Search

Background This study aimed to investigate the survival analysis of extramammary Paget’s disease (EMPD) in a Taiwanese population and to provide data for comparison with other studies in various locations and racial populations. Methods We retrospectively analyzed the medical records of 63 patients with EMPD who were surgically treated from 2002 to 2019 at a single institution. The primary endpoint was the 5-year overall survival rate of EMPD, and the secondary endpoint was recurrence-free 5-year survival. Independent variables included patients’ demographic data, concurrent malignancy (i.e., non-EMPD-related cancers), tumor size, distant metastasis, and surgery and/or radiation. Results Of all the 63 patients, 8 cases were excluded. A total of 43 patients (78.18%) were male, and 12 were female, with a mean age of 72.67 years (range 44–89 years). The most common affected anatomic site was the penoscrotal region (22 patients, 40.00%), followed by the perianal and perineal regions (17 patients, 30.91%). Among the 55 patients, 41 patients (74.55%) were diagnosed with at least one underlying disease, whereas the most common underlying disease was cardiovascular disease (30 patients, 54.55%). The overall survival rate was 80.00% at 36 months and 65.45% at the end of follow-up. EMPD with deep dermal invasion was a significant poor prognostic factor of overall survival in cause-specific hazard model (sub-hazard ratio (HR) 5.167, p = 0.0015, 95% confidence interval (CI) 1.876–14.230). Patients with regional metastasis or distant metastasis had poorer prognosis of 5-year survival (sub-HR 4.513, p = 0.0028, CI 1.683–12.103). The limitations of this study include its retrospective nature and sample size. Conclusions In our series, EMPD with metastasis and deep dermal invasion was the significant harmful factors in both overall 5-year survival and 5-year recurrence-free survival. The surgical excision is not associated with a low risk of local recurrence or overall survival, and long-term follow-up is still needed.

Purpose Four hundred and ninety-nine patients had burn injuries in an explosion in Taiwan on June 27, 2015, 24 were admitted to the intensive care units of Taipei Veterans General Hospital. This study details our experience with surgical management of these patients, focusing primarily on various skin graft techniques. Materials and methods This single-center retrospective study included patients who underwent at least one of the previously mentioned skin graft techniques because of extensive skin defects. The demography, burn diagram, treatment modalities, postoperative outcome, and costs were all analyzed, and a comparison with traditional mesh skin grafts was performed. The literature was also reviewed. Results Fourteen patients underwent the Meek skin graft technique. Only 3 received ReCell and 1 cultured epithelial autograft (CEA) at separate time point. Overall, the autologous skin grafts, including Meek/ReCell/CEA were completed within 6 months. The average skin graft success rate was approximately 72.9%, 79.2%, and 38% in Meek, ReCell, and CEA, respectively. The infection rate was approximately 35.7%, 25%, and 100% in Meek, ReCell, and CEA, respectively. The average surgical cost and total medical cost were significantly higher in patients who underwent Meek/ReCell/CEA treatments. Conclusions In our experience, Meek and ReCell treatments had acceptable success rates, but CEA treatment not. ReCell and CEA treatments are useful in the event of extremely limited donor sites, and they are fragile, easily infected, and technically challenging. These techniques also require longer hospitalization and tend to be more expensive, all factors that should be considered when assessing treatment options.

Background The pandemic of SARS-CoV-2 (COVID-19), which began in December 2019, spread mostly from person to person through respiratory droplets. A recommendation was issued to postpone all elective surgical practices. However, some confirmed or suspected COVID-19 patients required life-saving emergent surgeries. Methods To facilitate emergent surgical interventions for these patients, we have reviewed the current literature and established an algorithm of precautions to be taken by operating room team members during the COVID-19 pandemic. Results The initial algorithm of preparation for surgical intervention during the COVID-19 pandemic was relatively simple. However, the abrupt increase of confirmed COVID-19 cases due to returned overseas travelers since mid-March 2020 disrupted the routine hospital clinical service. Due to the large number of febrile patients, the algorithm was therefore revised according to travel history, occupation, contact and cluster history (TOCC), unexplained fever/symptoms, and emergent/nonemergent surgery. TOCC (+) patients presenting with otherwise unexplained fever/symptoms would be regarded as belonging to the fifth category of "severe special infectious pneumonia." If the patient requires emergent surgery to relieve the non-life-threatening disorders, two times of negative COVID-19 tests are necessary before the operation is approved. For life-threatening situations without two negative results of COVID-19 tests, the operation schedule should be approved by the Chairman of Surgery Management Committee. Conclusion The application of a clear and integrated algorithm for operating room team members aids in effective personal protective equipment facilitation to keep both healthcare providers and patients safe as well as to prevent hospital-based transmission of COVID-19.

Background To surgically remove osteoma and to keep an optimal cosmetic profile would be very challenging. To solve the difficulty, we utilized the three-dimensional (3D) printing technologies in generating a patient-specific instrument guide (PSIG) for the safe removal of a skull bone tumor. Methods The preoperational brain computed tomography (CT) provided the digital imaging with thin slices, and then images were reconstructed into a 3D skull model. Based on the model, we designed a PSIG to make landmarks on the osteoma to avoid excessive removal of the skull bone. During the operation, the surgeons could remove the osteoma piece by piece by using the landmark as a reference point. Results The PSIG was successfully applied to remove an osteoma that measured 60 × 48 × 40 mm over the left frontoparietal skull of a female patient. The 3D CT reconstruction taken both before and 4 months after surgery showed a significant change in the appearance of the osteoma. Conclusion The PSIG was able to guide the surgeon in the safe removal of the skull osteoma, as well as in maintaining the cosmetic skull profile.

BACKGROUND Burns that affect ≥20% of the total body surface area (TBSA) trigger a major inflammatory response in addition to capillary leakage and loss of serum proteins including albumin. Persistent hypoalbuminemia is therefore common in major burn patients. The purpose of this study was to determine whether human albumin solutions can benefit major burn patients with persistent hypoalbuminemia. METHODS We conducted a retrospective review of major burn patients with ≥20% of TBSA involved at Taipei Veterans General Hospital between January 2007 and December 2018. Thirty-eight patients were enrolled. Patient demographics, burn characteristics, fluid balance, laboratory results, and outcomes were recorded through chart review. RESULT No significant differences were found in the baseline characteristics of patients who received

Background Merkel cell carcinoma (MCC) is rare among Asians. To evaluate the presence and characteristics of MCC in Taiwan, we described the characteristics, treatment, and prognostic findings of MCC in our institution. Methods We revisited and carried out a retrospective chart review of 16 consecutive patients with MCC treated from 1995 to 2018. Patient demographic data, tumor size, location, previous treatment, and follow-up data about presence of locoregional recurrence and metastasis were evaluated. Results There were 14 male and 2 female patients (mean age = 75.1 years; range = 26-91 years). Clinical follow-up revealed local recurrences in 5 patients 1 to 4 months after surgical excision. Lymph node metastasis was observed in 3 patients. We reviewed previously published articles and analyzed the clinical findings, pathologic examinations, and treatments. Conclusions Surgical wide excision of the primary tumor remains the mainstay of treatment for patients with local/regional MCC. Additional management strategies, such as lymphadenectomy, radiotherapy, chemotherapy, and targeted therapy, depend on the presence or absence of clinically detectable lymph node disease. The prognosis for MCC is variable. Our findings highlight the importance of maintaining a high clinical suspicion for this malignancy in the appropriate clinical context to avoid delays in diagnosis and management.

The use of cryopreserved allogenic vascular graft in reconstructive microsurgery has rarely been reported. Here, we report a case of lower extremity reconstruction using cryopreserved hepatic artery as the vein conduit. Postoperative flap perfusion was uneventful with satisfactory wound healing, and graft patency was observed on follow-up color Doppler. Thus, cryopreserved allogenic vascular graft could be a source of vascular conduit in microsurgery.

Background The goal of this study was to investigate the prognostic factors for locoregional recurrence and metastasis in patients with cutaneous melanoma (CM) who underwent surgery, especially in the acral lentiginous melanoma (ALM) subtype. Methods This study was a retrospective review of patients who underwent surgery for CM at Taipei Veterans General Hospital between 2000 and 2018. We investigated the risk factors for locoregional and distant metastases. The association between clinicopathological factors and locoregional recurrence and distant metastasis of the CM and ALM subtypes was analyzed. In addition, the outcomes between the ALM and non-ALM groups were compared. Results A total of 161 patients were included in the analysis. The most common histological subtype was ALM. The overall locoregional recurrence rate of CM was 13.0% and the distant metastasis rate was 42.9%, whereas that of the ALM subtype was 12.5% and 45.5%, respectively. In patients with CM, male sex, tumor with lymphovascular invasion, and positive lymph node status were the prognostic factors for both locoregional recurrence and distant metastasis. Among the patients with ALM, positive lymph node status was significantly associated with both locoregional recurrence and distant metastasis. Conclusion In this cohort, factors influencing locoregional recurrence and distant metastasis were similar between the ALM and non-ALM groups. The above-recommended surgical margin did not show any benefit in either the CM or the ALM subtype. ALM can be handled using the same surgical strategy as CM in the Asian population.

Decellularized vascular grafts are useful for the construction of biological small-diameter tissue-engineered vascular grafts (≤6 mm). Traditional chemical decellularization requires a long treatment time, which may damage the structure and alter the mechanical properties. Decellularization using sonication is expected to solve this problem. The aim of this study was to develop an effective decellularization method using ultrasound followed by washing. Different power values of sonication at 40 kHz were tested for 2, 4, and 8 h followed by a washing procedure. The efficacy of sonication of decellularized human umbilical artery (sDHUA) was evaluated via DNA content, histological staining, mechanical properties, and biocompatibility. The sDHUAs were further implanted into rats for up to 90 days and magnetic resonance angiography (MRA) was performed for the implanted grafts. The results demonstrated that treatment of human umbilical artery (HUA) by sonication at ultrasonic power of 204 W for 4 h followed by washing for 24 h in 2% SDS buffer could eliminate more than 90% of cells and retain similar mechanical properties of the HUA. Recellularization was assessed by scanning electron microscopy (SEM), which indicated that sDHUA provided niches for human umbilical vein endothelial cells (HUVECs) to reside, indicating in vitro cytocompatibility. Further implantation tests also indicated the fitness of the sonication-treated HUA as a scaffold for small-caliber tissue engineering vascular grafts.

Matrix metalloproteinase 9 (MMP-9) expression is upregulated in vascular inflammation and participates in vascular remodeling, including aneurysm dilatation and arterial neointima development. Neointima at the arteriovenous (AV) fistula anastomosis site primarily causes AV fistula stenosis and failure, however, the effects of MMP-9 on perioperative AV fistula remodeling remain unknown. Therefore, we created AV fistulas (end-to-side anastomosis) in wild-type (WT) and MMP-9 knockout mice with chronic kidney disease to further clarify this. Neointima progressively developed in the AV fistula venous segment of WT mice during the four-week postoperative course, and MMP-9 knockout increased the lumen area and attenuated neointima size by reducing smooth muscle cell and collagen components. Early perioperative AV fistula mRNA sequencing data revealed that inflammation-related gene sets were negatively enriched in AV fistula of MMP-9 knockout mice compared to that in WT mice. qPCR results also showed that inflammatory genes, including tumor necrosis factor-a (TNF-α), monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1), were downregulated. In addition, Western blot results showed that MMP-9 knockout reduced CD44 and RAC-alpha serine/threonine-protein kinase (Akt) and extracellular signal-regulated kinases (ERK) phosphorylation. In vitro, MMP-9 addition enhanced IL-6 and MCP-1 expression in vascular smooth muscle cells, as well as cell migration, which was reversed by an MMP-9 inhibitor. In conclusion, MMP-9 knockout attenuated AV fistula stenosis by reducing perioperative vascular inflammation.

Background Severely burned patients, particularly when compounded with inhalation injuries, are at high risk for cardiopulmonary failure. Recently, promising studies have stimulated interest in using extracorporeal membrane oxygenation (ECMO) as a potential therapy for burn patients with refractory cardiac and/or respiratory failure. Several observational studies have been reported, but the findings in these vary. Methods In this study, we conducted a systematic review and meta-analysis using standardized mortality ratios (SMRs) to elucidate the benefits associated with the use of ECMO in patients with burn and/or inhalation injuries. A literature search using PubMed, EMBASE, MEDLINE, and the Cochrane Library were performed from inception to October 20, 2020. Clinical outcomes in the selected studies were compared. Results 22 studies were included in the final review and analysis. 13 studies with a total of 75 patients were included in SMR quantitative analysis. The overall pooled mortality rate of burn patients receiving ECMO was 48%. The meta-analysis found that the observed mortality was significantly higher than the predicted mortality in patients receiving ECMO, with a pooled SMR of 2.07 (95% CI: 1.04–4.14). However, in the subgroup of burn patients with inhalation injuries, all patients receiving V-V ECMO had lower mortality rates compared to their predicted mortality rates, with a pooled SMR of 0.95 (95% CI: 0.52–1.73). Other subgroup analyses, including an adult group, pediatric group, V-V setting group, and a V-A setting group reported no benefits from ECMO; however, these results were not statistically significant. Interestingly, the pooled SMR values decreased as the selected patients’ revised Baux scores increased (R=-0.92), indicating that the potential benefits from the ECMO treatment increased as the severity of patients with burns increased, especially when the patients’ revised Baux scores exceeded 90. Conclusions Our meta-analysis revealed that burn patients receiving ECMO treatment were at a higher risk of death. However, select patients, including those with inhalation injuries and those with the revised Baux scores over 90, would benefit from ECMO treatment. We suggest that burn patients with inhalation injuries or with revised Baux scores exceeding 90 should be considered for ECMO treatment and early transfer to an ECMO centre.

Preventive effects of two traditional Chinese medicines, Chia-wei-hsiao-yao-san and Kuei-lu-erh-hsien-chiao, on the bone loss induced by ovariectomy in Long-Evans rats were investigated. The rats were divided randomly into five groups. The first group was given a sham operation with administration of distilled water, whereas the second, third and fourth groups were ovariectomized with administration of distilled water, Kuei-lu-erh-hsien-chiao and Chia-wei-hsiao-yao-san, respectively. The rats of the fifth group were embedded by intraperitoneal with a silicon tube containing 17 β-estradiol (10% in cholesterol) at a dose of 10μg/kg. Eight weeks later, the mean differences of spinal bone mineral density (BMD) in groups 1, 4 and 5 were significantly higher than that in group 2. The mean differences of plasma alkaline phosphatase (ALP) in groups 1 and 5 were significantly lower than those in group 2, but there were no significant differences between groups 1 and 5. In histologic analysis, the cross sections from lower third of the tibial shaft in group 3 showed more mucopolysaccharide accumulation than those in groups 4 and 5. The urinary N-telopeptide of type I collagen (NTx) levels did not differ significantly among groups 1, 2, 3, 4 and 5. Nevertheless, the mean differences of urinary deoxypyridinoline (Dpd) levels in group 5 were significantly higher than those in group 2. 17 β-estradiol and Chia-wei-hsiao-yao-san showed inure profound effect than Kuei-lu-erh-hsien-chiao in the prevention of bone loss in the ovariectomized (OVX) rats. Although 17 β-estradiol exerted more profound effect, Chia-wei-hsiao-yao-san showed good compliance and safety for relief of climacteric symptoms for postmenopausal women in a previous study. Therefore, Chia-wei-hsiao-yao-san might be an alternative for preventing bone loss.

Glutathione is ubiquitous in eucaryotic cells and is implicated in many cellular functions. Release of reduced and oxidized glutathione (GSH and GSSG) into the plasma and the ratio of GSH/GSSG are considered a reliable index to evaluate the status of oxidative stress in biological systems. As storage temperatures and time periods have not been studied and discussed, we evaluated the effects of storage period and temperatures on the stability of GSH in blood samples by an automated capillary electropherograph system. After two-way ANOVA analysis, the result indicated that there were statistical significance between the GSH status and the storage period, and the GSH status and the preserved temperature as well. However, there was no statistical significance between samples with EDIA or with EDTA-NaF added as anticoagulant. Furthermore, no matter which freezing temperature (-20℃ or -80℃) was used for storing the samples, the concentration of total GSH was quite consistent over the course of the study. We suggest that the alteration of the GSH status at room temperature should be due to not only the autoxidation of GSH but also the enzyme-catalyzed degradation of GSH and GSSG.

Background Extracorporeal membrane oxygenation (ECMO) has been reported to improve outcomes in patients with refractory respiratory failure. These successful experiences have stimulated interest in using ECMO as a potential therapy for patients with acute pulmonary failure resulting from burn and inhalation lung injury. Current literature has supported the use of ECMO in critically-ill, pediatric burn patients. On the other hand, it is controversial to apply ECMO in adult burn patients, and the evidence is limited by the shortcomings of small sample size. We share our successful experience of ECMO treatment in the casualties of the Formosa Water Park Dust Explosion Disaster. Methods We investigated the data from the dust explosion event, which happened on June 27, 2015, in New Taipei, Taiwan. The medical records of five patients with severe acute respiratory distress syndrome receiving ECMO were evaluated. Results The mean study subject age was 21.8 years, with a mean total body surface area burned of 82.9%. The average time to ECMO setup was 48.6 days. Survivors and non-survivors averaged four days and 77.7 days, respectively. The overall mortality rate was 40%. Three survivors were discharged without any ECMO-related complications or pulmonary sequelae after one year of follow up. Conclusions ECMO may be a lifesaving modality for burn patients with severe lung injury who are nonresponsive to maximal medical management, especially for young patients with early ECMO intervention.

Background: Autologous fat graft is a well established technique for soft tissue augmentation and the most significant drawback remains the unpredictability of the absorption rate and the possible repeating fat harvest procedures. In our basic study, we found evidence to support that fat cryopreservation is a practical method of storing fat tissue and several anecdotal clinical experiences suggest its clinical efficacy. Methods: Thirty two patients who received autologous cryopreserved fat grafts for facial deficiencies were retrospectively reviewed. Autologous cryopreserved fat grafts were transplanted for “touch up” or augmentation of other soft tissue deficiencies at least three months after fresh fat grafting, The patients' satisfaction was evaluated by a study-specific questionnaire. Results: 84 autologous fresh fat graft and 178 autologous cryopreserved fat graft procedures for the face were performed in 32 patients. There was no infection, skin retraction, fibrosis or necrosis identified except one patient complained of lump formation in the left upper lid (1/178, 0.6%). The self-assessment questionaaire revealed no statistical difference of effectiveness rating between the fresh and cryopreserved fat grafting results (mean± standard deviation: 8.64±1.09 vs 8.73±0.985; P > 0.05) but there was significant statistical difference of convenience rating between the fresh and cryopreserved fat grafting (mean± standard deviation: 2.68±1.07 vs 8.41±1.05; P < 0.05). Of the twenty-two patients who returned the questionnaire, all reported willing to have the treatment in the future (9.73±0.456) and all said that they would like to recommend this treatment to their friends (9.82±0.395). Conclusions: Autologous cryopreserved fat graft is a safe, simple, and convenient technique to restore facial soft tissue defects with acceptable patient satisfaction rate. Clinical Question/Level of Evidence: Therapeutic, IV.

Corneal inflammation and injury result in scarring and the loss of transparency of the cornea, accounting for a million cases of blindness worldwide each year. Hence, tissue engineering for the reconstruction of the corneal endothelium is a potential therapy. In this study, hydrogels composed of various ratios of hyaluronic acid (H) and Pluronic F-127 (F) were synthesized. These hydrogels can transit between liquid below 15 °C and hydrogel at 37 °C and were injectable for treating corneal wounds via in situ polymerization. The hydrogel preparations were assessed by Fourier transform infrared spectroscopy and scanning electron microscopy, and their physical–chemical properties, including transparency, viscoelastic properties, biodegradation and swelling properties, were also evaluated. The results demonstrated that the two ratios of hydrogels, H:F = 1:15 (H1F15) and 1:20 (H1F20), exhibited thermal responsive rheological properties, biodegradation and swelling properties. Specially, the H1F15 hydrogel incubated with 10,000 U of a lysozyme solution still retained over 70% of its remaining weight for 7 days. Moreover, this study further compared the characteristics of bovine corneal endothelial cells (BCECs) cultured on the hydrogels with and without porcine platelet rich plasma (P-PRP) using cytotoxicity, migration, apoptosis/necrosis and cell cycle assays. The results showed that the H1F15 hydrogel with P-PRP displayed higher cell viability and cell migration. In addition, the incorporation of P-PRP positively affected the hydrogel to reduce apoptosis and to enhance the cell cycle of BCECs. Taken together, these results confirmed that the H1F15 hydrogel lacks cytotoxicity and is biodegradable. BCECs can survive, grow and retain normal characteristics in the H1F15 hydrogel with P-PRP. These results provide an opportunity for corneal endothelium reconstruction using a tissue engineering approach with the H1F15 hydrogel with P-PRP.

Ear reconstruction remains a challenge for plastic surgeons. A tissue-engineering approach could provide another route for obtaining shape maintenance in neoauricular tissue.The authors designed a novel tissue-engineering auricular construct by culturing human adipose stem cells, which differentiated into osteocytes but not chondrocytes, in small intestine submucosa scaffolds. The authors evaluated cell growth potential and mechanical properties. An ear-shaped construct was created in vitro and then implanted in the backs of nude mice. The histology, cellularity, neovascularization, mechanical properties, and ear shape maintenance were investigated.In vitro, human adipose stem cells could be successfully seeded in the small intestine submucosa and differentiated toward osteogenesis. The ear-shaped human adipose stem cell/small intestine submucosa construct could maintain its shape in vivo up to 1 year. Alizarin Red S staining confirmed osteogenic differentiation. CD31 stain showed prominent angiogenesis in the human adipose stem cell/small intestine submucosa construct at 6 months and persistence up to 1 year. h-MHC stain revealed the maintenance of cellularity at 6 months and persistence up to 1 year. The mechanical properties were similar to those of native ear cartilage.The authors' study found that the combination of human adipose stem cells and small intestine submucosa could provide a more durable ear-shaped construct in vivo. The mechanical properties, shape, and cellularity were maintained in the constructs for up to 12 months.Therapeutic, V.

Cutaneous malignant melanoma is notorious for its aggressive behavior and relatively poor outcome compared with other common skin malignancies. Acral lentiginous melanoma (ALM) accounts for at least 50% of melanoma in the Asian population and has a significantly lower survival rate. However, previous studies of the prognostic factors of melanoma-specific survival were all conducted from Western institutions. Here, we performed a retrospective analysis to investigate this issue.Fifty patients diagnosed as having clinical node-negative cutaneous malignant melanoma who underwent sentinel lymph node (SLN) biopsy at Taipei Veterans General Hospital between January 2007 and December 2018 were enrolled. Patient demographics, tumor characteristics, and lymph node characteristics were evaluated by chart review.Eighty-two percent of the melanoma in the sample population was ALM. Twelve patients (24.0%) presented at least 1 metastatic sentinel node, and the average number of retrieved SLNs was 3. Of the patients with positive SLNs who proceeded to completion lymph node dissection, only 2 (16.7%) had metastatic nonsentinel nodes (NSNs). The average follow-up time for all patients was 45 months. Recurrence and melanoma-specific death occurred in 21 patients (42.0%) and 15 patients (30.0%), respectively. Melanoma-specific survival was significantly lower in patients with ulcerative lesions (P = 0.005) and more metastatic SLNs (P = 0.036). The overall morbidity rate of completion lymph node dissection was 66.7%.The presence of ulcerations and number of metastatic SLNs were the most important prognostic factors in this ALM-dominant Asian cohort. Among patients with clinically negative nodes but positive SLNs, less than one-fourth of patients harbored metastatic NSNs. Completion lymph node dissection carries a relatively high risk of morbidity; therefore, further research regarding predictors of positive NSNs in the Asian population is necessary.

Background The aim of this study was to investigate the epidemiological and clinical characteristics of salivary gland tumors (SGTs) in a Taiwanese population and to provide data for comparison with other studies in various locations and racial populations. Methods We retrospectively analyzed the medical records of 559 patients with tumors of the salivary glands who were surgically treated from 2002 to 2017 at a single institution. Results There were 430 benign and 129 malignant tumors with a mean age of 53.5 years (range, 1-91 years). The mean age of patients with benign SGTs was 52.6 years, and the mean age of patients with malignant SGTs was 55.8 years. Most findings were similar to those reported in literature, with some variations. The salivary tumors slightly predominated in males. There were no differences in age and incidence of benign or malignant major SGTs between males and females. The frequency was 76.9% for benign tumors (430 patients) and 23.1% for malignant tumors (129 patients). The majority of the tumors occurred in the parotid gland (351 cases), followed by the submandibular gland (152 cases), the minor salivary glands (46 cases), and, lastly, the sublingual gland (10 cases). Minor SGTs occurred most frequently on the palate, with pleomorphic adenoma, the most frequent benign tumor type, and adenoid cystic carcinoma and mucoepidermoid carcinoma, the commonest malignant tumor types. Tumors of the sublingual gland were rare, but 80% were malignant. Conclusions In our series, SGTs were uncommon neoplasms that typically arose in the parotid gland. Benign tumors were far more common than malignant tumors. Pleomorphic adenoma was the most common benign tumors. Adenoid cystic carcinoma and mucoepidermoid carcinoma constituted the most common malignancies. Almost 60% of the tumors arising from minor salivary glands were malignant; thus, special care must be taken when these glands are affected.

Secondary lymphedema is associated with impaired lymph fluid drainage and remains incurable. Alternatively, cell-based therapy may pave the way for lymphedema treatment. We found 11 animal and seven human studies had been conducted from 2008 to 2018. Most studies showed great potential for this treatment modality. Emerging studies have focused on novel techniques, such as coupling cell therapy with lymph node transfer, or adding growth factors to cell therapy.

BACKGROUND Accurate assessment of breast volume is an essential component of preoperative planning in one-stage immediate breast reconstruction (IBR) for achieving breast symmetry and a satisfactory cosmetic outcome. In this study, we compared breast volume estimation using three-dimensional (3D) surface imaging with magnetic resonance imaging (MRI) to determine the accuracy of breast volume measurements. Further, a 3D printing mold for facilitating autologous breast reconstruction intraoperatively is described. METHODS Patients scheduled to therapeutic or prophylactic mastectomy with one-stage IBR, either by autologous tissue transfer or direct implant, from 2016 to 2019, were enrolled in this study. 3D surface image and MRI were performed to evaluate breast volume and shape. The results were validated by the water displacement volume of the mastectomy specimen. Finally, a 3D printing mold was designed for breast reconstruction with autologous tissue. RESULTS Nineteen women who were scheduled to have 20 mastectomies (18 unilateral and one bilateral) were included. There was a strong linear association between breast volume measured using the two different methods and water displacement of mastectomy specimens when a Pearson correlation was used (3D surface image: r = 0.925, p < 0.001; MRI: r = 0.915, p < 0.001). Bland-Altman plots demonstrated no proportional bias between the assessment methods. The coefficient of variation was 52.7% for 3D surface imaging and 59.9% for MRI. The volume of six breasts was evaluated by both measurements and the intraclass correlation coefficient was 0.689 for 3D surface image (p = 0.043) and 0.743 for MRI (p = 0.028). CONCLUSION Using 3D surface image to evaluate breast shape and volume is a quick, effective, and convenient method. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in our study. In addition, 3D-printed molds can achieve better symmetry and aesthetic outcomes in immediate autologous breast reconstructions.

BACKGROUND The study of effectiveness of adipose-derived stem cells (ASCs) in treating burn wounds is still a developing field. The process of wound contraction in areas of loose skin is a major confounding factor in the evaluation and study of burn wound healing in animal models. METHODS To evaluate the effect of local ASCs administration, deep partial thickness burn wounds were induced by 30 s application of hot copper plates in a novel skin island burn wound rat model to avoid interference from primary wound contraction. Skin islands were divided into two treatment groups-control group (n = 9) injected with PBS and ASCs-treated group (n = 9) injected with 5 × 10 ASCs intradermally. Progress in wound healing was checked at regular intervals after injury (on 1st, 2nd, 3rd, and 4th week) by measuring the mean wound area and analyzing the wound histologically and immunohistochemically, after unstitching the overlaying skin to expose the skin island. RESULTS It was found that local intradermal injection of ASCs improved burn wound healing at all given time points when compared with control groups, especially in the first 2 weeks (p < 0.05). The percentage of live follicles increased gradually in the ASCs-treated groups compared with control groups between the 3rd and 4th weeks (p < 0.05). The vascular density and proliferating cell nuclear antigen index were also significantly increased in the ASCs-treated groups. CONCLUSION Thus, in this study, a novel burn wound rat model with reduced interference from wound contraction has been put forth to investigate the therapeutic effects of local administration of ASCs on burn wound healing. Local injection of ASCs not only improved burn wound recovery but also enhanced angiogenesis and skin appendage regeneration.

Background: S1P has been shown to improve the endothelialization of decellularized vascular grafts in vitro. Here, we evaluated the potential of tissue-engineered vascular grafts (TEVGs) constructed by ECs and S1P on decellularized vascular scaffolds in a rat model. Methods: Rat aorta was decellularized mainly by 0.1% SDS and characterized by histology. Rat ECs, were seeded onto decellularized scaffolds, and the viability of the ECs was evaluated by biochemical assays. Then, we investigated the in vivo patency rate and endothelialization for five groups of decellularized vascular grafts (each n = 6) in a rat abdominal aorta model for 14 days. The five groups included (1) rat allogenic aorta (RAA), (2) decellularized RAA (DRAA), (3) DRAA with S1P (DRAA/S1P), (4) DRAA with EC recellularization (DRAA/EC), and (5) DRAA with S1P and EC recellularization (DRAA/EC/S1P). Results: In vitro, ECs were identified by the uptake of Dil-Ac-LDL. S1P enhanced the expression of syndecan-1 on ECs and supported the proliferation of ECs on decellularized vascular grafts. In vivo, RAA and DRAA/EC/S1P both had 100% patency without thrombus formation within 14 days. Better endothelialization, more wall structure maintenance and less inflammation were noted in the DRAA/EC/S1P group. In contrast, there was thrombus formation in the DRAA, DRAA/S1P and DRAA/EC groups. Conclusion: S1P could inhibit thrombus formation to improve the patency rate of EC-covered decellularized vascular grafts in vivo and may play an important role in the construction of TEVGs.

Background Split-thickness skin grafts are widely used in reconstruction of large area defects. Conventional postoperative recipient site care includes saline-moistened gauze with a protective layer of petroleum gauze and splints for immobilization. This method causes pain while changing the dressing. We designed a better occlusive drainage system for split-thickness skin grafts. We compared the treatment effect and subjective evaluation of our occlusive drainage system with that of the conventional method for coverage of split-thickness skin grafts. Methods A randomized controlled trial was carried out in patients who received split-thickness skin grafts. Patients aged 24–76 years were randomly assigned to the occlusive drainage system or the conventional indirect wet dressing method. The status of graft take, pain, and subjective evaluations were compared. Results Twenty-eight participants were enrolled, with 14 in each group. The percentage of graft take was no difference between the 2 groups. No wound infection developed. Patients in the occlusive drainage system group experienced less pain and greater satisfaction. All patients followed up for at least 3 months, and no hypertrophic scar formation was noted. Conclusion Comparing with the indirect wet dressing method, this new method is practical for covering split-thickness skin grafts, causes less pain, and provides a better experience for patients.

Due to the controversial nature of fetal bovine serum (FBS) production and safety concerns, there is a major interest in finding a potential FBS replacement, such as human platelet-rich plasma (PRP). However, traditional PRP production is largely limited by yield and is unsuitable for large-scale production. In this study, our first aim is to optimize the porcine PRP production protocol, and render it capable of manufacturing a large amount of porcine PRP that is suitable as an FBS replacement. Additionally, our secondary aim is to determine the effects of porcine PRP on human follicle dermal papilla cells (HFDPCs). In our process, the platelets are separated and concentrated via small- (with a capacity of 2.4 L/h) or large-scale preparations (with a capacity of 200–500 L/h). The porcine PRP is activated using a combination of collagen, thrombin, and calcium chloride, resulting in three distinct PRP formulations. Growth factor levels and stabilities of PRP under different treatments were measured using ELISA, MTT and real-time PCR assays. Our results showed that porcine PRP has higher growth factor levels than FBS, and is stable during freeze-drying and surfactant treatments, whereas HFDPCs treated with freshly prepared or freeze-dried PRP showed no significant difference in proliferation compared to FBS. In conclusion, our study is the first to confirm the commercial viability of porcine PRP as an FBS replacement and hair growth promoter.

The Southwest coastal plain of Taiwan is an endemic area of arsenic contamination. Residents who lived there before the 1970s and who used raw groundwater for drinking have a higher risk of arsenic poisoning. In 1968, Tseng et al. described Blackfoot disease as a peripheral vascular disease caused by chronic exposure to arsenic, thereby introducing the concept of arsenic-induced systemic illness in Taiwan. Multiple Bowen's disease (BD) is one of the characteristic consequences of chronic arsenic poisoning and it usually presents as cutaneous carcinoma in situ. Multiple BD can also be associated with squamous cell carcinoma and basal cell carcinoma of the skin, as well as lung, liver, gastrointestinal, and bladder cancers. We encountered a 79-year-old male from Yun-Lin, a county in Southwest Taiwan, who presented with a progressing tumor in his right anterior chest wall. In addition, numerous keratoses and scaly skin lesions were noted on his trunk and extremities, some of which were combined with erosions. The patient was diagnosed with chronic arsenic poisoning with multiple BD and the huge tumor was confirmed as an epithelioid malignant peripheral nerve sheath tumor.

To investigate the clinicopathologic characteristics of patients with immunoglobulin G4-related chronic sclerosing sialadenitis (IgG4-RCSS), a recently recognized disease.Case series with chart review and pathology study.Tertiary care hospital.We evaluated chronic sialadenitis specimens obtained over 11 years using pathologic examination and IgG4 immunohistochemistry staining. The specimens were assigned a revised diagnosis of IgG4-RCSS or chronic sialadenitis not otherwise specified, and clinicopathologic data from each group were compared.Of the 84 patients, 21 were diagnosed with IgG4-RCSS and 63 with chronic sialadenitis not otherwise specified. IgG4-RCSS patients were older (68.2 ± 13.9 vs 54.2 ± 15.8 years, P = .001), predominantly male (85.7% vs 61.9%, P = .036), and more likely to present with painless swelling (75% vs 44.3%, P = .001) and bilateral involvement (52.4% vs 6.3%, P.001). Ratio of IgG4-positive plasma cells to IgG-positive plasma cells in IgG4-RCSS tissues was 0.81 ± 0.14. The mean value of serum IgG4 in IgG4-RCSS patients was 918.8 mg/dL.IgG4-RCSS is more common in older male patients and frequently presents with bilateral involvement. Informing head and neck surgeons of the clinical features of IgG4-RCSS and promoting a combined approach of clinical evaluation, imaging, and biopsy can improve the accuracy of preoperative diagnoses.

A perforator-based fasciocutaneous flap is an alternative type of flap for pressure sore reconstruction. The aim of the present study was to determine whether a single-perforator-based flap or a multiple-perforator-based flap is better for pressure sore reconstruction. We reviewed the general data and postoperative complications in patients who received single-perforator-based or multiple-perforator-based fasciocutaneous flaps for pressure sore reconstruction between July 2009 and July 2012. No differences in general data, comorbidities, wound locations, flap sizes (73.9 vs. 67.0 cm2, P = 0.455), and operative times were noted between the single-perforator-based and multiple-perforator-based flap groups. The flap rotation arc was larger in the single-perforator-based flap group than in the multiple-perforator-based flap group; however, the difference in the rotation arc was not significant (99.2° vs. 55.5°, respectively; P = 0.199). Two patients had total flap necrosis and one had partial flap necrosis in the single-perforator-based flap group. None of flap necrosis was noted in the multiple-perforator-based flap group; however, no significant differences in major complications were noted between the two groups. All donor sites underwent primary closure. This is the first clinical patient-matched research that considered the number of perforators and the rotation arc in applying perforator-based fasciocutaneous flaps in wound reconstruction. The results showed that the number of perforators is not the determinant factor of surgical outcome of the use of perforator-based fasciocutaneous flaps in pressure sore reconstruction. Thus, whether a single- or a multiple-perforator-based fasciocutaneous flap is used for flap perfusion does not jeopardize the operation. These results emphasize the reliability and convenience of using freestyle design of perforator-based flaps for pressure sore reconstruction. The design and clinical utility of the flaps have the advantage of being versatile. 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 .

Purpose To study outcomes among survivors of the mass-casualty powder explosion on 27 June 2015, at Formosa Fun Coast Waterpark, New Taipei City, Taiwan. Methods Using retrospective data on Taiwanese survivors, we analyzed prehospital management, burns assessment and prognosis, functional recovery, and medical costs, followed-up through 30 June 2017. We related outcomes to burn extent, categorized according to the percentages of total body surface area with second/third-degree burns (%TBSA) or autologous split-thickness skin grafts (%STSG), and an investigational scale: f{SASG} = (%TBSA + %STSG)/2, stratified by %STSG. Analyses included casualty dispersal, comparisons between %TBSA, %STSG and f{SASG}, and their relationships with length of hospitalization, times to rehabilitation and social/school re-entry, physical/mental disability, and medical costs. We also investigated how burn scars restricting joint mobility affected rehabilitation duration. Results 445 hospitalized casualties (excluding 16 foreigners, 23 with 0% TBSA and 15 fatalities) aged 12–38 years, had mean TBSA of 41.1%. Hospitalization and functional recovery durations correlated with %TBSA, %STSG and f{SASG} – mean length of stay per %TBSA was 1.5 days; more numerous burn scar contractures prolonged rehabilitation. Females had worse burns than males, longer hospitalization and rehabilitation, and later school/social re-entry; at follow-up, 62.3% versus 37.7% had disabilities and 57.7% versus 42.3% suffered mental trauma (all p ≤ 0.001). Disabilities affecting 225/227 people were skin-related; 34 were severely disabled but 193 had mild/moderate impairments. The prevalence of stress-related and mood disorders increased with burn extent. Treatment costs (mean USD-equivalents ∼$48,977/patient, ∼$1192/%TBSA) increased with burn severity; however, the highest %TBSA, %STSG and f{SASG} categories accounted for Conclusions Besides %TBSA, skin-graft requirements and burn scar contractures are complementary determinants of medium/long-term outcomes. We recommend further elucidation of factors that influence burn survivors’ recovery, long-term physical and mental well-being, and quality of life.

Summary Background Skin flap necrosis is a common postoperative complication in reconstructive surgery. Recent evidence suggests that subcutaneously injected adipose-derived stem cells (ASCs) increase the viability of random skin flaps. Here, we examined whether intra-arterial human ASC administration could improve random component survival of axial skin flaps in nude mice. Methods Human ASCs isolated from a healthy volunteer by liposuction were injected into nude mice through the right femoral artery at a low (1 × 103 cells), medium (1 × 104 cells), or high (1 × 105 cells) dose. After ASC infusion, right superficial inferior epigastric vessels were ligated to create unipedicled superficial inferior epigastric artery (SIEA) flap with random extension. Results Flap survival was higher in mice from all three ASC-treated groups, and particularly the medium-dose group was 30% better, than in the control group. Histological examination demonstrated a significantly higher vascular density in the axial skin flap in nude mice treated with the medium ASC dose than in control mice. PKH26-labeled ASCs were identified in skin flaps of ASC-treated mice; some endothelial cells exhibited positive staining for human HLA-A. Compared to the control group, mice in ASC-treated groups had higher vascular endothelial growth factor levels and lower tumor necrosis factor α, interferon γ, and interleukin-6 levels. Conclusions Intra-arterial human ASC administration increased the survival of axial skin flaps by attenuating inflammatory reactions and enhancing neovascularization. Intra-arterial ASC administration might yield a higher rate of these cells and of engraftment in the skin flaps. This approach may have a therapeutic role in increasing flap survival.

Background Most of the patients with hypopharyngeal cancer are still diagnosed with advanced stage, and total or partial pharyngectomy with free flap reconstruction is the mainstay of treatment. The aim of this study was to find out the possible risk factors related to surgical complications after free fasciocutaneous flap reconstruction for partial pharyngeal defect and its sequelae in the follow-up. Patients and methods We retrospectively reviewed the charts of patients with advanced hypopharyngeal cancer who received free fasciocutaneous flaps for partial pharyngeal defects reconstruction. From 2005 to 2015, 79 free fasciocutaneous flaps (59 free fasciocutaneous flaps and 20 anterolateral thigh flaps) were performed in our department. The risk factors for free flap outcome and complications were evaluated with multivariant linear regression model. Results The mean age of patients was 60.8 years with male predominance. The mean follow-up duration was 39.6 months. Most of the cases (97.5%) were in stage III or IV. Patients with comorbidities showed significant correlation to flap failure (95% confidence interval [CI] = 0.038 to 0.264, P = 0.10). Anastomosis style (end-to-side vs end-to-end) was the only operation-related factors significantly related to flap failure rate (18.8% vs 3.2%, 95% CI = 0.031 to 0.32, P = 0.18). Flap size was significantly associated with fistula formation (95% CI = -0.005 to 0.000, P = 0.38). Conclusions In our experience, patients with comorbidities and end-to-side anastomosis illustrate significantly higher flap failure rate in free fasciocutaneous flap reconstruction of partial hypopharyngeal defect. Reconstruction with smaller flap size had higher possibility of fistula formation.

The nonlinear pseudoelastic behavior of a native/decellularized vascular tissue is closely related to the detailed composition and microstructure of the extracellular matrix and is important in maintaining the patency of a small-caliber vascular graft. A commonly used enzyme-detergent based decellularization protocol is effective in cell component removal but it also changes the microstructure and composition of the decellularized tissues. Previous studies provide limited information to correlate the mechanical property change with the alterations in composition and microstructure in a decellularization process. In this study, the correlations were studied by implementing a previously established fiber-progressive-engagement model to describe the nonlinear pseudoelastic behavior of a vascular tissue and to evaluate the effects of trypsin concentration and exposure duration on porcine coronary artery decellularization RESULTS: Results showed that tissue length and width increased and thickness and wet weight decreased with the exposure of trypsin. The effects of trypsin exposure times on the four mechanical parameters, i.e. initial strain, turning strain, initial modulus and stiffness modulus, in the longitudinal and circumferential directions were similar, but stronger in the circumferential direction. Major components of the extracellular matrix were vulnerable to the trypsin-based decellularization process. The decreases in initial and turning strain and the increase in initial modulus in circumferential direction were correlated with the significant decrease of collagen and glycosaminoglycans in the media layer.Although trypsin-based decellularization achieved cell component removal and preservation of ultimate tensile stress, the microstructure and composition changed with alterations in the pseudoelastic behavior of the porcine coronary artery. Taken together, the current observations suggested less waviness, early engagement, or re-alignment of insoluble collagen fibers in the media layer, which resulted in turning from anisotropic into isotropic uniaxial mechanical property of porcine vascular tissue. Selecting the proper trypsin concentration (0.03-0.5%) and duration (12 h) of trypsin exposure in combination with other methods will achieve optimal porcine coronary artery decellularization.

Chronic radiation ulcers that develop after cardiac catheterization have become common recently because of the rapid increase in the use of diagnostic and interventional cardiac catheterization procedures. However, their diagnosis and treatment remain difficult. We encountered 10 patients with National Cancer Institute grade 4 radiation ulcers related to prolonged percutaneous coronary intervention. Data of these 10 patients, including clinical presentations and treatments, were collected and analyzed. A quality-of-life questionnaire was administered to the patients preoperatively and postoperatively. Most of the lesions (8/10 patients) were located on the back. All of the patients received prolonged cardiac catheterization lasting for more than 3 hours, at least once, and all of the coronary artery lesions showed chronic total or near-total occlusion. The surgical procedures included complete resection of the lesion followed by fasciocutaneous flap coverage (9/10) or skin grafting (1/10). The mean ± SD follow-up time was 23.3 ± 19.79 months, and the wounds in all the patients healed well without complications. After the surgery, the symptoms reduced and the quality of life improved significantly according to the scores in the quality-of-life questionnaire. In conclusion, the early diagnosis of chronic ulcers related to prolonged percutaneous coronary intervention depends on careful history taking and a highly suspicious clinical presentation. For National Cancer Institute grade 4 radiation ulcers, complete resection and immediate reconstruction with flaps or grafts may improve the symptoms and achieve reliable wound coverage without complications.

Background Through-and-through cheek-buccal soft tissue defects usually require fasciocutaneous flaps for reconstruction. However, no ideal flap has been established for reconstruction. Methods A retrospective chart review of head and neck reconstruction performed at Taipei Veterans General Hospital between 2003 and 2012 was conducted. Surgical outcomes and quality-of-life assessments between different fasciocutaneous flaps were collected and compared. Results Eighty-five patients received a free anterolateral thigh flap, and 25 patients received a free forearm flap. The flap success rates were 96.4% for the free anterolateral thigh flap and 96% for the free forearm flap. Appearance, swallowing, and speech were less satisfactory in long-term follow-up; and recurrent tumor, flap size (>100 cm²), oral commissure involvement, and long hospital stay (>40 days) were associated with unsatisfactory quality of life. Conclusions Free fasciocutaneous flap can result in acceptable success rates, but patient satisfaction with appearing, swallowing, and speech function was relatively low after reconstruction. Tumor status (primary or recurrent), flap size, oral commissure involvement, and length of hospital stay are the main factors that affect quality of life.

Background Atypical lipomatous tumor (ALT) is a low-grade, slow-growing, locally aggressive malignant mesenchymal neoplasm. ALT of the extremities and trunk wall is associated with a relatively favorable outcome. However, these tumors can still recur locally and secondary dedifferentiation after recurrence has been reported. There is currently no consensus about the optimal surgical treatment of ALT. Therefore, we aimed to clarify the clinical behavior, appropriate treatment, and outcomes of ALT of the extremities and trunk wall. Methods We retrospectively reviewed the files of 45 patients treated between 2000 and 2014 with the diagnosis of atypical lipomatous tumors of the extremities and trunk wall at our institution. The median follow-up period was 84.5 months (range, 24-183 months). The patient demographics, clinical presentation, surgical methods, margin status, and administration of radiation therapy were recorded. Patients were evaluated for their local recurrence, dedifferentiation, and postoperative complications. Results Wide resection was performed on 11 patients, and marginal resection was performed on 34 patients. Seven patients underwent adjuvant radiotherapy. The overall recurrence rate was 17.8% (8/45), and dedifferentiation rates was 0% (0/8). The mean time to local recurrence was 5.25 years (range, 2.6-10.6 years). No ALT-related deaths occurred during the follow-up period. There were no differences in recurrence-free survival for the different surgical methods (P = 0.337) and radiotherapy (P = 0.228), whereas the R0 resection had better recurrence-free survival (P = 0.031). The postoperative complication rates were higher in wide resection group than in marginal resection group. (45.5% vs 14.7%, P = 0.048). Conclusions Atypical lipomatous tumors of the extremities and trunk wall are associated with a favorable overall survival and do not metastasis. Although they have a tendency to recur, the risk of secondary dedifferentiation is small. Wide resection had similar recurrence rates to marginal resection, but it might lead to more complications. Therefore, marginal resection is considered appropriate for the treatment of ALTs.

Summary Carcinoma cuniculatum, also known as cutaneous verrucous carcinoma, is a rare, low-grade, well-differentiated squamous cell carcinoma usually involving the foot. It is often locally aggressive but rarely metastatic. Only 10 cases involving the skin of the face (except the lips and scalp) have been reported. We describe a 74-year-old man who presented with carcinoma cuniculatum on the nasal tip arising from a keratoacanthoma-like lesion. To our knowledge, this is the first report of such a case in the literature. Literature related to carcinoma cuniculatum is also reviewed, and the challenges in diagnosis and choice of treatment are also described. In this case, the patient initially presented with keratoacanthoma on the nasal tip, and rapid recurrence with a verrucous mass occurred 1 month following tumor excision. Wide excision with 5-mm safe margins and full-thickness skin graft resurfacing were performed smoothly after recurrence. Histopathologic examination revealed carcinoma cuniculatum. The patient recovered uneventfully, and no recurrence of the lesion was reported over a 62-month period of observation. Overall, the prognosis of carcinoma cuniculatum is usually favorable. However, early diagnosis and treatment of carcinoma cuniculatum are crucial by clinicopathological standards. General clinical awareness of this entity contributed to more appropriate and timely treatment.

Primary malignant peripheral nerve sheath tumors (MPNSTs) with a cutaneous or subcutaneous origin represent a small subset of MPNSTs thought to be derived from cutaneous neurofibromas or small peripheral nerves. Few cases of superficial MPNSTs originating from the skin have been reported in the literature.From October 1999 to February 2014, 13 patients were diagnosed with superficial or cutaneous MPNSTs and received treatment at Taipei Veterans General Hospital. Clinical data were collected via retrospective chart review. A retrospective study was performed to compare superficial and deep-seated lesions in terms of local recurrence, distal metastasis, and survival analysis. The relevant literature is also briefly reviewed.The most frequent initial symptoms were local swelling and pain. Ten tumors were found in the extremities, and 3 tumors were located on the trunk. All patients underwent surgery with curative intent. Four patients developed local recurrence, and 3 developed distant metastasis. Three of 13 patients died after a follow-up period of 11 to 180 months (mean, 53.4). Compared to deep-seated MPNSTs, superficial MPNSTs had a lower histopathological grading and better survival rate.Superficial MPNSTs are a rare variant of MPNST. The relatively frequent lack of associated neurofibromatosis and superficial location within the dermis and subcutis may result in this entity being overlooked. According to our clinical experience, superficial MPNSTs might have better prognosis, but similar recurrence and metastasis rates compared with deep-seated lesions. Hence, awareness of this entity should prompt its consideration in the differential diagnosis of cutaneous sarcomas.

Background Epidermal cysts, also called epidermal inclusion cysts or epidermoid cysts, are firm, slowly growing benign tumors commonly seen in young or middle-aged adults. Surgical excision is the usual treatment for such lesions, with the inevitable sequelae of scarring, especially in the face, back, or sternal region. Materials and methods To evaluate the safety and feasibility of erbium:yttrium aluminum garnet laser fenestration of epidermal cysts for patients concerned about scarring, from January 2010 to July 2013, 25 patients with cosmetic concerns underwent serial laser treatment using the fenestration technique to decompress the cyst contents. Patient' satisfaction, scarring, and complications were assessed and analyzed. Results Twenty-three of the 25 patients obtained satisfactory cosmetic outcomes with rapid healing and minimal invasiveness. There was no evidence of scar formation, and no complications were observed at follow-up. Two patients received elective excision after reduction of the size of the cysts, and their scars were hidden well. Conclusion Erbium:yttrium aluminum garnet laser fenestration might be a promising alternative to the surgical treatment of epidermal cysts, especially when the lesions are large or located in an aesthetically important area.

Summary Background/Introduction Endoscope-assisted resection of forehead osteoma is a well-established procedure with the advantages of improved safety, accessibility, and visualization of the mass, avoidance of visible scarring or pigmentation on the forehead, and reduced risk of bleeding, hematoma formation, nerve injury, or paresthesia. The potential drawbacks are alopecia on the scalp incision sites and injury of the deep supraorbital nerve branch. Purpose/Aim This study aimed to evaluate the feasibility of using a single scalp access point to remove forehead osteomata. Methods From 2003 to 2008, 13 patients diagnosed with forehead osteoma were retrieved from the pathology database of Taipei Veterans General Hospital, Taipei, Taiwan. Ten of the 13 patients underwent endoscope-assisted resection of the osteoma with a single scalp incision. Retrospective data collection and chart reviews were performed. Results The mean age of patients undergoing the operation was 49 years. The mean size of the osteoma was 13.5 mm and the mean operative time was 27 minutes (25–30 minutes). No complications such as hematoma, alopecia, nerve injury, or infection were identified and the patients were satisfied with the esthetic results. Mean follow-up duration was 76.3 months (63–122 months). Conclusion Removal of forehead osteoma from a single remote access with the aid of endoscopy is a safe and effective alternative. It can achieve the same esthetic and therapeutic results as the conventional two- or three-port approach without increasing the operative time or morbidities.

Osteosarcoma is the most common primary malignancy of the bone and is characterized by local invasion and distant metastasis. Over the past 20 years, long-term outcomes have reached a plateau even with aggressive therapy. Overexpression of insulin-like growth factor 1 receptor (IGF‑1R) is associated with tumor proliferation, invasion and migration in osteosarcoma. In the present study, our group developed a novel quinazoline derivative, 6-fluoro‑2-(3-fluorophenyl)-4-(cyanoanilino)quinazoline (HMJ‑30), in order to disrupt IGF‑1R signaling and tumor invasiveness in osteosarcoma U‑2 OS cells. Molecular modeling, immune-precipitation, western blotting and phosphorylated protein kinase sandwich ELISA assays were used to confirm this hypothesis. The results demonstrated that HMJ‑30 selectively targeted the ATP-binding site of IGF‑1R and inhibited its downstream phosphoinositide 3-kinase/protein kinase B, Ras/mitogen-activated protein kinase, and IκK/nuclear factor-κB signaling pathways in U‑2 OS cells. HMJ‑30 inhibited U‑2 OS cell invasion and migration and downregulated protein levels and activities of matrix metalloproteinase (MMP)‑2 and MMP-9. An increase in protein levels of tissue inhibitor of metalloproteinase (TIMP)‑1 and TIMP‑2 was also observed. Furthermore, HMJ‑30 caused U‑2 OS cells to aggregate and form tight clusters, and these cells were flattened, less elongated and displayed cobblestone-like shapes. There was an increase in epithelial markers and a decrease in mesenchymal markers, indicating that the cells underwent the reverse epithelial-mesenchymal transition (EMT) process. Overall, these results demonstrated the potential molecular mechanisms underlying the effects of HMJ‑30 on invasiveness and EMT in U‑2 OS cells, suggesting that this compound deserves further investigation as a potential anti-osteosarcoma drug.

Autologous fat grafting procedures have noted a markedly increased frequency, not only for cosmetic purposes, but also for deformities after head and neck cancer and breast cancer surgery. Carcinogenesis is always a major concern in cell therapy-related issues. However, there is no literature discussing this issue in head and neck squamous cell carcinoma patients. To evaluate the interaction of tongue cancer cells and adipose-derived stem cells, we performed a series of in vitro experiments. Our results demonstrated that cisplatin significantly reduced the viabilities of SCC‑25 and CAL‑27 cells in a concentration-dependent manner, but it had low cytotoxicity in cisplatin-resistant CAL‑27 (CAR) cells. There was no significant difference in terms of viability among the SCC‑25, CAL‑27, and CAR cells in the adipose-derived stem cell conditioned medium and control groups. There was also no significant difference in terms of cell migration as determined by wound healing assay of SCC‑25, CAL‑27, and CAR cells between the adipose-derived stem cell conditioned medium treatment and control treatment. Importantly, the adipose-derived stem cell conditioned medium attenuated cisplatin-triggered cell death in the SCC‑25 and CAL‑27 cells. Moreover, adipose-derived stem cell conditioned medium markedly inhibited cisplatin-induced apoptotic cell death (sub‑G1 phase) in the CAL‑27 cells. Western blot analyses indicated that cisplatin-induced reductions in pro‑caspase‑3, pro‑caspase‑9, phospho-BAD, phospho-IGF-1R, phospho-AKT, and phospho-ERK in CAL‑27 cells were reversed by adipose-derived stem cell conditioned medium supplement. Taken together, we provide evidence that adipose-derived stem cell conditioned medium protects CAL‑27 cells from cisplatin-induced cell death, possibly through upregulation of the IGF-1R/AKT/ERK signaling pathway.

Introduction The aim of the study is to understand the incidence of burns among outpatients and inpatients of Taiwan in 2010. Characteristics of the burned patients were also studied in terms of gender, age, burn sites, burn degree, reconstructive surgical treatment, as well as which specialty and medical facility they are treated in. Methods Burned patients were identified from the 1,000,000-person cohort dataset sampled from the Taiwan National Health Insurance database. Ones who had been hospitalized with discharge diagnoses related to burns were categorized as inpatients and others who had only ambulatory visits and emergency room visits were classified as outpatients. Results 7630 burn-injury patients were found, presenting an annual incidence of burns as 670.8/10 5 in males ( n = 3303) and 852.5/10 5 in females ( n = 4327). Only 3.4% (156 males and 107 females) of them were hospitalized. Higher incidence of burns were found in females and young children, while males and the elderly tended to have more severe burns, based on high-degree burns, admission rate, and incidence of hospitalizations for burns. Conclusion This is a population-based study demonstrating the epidemiology of burns among outpatients and inpatients in Taiwan, leading us closer to the reality of burns treated in different settings of medical facilities.

Multipotent stem/progenitor cells localize perivascularly in many organs and vessel walls. These tissue-resident stem/progenitor cells differentiate into vascular endothelial cells, pericytes, and other mesenchymal lineages, and participate in physiological maintenance and repair of vasculatures. In this study, we characterized stromal vascular cells obtained through the explant culture method from three different vessel walls in humans: arterial wall (ART;500 μm in diameter), venous wall (VN;500 μm in diameter), and small vessels in adipose tissue (SV; arterioles and venules,100 μm in diameter). These were examined for functionality and compared with adipose-derived stem/stromal cells (ASCs). All stromal vascular cells of different origins presented fibroblast-like morphology and we could not visually discriminate one population from another. Flow cytometry showed that the cultured population heterogeneously expressed a variety of surface antigens associated with stem/progenitor cells, but CD105 was expressed by most cells in all groups, suggesting that the cells generally shared the characteristics of mesenchymal stem cells. Our histological and flow cytometric data suggested that the main population of vessel wall-derived stromal vascular cells were CD34(+)/CD31(-) and came from the tunica adventitia and areola tissue surrounding the adventitia. CD271 (p75NTR) was expressed by the vasa vasorum in the VN adventitia and by a limited population in the adventitia of SV. All three populations differentiated into multiple lineages as did ASCs. ART cells induced the largest quantity of calcium formation in the osteogenic medium, whereas ASCs showed the greatest adipogenic differentiation. SV and VN stromal cells had greater potency for network formation than did ART stromal cells. In conclusion, the three stromal vascular populations exhibited differential functional properties. Our results have clinical implications for vascular diseases such as arterial wall calcification and possible applications to regenerative therapies involving each vessel wall-resident stromal population.

The process of copying figures with a pencil, crayon, or similar tool is a fun activity for young children, enabling them to express their ideas and learn about the world. While copying skills typically emerge in first and second grades, some children with autism spectrum disorder (ASD) struggle to copy the whole form of figures, producing a fragmented final product. In this article, we propose an intervention protocol for children with ASD who possess a detail-focused cognitive style (weak central coherence) that restricts their skills to see and copy complete drawings. Employing these children's unique cognitive style, we propose intervention principles to develop visual searching skills. Visual searching skills allow children to see all components in a picture and to understand the relationships between all components. Once children learn how to search drawings thoroughly, they can analyze the components of a new figure and copy it more accurately.

In Chinese physiognomy, lower-lid pretarsal fullness is considered a sign of beauty in women. However, there are no data regarding the normal measurements of pretarsal fullness. The purpose of this study was to evaluate the average appearance of lower-lid pretarsal fullness in oriental women of specific age groups with the intention of obtaining data that surgeons could use when performing lower blepharoplasty. The effects of the orbicularis oculi muscle on pretarsal fullness are also discussed. A total of 260 oriental women were included in this study. The parameters of the eyelid, including the size of lower-lid pretarsal fullness, upper-lid crease, and palpebral fissure, were measured. The changes in these parameters with age, the ratio of lower-lid pretarsal fullness to palpebral fissure height, and the effect of the orbicularis oculi muscle on pretarsal fullness were analyzed. Two-hundred sixty women (520 eyes) were analyzed in the study. The average age of the participants was 39.3 years (range 21–60 years). The prevalence of static and dynamic pretarsal fullness was 19.2 and 74.0 %, respectively. The prevalence was higher in subjects in the fourth and fifth decades of their lives and lowest in subjects in their sixth decade. In the younger group, the average size of static pretarsal fullness was approximately 6.1–6.5 mm, and the static pretarsal fullness ratio was approximately 0.4. The vertical dimensions of static and dynamic pretarsal fullness increased with age. The changes were significantly higher in subjects over 20 years of age. This study provided data about the size and prevalence of pretarsal fullness, and allowed us to provide reference data for doctors to utilize when treating patients seeking lower-eyelid pretarsal fullness. Patients may appear younger when their new static pretarsal fullness falls within the range of 6.1–6.5 mm in the vertical dimension and when the pretarsal fullness ratio is about 0.4. 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 .

BACKGROUND Cutaneous leiomyosarcoma (CLM) is a rare soft tissue tumor of smooth muscle derivation. We report the clinical treatment, long-term outcomes, and prognostic findings of CLM in our institution. MATERIALS AND METHODS We revisited and carried out a retrospective chart review of 16 consecutive patients with CLM treated from 1991 through 2015. Patient demographic data, tumor size, location, previous treatment, follow-up data, and the presence or absence of recurrence were evaluated. RESULTS There were 6 males and 10 females (mean age, 48.6 years; range, 20-78 years). Clinical follow-up revealed local recurrences in 4 patients 1.3 to 72 months after surgical excision. No distant metastases were observed. We reviewed previously published articles and analyzed the clinical findings, pathologic examinations, and treatments. CONCLUSIONS Surgical tumor excision with a wide lateral and deep margin is the most appropriate method. Other therapeutic methods such as radio- or chemotherapy provide no significant benefits. We recommend long-term follow-up of patients because recurrence is possible although not common.

Primary cutaneous and soft tissue angiosarcoma is a rare but highly aggressive malignancy. To date, surgical resection is the mainstay of treatment, but poor prognosis is expected. To investigate whether there are factors associated with poor prognosis after surgical resection and to develop a treatment guideline for current therapy, we retrospectively collected data on 28 patients who underwent surgery as initial treatment and reviewed patient demographics, tumor characteristics, disease courses, and prognoses from September 1996 to May 2013. Of these 28 patients, 17 (60.7%) were men and the mean age at first diagnosis was 66.57 ± 18.57 years. Anatomically, 17 (60.7%) tumors were in the scalp and 11 (39.3%) were in other sites of the body. Of the 28 patients, 23 (82.1%) had achieved negative surgical margins, 24 (85.7%) received adjuvant radiation therapy, and 17 (60.7%) received adjuvant chemotherapy. Twenty-one patients (75%) died during a mean follow-up time of 35.86 ± 28.91 months, and all deaths were caused by angiosarcoma. The 5-year overall survival rate was 17.86%. Sixteen (57.1%) patients had locoregional tumor recurrence, and 20 (71.4%) had distant metastases, with a median of 9.17 (range, 1.9-98.07) months to recurrence or metastasis. Possible predictors of poor prognosis (P < 0.05) in terms of disease-free survival after surgical resection were male sex, cardiovascular disease, smoking, and scalp angiosarcomas, those in terms of overall survival were older than 70 years, male sex, cardiovascular disease, smoking, scalp angiosarcomas, distant metastases, and not receiving adjuvant chemotherapy. In conclusion, although multimodal treatments are used, the overall prognosis after surgical resection is still poor, especially for patients with the above predictive factors. An early diagnosis and complete resection of the primary tumor with or without adjuvant radiotherapy and chemotherapy are suggested for a potential better outcome. For those who have a diffuse lesion pattern with the involvement of vital structures, recurrence, or metastasis, palliative resection could be an alternative treatment choice.

Summary Background Despite significant advances in medical care and surgical techniques, pressure sore reconstruction is still prone to elevated rates of complication and recurrence. We conducted a retrospective study to investigate not only complication and recurrence rates following pressure sore reconstruction but also preoperative risk stratification. Methods This study included 181 ulcers underwent flap operations between January 2002 and December 2013 were included in the study. We performed a multivariable logistic regression model, which offers a regression-based method accounting for the within-patient correlation of the success or failure of each flap. Results The overall complication and recurrence rates for all flaps were 46.4% and 16.0%, respectively, with a mean follow-up period of 55.4 ± 38.0 months. No statistically significant differences of complication and recurrence rates were observed among three different reconstruction methods. In subsequent analysis, albumin ≤3.0 g/dl and paraplegia were significantly associated with higher postoperative complication. The anatomic factor, ischial wound location, significantly trended toward the development of ulcer recurrence. In the fasciocutaneous group, paraplegia had significant correlation to higher complication and recurrence rates. In the musculocutaneous flap group, variables had no significant correlation to complication and recurrence rates. In the free-style perforator group, ischial wound location and malnourished status correlated with significantly higher complication rates; ischial wound location also correlated with significantly higher recurrence rate. Conclusions Ultimately, our review of a noteworthy cohort with lengthy follow-up helped identify and confirm certain risk factors that can facilitate a more informed and thoughtful pre- and postoperative decision-making process for patients with pressure ulcers.