Trapdoor Deformity Correction Post Nasal Bilobed Flaps for Basal Cell Carcinoma Reconstruction With Multiple Laser Modalities.

ABSTRACT: In case of excision of nasal basal cell carcinoma (BCC), bilobed flaps are considered the criterion standard of reconstruction for defect less than 15 mm in size. However, there is still a risk of trapdoor deformity formation, of which its treatment is less discussed. A 44-year-old woman who was diagnosed with nasal BCC and underwent tumor excision with bilobed flap reconstruction presented with trapdoor deformity postoperatively. The computed Vancouver Scar Scale was 7. After early intervention of multiple laser modalities, including 2 sessions of 585-nm pulsed dye laser with a fluence of 9 J/cm2, pulse duration of 6 milliseconds, and spot size of 6 mm, 2940-nm Er-yttrium aluminum garnet (YAG) laser with a pulse energy of 800-900 mJ, repetition rate of 8-9 Hz, and laser spot size of 3-7 mm, and 5 sessions of 1064-nm Nd:YAG fractional picosecond laser with a pulse energy of 2.30-2.70 mJ, repetition rate of 8 Hz, and laser spot size of 6 mm from 5 to 23 weeks postoperatively, the Vancouver Scar Scale score improved to 1, with significant reduction of trapdoor scar erythema and puffiness. Although BCC is often curable, tumor excision causes unsatisfactory appearance satisfaction problem, owing to the apparent location of the lesion. Factors, such as sebaceous tissue thickness, reconstruction over multiple aesthetic subunits of nose, and damage to nasal cartilage framework structure during tumor removal, may increase the risk of trapdoor formation. Early intervention with multiple laser treatment can significantly revise the deformity.

The quantitative analysis of low-concentration (2%) ALA-PDT assisted with Q-switch 1064-nm Nd:YAG laser for acne vulgaris treatment.

Conventional 5-aminolevulinic acid-photodynamic (ALA-PDT) therapy (10-20%) has been widely applied for moderate-to-severe acne. The aim of this study is to investigate the effects of non-ablative Q-switched 1064-nm Nd:YAG laser-assisted ALA-PDT with low concentration (2%) on the treatment of acne vulgaris. Enrolled patients were randomly assigned to 2 groups. One group received combined therapy of 2% ALA-PDT and non-ablative Q-switched 1064-nm Nd:YAG laser, and the other received only 2% ALA-PDT. Patients in each group had received 3-session treatments with 4-week intervals (week 0, 4, and 8). Sebum secretion, melanin index, erythema index, and transepidermal water loss (TEWL) were assessed at week 2, 8, 12, and 24. VISIA® skin image system score and global esthetic improvement scale (GAIS) were also evaluated. Twenty-four participants were enrolled and evenly randomized to two groups. Significant improvement in sebum secretion was noted in combined therapy group compared to the monotherapy group at week 12 (37.5% versus 16.3%), and the improvement would still be noted until week 24 (18.3% versus 17.4%). Combined group also showed more severe melanin index and erythema index after treatment. For VISIA® skin analysis, patients in combined group had better percentile ranking in porphyrins and red-light images. There were no significant differences in GAIS at the end of the follow-up between each group, whereas higher proportion of satisfaction was noted in combined group at week 2. With the assistance of laser, low concentrations (2%) of 5-ALA can provide effective phototoxic reactions in treating acne vulgaris. The satisfaction of patients is high with acceptable adverse effects.

Coffea arabica Extract Attenuates Atopic Dermatitis-like Skin Lesions by Regulating NLRP3 Inflammasome Expression and Skin Barrier Functions.

Atopic dermatitis (AD) is a common skin disease worldwide. The major causes of AD are skin barrier defects, immune dysfunction, and oxidative stress. In this study, we investigated the anti-oxidation and anti-inflammation effects of Coffea arabica extract (CAE) and its regulation of the skin barrier and immune functions in AD. In vitro experiments revealed that CAE decreased the reactive oxygen species levels and inhibited the translocation of nuclear factor-κB (NF-κB), further reducing the secretion of interleukin (IL)-1ß and IL-6 induced by interferon-γ (IFN-γ)/tumor necrosis factor-α (TNF-α). Moreover, CAE decreased IFN-γ/TNF-α-induced NLR family pyrin domain-containing 3 (NLRP3), caspase-1, high-mobility group box 1 (HMGB1), and receptor for advanced glycation end products (RAGE) expression levels. It also restored the protein levels of skin barrier function-related markers including filaggrin and claudin-1. In vivo experiments revealed that CAE not only reduced the redness of the backs of mice caused by 2,4-dinitrochlorobenzene (DNCB) but also reduced the levels of pro-inflammatory factors in their skin. CAE also reduced transepidermal water loss (TEWL) and immune cell infiltration in DNCB-treated mice. Overall, CAE exerted anti-oxidation and anti-inflammation effects and ameliorated skin barrier dysfunction, suggesting its potential as an active ingredient for AD treatment.

Adaptability of melanocytes post ultraviolet stimulation in patients with melasma.

BACKGROUND: Dynamic in vivo changes in melanin in melasma lesions after exposure to ultraviolet (UV) irradiation have not been described. OBJECTIVES: To determine whether melasma lesions and nearby perilesions demonstrated different adaptive responses to UV irradiation and whether the tanning responses were different among different locations on face. METHODS: We collected sequential images from real-time cellular resolution full-field optical coherence tomography (CRFF-OCT) at melasma lesions and perilesions among 20 Asian patients. Quantitative and layer distribution analyses for melanin were performed using a computer-aided detection (CADe) system that utilizes spatial compounding-based denoising convolutional neural networks. RESULTS: The detected melanin (D) is melanin with a diameter >0.5 µm, among which confetti melanin (C) has a diameter of >3.3 µm and corresponds to a melanosome-rich package. The calculated C/D ratio is proportional to active melanin transportation. Before UV exposure, melasma lesions had more detected melanin (p = 0.0271), confetti melanin (p = 0.0163), and increased C/D ratio (p = 0.0152) in the basal layer compared to those of perilesions. After exposure to UV irradiation, perilesions have both increased confetti melanin (p = 0.0452) and the C/D ratio (p = 0.0369) in basal layer, and this effect was most prominent in right cheek (p = 0.030). There were however no significant differences in the detected, confetti, or granular melanin areas before and after exposure to UV irradiation in melasma lesions in all the skin layers. CONCLUSIONS: Hyperactive melanocytes with a higher baseline C/D ratio were noted in the melasma lesions. They were "fixed" on the plateau and were not responsive to UV irradiation regardless of the location on face. Perilesions retained adaptability with a dynamic response to UV irradiation, in which more confetti melanin was shed, mainly in the basal layer. Therefore, aggravating effect of UV on melasma was mainly due to UV-responsive perilesions rather than lesions.

Management of an Unusual Avulsion Trauma of Total Esophagus During Upper Gastrointestinal Endoscopy.

BACKGROUND: An esophageal defect usually resulted from surgical ablation of tumors or corrosive injury. Staged reconstructions are required usually in extensive defects. AIM AND OBJECTIVES: This study aimed to present a rare iatrogenic complication of total esophageal avulsion injury during upper gastrointestinal endoscopic treatment and to perform staged reconstructions to create a neoesophagus. MATERIALS AND METHODS: In the presented case, staged reconstructions with a tubed deltopectoral flap and a supercharged colon interposition flap were performed to reconstruct the hypopharynx and esophagus. However, recurrent choking occurred because of the extent of injury involving the epiglottis. A tubed free radial forearm flap connected to the lower buccogingival sulcus was used to create a new route for food passage. RESULTS: The patient resumed oral intake after rehabilitation. CONCLUSIONS: The avulsion injury of the total esophagus is rare and devastating. Staged reconstructions with a tubed deltopectoral flap, a supercharged colon interposition flap, and a tubed free radial forearm flap would be a safe and reliable method.

Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major-latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction.

BACKGROUND: The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options. METHODS: This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n = 24) and free extended ALT (n = 20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis. RESULTS: The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm2 , and the mean flap size was 150.0 (8*12-15*15) cm2 and 205.0 (8*15-10*25) cm2 in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm2 , and the mean flap size was 285.2 (9*30-12*25) cm2 . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p = .048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p = .030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p = .044) than the free extended ALT myocutaneous flap. CONCLUSION: The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.

Photoaging and Sequential Function Reversal with Cellular-Resolution Optical Coherence Tomography in a Nude Mice Model.

Although nude mice are an ideal photoaging research model, skin biopsies result in inflammation and are rarely performed at baseline. Meanwhile, studies on antiphotoaging antioxidants or rejuvenation techniques often neglect the spontaneous reversal capacity. Full-field optical coherence tomography (FFOCT) can acquire cellular details noninvasively. This study aimed to establish a photoaging and sequential function reversal nude mice model assisted by an in vivo cellular resolution FFOCT system. We investigated whether a picosecond alexandrite laser (PAL) with a diffractive lens array (DLA) accelerated the reversal. In the sequential noninvasive assessment using FFOCT, a spectrophotometer, and DermaLab Combo®, the photodamage percentage recovery plot demonstrated the spontaneous recovery capacity of the affected skin by UVB-induced transepidermal water loss and UVA-induced epidermis thickening. A PAL with DLA not only accelerated skin barrier regeneration with epidermal polarity, but also increased dermal neocollagenesis, whereas the nonlasered group still had >60% collagen intensity loss and 40% erythema from photodamage. Our study demonstrated that FFOCT images accurately resemble the living tissue. The photoaging and sequential function reversal model provides a reference to assess the spontaneous recovery capacity of nude mice from photodamage. This model can be utilized to evaluate the sequential noninvasive photodamage and reversal effects after other interventions.

Quantified Facial Rejuvenation Utilizing High Intense Focus Ultrasound with Multiple Penetrative Depths.

Background: Multiple penetration depths of high-intensity focused ultrasound (HIFU) treatment for facial rejuvenation have not been quantified. Methods: We enrolled 12 participants (n=24) to undergo one session of HIFU rejuvenation between January 1, 2019, and January 10, 2020. We used a 2-, 4.5-, and 6-mm focal depth transducer on the upper and middle face. We evaluated efficacy on days 60 and 90 by using our specific assessment system. Results: The average eyebrow peak and pupil-eyebrow peak angles significantly increased by 2° (p < 0.0005) and decreased by 1° (p < 0.0001), respectively, at day 90. The shortened eyebrow-iris length indicated that the forehead tissues had lifted and moved medially to the central face. Supraorbital tissues were also vertically elevated, marked by the eyebrow-orbital (p = 0.0016) and vertical palpebral fissure lengths (p = 0.0052), which both exhibited a 0.8-cm elevation. For the midface, the increased canthus-oral-nasal angle (p = 0.5881) and decreased tragus-oral length (p = 0.5881) indicated that laxity had been corrected through lifted oral commissure, though the data were not statistically significant. No serious side effects were observed. Conclusion: HIFU treatment with multiple depths quantitatively improved both upper-facial rejuvenation and midface rejuvenation after a single session.

Cephalometric analysis following combined Sub-SMAS hyaluronic acid injection and subdermal and supraperiosteal poly-L-lactic acid injections in Asian women.

BACKGROUND: The aging face is characterized by skin laxity and volume loss. Attenuation of facial retaining ligaments significantly contributes to skin sagginess and soft tissue volume loss. AIMS: We designed a prospective cohort study to quantitatively assess the efficacy of hyaluronic acid (HA) with adjunct poly-L-lactic acid (PLLA) injections in strengthening the retaining ligaments. PATIENTS/METHODS: A total of 12 Asian women were treated with HA injections to the orbital, zygomatic, buccal-maxillary, and mandibular retaining ligaments with adjunct supraperiosteal and subdermal PLLA injections to the temporal region, midface, and lower face. Cephalometric measurements were done before treatment and 2, 4, 12, and 24 weeks post-procedurally. RESULTS: Eyebrow peak and tail angles increased 20.0° ± 3.8° to 21.0° ± 3.8° (p < 0.05) and -2.9° ± 4.2° to -1.3° ± 3.3° (p < 0.001) at week 12. Eyebrow-to-orbital-rim distance increased 1.9 ± 2.0 mm to 3.9 ± 1.5 mm (p < 0.001) at week 12. Eyebrow-to-upper-eyelid distance increased 11.6 ± 3.0 mm to 12.7 ± 3.2 mm (p < 0.001) at week 24. Eyebrow-peak-to-lateral-limbus distance decreased 6.1 ± 3.1 mm to 5.3 ± 2.4 mm (p < 0.05) at week 4. Tragus-oral-commissure length and lower-facial-contouring length decreased 281 ± 11 mm to 275 ± 10 mm (p < 0.01) and 297 ± 14 to 292 ± 11 mm (p < 0.05) at week 12, respectively. CONCLUSION: Hyaluronic acid injection for strengthening of facial retaining ligaments with adjunct PLLA is viable, safe, and effective in facial rejuvenation as supported by quantitative data.

A Comparison of the Use of Two-Dimensional and Three-Dimensional Visualization Systems by Novice and Experienced Microsurgeons in Microsurgical Vessel Anastomosis: An Analysis Using the Chicken Model.

BACKGROUND: Various studies have discussed the benefits of applying three-dimensional (3D) techniques, specifically its advantages with respect to ergonomics, feasibility, and the rate of learning achievable in microsurgery training. However, no study has been conducted that compares the operator experience of using two-dimensional (2D) and 3D systems in microsurgical training. The aim of this study is to compare 2D- and 3D-assisted microsurgical training in novices based on anastomosis of chicken femoral arteries. METHODS: The participants were grouped by previous microsurgical experience. Group A includes novice participants. Group B includes 2D-experienced participants. Group C includes both participants in groups A and B. A questionnaire composed of 10 parameters in the field of image quality, dexterity, ergonomic, and feasibility will be filled out after each participant finished their anastomoses by the 2D and 3D systems. RESULTS: The results demonstrated 3D system was scored better on "field of view" (p = 0.004), "less tremor" (p = 0.005), "neck/upper back comfort" (p = 0.043), "lower back comfort" (p = 0.015), "technical feasibility" (p = 0.020), and "educational feasibility" (p = 0.004) in group A (N = 12). In group B (N = 9), 3D system was scored better on "field of view" (p = 0.041) but worse on "image resolution" (p = 0.031). CONCLUSION: With the 3D visualization system for microsurgical anastomosis of chicken femoral model, there are significant improvements in the field of view, stability, ergonomics, and educational value compared with 2D system among all participants. Accordingly, 3D-assisted microsurgery training can be a novel and potential popular training method.

Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta-analysis.

Negative pressure wound therapy (NPWT) decreases postoperative complications of various surgeries. However, the use of NPWT for oncological surgical wounds remains controversial. To evaluate the association of NPWT with oncologic recurrence in surgical wounds without residual malignancy, we analysed studies that compared NPWT with conventional non-pressure dressings for cancer surgical wounds without residual tumour by August 12, 2020. We compared tumour recurrence rates and postoperative complications between the two procedures. The six studies included 118 patients who received NPWT, and 149 patients who received conventional non-pressure wound care. The overall quality of the included studies was high based on the Newcastle-Ottawa scale score of 7.5. Tumour recurrence after NPWT was not significantly different compared with conventional non-negative pressure wound care (9.3% versus 11.4%, P = 0.40). There was no significant heterogeneity between the studies (I2  = 3%). Although NTWT was associated with a lower complication rate compared with the control group, the result was non-significant (P = 0.15). Application of NPWT in oncologic resection wounds without residual malignancy revealed no difference in local recurrence and may reduce the risk of postoperative complications compared with conventional non-negative pressure dressings. NPWT can be considered an alternative method for reconstruction in challenging cases.

Non-Conventional Fluorescence and Cytotoxicity of Two Aliphatic Hyperbranched Polymer Dots Having Poly(amic acid) Structures: Implications for Labeling Nanodrug Carriers.

In this study, we used one-pot A2 + B3 polymerizations to synthesize two aliphatic + alicyclic polymer dots (PDs) having non-conjugated hyperbranched structures, employing two types of dianhydrides as the A2 components, possessing bridged bicyclic alkene (PD-BT) and non-alkene (PD-ET) units, and Jeffamine T403 polyetheramine (T403) as the B3 components. We prepared PD-ET from commercially available ethylenediaminetetraacetic dianhydride (EDTAD, A2) and T403 (B3) and PD-BT from bicyclo[2.2.2]oct-7-ene-2,3,5,6-tetracarboxylic dianhydride (BCDA, A2) and T403 (B3). These two types of PDs possessed non-conjugated hyperbranched poly(amic acid) structures with terminal amino functional groups. PD-BT and PD-ET exhibited non-conventional fluorescence with emissions at 435 and 438 nm, respectively, and quantum yields of 12.8 and 14.0%, respectively. The fluorescence intensity of PD-ET was influenced by the pH, but PD-BT was less affected because of its rigid aliphatic bridged bicyclic structure. In aqueous solutions, the sizes of the PD-BT and PD-ET nanoparticles were 3-5 nm, and their net charges can be adjusted by varying the pH. These PDs were non-cytotoxic toward human MCF-7 breast cancer cells and human keratinocyte HaCaT cells at concentrations of 50 µg mL-1 for PD-BT and 500 µg mL-1 for PD-ET. Confocal microscopic bioimaging revealed that the PDs were located within the cells after treatment for 6 h. These PDs were easy to prepare, highly water-soluble, and possessed a large number of peripheral functional groups for further modification. Combined with their non-conventional fluorescence, they appear to have potential uses in bioimaging and as drug-labeling carriers.

Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study.

An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], p = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], p = 0.030, postoperative first month; 2.8 [1.0, 4.2], p = 0.027, postoperative third month; and 1.3 [1.3, 3.4], p = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], p = 0.049, postoperative first month; 3.2 [0.9, 6.3], p = 0.003, postoperative third month; and 3.6 [2.5, 4.1], p < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time (rho = 0.456, p = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.

Computer-Aided Detection (CADe) System with Optical Coherent Tomography for Melanin Morphology Quantification in Melasma Patients.

Dark skin-type individuals have a greater tendency to have pigmentary disorders, among which melasma is especially refractory to treat and often recurs. Objective measurement of melanin amount helps evaluate the treatment response of pigmentary disorders. However, naked-eye evaluation is subjective to weariness and bias. We used a cellular resolution full-field optical coherence tomography (FF-OCT) to assess melanin features of melasma lesions and perilesional skin on the cheeks of eight Asian patients. A computer-aided detection (CADe) system is proposed to mark and quantify melanin. This system combines spatial compounding-based denoising convolutional neural networks (SC-DnCNN), and through image processing techniques, various types of melanin features, including area, distribution, intensity, and shape, can be extracted. Through evaluations of the image differences between the lesion and perilesional skin, a distribution-based feature of confetti melanin without layering, two distribution-based features of confetti melanin in stratum spinosum, and a distribution-based feature of grain melanin at the dermal-epidermal junction, statistically significant findings were achieved (p-values = 0.0402, 0.0032, 0.0312, and 0.0426, respectively). FF-OCT enables the real-time observation of melanin features, and the CADe system with SC-DnCNN was a precise and objective tool with which to interpret the area, distribution, intensity, and shape of melanin on FF-OCT images.

Strategic Approach to Massive Chylous Leakage after Neck Dissection.

(1) Background: A high volume of chylous leakage (>1 L/day) is a potentially lethal complication after neck dissection. However, a strategic treatment for when the leakage progresses from high to massive (>4 L/day) is lacking. (2) Methods: The PubMed database was searched for articles on neck dissection-associated chylous leakage. Nine articles that included 14 cases with >1 L/day chylous leakage (CL) were analyzed. (3) Results: Of the nine patients with 1-4 L/day CL, three were successfully managed with conservative treatment, two with thoracic ductal ligation, three with ductal embolization, and one with local repair with a strap muscle flap. Of the remaining five cases with >4 L/day chylous leakage, three were successfully treated with the pectoralis major myocutaneous flap (PMMF) and one was successfully treated with thoracic ductal ligation and one case died. (4) Conclusions: In this review, when leakage was >4 L/day, the aforementioned interventions were ineffective, but applying the PMMF could rescue the intractable complication. We propose a strategic treatment for high (1-4 L/day) and massive (>4 L/day) chylous leakage.