Is the retroauricular region a suitable donor site for full-thickness skin grafting in the era of mask wearing?

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, the everyday use of face masks massively increased to prevent the spread of infection. Many people complain of ear pain and erosion when wearing a mask for extended periods of time. If prolonged mask usage is uncomfortable for ordinary people, a question arises-how much more inconvenient must mask wearing be for patients with a full-thickness skin graft (FTSG) donor site in the retroauricular region? Herein, we evaluated complications related to face mask use in 27 patients with a retroauricular FTSG donor site, with the goal of clarifying whether the retroauricular region is still an appropriate FTSG donor site in the context of the COVID-19 pandemic. METHODS: Complications in 27 patients treated by FTSGs harvested from the retroauricular region from 2019 to 2021 were investigated. A questionnaire comparing the normal and the operated sides was administered. Pain, itching, soreness, deformity, and symmetry were further investigated. RESULTS: Pain and itching were the only observed complications. The operated side was slightly more painful than the normal side in four patients (14.8%), and four patients (14.8%) reported itching on the operated side. However, all patients who experienced complications stated that the pain or itching did not interfere with mask wearing. Most symptomatic patients were older than 60 years of age (23.8%, p=0.185) and wore masks for longer periods of time (28.5%, p=0.326). CONCLUSION: Few retroauricular donor site-related complications occurred, and none of these complications caused inconvenience in daily life. Therefore, in the COVID-19 pandemic, the use of the retroauricular region as an FTSG donor site remains appropriate.

Correlation between Collagen Type I/III Ratio and Scar Formation in Patients Undergoing Immediate Reconstruction with the Round Block Technique after Breast-Conserving Surgery.

The aim of this study was to investigate the relationship between the collagen type I/III ratio and scarring in patients who underwent immediate reconstruction with the round block technique (RBT) after breast conservation surgery. Seventy-eight patients were included, and demographic and clinical characteristics were recorded. The collagen type I/III ratio was measured using immunofluorescence staining and digital imaging, and scarring was assessed using the Vancouver Scar Scale (VSS). The mean VSS scores were 1.92 ± 2.01 and 1.79 ± 1.89, as assessed by two independent plastic surgeons, with good reliability of the scores. A significant positive correlation was found between VSS and the collagen type I/III ratio (r = 0.552, p < 0.01), and a significant negative correlation was found between VSS and the collagen type III content (r = -0.326, p < 0.05). Multiple linear regression analysis showed that the collagen type I/III ratio had a significant positive effect on VSS (ß = 0.415, p = 0.028), whereas the collagen type I and collagen type III content had no significant effect on VSS. These findings suggest that the collagen type I/III ratio is associated with scar development in patients undergoing RBT after breast conservation surgery. Further research is needed to develop a patient-specific scar prediction model based on genetic factors affecting the collagen type I/III ratio.

What Is the Minimum Number of Sutures for Microvascular Anastomosis during Replantation?

As vessel diameter decreases, reperfusion after anastomosis becomes more difficult. When a blood vessel is sutured, its inner diameter becomes narrower owing to the thickness of the suture material and the number of sutures. To minimize this, we attempted replantation using a 2-point suture technique. We reviewed cases of arterial anastomosis in vessels with a diameter of less than 0.3 mm during replantation performed over a four-year period. In all cases, close observation was followed by absolute bed rest. If reperfusion was not achieved, a tie-over dressing was applied, and hyperbaric oxygen therapy was administered in the form of a composite graft. Of the 21 replantation cases, 19 were considered successful. Furthermore, the 2-point suture technique was performed in 12 cases, of which 11 survived. When three or four sutures were performed in nine patients, eight of these cases survived. Composite graft conversion was found in three cases in which the 2-point suture technique was used, and two of these cases survived. The survival rate was high in cases where 2-point sutures were used, and there were few cases of conversion to a composite graft. Reducing the number of sutures aids in optimizing reperfusion.

Correlation between acellular dermal matrix (ADM) volume and breast implant size selection among patients undergoing prepectoral direct-to-implant (DTI) breast reconstruction using complete ADM.

BACKGROUND: In prepectoral direct-to-implant breast reconstruction using the acellular dermal matrix (ADM)-assisted technique, breast volume asymmetry can occur. We hypothesized that ADM size influences implant size selection in prepectoral breast reconstruction with implant coverage using an ADM. We investigated factors influencing implant size selection and provide guidelines for surgeons. METHODS: A retrospective chart review was performed to identify all patients who underwent prepectoral direct-to-implant breast reconstruction between January 2017 and October 2020. We assessed patient characteristics, preoperative expected implant volume, ADM size, volume of implant used in surgery, and symmetry scale of aesthetic item scale (AIS) 6 months after surgery. We compared the symmetry score of AIS between a group in which the preoperative expected silicone implant size (ES) was used and a group in which a silicone implant of a smaller size than planned (SS) was used. RESULTS: Patient characteristics, including age, body mass index (BMI), and excised breast volume, were similar between the groups (P > .05). ADM size had a significant effect on implant size selection (odds ratio = 1.760, P < .01). The symmetry score of AIS was higher in the SS group. CONCLUSIONS: ADM size must be considered when selecting implant size in prepectoral direct-to-implant breast reconstruction using the ADM-assisted technique.

"Tear-Drop Appearance" Wrap: A Novel Implant Coverage Method for Creating Natural Contour in Prepectoral Prosthetic-Based Breast Reconstruction.

Various implant wrapping methods with acellular dermal matrix (ADM) have been introduced, but most focus on random trimming and suturing aimed to maximize implant coverage. Here we present our clinical experience using a "tear-drop appearance" wrapping method to achieve natural contours through upper pole volume replacement. We retrospectively reviewed the data of 56 consecutive cases of prepectoral prosthetic-based breast reconstruction (PPBR) using this wrapping method following nipple-sparing mastectomy between March 2020 and June 2021. The "tear-drop appearance" wrapping design creates an anatomical tear-drop-shaped pocket to encourage lower pole fullness and create a natural contour through upper pole volume replacement by ADM. Patients' baseline characteristics, operative data, and complications were analyzed. Aesthetic outcomes were measured using the BREAST-Q and Aesthetic Item Scale (AIS). A successful reconstruction was achieved without major complications and using a single ADM sheet. Four types and three sizes of ADMs were used. The mean resected breast tissue weight was 274.3 g, while the mean implant volume was 230.0 cc. The average BREAST-Q and AIS scores were 4.6 ± 0.8 and 4.5 ± 0.7, respectively. Owing to its simplicity, reproducibility, and effectivity, this method is an excellent implant coverage option that achieves a natural contour in PPBR.

Changing Susceptibility of Staphylococci in Patients with Implant-Based Breast Reconstructions: A Single-Center Experience.

Background and Objectives: Infections and capsular contractures remain unresolved issues in implant-based breast reconstruction. Capsular contractures are thought to be caused by the endogenous flora of the nipple duct. However, little is known about the antibiotic susceptibility of the microorganisms involved. This study aimed to evaluate the composition of endogenous breast flora and its antimicrobial susceptibility in patients with breast cancer. This study will aid in selecting a prophylactic antibiotic regimen for breast reconstruction surgery. Materials and Methods: We obtained bacteriologic swabs from the nipple intraoperatively in patients who underwent implant-based breast reconstruction following nipple-sparing mastectomy between January 2019 and August 2021. Antibiotic susceptibility tests were performed according to the isolated bacteriology. Statistical analysis was performed based on several patient variables to identify which factors influence the antibiotic resistance rate of endogenous flora. Results: A total of 125 of 220 patients had positive results, of which 106 had positive culture results for coagulase-negative Staphylococcus species (CoNS). Among these 106 patients, 50 (47%) were found to have methicillin-resistant staphylococci, and 56 (53%) were found to have methicillin-susceptible staphylococci. The methicillin resistance rate in the neoadjuvant chemotherapy group (56.3%) was significantly higher (OR, 2.3; p = 0.039) than that in the non-neoadjuvant chemotherapy group (35.5%). Conclusions: Based on the results, demonstrating high and rising incidence of methicillin-resistant staphylococci of nipple endogenous flora in patients with breast cancer compared to the past, it is necessary to consider the selection of prophylactic antibiotics to reduce infections and capsular contracture after implant-based breast reconstruction.

Necrotizing Soft-Tissue Infections: A Retrospective Review of Predictive Factors for Limb Loss.

Background: Emergent diagnosis and treatment are important for the survival of patients with necrotizing soft-tissue infections (NSTIs). Death is the most catastrophic outcome, but limb loss is also one of the most important complications that can have a significant impact on the rest of the patient's life. The purpose of this study was to identify predictive factors for limb loss caused by NSTIs. Methods: The data of patients at our center who were diagnosed with NSTIs from May 2003 to January 2019 were analyzed retrospectively. The inclusion criteria were patients with a definite diagnosis of NSTI involving the upper or lower limb. A total of 49 patient records were analyzed in terms of demography, laboratory data, microbiological causes, treatment, and final outcome. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scores at initial admission were also collected as laboratory data. Final outcomes were classified into survival with limb salvage and survival with limb loss. Results: The limb loss rate was 20.4% (10/49) in our study. On comparison between the limb salvage group and the limb loss group, independent risk factors of limb loss were as follows: presence of hypotension at admission (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.7-38.3; p = 0.008); LRINEC score ≥ 9 (OR, 5.8; 95% CI, 1.3-25.6; p = 0.012), and glucose level > 300 mg/dL (OR, 4.5; 95% CI, 0.9-21.9; p = 0.041). Various microbiological organisms were isolated; the most prevalent specimen was streptococci (32.6%), followed by staphylococci (26.5%). Poor outcomes including limb loss and mortality had no correlation with microbiological organisms. Conclusions: For patients with NSTIs, the presence of hypotension at admission, a high glucose level (> 300 mg/dL), and a high LRINEC score (> 9) were independent risk factors for limb loss.

Review of 107 Oncoplastic Surgeries Using an Acellular Dermal Matrix with the Round Block Technique.

The round block technique (RBT) is an oncoplastic surgery method that uses volume displacement techniques after partial mastectomy. However, cosmetic problems occur after tissue rearrangement in patients with small breasts or those in whom a large amount of breast tissue is excised. Therefore, we used an acellular dermal matrix (ADM) when the volume was insufficient after tissue rearrangement. Patients who underwent breast reconstruction using the ADM with the RBT after breast-conserving surgery (BCS) were included. The ADM graft was performed in two layers. First, it was placed on the glandular flap, and the patient was then seated to ascertain the degree of deformity. If the volume was insufficient, a graft was also performed under the skin flap. Overall, 107 oncoplastic surgeries were performed. Tumors were most commonly located in the upper outer quadrant of the breast, and the mean resected breast tissue was 27.1 g. Seroma was the most common complication, but it improved with several aspirations. There were no major complications or cosmetic problems requiring reoperation. Therefore, if the ADM was used for defects that could not be reconstructed with the RBT alone, safe and cosmetically good results could be obtained.

Staged Chest Wall Reconstruction for Radiation-induced Costochondritis.

Costochondritis after breast reconstruction and radiation therapy is rarely reported. Moreover, it is difficult to diagnose using computed tomography and magnetic resonance imaging; as such, wound debridement and reconstruction must be performed in several stages. A 51-year-old woman was diagnosed with invasive cancer of the right breast, and she underwent nipple sparing mastectomy and direct-to-implant breast reconstruction in November 2007. Thirteen years later, in September 2020, she experienced pain and swelling on her right breast. Incisional drainage and implant removal were performed in another clinic; however, the infection was not controlled. An implant-induced infection was suspected, and debridement was performed to a level where fresh tissue appeared in the upper layer of the intercostal muscle. Antibiotics and open dressing were used for 10 days; however, yellowish debris was noted, and third to fifth ribs and costal cartilages turned dark brown. Radiation-induced costochondritis was diagnosed based on clinical findings from the intraoperative field, wound course, and cartilage biopsy. Radical chest wall resection and reconstruction was performed using Teflon (Dupont/Chemours, Wilmington, Del.) and latissimus dorsi musculocutaneous flap. The patient was discharged 2 weeks after surgery without any complications. Costochondritis should be clinically diagnosed while performing the first debridement in staged operation. Radical chest wall resection is essential with chest wall reconstruction using Teflon and a latissimus dorsi musculocutaneous flap.

Factors Influencing Patient Satisfaction with Upper Blepharoplasty in Elderly Patients.

Upper blepharoplasty in elderly patients has characteristics that differ from those of younger patients. Blepharoptosis in elderly patients causes not only aesthetic problems but also functional problems such as entropion, visual disturbance, and sore eyes. We hypothesized that factors influencing patient satisfaction with upper blepharoplasty in elderly patients include aesthetic outcomes, functional outcomes, and personal factors. METHODS: This study included 57 patients aged >65 years who underwent upper blepharoplasty between April 2018 and March 2019. All surgeries were performed through the "Upper Blepharoplasty Service Project" of the public health center in Geoje City. To evaluate the individual characteristics of the patients, a preoperative questionnaire (including sociodemographic characteristics, main symptoms of discomfort in the upper eyelid, and degree of expectation of surgical results) was administered to the patients. After 6 months, a satisfaction survey was conducted accordingly. RESULTS: The main symptoms of discomfort were sagging of the skin of the upper eyelid. The mean score for patient satisfaction was 3.84 ± 0.40, and satisfaction with the results of surgery relative to the cost was 4.53 ± 0.63, which was the highest score. Significant verification of the regression coefficients showed that functional improvement and cognitive degree of postsurgery precautions had a significant effect on patient satisfaction, whereas aesthetic outcomes and expectations of surgical results were not correlated with patient satisfaction. CONCLUSION: The findings indicated that elderly patients tended to be satisfied with functional improvement that resolved their symptoms of discomfort and personal factors such as cost and cognitive degree of precautions after upper blepharoplasty.

Reconstruction of a small defect of the lower vermilion adjacent to white roll using a modified O-Z flap.

Reconstruction of lip defects is important because the lips play an important role in maintaining aesthetic facial balance, facial expressions, and speech. There are various methods of lip reconstruction such as primary repair, skin grafting, and utilization of local and free flaps. It is important to select a proper reconstruction method according to the size and location of lip defect. Failure to select an appropriate method may result in distortion, color mismatch, sensory loss, and aesthetic imbalance. Herein we present a case of successful aesthetic reconstruction of the lower vermilion. We removed a venous malformation, which was limited to the lower vermilion and adjacent to the white roll, and repaired the defect using the modified O-Z flap.

Retrospective review of 108 breast reconstructions using the round block technique after breast-conserving surgery: Indications, complications, and outcomes.

BACKGROUND: Several oncoplastic approaches have been implemented in recent years to enhance cosmetic results and to reduce complications. The round block technique is a volume displacement technique for breast reconstruction after breast-conserving surgery (BCS). However, its indications are currently limited according to tumor location, and its cosmetic results and complications have not been clearly established. We hypothesized that the round block technique could produce favorable cosmetic results without major complications regardless of tumor location or nipple-tumor distance, below a certain resected tumor volume and tumor-breast volume ratio. METHODS: All breast reconstructions using the round block technique after BCS were included in this analysis. Patients' data were reviewed retrospectively to investigate complications during follow-up, and clinical photos were used to evaluate cosmetic results. The relationships of tumor location, nipple-tumor distance, tumor volume, and the tumor-breast volume ratio with cosmetic results were investigated. RESULTS: In total, 108 breasts were reconstructed. The mean resected tumor volume was 30.2±15.0 mL. The cosmetic score was 4.5±0.6 out of 5. Tumor location, nipple-tumor distance, tumor volume, tumor-breast volume ratio, radiotherapy, and chemotherapy had no significant effects on cosmetic results or complications. There were no major complications requiring reoperation. CONCLUSIONS: Breast reconstruction using the round block technique after BCS can lead to good cosmetic results without major complications regardless of the tumor location, nipple-tumor distance, radiotherapy, or chemotherapy. Below the maximum tumor volume (79.2 mL) and the maximum tumor-breast volume ratio (14%), favorable results were consistently obtained.

Clinical outcomes of arthroscopic lateral ulnar collateral ligament repair with or without intra-articular fracture.

BACKGROUND: The pathoanatomy and biomechanics of elbow instability have been previously reported; however, few researchers have dealt with the operative management and clinical consequence of recurrent elbow instability. Recent studies on arthroscopic lateral collateral ligament (LCL) complex repair have reported successful outcomes similar to those achieved by open repair. We aimed to determine the validity of arthroscopic repair of the LCL complex in elbows with unstable dislocation with or without intra-articular fracture. METHODS: Eighteen consecutive patients who had undergone arthroscopic repair of the LCL complex for unstable dislocation of the elbow with or without intra-articular fracture and who were followed for at least 12 months were included in the study. Ligament injury combined with coronoid and/or radial head fractures were treated with arthroscopic technique. Pain, range of motion, clinical outcomes based on the Mayo Elbow Performance Score (MEPS), and surgical complications were evaluated. RESULTS: At 12 months follow-up, all 18 patients demonstrated complete settlement of the instability and mean (and standard deviation) extension of 1.7 ± 3.8°, flexion of 138.3 ± 3.8°, supination of 88.6 ± 5.3°, and pronation of 88.2 ± 5.6°. The average MEPS was 97.7 ± 3.9 points and according to this validated outcome score. However, slight widening (2 mm) of the radiocapitellar joint space was accompanied in one patient, although the varus stress test and pivot shift test were not observed. One patient showed delayed union of the anteromedial facet fracture, and two patients showed pin site irritation, which was a complication of arthroscopic coronoid fracture fixation and was fully resolved after pin removal. CONCLUSION: In patients with unstable elbow dislocation, with or without an intra-articular fracture, arthroscopic repair of the LCL complex is an effective and alternative treatment option that can restore elbow stability and have satisfactory clinical and radiographic results.

Treatment of post-traumatic chin deformities using bilateral botulinum toxin injections.

Post-traumatic hematoma formation is a common complication of contusion. If the hematoma is large enough to aspirate or drain, it can be treated quickly and appropriately. However, if the hematoma is small or concealed by local swelling, it may be overlooked and left untreated. In most cases, a hematoma will resolve following conservative treatment; however, associated infection or muscle fibrosis can occur. Herein, we present the case of a patient with a chin deformity caused by a post-traumatic hematoma. The deformity was treated using botulinum toxin and triamcinolone acetonide injections as minimally invasive treatments. The course of treatment was good.

Rhinogenic Headache: Standardization of Terminologies Used for Headaches Arising From Problems in the Nose and Nasal Cavity.

OBJECTIVE: The use of different expressions between physicians frequently results in confusion in the process of diagnosis and treatment of patients with headaches due to problems in the nose and nasal cavity. The aim of this study was to assess the terminologies that have been used most frequently to standardize these terminologies. METHODS: Terminologies that are most frequently used in general, including rhinogenic migraine, sinus headache, rhinogenic contact point headache, middle turbinate headache syndrome, and rhinogenic headache, were found by searching PubMed, Web of Science, and Google Scholar. These terminologies were objectively assessed on the basis of existing research and definitions and the range of diagnoses by organizations with public credibility. RESULTS: There were many terminologies in use for headache related to nose; however, these were not logical expressions and only partly explained the phenomenon. Among the terms, "rhinogenic headache" was most appropriate in expressing and describing the related symptoms. CONCLUSION: The results indicated that the term "rhinogenic headache" is most appropriate for describing pain in the nose and eyes in patients with deformation within the nose or the nasal cavity due to external injuries or underlying diseases related to nose as observed on computed tomography.

Correlation between dermal thickness and scar formation in female patients after thyroidectomy.

BACKGROUND: Minimizing scarring has long been a challenge in plastic surgery. Factors affecting scar formation are well known, but the effect of some patient-specific factors such as dermal thickness remains unverified. Management of factors predictive of scarring can improve postoperative patient satisfaction and scar treatment. METHODS: For 3 years, we used ultrasonography to measure dermal thickness in female patients who had undergone thyroidectomy for cancer at our hospital. We confirmed the influence of dermal thickness on hypertrophic scar formation and the Patient and Observer Scar Assessment Scale scar score 6 months after surgery. RESULTS: There was a positive correlation between dermal thickness and scar score (p<0.05), and dermal thickness appears to be a cause of hypertrophic scar formation (p<0.05). CONCLUSION: Thick dermis was found to cause poor scar formation and hypertrophic scarring. Prediction of factors that can influence scar formation can be used to educate patients before surgery and can help in scar management and improvement in patient satisfaction.

Modified Anterior Craniofacial Osteotomy Using Partial Nasal Bone Division and Reconstruction in Frontoethmoidal Sinus Meningioma.

Typical transcranial approaches are insufficient for adequate visualization and resection of skull base tumors. Different approaches with multiple modifications have been attempted. Here, we describe a new approach for a lesion that is central and hard to treat by conventional craniotomy and successful reconstruction with calvarial bone graft and titanium mesh plate. A 69-year-old female patient presented with recurrent meningioma. The tumor had invaded the frontal lobe, right supraorbital rim, and ethmoidal bone. We performed a modified anterior craniofacial approach that fully exposed the tumor and invaded bone. In consideration of the patient's age and cosmetic result, the tumor and invaded bone was resected and the defect area was reconstructed with titanium mesh and calvarial bone graft. At 6 months postoperative the patient had no complications and was satisfied with the esthetic result. We report this case to demonstrate the successful approach and reconstruction using this technique.

Wound Healing and Anti-inflammatory Effects of Topical Hyaluronic Acid Injection in Surgical-Site Infection Caused by Staphylococcus aureus.

Surgical-site infection (SSI) is a common postoperative complication, primarily caused by Staphylococcus aureus. S aureus produces hyaluronidase which degrades hyaluronic acid (HA). HA prevents bacterial proliferation and has anti-inflammatory effects to promote wound healing. We evaluated the effect of HA injection with systemic antibiotics for prevention and treatment of SSIs caused by S aureus. An open wound was created on the dorsum of 40 rats. The wound bed was sutured with S aureus inoculated thread. The test group was injected with HA (HA group), and the control group received a subcutaneous injection of normal saline (NS group). All groups were then treated with intraperitoneal cefazolin injection. The sutures were removed 2 days after the procedure. Gross pathology, bacterial count, and wound histology were assessed at days 2, 4, 6, and 8 postprocedure. The HA group showed a significant reduction in the wound area compared with the control group on gross pathology (at days 8 postprocedure, 36.54% ± 6.12% vs 50.59% ± 5.50%, P < .001). The HA group showed significantly better wound healing than the control group on histological analysis, including assessment of abscess, neutrophilic infiltration, and necrosis (4.2 ± 1.2 vs 11.5 ± 2.1, P < .001). The HA group showed a lower bacterial count compared with the NS group, but the result was not significant statistically (at days 6 postprocedure, 5.11 ± 0.31 vs 5.91 ± 0.35 logCFU/mL, P = .706). In conclusion, immediate local injection of HA in wounds can reduce SSI occurrence and promote wound healing in an animal model.

Safe and Effective Method to Transfer Pedicle Vessels in Free Flap Reconstruction.

Free tissue transfer is a useful method to cover soft tissue defects following trauma or tumor excision. At the time of transfer of the pedicle, its status is not investigated. Therefore, kinking of the pedicle can occur, and pedicle injuries can result from surgical instruments. The authors would like to introduce a simple, safe, and effective method to overcome these problems using a Penrose drain. The present method can help reconstructive microsurgeons with the transfer of pedicle vessels through a tunnel without torsion or injury.

Diagnostic accuracy of laser Doppler imaging in burn depth assessment: Systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Accurate assessment of burn depth is important for determination of treatment modality. Laser Doppler imaging (LDI) is known to be an objective and effective measurement tool in burn depth assessment. Our study evaluated the diagnostic accuracy of LDI across enrolled studies and subgroups. METHODS: A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. Data from LDI cases were extracted from all primary studies and categorized into four cell values (true positives, false positives, true negatives, and false negatives). Subgroup analyses were performed according to perfusion units of LDI, clinical criteria of superficial and deep burns during the treatment period, and publication date of enrolled studies. RESULTS: The search strategy identified 321 publications. After screening, 10 articles were selected for review. The pooled sensitivity and specificity of LDI in all enrolled studies and subgroups were found to be similarly high. However, the sensitivity of LDI in our meta-analysis was not as high as that identified in previous studies. CONCLUSION: Although LDI in burn depth assessment was identified as an accurate measurement tool in this meta-analysis, careful clinical assessment should be performed along with LDI in patients with deep burns.