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Background:. The effectiveness of conservative treatment for congenital auricular deformities depends primarily on the plasticity of the auricular cartilage. However, the effect remains uncertain due to various confounding factors such as differences in the characteristics of the deformity and timing of treatment initiation. In this study, we investigated the optimal timing for initiation of conservative treatment. Methods:. We investigated the age at treatment initiation and surgical avoidance rate among 158 children with congenital auricular deformities who were treated with corrective devices at our hospital. In addition, we conducted and analyzed questionnaires containing items assessing treatment satisfaction and characteristics. Results:. Surgical avoidance rates decreased markedly among those starting treatment after 5 months of age, and satisfaction was significantly higher in the surgical avoidance group. Multivariate analysis showed that the only factor affecting the treatment effect was the age at treatment initiation. Conclusions:. This study suggests that the initiation of conservative treatment with corrective devices within 5 months of age for congenital auricular deformities may lead to avoidance of surgery and increased satisfaction. However, we should not judge the indication for conservative treatment solely based on age in months. Bearing in mind the effectiveness of initiating treatment within the first 5 months of age, we should initiate treatment at the earliest appropriate age with consideration of the individual patient's type and severity of deformity and cartilage elasticity.

Background:. In Japan, oral propranolol (PPL) and pulsed dye laser are available for infantile hemangioma (IH) treatment without patient cost-sharing. However, no standardized algorithm exists to guide treatment selection that balances efficacy, potential side effects, and aesthetic risks. This study presents a comprehensive approach utilizing a treatment algorithm and aesthetic risk scoring system. Methods:. This retrospective study analyzed outcomes from 156 patients with IHs. Oral PPL was used in IH patients with functional issues, whereas the rest underwent an aesthetic risk assessment that categorized them into low-, moderate-, or high-risk groups to guide treatment choices. Final treatment decisions depended on parental preference. The outcomes of algorithm-compliant and noncompliant patients were compared statistically. Results:. The risk score's interrater reliability was 0.973 (95% confidence interval 0.933–0.992), with a mean intrarater reliability of 0.968 ± 0.027 and a mean evaluation time of 14.1 ± 5.0 seconds per case. Among the 156 patients, 88% pursued the algorithm-recommended treatment, whereas 12% opted for different approaches. Algorithm-compliant patients experienced significantly fewer sequelae than did noncompliant patients (5% versus 33%, P < 0.001). Compared with noncompliant patients, algorithm-compliant patients tended to require shorter treatment durations (17.9 versus 25.4 mo, P = 0.08) and fewer laser sessions (5.8 versus 7.2, P = 0.30), with a younger age at resolution (21.3 versus 29.0 mo, P = 0.08). Conclusions:. Aesthetic concerns can be crucial for patients with IHs. This study introduces a comprehensive IH management algorithm to reduce the sequelae requiring surgical interventions and improve patients’ quality of life.

Summary:. Accurate burn depth assessment is essential to decide an appropriate surgical procedure. However, most cases of burn depth are diagnosed with subjective judgment by an experienced plastic surgeon. There is a need for a simple, noninvasive, and accurate diagnostic method. Here, the authors present two burn cases in which burn depth was predicted using high-frequency power Doppler ultrasonography. In case 1, the patient showed partial deep burn area prediagnosed by clinical inspection in dorsal area. However, pulsatile microcirculation was detected in the deep dermal layer using high-frequency power Doppler ultrasonography, and we rediagnosed it as deep dermal burn. Tangential excision was performed to debride necrotic tissue, preventing excessive removal of viable dermal tissue. In case 2, the patient showed anterior chest burn covered eschar. Pulsatile microcirculation was detected in the dermis using high-frequency power Doppler ultrasonography. The authors diagnosed the area as superficial dermal burn and opted for conservative treatment. Dermal microvascular damage is a more sensitive indicator of tissue injury. Hence, the burn depth can be assessed using dermal microcirculation. To the best of the authors’ knowledge, there are no reports on the evaluation of blood flow in burn wounds using high-frequency power Doppler ultrasonography. In this case report, the authors introduce the possibility of using high-frequency ultrasonography to assess burn depth.

Summary:. We present a technique for treating orbital floor fractures using three-dimensional (3D) printing technology and a preoperative template based on the mirror image of the unaffected orbit. Our patient, a 56-year-old man, experienced persistent diplopia in the upward direction and left enophthalmos after previous open reduction internal fixation surgery. To address these complications, we used a simulation of the ideal orbital floor from computed tomography images and used a 3D printer to create a template. Subsequently, an absorbable plate was molded intraoperatively based on this template. Notably, the plate fit seamlessly into the fracture site without requiring any adjustment, reducing the operation time. Postoperative computed tomography scans confirmed successful reduction, improved visual function, and the absence of complications. Our method offers a precise and efficient approach to reconstructing fractured orbital floors. By leveraging 3D printing technology and preoperative templates, surgeons can enhance postoperative outcomes and minimize patient burden. Further investigations are warranted to assess the long-term effectiveness and cost-effectiveness of this technique. Our findings highlight the potential of this approach to improve treatment strategies for patients with orbital floor fractures.

Background:. Lumbar sympathetic nerve block (LSNB) improves blood flow in the lower limbs and relieves pain involving the sympathetic afferents. This study examines the use of LSNB, but there are no reports of its use for the purpose of wound healing. Therefore, the authors planned the following study. Methods:. An ischemic limb ulcer was created on both lower limbs using a rat model (N = 18). The rats were divided into three groups, namely, A, B, and C. Group A received LSNB on one side (N = 6). Group B was sprayed with basic fibroblast growth factor preparation (trafermin/fiblast) on one side (N = 6). Group C was used as a control (N = 6). Lower limb temperature and the ulcer area were measured over time in each group. Furthermore, the correlation between the ulcer temperature and the ulcer area reduction rate was analyzed. Results:. Group A had higher skin temperature on the LSNB-treated side than on the nontreated side (P = 0.0022 < 0.05). Regarding the correlation between the average temperature and the ulcer area reduction rate, the correlation coefficient was as high as 0.691 in group A. Conclusions:. In the LSNB group, the skin temperature increased and the ulcer area decreased significantly. Conventionally, LSNB has been used for pain relief purposes, although the authors consider that it will be useful in the treatment of ischemic ulcers and that it is a potential treatment option for future chronic limb ischemia/chronic limb-threatening ischemia cases.

Background:. No standards for the assessment of axillary odor intensity and the effects of therapy for osmidrosis have been established. This study presents an objective method for assessing odor severity in patients with osmidrosis and investigates the volatile odorants and skin flora. Methods:. The odor intensity was measured pre- and postoperatively using an industrial odor sensor in 79 patients with osmidrosis. Cultures of the axillary skin were obtained during skin flap surgery. Volatile odorants of the patients were assessed using an odor-sensor gas chromatograph mass spectrometer, and samples collected from clothing worn by the patients before and after surgery. The skin pH of the axilla was measured before and after surgery. The locations of odorants and bacteria in the skin were observed using electron microscopy. Results:. The mean patient age was 28.8 years, and the male-to-female ratio was 4:3. The odor significantly decreased from 52.6 preoperatively to 20.5 postoperatively (P < 0.001). The bacterial flora on the skin included mostly Staphylococcus. Multiple causative substances (volatile proteins) were identified on gas chromatography. The mean preoperative axillary skin pH was 6.21, which was significantly different than that of patients without osmidrosis (5.92; P < 0.01). Conclusions:. An odor sensor accurately assesses odor intensity in patients with osmidrosis. The neutralization of axillary pH may promote the production of odorants by creating the optimal pH for bacterial growth. Odor sensor and pH values can be used pre- and postoperatively as objective assessment measurements for patients with osmidrosis.

Background:. Keloids are red‚ invasive scars that are driven by chronic inflammation in the reticular dermis. The role of blood vessels in keloid behavior remains poorly understood. In the present study with 32 keloid patients, we examined the hemodynamics of keloid tissue, the anatomy of the blood vessels feeding and draining the keloids, and the vascular histology of keloids. Methods:. Ten patients with large anterior chest keloids underwent near-infrared spectroscopy, which measured regional saturation of oxygen and total hemoglobin index in the keloid and surrounding skin. Another 10 patients with large chest keloids and three healthy volunteers underwent multidetector-low computed tomography. The extirpated chest keloids of 12 patients were subjected to histology with optical, CD31 immunohistochemical, and electron microscopy. Results:. All keloids had a low regional saturation of oxygen and a high total hemoglobin index, which is indicative of blood congestion. Multidetector-low computed tomography revealed dilation of the arteries and veins that were respectively feeding and draining the keloid leading edge. Hematoxylin-eosin staining and CD31 immunohistochemisty revealed considerable neovascularization in the keloid leading edge but not in the center. Electron microscopy showed that the lumens of many vessels in the keloid center appeared to be occluded or narrowed. Conclusions:. Keloids seem to be congested because of increased neovascularization and arterial inflow at the leading edge and blocked outflow due to vascular destruction in the center. The surrounding veins seem to expand in response to this congested state. Methods that improve the blood circulation in keloids may be effective therapies.

Summary:. Cryptotia is a congenital auricular deformity. Common methods of surgical reconstruction involve creating an auricular temporal groove using local flaps and/or a skin graft. However, it can be difficult to determine which method is most suited to the unique 3-dimensional (3D) structure of each cryptotic ear. Here, we showed that creating 3D ear models of a cryptotic ear with a 3D camera and printer and using these models to simulate surgery with two different flap methods (cat’s-ear and square) allowed selection of a reconstruction method that led to good outcomes after the actual surgery. The patient was a 7-year-old girl with left cryptotia. A 3D camera was used to acquire 3D data for the ear. After structural analysis, a home 3D printer was used to print the data into 3D ear models using an elastic material. These models exhibited good plasticity. After subjecting the models to simulated cat’s-ear and square flap surgeries, the cat’s-ear flap method was considered to better reproduce the healthy side of the ear compared with the square flap method for this particular case. Ear morphology during and after the actual surgery closely resembled the model-ear morphology during and after the simulated cat’s-ear flap surgery. We successfully created a full-scale 3D model with good plasticity using a 3D camera and 3D printer. This allowed easy, noninvasive preoperative evaluation and identification of the most suitable operation for the specific case, facilitating easier, more successful surgery.

Background:. A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection. Methods:. All consecutive patients with umbilical keloids that developed from endoscopic surgical scars and underwent minimal-margin keloid excision followed by umbilicoplasty with a flap if needed, tension-reduction suturing, and postoperative radiotherapy in 2013–2017 in the keloid/scar-specialized clinic at the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School. The postsurgical radiotherapy regimen was 15 Gy administered in 2 fractions over 2 consecutive days. Radiotherapy was followed by tension-reducing wound self-management with silicone tape or, if needed, steroid plaster. The primary study focus was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the growth of stiff red lesions in even small areas of the scar that was refractory to 2–6 months of steroid-plaster therapy. Results:. The case series consisted of 34 patients with 34 lesions. Three lesions (8.8%) recurred. One recurrence was successfully treated by concomitant steroid plaster/injection. The other 2 cases were resistant to steroid injection and underwent reoperation without radiotherapy followed by 6 months of steroid-plaster therapy. None of the 3 cases recurred within 2 years of steroid plaster/injection completion or reoperation. Conclusion:. Umbilical keloids can be successfully treated by customized treatment plans that involve appropriate surgical modalities (including umbilicoplasty, if required), postoperative radiotherapy (15 Gy/2 fractions/2 days), and wound/scar self-management with silicone tape and steroid plaster.

Background:. Therapies for upper arm keloids include surgical excision followed by postoperative radiotherapy, silicone tape stabilization, and steroid plaster. However, a universally accepted therapeutic strategy for upper-arm keloids is lacking. Methods:. All consecutive patients with single upper-arm keloids who underwent keloid excision followed by tension-reducing suturing, multiple z-plasties, and postoperative radiotherapy in 2013–2016 in the keloid/scar specialist clinic at the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School, were included in this case series study. Only keloids that arose from the small injury produced during Bacillus Calmette–Guérin vaccination were selected. The postsurgical radiotherapy regimen was 18 Gy administered in 3 fractions over 3 days. Radiotherapy was followed by tension-reducing wound self-management with silicone tape and, if needed, steroid plaster. The primary study objective was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the growth of stiff red lesions in even small areas of the scar that was refractory to at least 2 months of steroid plaster therapy. Results:. In total, 38 patients with 38 lesions were enrolled. Two lesions (5.3%) recurred. Both recurrences were successfully treated by concomitant steroid plaster and steroid injection. The recurrence patients were significantly more likely than the nonrecurrence patients to have multiple keloids. The 2 groups did not differ in terms of original keloid size. Conclusions:. Upper-arm keloids can be successfully treated by customized plans that involve appropriate surgical modalities (including multiple z-plasties), postoperative radiotherapy (18 Gy/3 fractions/3 d), and postoperative wound/scar self-management with silicone tape and steroid plaster.

Background:. The therapies for anterior chest wall keloids include surgical excision, postoperative radiotherapy, silicone taping stabilization, and steroid plaster. However, to date, there is no universally accepted combination treatment strategy for anterior chest wall keloids. Methods:. All consecutive patients with single or multiple anterior chest wall keloids who underwent keloid excision, tension-reducing suturing, z-plasty, and postoperative radiotherapy in 2013–2016 in Nippon Medical School were included in this case series study. Only keloids that arose from small injuries such as folliculitis or acne were selected. The surgery was followed by tension-reducing self-management of the wounds with silicone tape and steroid plaster. The postsurgical radiotherapy modality was 18 Gy administered in 3 fractions over 3 days. The primary study outcome was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the development of stiff and red lesions in even a small part of the scar that did not respond to 6 months of steroid plaster therapy. Results:. In total, 141 patients with 141 lesions were enrolled. Of the 141 lesions, 15 (10.6%) recurred. All recurrences were successfully treated by steroid plaster and steroid injection. The recurrence patients did not differ from the nonrecurrence patients in terms of the size of the original keloid or gender distribution. Conclusions:. Anterior chest wall keloids can be successfully treated by customized plans that involve appropriate surgical modalities (including z-plasty) followed by postoperative radiotherapy (18 Gy in 3 fractions over 3 days) and scar self-management with silicone tape and steroid plaster.

Summary:. Keloids are caused by excessive scar formation that leads to scar growth beyond the initial scar boundaries. Keloid formation and progression is promoted by mechanical stress such as skin stretch force. Consequently, keloids rarely occur in paralyzed areas and areas with little skin tension, such as the periauricular region. Therefore, periauricular incision is commonly performed for face lifts. We report a rare case of keloids that arose from face-lift scars in a patient with bilateral facial nerve paralysis. A 51-year-old Japanese man presented with abnormal proliferative skin masses in bilateral periauricular scars. Seventeen years before, he had a cerebral infarction that resulted in permanent bilateral facial nerve paralysis. Three years before presentation, the patient underwent face-lift surgery with periauricular incisions. We diagnosed multiple keloids. We removed the masses surgically, closed the wounds with sutures in the superficial musculoaponeurotic system layer to reduce tension on the wound edges, reconstructed the earlobes with local skin flaps, and provided 2 consecutive days of radiotherapy. The wounds/scars were managed with steroid plasters and injections. Histology confirmed that the lesions were keloids. Ten months after surgery, the lesions did not exhibit marked regrowth. The keloids appeared to be caused by the patient's helmet, worn during his 3-hour daily motorcycle rides, which placed repeated tension on the periauricular area. This rare case illustrates how physical force contributes to auricular and periauricular keloid development and progression. It also shows that when performing surgery with periauricular incisions, care should be taken to eliminate wound/scar stretching.

Background: The present retrospective cohort study was performed to determine the efficacy of contact-mode 1064 nm neodymium-yttrium-aluminum-garnet (Nd:YAG) laser laser for keloids and hypertrophic scars. The indication and limitations of this modality are discussed. Methods: The cohort consisted of 102 consecutive Japanese patients (23 males and 79 females) with keloids and hypertrophic scars for more than 1 year. They were treated every 3–4 weeks for 1 year with a long-pulsed 1064 nm Nd:YAG laser (Cutera, Brisbane, Calif.) in contact mode. Thirty-eight patients had hypertrophic scars and 64 had keloids. The scars were evaluated before the treatment commenced and 1 month after the last session by using the Japan Scar Workshop Scar Scale 2011. Recurrence was assessed at 6 months after the termination of treatment. Results: The average total Japan Scar Workshop score of the keloid and hypertrophic scar region groups dropped significantly after 1 year of treatment compared with before treatment (all P < 0.05). None of the hypertrophic scars or keloids deteriorated. However, 3 of the 34 anterior chest keloids (8.8%) did not respond. The following recurrence rates were observed 6 months after stopping laser treatment: 1 of the abdomen hypertrophic scars (4%), 18 of the anterior chest keloids (52.9%), 5 of the upper arm keloids (35.7%), and 4 of the scapula keloids (25%). Conclusions: Hypertrophic scars responded significantly better to 1064 nm Nd:YAG laser treatment than keloids. However, keloid recurrence occurred when there was remaining redness and induration, even if only a small part of the scar was affected.

Summary: The development of cutaneous pathological scars, namely, hypertrophic scars (HSs) and keloids, involves complex pathways, and the exact mechanisms by which they are initiated, evolved, and regulated remain to be fully elucidated. The generally held concepts that keloids and HSs represent “aberrant wound healing” or that they are “characterized by hyalinized collagen bundles” have done little to promote their accurate clinicopathological classification or to stimulate research into the specific causes of these scars and effective preventative therapies. To overcome this barrier, we review here the most recent findings regarding the pathology and pathogenesis of keloids and HSs. The aberrations of HSs and keloids in terms of the inflammation, proliferation, and remodeling phases of the wound healing process are described. In particular, the significant roles that the extracellular matrix and the epidermal and dermal layers of skin play in scar pathogenesis are examined. Finally, the current hypotheses of pathological scar etiology that should be tested by basic and clinical investigators are detailed. Therapies that have been found to be effective are described, including several that evolved directly from the aforementioned etiology hypotheses. A better understanding of pathological scar etiology and manifestations will improve the clinical and histopathological classification and treatment of these important lesions.