the feasibility of placing patients in a tilted head position as part of routine clinical practice for fractionated stereotactic radiotherapy (FSRT) of intracranial tumors using helical tomotherapy (HT), by assessing its dosimetric benefit and setup accuracy. We reviewed treatment plans of four cases that were to receive FSRT for brain lesions in normal and head-tilted positions. These patients underwent two computed tomography (CT) scans: first in the normal supine position and then in the supine position with the head tilted at a 458 angle. Two separate HT plans for each position were generated in these four patients, using the same planning parameters. Plans were compared for target conformity and dose homogeneity. Maximum and average doses to critical organs, including normal brain, brain stem, optic chiasm, optic nerves, and the eyes, were considered. To evaluate setup accuracy, patient movement during treatment was assessed by post-treatment megavoltage CT scans. Both HT plans achieved similar conformal and homogeneous dose coverage to the target. Head-tilted HT delivered lower average and maximum doses to critical organs in the cases where the tumor was located on the same plane with critical organs, particularly when they were not directly attached. Placement in the head-tilted position without a mouthpiece allowed for increased patient movement during treatment, while use of a mouthpiece reduced patient movement to even less than that observed for normal setup in the supine position. This pilot study showed that placement in a tilted head position for FSRT of intracranial tumors using HT may be of clinical use, but depends on the tumor location.

Radiofrequency ablation combined with transcatheter arterial embolisation in rabbit liver: investigation of the ablation zone according to the time interval between the two therapies

OBJECTIVES

This study was designed to evaluate the extent of the radiofrequency ablation zone in relation to the time interval between transcatheter arterial embolisation (TAE) and radiofrequency ablation (RFA) and, ultimately, to determine the optimal strategy of combining these two therapies for hepatocellular carcinoma.

METHODS

15 rabbits were evenly divided into three groups: Group A was treated with RFA alone; Group B was treated with TAE immediately followed by RFA; and Group C was treated with TAE followed by RFA 5 days later. All animals underwent perfusion CT (PCT) scans immediately after RFA. Serum liver transaminases were measured to evaluate acute liver damage. Animals were euthanised for pathological analysis of ablated tissues 10 days after RFA. Non-parametric analyses were conducted to compare PCT indices, the RFA zone and liver transaminase levels among the three experimental groups.

RESULTS

Group B showed a significantly larger ablation zone than the other two groups. Arterial liver perfusion and hepatic perfusion index represented well the perfusion decrease after TAE on PCT. Although Group B showed the most elevated liver transaminase levels at 1 day post RFA, the enzymes decreased to levels that were not different from the other groups at 10 days post-RFA.

CONCLUSIONS

When combined TAE and RFA therapy is considered, TAE should be followed by RFA as quickly as possible, as it can be performed safely without serious hepatic deterioration, despite the short interval between the two procedures.

Role of JAK3 in myogenic differentiation

Skeletal muscle differentiation is regulated by transcription factors, including members of the myogenic regulatory factor (MRF) family and many signaling pathways. The JAK1 and JAK2 pathways are known to each have different effects on myoblast proliferation and differentiation; however, the role of JAK3 in myoblast differentiation remains unclear. In this study, we investigated the effect of JAK3 inhibition on myogenic differentiation in the C2C12 mouse myoblast cell line. During myogenic differentiation, treatment with the JAK3 inhibitor WHIp154 significantly increased the number of MHC-positive multinucleated myotubes and the expressions of myosin heavy chain (MHC), myogenin (MGN), MyoD, and myogenic enhancer factor 2 (MEF2). Knockdown of the JAK3 gene using siJAK3 also significantly increased MHC, MGN and MyoD mRNA expressions as well as insulin-like growth factor-II (IGF-II) gene expression. During differentiation, JAK3 was initially activated and later decreased. Differentiation decreased STAT1, which was further decreased by WHIp154. In contrast, STAT3 gradually was elevated during differentiation, and was increased by JAK3 inhibition. Moreover, we found that up-regulation of AKT activity and down-regulation of ERK activity cooperated to accelerate myogenic differentiation. Taken together, these data indicate that JAK3 inhibition potently facilitates myoblast differentiation through antagonistic STAT1/STAT3 activities. Additionally, JAK3 inhibition induced precocious differentiation and played important roles for terminal differentiation, including fusion, which is involved with regulation of AKT and ERK pathways.