Search

Pressure, friction, shear force, and micromoisture can cause pressure ulcer. With the increase of the elderly population in Korea, the number of decubitus pressure ulcer patients is increasing due to worsening medical conditions by aging. In the case of quadriplegic and hemiplegic patients, there is considerable interest in the prevention and self-treatment of pressure ulcer following daily life recovery through rehabilitation. It is important to recognize that pressure ulcer can sometimes be avoided and can sometimes occur inevitably, and that preventive measures should be put in place. For the improvement of pressure ulcer, the patient’s systemic condition and the understanding of indications for local treatment should be improved. Recently, guidelines for dressing formulations related to exudate absorption capacity were introduced. For the successful treatment of pressure ulcer, adequate support of nutrition, control of stiffness, prevention of bacterial bioburden, removal of dead tissue (debridement), moisturizing of the skin, and selection of appropriate dressing materials should be applied comprehensively for individual patients.

Background: Older patients with pressure sores secondary to medical problems generally are not likely to become physically active again and are therefore rarely considered candidates for flap surgery. When surgeons decide whether to perform surgery in older individuals with multiple morbidities, they must weigh the risks of prolonged general anesthesia and the burdens of flap surgery against the benefits of the flap.Methods: This retrospective study included patients over 65 years of age who were treated at our clinic from May 2010 to August 2018 for grade III or IV pressure sores. They underwent either general wound care without flap coverage (debridement only) or complete flap coverage of the sore (debridement plus flap group). We compared changes in laboratory blood tests from pre-operation to post-operation.Results: A total of 63 patients were included, with 53 in the flap coverage group and 10 in the control group. Age, sex, and flap size were statistically similar between groups (P>0.05). The control group exhibited no significant laboratory changes after debridement. The flap coverage group exhibited statistically significant improvements in neutrophil percentage and C-reactive protein level postoperatively (P0.05, Wilcoxon signed-rank test and paired t-test).Conclusion: As pressure sore coverage with flaps may have a positive effect on controlling inflammation, flap surgery could be a viable option for older patients with severe pressure sores.

Background Age-related changes in facial skin is a major concern in women. This study aimed to objectively evaluate normal skin elasticity and age-related differences in the faces of East Asian women. There are no standard values for data related to normal skin on East Asian women. Methods We studied 129 healthy East Asian women without a history of cosmetic procedures or surgeries. Skin elasticity was assessed at the cheek and lower eyelid points, which were assessed on both the right and left sides of the face. Results The age of the subjects showed significant negative correlations with the R2 and R7 parameters, which represent skin elasticity after deformation. Conclusion We therefore concluded that the primary decrease in skin elasticity in East Asian women occurs in the midface region.

Even though scars are major issues for patients who undergo facial lacerations, programs for their prevention and early management are not well established. The purpose of this study was to evaluate the clinical outcomes of prophylactic scar assessments and early scar interventions in patients with lacerations. A total of 116 patients underwent suture line and scar prevention treatment in the emergency room from 2014 to 2015. In the retrospective study, 46 patients who met all the criteria were included in the study. They were assigned to one of the following two scar prevention programs: the standard scar program for prevention, which included taping, silicone sheets, and ointments, and the multimodality scar program for treatment, which included triamcinolone, botulinum toxins, or CO2 fractional lasers. The patterns of early scar program were investigated for the standard scar prevention program and the multimodality scar management program, and we evaluated the scar assessment scores of the patients at 3 and 6 months. Scar scores for the patients who received multimodality scar management showed statistically significant improvements in Patient Scar Assessment (PSA) scales, Stony Brook Scar Evaluation Scales (SBSES), Vancouver Scar Scale (VSS) scores, and Visual Analog Scar (VAS) scales (the p values were 0.008, 0.007, 0.017, and 0.01, respectively). The multimodality scar program is more effective for scar prevention than the standard scar program. 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 .

Recent research on stromal vascular fraction (SVF) has demonstrated the presence of numerous growth factors that aid in tissue regeneration and suggest the potential for scar treatment. This study was conducted to clinically show that adding stem cells can improve the surgical outcomes of scar formation. Between March 2014 and February 2016, 17 patients underwent injections of fat and highly condensed SVF simultaneously with scar reduction surgeries and 15 patients received scar revision with or without simultaneous application of highly condensed SVF (4.90 × 107 stem cells/ml) at our institution. Clinical photographs were taken before and after surgery, and the scars were graded using the following standard scales: the Observer Scar Assessment Scale (OSAS), Stony Brook Scar Evaluation Scale (SBSES), Vancouver Scar Scale (VSS), and Visual Analog Scale (VAS). All patients showed improvement, registering significant increases in scar tissue scores (P

Intraoperative expansion has been used to cover small to large defects without disadvantages of the conventional tissue expanders. Various materials, for example, expanders and Foley catheters are being used. We introduce a new, convenient and economical device immediately available in the operating room, according to the defect size for intraoperative expansion, with latex gloves or balloons. The retrospective study was done with 20 patients who presented with skin and soft tissue defects. During the operation, expansion was done with latex gloves or balloons inflated with saline through an intravenous line and a three-way stopcock. After the inflation, the glove was removed and skin was covered with expanded tissue. A careful decision was made regarding the inflation volume and placement of the expander according to the defect size. There were no postoperative complications. The skin contracture and tension was minimal with a texture similar to the adjacent tissue. The new intraoperative expansion devices with latex gloves and balloons were cheap and made easily right in the operation room. The reconstruction of small to large sized skin defects can be done successfully, functionally and aesthetically without using expensive commercial materials.

Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.

Polydioxanone (PDO) is absorbable thread which is usually used for wound closure and face lifting. These days, PDO thread is used increasingly for aesthetic purposes such as correction of facial wrinkles, laxity and even rhinoplasty in many oriental traditional medicine clinics. As rhinoplasty with PDO thread increases, complications also increase. In this study, we will report on the clinical features of patients who got rhinoplasty using PDO thread. From August 2018 to July 2019, seven patients (three males and four females) visited our clinic for complications after rhinoplasty with PDO thread. We checked ultrasonography and laboratory findings including wound cultures. We used conservative treatment using antibiotics and performed surgery on three patients. Three patients experienced severe complications with open wounds, abscesses and skin necrosis. Four patients experienced mild complications including redness and thread exposure without open wounds. The location of infection included the nasal tip and inner lining. Six patients had a history of rhinoplasty before. On ultrasonography, abscess formation was seen around the implant inserted before. During the operation, PDO thread cannot be seen except in one patient. PDO thread cannot be seen in radiologic findings and can cause severe infections like abscess formation with open wounds. In severe infections, massive debridement with the removal of the implant would be required. PDO thread is absorbed usually after six months; mild infection can be controlled by the conservative treatment. The best is not undergoing rhinoplasty with PDO thread for patients who had implants because of potential side effects. 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: Botulinum toxin type A (BoNTA) is known to prevent fibroblast proliferation and expression of transforming growth factor beta 1 (TGF-β1). It also induces temporary muscle paralysis and decreases tension vectors. Fibroblasts induce scar contracture and hypertrophy by producing collagen fibers in wound healing processes. The aim of this study is to identify the effect of BoNTA on the scar formation. Methods: Forty-five patients with forehead laceration were enrolled in this study and randomized into 2 groups with or without injection of BoNTA. When the patients presented to the clinic to remove the stitches, BoNTA was injected to the BoNTA group with 24 patients and saline was injected to the control group with 21 patients. The BoNTA was injected on dermal layer with 5 IU/cm. After that, follow-up was done in 1, 3, and 6 months. The scars were analyzed with the patient and observer scar assessment scale, Stony Brook scar evaluation scales (SBSESs), and visual analog scale (VAS) and analyzed with independent T-test, along with clinical photographs, cutometer, and biopsies. Results: In all scar scales, the scores changed into favorable direction in both groups and the changes were larger in BoNTA group compared with the control group. On SBSES and VAS, better improvements on BoNTA group showed statistical significance. Skin biopsy showed less collagen deposition on dermal layer in BoNTA group. Conclusion: Improvement of aesthetic, functional, and emotional aspect of the scar formation in the groups treated with BoNTA was illustrated. The application of BoNTA may be expanded to prevent hypertrophic scar after trauma, burns, or operations.

Rationale: A craniectomy, which results in a large skull defect, is performed to decrease the intracranial pressure under conditions such as intracranial hemorrhage and ischemic stroke. When the patient's condition is stabilized, autologous cranioplasty using the bone flap previously removed in the craniectomy is performed. Bone flap infection after the autologous cranioplasty is not uncommon and is difficult to treat. After the infection is controlled, cranioplasty is needed to improve the head deformity and neurologic function. Cranioplasty with a titanium mesh can result in aesthetic improvement and a low infection rate. Using 3-dimensional computed tomography (3D-CT) and 3D printing, titanium mesh is manufactured to fit perfectly on the patient's skull defect. Patient concerns: Two patients with large skull defects in the right temple area due to previous craniectomy were referred to our department for reconstruction. They had histories of recurrent infections at the operation site even after removal of the autologous bone flap that had been used for the cranioplasty. Diagnosis: Preoperative computed tomography (CT) showed 12×16 cm and 8×8.3 cm skull defect on right temporal area, respectively. Interventions and outcome: The infection was controlled by well-vascularized free flap coverage. After the surgery, cranioplasty with custom-made titanium mesh was performed to improve the aesthetic and functional problems of the patients. The contour of the temporal area was symmetric. The patients were satisfied with the results. Lessons: Staged reconstruction of large skull defects with soft tissue infection after craniectomy using free flap followed by cranioplasty with titanium mesh on can lead to safe, aesthetic, and satisfactory result.

A linear surgical scar, when located in the head and neck region, can be a significant cosmetic concern. Laser skin resurfacing with a fractional laser and a pulsed dye laser has been proven to be useful for treating such scars. As alternatives, we used a classic ablative CO2 laser in continuous mode with a 1-mm spot size and a 595-nm Nd:YAG laser. We investigated the effect of the combination of the continuous CO2 laser and 595-nm Nd:YAG laser and compared it to the effect of fractional CO2 laser monotherapy on linear scars. This was a retrospective, case-controlled study designed to compare the efficacy between fractional CO2 laser therapy and combination therapy with a conventional CO2 laser in continuous mode and a 595-nm Nd:YAG laser. Treatment efficacy was evaluated by two different scar scales: the Stony Brook Scar Evaluation Scale (SBSES) and the modified Vancouver Scar Scale (mVSS). Laser treatments were performed every month until the 6th month after surgery. The SBSES and mVSS scores improved over time in both the monotherapy and the combination therapy (P

Although botulinum toxin type A has been shown to inhibit the formation of hypertrophic scars, little is known about the underlying mechanisms of action. Studies have reported that botulinum toxin type A is able to inhibit fibroblast proliferation and transforming growth factor (TGF)-β1 expression; therefore, in this study, the authors evaluated its effect on the differentiation of fibroblasts derived from normal and hypertrophic scar tissue.Under local anesthesia, tissue specimens from 10 scars (five normal mature scars and five hypertrophic scars) were obtained from nine patients who visited the authors' department for scar revision. Fibroblasts isolated from the tissue specimens were cultured until confluent and pretreated with TGF-β1 to induce differentiation before treatment with botulinum toxin type A. Expression of the myofibroblast marker α-smooth muscle actin in cell cultures was evaluated by enzyme-linked immunosorbent assay and quantitative reverse transcription polymerase chain reaction. Fibroblast-to-myofibroblast differentiation was further evaluated by immunocytochemistry and confocal microscopy.The authors' results showed that α-smooth muscle actin mRNA and protein levels were significantly lower in the botulinum toxin type A-treated group than in the control group (treated with TGF-β1 only) of fibroblasts derived from hypertrophic scars, but not fibroblasts derived from normal scars. Immunocytochemistry results also showed that fibroblast-to-myofibroblast differentiation was significantly decreased after botulinum toxin type A treatment in fibroblasts derived from hypertrophic scars.The authors' results show that botulinum toxin type A directly inhibits fibroblast-to-myofibroblast differentiation in vitro, and indicate its potential for use in treating wounds expected to develop into hypertrophic scars after trauma, burn, or surgery.Therapeutic, V.

Objective: Retrograde infections often occur with excessive or incomplete drainage of exudate, or as a result of adherence of dressings to wounds. Dialkylcarbamoyl chloride (DACC) irreversibly binds to bacterial surfaces and physically removes bacteria when dressings are changed. Chlorhexidine acetate-soaked paraffin gauze provides a moist wound-healing environment. We hypothesise that when DACC is combined with chlorhexidine acetate-soaked paraffin gauze, wound healing times decrease. Method: From January 2013 to June 2015, medical records were retrospectively evaluated in 60 patients who underwent split-thickness skin grafts (STSG). Patients were divided into two groups: a ‘thick skin group’ and a ‘thin skin group’. These two groups were further subdivided into a control group, where conventional foam dressings were applied to wounds, and an experimental group, where chlorhexidine acetate-soaked paraffin gauze with DACC was applied (DACC group). We compared the wound healing time between these subgroups. Differences in infected wound healing times were also compared. The Mann-Whitney test was applied to compare wound healing times between groups. Results: Epithelialisation duration was significantly shorter in the DACC group. The control group had longer wound healing times, regardless of wound size. In the thick skin group, the median healing duration was 12 days in the control subgroup, compared with 9.5 days in the DACC subgroup (p=0.049). In the thin skin subgroup, the median healing duration in the control group was 18 days, compared with 10 days in the DACC subgroup (p=0.013). Conclusion: Application of DACC and chlorhexidine acetate-soaked paraffin gauze to skin graft donor sites can shorten healing times and is effective in treating infected wounds.

Background Negative-pressure wound therapy (NPWT) induces angiogenesis and collagen synthesis to promote tissue healing. Although acetic acid soaks normalize alkali wound conditions to raise tissue oxygen saturation and deconstruct the biofilms of chronic wounds, frequent dressing changes are required. Methods Combined use of NPWT and acetic acid irrigation was assessed in the treatment of chronic wounds, instilling acetic acid solution (1%) beneath polyurethane membranes twice daily for three weeks under continuous pressure (125 mm Hg). Clinical photographs, pH levels, cultures, and debrided fragments of wounds were obtained pre- and posttreatment. Tissue immunostaining (CD31, Ki-67, and CD45) and reverse transcription-polymerase chain reaction (vascular endothelial growth factor [VEGF], vascular endothelial growth factor receptor [VEGFR]; procollagen; hypoxia-inducible factor 1 alpha [HIF-1-alpha]; matrix metalloproteinase [MMP]-1,-3,-9; and tissue inhibitor of metalloproteinase [TIMP]) were also performed. Results Wound sizes tended to diminish with the combined therapy, accompanied by drops in wound pH (weakly acidic or neutral) and less evidence of infection. CD31 and Ki-67 immunostaining increased (P Conclusions By combining acetic acid irrigation with negative-pressure dressings, both the pH and the size of chronic wounds can be reduced and infections be controlled. This approach may enhance angiogenesis and collagen synthesis in wounds, restoring the extracellular matrix.

After restoration of orbit wall fracture, preventing sequelae is important. An absorbable mesh is commonly used in orbit wall fracture, yet it has limitation due to orbit sagging when bony defect is larger than the moderate size (1 × 1 cm2). In this study, the authors present a satisfactory result in treating orbit wall fracture larger than the moderate size with a combination of absorbable mesh and demineralized bone matrix.From 2009 to 2012, 63 patients with bony defect larger than the moderate size, who were treated with a combination of absorbable mesh and demineralized bone matrix, were reviewed retrospectively. The site of bony defect, size, and applied amount of demineralized bone matrix were reviewed, and a 2-year follow-up was done. Facial computed tomography scans were checked preoperative, immediate postoperative, and 2-year postoperative.Among the 63 patients, there were 52 men and 11 women. Mean age was 33.3 years. The most common cause was blunt blow (35 cases); mean defect size was 13.36 × 12.82 mm2 in inferior wall fracture and 20.69 × 14.41 mm2 in medial wall fracture. There was no complication except for 3 cases of infraorbital nerve hypoesthesia. A 2-year follow-up computed tomography showed that the surgical site preserved bony formation without herniation. In treating moderate-sized bony defect in orbit wall fracture, absorbable mesh and demineralized bone matrix can maintain structural stability through good bony formation even after degradation of absorbable mesh.

Calves can be easily seen in daily life and are an important part of the body contour. Asymmetric calves can develop from unbalanced distribution and deposition of fat and muscles between the legs. Calf asymmetry may be due to congenital factors, disease (e.g., poliomyelitis, cerebral palsy, or infection), spinal cord injury, or the ef- fects of surgical treatment and may have severe adverse psychological and social im- plications. Generally, an asymmetric calf is diagnosed when the difference of the lon- gest circumference between both calves is more than 2 cm. Several surgical methods have been introduced for the correction of an asymmetric calf. Implant insertion or fat injection is used to augment a hypotrophic calf. Selective neurectomy, liposuc- tion, muscle resection, radiofrequency, and botulinum toxin injection are used to treat a hypertrophic calf. With the development of microsurgery, the authors planned to use a latissimus dorsi musculocutaneous free flap (LDMC free flap) with silicone implant to add calf volume to obtain natural calf contour. The authors pres- ent the first successful case of correction of a severely asymmetric calf using an LDMC free flap and customized silicone implant.

Background Botulinum toxin type A (BoNTA) is known to prevent fibroblast proliferation and expression of transforming growth factor beta 1 (TGF-β1). It also induces temporary muscle paralysis and decreases tension vectors. Fibroblasts induce scar contracture and hypertrophy by producing collagen fibers in wound healing processes. The aim of this study is to identify the effect of BoNTA on the scar formation. Methods Forty-five patients with forehead laceration were enrolled in this study and randomized into 2 groups with or without injection of BoNTA. When the patients presented to the clinic to remove the stitches, BoNTA was injected to the BoNTA group with 24 patients and saline was injected to the control group with 21 patients. The BoNTA was injected on dermal layer with 5 IU/cm. After that, follow-up was done in 1, 3, and 6 months. The scars were analyzed with the patient and observer scar assessment scale, Stony Brook scar evaluation scales (SBSESs), and visual analog scale (VAS) and analyzed with independent T-test, along with clinical photographs, cutometer, and biopsies. Results In all scar scales, the scores changed into favorable direction in both groups and the changes were larger in BoNTA group compared with the control group. On SBSES and VAS, better improvements on BoNTA group showed statistical significance. Skin biopsy showed less collagen deposition on dermal layer in BoNTA group. Conclusion Improvement of aesthetic, functional, and emotional aspect of the scar formation in the groups treated with BoNTA was illustrated. The application of BoNTA may be expanded to prevent hypertrophic scar after trauma, burns, or operations.

There is consensus that all patients should experience minimal pain following reduction of a fractured nasal bone. The issue requiring further study is what technique will provide patients with the greatest pain relief following the reduction of nasal fractures. This study investigated the use of an anterior ethmoidal nerve block as preemptive analgesia for the management of postoperative pain associated with reduction of nasal bone fractures. The medical documents of 85 patients were reviewed for a retrospective case-controlled comparative study. Patients in the nerve block group (n=45) were injected with 2% lidocaine containing epinephrine into the anterior ethmoidal nerve and dorsal periosteum, and those in the control group (n=40) were not. The rate of patients requiring postoperative injectable analgesics was compared between the two groups. The rate of patients who received a postoperative analgesic injection was significantly lower in the nerve block group than in the control group (P=0.034). The use of an anterior ethmoidal nerve block and dorsal periosteal injection of anaesthetic solution during reduction of fractured nasal bones under general anaesthesia resulted in the effective reduction of postoperative pain. Thus, this is regarded as a good method for enhancing patient quality of care and compliance in the reduction of fractured nasal bones.

Purpose With the increasing use of microsurgical techniques in clinical work, regular laboratory training in these techniques has become essential. Several specialized materials have been used for this purpose. We investigated whether effective training could be provided with greater convenience and less expense using fresh chicken thighs. Also, we present the histologic characteristics of chicken femoral neurovascular structures. Methods The femoral neurovascular bundles of fresh chicken thighs were dissected. Microanastomosis of vessels and nerves were performed with the aid of a microscope. Tissue from the midthigh of 8 chickens was examined histologically. Results It was found to reduce the time taken to perform anastomoses using the chicken thigh model with statistically significance. The mean diameters (± standard deviations) of the arteries, veins, and nerves were 2.04 ± 0.17 mm, 1.45 ± 0.06 mm, and 1.24 ± 0.08 mm, respectively. The observed tunica adventitia to media ratio was 1:1 and multiple nerve fascicles were wrapped in a single epineurium. Microsurgery training with this material provides several advantages: ready availability, minimal expense, no scheduling or location limitations, neurorrhaphy training, no need for special facilities for animal care or anesthesia, and no need for the trimming of adventitia. Conclusion The femoral neurovascular bundles of chicken are an appropriate and effective model for teaching and practicing microsurgery.

Background There have been few studies of the action of epinephrine injected into scalp tissue, or whether the action of epinephrine differs according to vascular anatomy within the same surgical field. Effective perioperative control of bleeding is critical during hair transplantation due to its time-consuming nature. Objective To identify the vasoconstriction time of epinephrine by concentration and injection site in the scalp tissue. Methods Twenty-five volunteers were injected with epinephrine at concentrations of 1:400,000, 1:200,000, 1:100,000, and 1:50,000 in the path of the supraorbital artery on the anterior hairline in the midfrontal area (Point A) and at the frontotemporal junction of the frontal hairline (Point B). Laser Doppler was used to measure scalp blood flow, and vasoconstriction time at Points A and B with each concentration of epinephrine was recorded. Results The duration of action of epinephrine increased in direct proportion with the concentration of epinephrine. The duration of vasoconstriction was shorter at Point A than at Point B, but this difference was only statistically significant at an epinephrine concentration of 1:50,000. Conclusion The vasoconstriction time of epinephrine in the scalp correlated positively with concentration, and the duration of vasoconstriction was longer at Point B than at Point A.

Osteonevus of Nanta is a melanocytic nevus displaying secondary ossification and carrying a potential for malignancy. A solitary occurrence is reported herein, presenting as a flesh-colored papule following laser ablation.A 56-year-old woman sought treatment for a minor papular growth of the cheek. This lesion had developed at the site of prior CO2 laser ablation done elsewhere to eradicate a pigmented nevus. The patient's medical records and histopathology report were obtained after surgical excision.Histologically, a completely excised osteonevus of Nanta was evident, marked by an intradermal nevus with subjacent osseous metaplasia. Clinical presentations of these lesions may vary, but the potential for malignancy remains.

Nevus comedonicus is a type of hamartoma that arises from a developmental anomaly of the mesodermal part of the pilosebaceous gland. In most cases of nevus comedonicus, an acne-like skin condition develops. Repeated inflammation can cause a morphological change to the cyst, papule, to abscess. We experienced a case of congenital nevus comedonicus, which led to the formation of large multiple cysts. A 50-year-old man was referred with a 12.5×10 cm lobulated mass on the posterior neck and upper back. The patient had a widespread presence of nevus comedonicus in the region ranging from the right superior chest to the posterior neck. The patient had a 30-year history of six prior excisions. A magnetic resonance imaging review led to a diagnosis of nevus comedonicus. Surgical treatment consisted of excision of the mass and wide excision for the patch type of nevus comedonicus around the neck. On histopathology, multiple masses were diagnosed as typical cysts containing keratinized tissue. The diffuse comedone lesions were diagnosed as nevus comedonicus. This case shows that large, multiple cysts can occur as a long-term complication of nevus comedonicus, and also highlights the importance of radical resection to prevent its further invagination.

Nevus comedonicus is a type of hamartoma that arises from a developmental anomaly of themesodermal part of the pilosebaceous gland. In most cases of nevus comedonicus, an acnelikeskin condition develops. Repeated inflammation can cause a morphological change to thecyst, papule, to abscess. We experienced a case of congenital nevus comedonicus, which ledto the formation of large multiple cysts. A 50-year-old man was referred with a 12.5×10 cmlobulated mass on the posterior neck and upper back. The patient had a widespread presenceof nevus comedonicus in the region ranging from the right superior chest to the posteriorneck. The patient had a 30-year history of six prior excisions. A magnetic resonance imagingreview led to a diagnosis of nevus comedonicus. Surgical treatment consisted of excision ofthe mass and wide excision for the patch type of nevus comedonicus around the neck. Onhistopathology, multiple masses were diagnosed as typical cysts containing keratinized tissue.The diffuse comedone lesions were diagnosed as nevus comedonicus. This case shows thatlarge, multiple cysts can occur as a long-term complication of nevus comedonicus, and alsohighlights the importance of radical resection to prevent its further invagination.

BACKGROUND Successful skin grafting requires immobilization and compression of the graft site. Traditional dressing methods such as tie-over dressings, cast splints, and elastic bandages are bulky in the joint area and can cause abrasion, maceration, and even circulatory insufficiency. OBJECTIVE To test the effectiveness of a hydrocolloid dressing, which provides a moist wound environment, is flexible and elastic, and adheres well to skin, for securing skin grafts. MATERIALS & METHODS A case-controlled retrospective study was conducted of 62 patients treated with skin grafts at Myongji Hospital between February 2007 and September 2009. Patients were treated with additive hydrocolloid dressing (n=31) or bolster dressing and splinting (n=31). RESULTS Treatment duration for the hydrocolloid group was significantly less than for the bolster dressing and splinting group (mean ± standard deviation 8.32 ± 1.82 days vs 13.55 ± 5.30 days, p

The distal forearm is the preferred site for hemodialysis access. However, forearm vessels have small diameter, which may lead to complications of arteriovenous fistulas constructed at this site. Indeed, the mean patency rate of such fistulas has been reported at 65.2% (range, 56–79%) at 1 y

Nasal bone fractures are the most common type of facial fracture. Closed reduction has been used as the standard treatment modality for nasal fractures for many years. In cases of nasal fracture with lacerations at the fracture sites, bioabsorbable/metallic plate or interfragment wire fixation can be used with accurate alignment through the openings created by the lacerations. However, in cases of severe comminuted nasal fractures that are difficult to drill and fix, this type of fixation may not be feasible. We performed in 5 patients open reduction with internal fixation through laceration openings using the biomaterial Greenplast (Greencross Corporation, Seoul, Republic of Korea; human plasma fibrinogen, thrombin, aprotinin, and calcium chloride) under general anesthesia. Both structural and aesthetic outcomes were satisfactory. Open reduction through laceration openings and internal fixation with fibrin glue under general anesthesia may be a simpler and more effective method than those currently in general use for the repair of complicated comminuted open nasal fractures.

BACKGROUND Midface concavity is a relatively common facial feature in East Asian populations. Paranasal augmentation is becoming an increasingly popular procedure for patients with mild concavity and normal occlusion. In this study, we evaluate clinical outcomes following a series of paranasal augmentation. METHODS A retrospective review was performed for patients with Class I occlusion who had undergone bilateral paranasal augmentation using custom-made silicone implants, between October 2005 and September 2013. Patient charts were reviewed for demographic information, concomitant operations, and postoperative complications. Preoperative and postoperative (1-month) photographs were used to evaluate operative outcome. RESULTS The review identified a total of 93 patients meeting study criteria. Overall, aesthetic outcomes were satisfactory. Five-millimeter thick silicone implant was used in 81 cases, and the mean augmentation was 4.26 mm for this thickness. Among the 93 patients, 2 patients required immediate implant removal due to discomfort. An additional 3 patients experienced implant migration without any extrusion. Nine patients complained of transient paresthesia, which had resolved by 2 weeks. There were no cases of hematoma or infection. All patients reported improvement in their lateral profile and were pleased at follow-up. Complications that arose postoperatively included 9 cases of numbness in the upper lip and 3 cases of implant migration. All cases yielded satisfactory results without persisting complications. Sensations were fully restored postoperatively after 1 to 2 weeks. CONCLUSION Paranasal augmentation with custom-made silicone implants is a simple, safe, and inexpensive method that can readily improve the lateral profile of a patient with normal occlusion. When combined with other aesthetic procedures, paranasal augmentation can synergistically improve outcome and lead to greater patient satisfaction.

Background Many techniques have been reported for the correction of inverted nipples. However, the conventional methods may be insufficient, especially for moderate to severe inversions. We propose a modification of Elsahy’s method and report satisfactory results. Methods A single-institutional retrospective review was performed for all patients who received the modified operation. Patient charts were reviewed for demographic data, pertinent preoperative factors such as Han and Hong classification, and clinical outcomes including postoperative nipple height and sensation. Surgical details are described within the main text. Results The review identified 26 female patients amongst whom 47 inverted nipples were corrected using the modified method. The mean nipple height was 9 mm with an average follow-up period of 14 months. Brush stimulation elicited nipple contraction in all patients. There was no recurrence of nipple inversion, nor were there any surgical complications to report. Conclusion The suspension technique is a simple, reliable method for correcting grade II and III nipple inversions.

Soft tissue filler injection has been a very common procedure worldwide since filler injection was first introduced for soft tissue augmentation. Currently, filler is used in various medical fields with satisfactory results, but the number of complications is increasing due to the increased use of filler. The complications after filler injection can occur at any time after the procedure, early and delayed, and they range from minor to severe. In this review, based on our experience and previously published other articles, we suggest a treatment algorithm to help wound healing and tissue regeneration and generate good aesthetic results with early treatment in response to the side effects of filler. Familiarity with the treatment of these rare complications is essential for achieving the best possible outcome. Graphical Abstract

One of the most frequently used packing materials in closed reduction of a nasal bone fracture is the hydroxylated polyvinyl acetate sponge (PVAS; Merocel(®)); however this may cause synechia, epistaxis, and pain. Synthetic polyurethane foam (SPF; Nasopore(®) Forte) has recently been used in septoplasty to prevent synechia or restenosis and haematoma formation. The purpose of this study was to compare the effects of PVAS and SPF on postoperative appearance and discomfort following the reduction of nasal bone fractures. We retrospectively reviewed all patient questionnaires and medical histories, and clinical photographs and computed tomography scans obtained before and after surgery. Outcomes were assessed using the Global Aesthetic Improvement Scale (GAIS) score and visual analogue scale (VAS) scores, which were used to assess discomfort during the 6-month follow-up period. Postoperatively, there was no statistically significant difference in the GAIS for the two packing materials (P > 0.05). Postoperative epistaxis was observed at a significantly lower rate in the SPF group than in the PVAS group, whereas anterior rhinorrhea and posterior nasal drip occurred at significantly higher rates following removal of packing in the SPF group (P < 0.05). The results of this study suggest that synthetic dissolvable polyurethane may be a reliable alternative material for nasal packing and postoperative management following the reduction of nasal bone fractures.

It is generally accepted that the developmental deficiency of the unilateral perinasal skeleton, cartilages, and skin originates from the secondary cleft nasal deformity. To date, numerous attempts have been made to correct these deformities, but no clinical data are available about the simpler, comprehensive, and patient-customized methods for correction of the secondary cleft nasal deformity. In the correction of Asian patients with secondary cleft nasal deformity, the clinical experience with the simplified Tajima method and several adjunctive procedures based on the severity of the disorder were retrospectively reviewed.During the period January 1982 to May 2009, 197 consecutive patients underwent repair through the modified Tajima method followed by several adjunctive procedures.These series had no recurrence requiring surgery except for cases in which the nasal ala was depressed to some extent. The mean degree of patient satisfaction as rated on the 5-point Global Aesthetic Improvement Scale (GAIA) was 3.88 ± 0.59.Various types of surgical procedures were performed using the modified Tajima method depending on the degree of alar cartilage displacement. These procedures were effective in achieving symmetry of the nasal tip for patients with secondary unilateral cleft lip.

PURPOSE There have been numerous attempts to use pharyngoesophageal reconstruction to restore swallowing function. Much controversy exist over reconstruction after total or partial pharyngectomy, and there is also debate over whether to continue with the reconstructive procedure with a narrow strip of remnant mucosa or complete it after total pharyngectomy. We analyzed the utility of omega-shaped radial forearm free flap (RFFF) using the narrow remnant posterior pharyngeal wall. METHODS Patients in group 1 (n = 12) had a narrow remnant pharyngeal wall with a width of less than 3 cm. Those in group 2 (n = 35) had a remnant pharynx with a width larger than 3 cm. The incidence of fistula, stricture, and swallowing difficulty were evaluated. Swallowing difficulty was graded using a 7-point visual analog scale. All circumferential hypopharyngeal reconstruction with tubed RFFF, pectoralis major flap, and jejunal free flap were also compared with group 1. RESULTS All flaps survived, and 1 fistula (8%) was detected in group 1. Compared with tubed RFFF (46%) and tubed pectoralis major flap (57%), this is a relatively low rate of fistula formation. In group 1, normal diet was possible in 92% of patients, but 1 patient can tolerate a liquid diet only. In group 2, normal diet was possible in 80% of patients. As for swallowing difficulty, the median visual analog scale score for both groups 1 and 2 was 6 points. When comparing different flaps, stricture and fistula rate was 0 and 8% in group 1, 15 and 46% in tubed RFFF, 43 and 57% in tubed pectoralis major flap, and 33 and 5% in jejunal flap, respectively. CONCLUSIONS We performed all surgeries taking care not to transgress the wide excision principle with the remnant hypopharyngeal wall. For remnant lesions greater than 3 cm, patch-type RFFF was performed, whereas for those less than 3 cm, omega-shaped RFFF was done. We achieved fairly good results in both groups without total resection of the narrow remnant hypopharyngeal wall.

Objective:Local extension of thyroid carcinoma can result in massive invasion of the trachea, causing severe airway compromise. The pre- and peri-operative management of such airway compromise is difficult but critical. We report the use of extracorporeal oxygenation support as an alternative peri-operative airway management option in such a situation. This approach facilitated curative surgery in a patient with papillary thyroid carcinoma invading the trachea.Method:We present a case report regarding extracorporeal oxygenation support in a patient with locally advanced thyroid carcinoma.Results:The patient was a 68-year-old woman with aggressive thyroid papillary carcinoma invading the trachea. The airway was almost totally obstructed, and tracheal resection and end-to-end anastomosis was planned. A venovenous bypass catheter was placed for cardiopulmonary bypass, using the bilateral femoral veins. Curative surgery and reconstruction were then performed successfully, under general anaesthesia assisted by cardiopulmonary bypass oxygenation.Conclusion:Cardiopulmonary bypass oxygenation is a safe and effective alternative airway management option in patients with locally aggressive thyroid cancer.

Background Defects of the cheek present a reconstructive challenge because of the visibility of the site, as well as the limited local tissue supply. In addition, the cheek abuts several structures with expressive function, such as the eye, mouth, and surrounding facial musculature. This report describes a system of classifying cheek defects according to tumor size and location and present corresponding reconstruction techniques used to accomplish three-dimensional restoration of all missing components and adequate texture matching. Methods From 2008 to 2013, 27 patients with cheek defects resulting from skin cancer excision were treated. According to the size of the defect, location on the cheek, and relationships to adjacent structures and existing skin tension lines, different surgical methods were applied. Results The procedures used for cheek reconstruction included direct closure, Limberg flap, V-Y advancement flap, slide-swing flap, cheek rotation flap, and full-thickness skin graft. All flaps healed well without major complications, and no cancer recurrence was detected during follow-up. Conclusions The anatomic classification of skin cancers and surgical protocols described in this report is simple and appropriate for reconstruction involving the cheek. Wide excision of skin cancer and appropriate, relatively easy-to-perform flaps based on this classification system can successfully produce safe and aesthetically-pleasing surgical outcomes.

Breast implants used for augmentation mammoplasty or breast reconstruction could rupture from various causes such as trauma or spontaneous failure. The objectives of this study were to investigate the relationships between the causes of implant rupture and the degree of capsular contracture, and then to evaluate the relative efficacies of specific signs on magnetic resonance imaging (MRI) known to be beneficial for diagnosing the rupture. A retrospective review identified patients with prosthetic implant rupture or impending rupture treated by the senior author. The 30 cases of implant rupture available for review were classified into two groups: intracapsular and extracapsular ruptures. The 30 cases of breast implant ruptures were analyzed with respect to the clinical symptoms and signs, the causes of rupture, the degree of capsular contracture, and therapeutic plans. Among the 30 cases, 14 patients who had undergone MRI during the diagnostic period were analyzed with respect to the relationships between MRI readings and operative findings. Spontaneous rupture of membranes was most common (80%), followed by failure because of trauma (7%) and valve or implant base (4%). The symptoms during implant rupture were contour deformity, palpated mass-like lesions, pain, and focal inflammation. According to the analysis of specific MRI signs, the sensitivity and specificity of the linguine sign were 87% and 100%, respectively, for intracapsular rupture. For extracapsular rupture, the sensitivity and specificity of the linguine sign were, respectively, 67% and 75%. The sensitivity and specificity of the rat-tail sign and tear drop sign were 14% and 50%, respectively. Breast implant rupture was correlated with the degree of capsular contracture in our study. Among the various specific MRI signs used in diagnosing the rupture, the linguine sign was reliable and had a high sensitivity and specificity, especially in cases of intracapsular rupture. On the other hand, the rat-tail and tear drop signs were nonspecific signs for diagnosing the rupture of breast implant.