Utilizing 3D Printing for the Surgical Management of Orbital Floor Fractures.

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

Lumbar Sympathetic Ganglion Block Facilitates Wound Healing in a Rat Ischemic Hindquarter Model.

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

Objective Odor Assessment in Patients with Osmidrosis.

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

Preoperative Flap Surgery Simulation for a Case of Cryptotia Using a 3D Printer.

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

Multicentric endocrine mucin-producing sweat gland carcinoma and mucinous carcinoma of the skin: A case report.

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a rare low-grade sweat gland carcinoma. EMPSGC is thought to be a precursor to mucinous carcinoma of the skin (MCS). Since the first description of EMPSGC in 1997, only a few cases have been reported, and its etiology and mechanisms remain unknown. In this report, we describe a 71-year-old Japanese woman with two isolated EMPSGC and one MCS lesion on her face. She was simultaneously diagnosed with invasive ductal carcinoma of the breast. She had a history of uterine cancer of unknown histopathological diagnosis 24 years previously. The presence of in situ lesions confirmed by myoepithelial cells suggested that the cutaneous lesions were primary tumors. To the best of our knowledge, this is the first case of multiple primary EMPSGC/MCS tumors. Additionally, this might be the first case with multiple primary carcinomas including adnexal cutaneous tumors, breast cancer, and uterine cancer, which may share the common feature of expressing female hormonal receptors. This case indicates that EMPSGC/MCS may be triggered by a hormonal receptor abnormality, perhaps because of genetic defects. A larger number of reports examining this issue may be necessary to further assess our initial observations.

Single-Institution, Multidisciplinary Experience of Soft Tissue Sarcomas in the Chest Wall.

INTRODUCTION: We report our single-institution, multidisciplinary experience of nearly 20 years of working on chest wall soft tissue sarcoma cases. The aim of this study was to evaluate clinical outcomes in patients with chest wall soft tissue sarcoma. MATERIALS AND METHODS: A retrospective review of 49 surgically treated patients with chest wall soft tissue sarcoma was conducted from 1997 to 2015. RESULTS: The median age of the patients was 57.0 years. There were 19 full-thickness and 30 partial-thickness resections. Reconstruction was warranted in 37 cases. Sarcomas were high grade in 31 (63.3%) and low grade in 18 (36.7%) cases. Local recurrence developed in 8 and metastasis in 9 patients. No 30-day mortality occurred. By the end of the study period, 35 patients were alive and 14 had died. The 1-, 5-, and 10-year survival rates were 93.8%, 76.0%, and 71.6%, whereas the overall recurrence-free rates were 84.4%, 70.7%, and 70.7% respectively. Favorable prognostic variables for survival included age <50 years and radical treatment (resection with wide margin or resection with marginal margin and adjuvant radiotherapy). Patients who had undergone nonradical treatment had a 3.1-fold lower chance of survival than did those who had undergone radical treatment (95% confidence interval, 0.96-10.12; P = 0.06). CONCLUSIONS: Our study suggests that surgical resection with wide margins should continue to be the mainstay for patients with chest wall sarcoma. Even extensive chest wall resections and reconstructions are safe. If wide margins are not achieved, (neo)adjuvant radiotherapy should be considered to improve local control.

A Comparative Finite Element Analysis of Two Surgical Methods for Cryptotia.

Cryptotia is an auricular muscle abnormality that causes the superior and posterior auricular area to be buried under the temporal skin. Surgical treatment approaches can be divided into skin grafts and local flaps. Complex cases also require cartilage/muscle modification. In this study, we treated one case each with the Square flap method and the Cat's Ear flap method. The aim was to help surgeons select the most appropriate surgical procedure on a case-by-case basis. METHODS: Two typical cryptotia cases were treated with the Square or Cat's Ear flap method. Finite element analysis was performed with ADINA v8.9 software, a PC (Windows 7, CPU: Core i7, Memory: 8 GB), and a hyperelastic skin model (skin diameter 20 cm; thickness 2 mm). The model scales were about 500 nodes and 500 elements (tetrahedron). RESULTS: The Square flap method involved advancing the square flap between the two triangular flaps. Switching then generated dog-ears that created a big valley. In the Cat's Ear flap method, the two triangular flaps were rotated in the same direction, whereas a square flap was advanced slightly on the opposite side. This created a large dog-ear. CONCLUSIONS: This study suggested that the Cat's Ear flap method may be particularly useful for cryptotia patients whose posterior auricular groove is shallow when the buried helix is pulled out. The Square flap method may be suitable for other cases because it effectively extrudes the buried helix with comparatively small excision.

Two Cases of Sclerotic Fibroma of the Skin that Mimicked Keloids Clinically.

Sclerotic fibromas of the skin (SFSs) have a very characteristic histology but the clinical signs are non-specific. Consequently, it is extremely difficult to make a diagnosis of SFS on the basis of the clinical findings only. We report here two cases of SFS arising on the right scapular region and the right lower leg, respectively. Both cases were clinically similar to keloids. Skin surgeons should remember that SFSs are an important differential diagnosis from keloids.

Reconstruction of Anterior Neck Scar Contracture Using A Perforator-Supercharged Transposition Flap.

Reconstruction of the anterior neck requires attention to both aesthetic and functional outcomes. In general, skin grafts are not suitable for anterior neck reconstruction in Asian patients, even when artificial dermis is used before skin grafting. Therefore, we have employed various types of thin flaps for anterior neck reconstruction, including the cervico-pectoral flap. However, we have realized that, to fully release neck contractures and therefore achieve the full range of neck extension, the skin pedicle must be sufficiently wide. Therefore, we have started reconstructing anterior neck scar contractures using wide, thin, and long flaps that are harvested from the anterior chest wall. In this article, we describe the case of a 71-year-old man who presented with a neck contracture and tracheal fistula after receiving extensive burns. A transposition flap bearing the internal mammary artery perforator was harvested from the anterior chest wall to repair the neck wounds that were left after removing the scar. At the same time, the tracheal fistula was covered by the flap. The aesthetic and functional results were acceptable. The effectiveness of supercharged transposition flaps from the anterior chest wall for reconstructing anterior neck scar contraction is discussed.

Diaphragm reconstruction combined with thoraco-abdominal wall reconstruction after tumor resection.

BACKGROUND: Thoraco-abdominal wall resection including diaphragm resection results in a challenging surgical defect. Various methods have been used for diaphragm reconstruction. The aim of this study was to describe our methods of diaphragm and thoraco-abdominal wall reconstruction after combined resection of these anatomical structures. METHODS: Twenty-one patients underwent diaphragm resection at our institution between 1997 and 2015. We used a mesh or direct closure for diaphragm defect and a mesh for chest wall stabilization. A pedicled or free flap for soft tissue coverage was used when direct closure was not possible. RESULTS: Indications for resection were primary sarcoma (n = 14), cancer metastasis (n = 4), desmoid tumor (n = 2), and solitary fibrous tumor (n = 1). The median patient age was 58.9 years. The diaphragm was pulled to its original position and sutured directly (n = 15) or reconstructed with mesh (n = 6). Chest wall reconstructions were performed with a mesh (n = 14), mesh and a pedicled flap (n = 4), mesh and a free flap (n = 3). No perioperative mortality occurred. One-year and 5-year survival rates were 85.7 and 65.9%, respectively, while overall recurrence-free rates were 80.4 and 60.8%, respectively. CONCLUSIONS: We have described our surgical methods for the resection of tumors of the chest or abdominal wall, including our method of distal diaphragm resection with wide or clear surgical margins. The method is safe and the reconstructions provided adequate stability, as well as water-tight and air-tight closure of the chest cavity. There were no cases of paradoxical movement of the chest or of diaphragm or thoraco-abdominal hernia.

Outcomes, safety, and feasibility of video-assisted thoracic surgery in lung cancer patients on hemodialysis: a case series.

OBJECTIVE: The rate of surgical resection of lung cancer in patients on hemodialysis is expected to increase due to the development of hemodialysis, improved diagnosis of lung cancer, and increases in the number and age of patients. However, studies assessing outcomes of lung resection in these patients are limited. In this retrospective case series, we investigated the safety and efficacy of video-assisted thoracic surgery (VATS) for lobectomy or segmentectomy for lung cancer in patients on hemodialysis. METHODS: Between January 2010 and January 2017, lobectomy or segmentectomy using VATS was performed for seven lung cancer cases in six patients receiving hemodialysis at our institution. There were two female and five male patients, with a median age of 61 years (range 53-76 years). Six patients underwent lobectomy, and segmentectomy and wedge resection were performed in each one case, respectively; systematic mediastinal lymph node dissection (ND2a-2) was performed in six patients. RESULTS: There were no perioperative deaths in this case series. Median recurrence-free and overall survival rates were 20 months (range 3-82 months) and 31 months (range 3-82 months), respectively. CONCLUSIONS: Video-assisted thoracic surgery (VATS) is a safe and effective procedure for resection of lung cancer in hemodialysis patients and should be considered after accurate determination of surgical indications and careful perioperative management.

Prompt Procedures Have a Great Impact on the Consequences of Asiatic Black Bear Mauling.

INTRODUCTION: Although bear-inflicted human injuries are rare and the mortality rate of the injuries is usually not high, the chances of bear-human interactions have been increasing, with fatal cases being reported in Japan every year. The aim of this study was to report a series of bear-inflicted injuries and discuss their management and severity. MATERIALS AND METHODS: A retrospective study was performed at the emergency and critical care center of Aizu Chuo Hospital, a tertiary care center in Japan, from May 2013 to September 2015. During this period, we encountered 14 black bear injury patients (12 men and 2 women). RESULTS: Six victims were attacked in dense forests while collecting wild vegetables; 4 victims were attacked near their houses. Lacerations of the scalp and face were the most frequent injuries, affecting 13 patients. Three patients developed hemorrhagic shock. Injury severity scores ranged from 2 to 12 (median value, 6). None of the injuries was fatal. Thirteen patients were transported by the local fire department's ambulances, 9 of whom were transferred to doctor ambulances. CONCLUSIONS: Although the severity and mortality rate following bear-inflicted injuries are not high, these encounters usually take place in remote rural areas, so a delay in rescue and proper care can lead to the incident becoming fatal. Hence, early decisions and arrangements for patient transportation to a tertiary care center and prompt measures to save lives will have a positive impact on the consequences of such incidents.

Usefulness of the Clavien-Dindo Classification in Understanding the Limitations and Indications of Larynx-preserving Esophageal Reconstruction.

BACKGROUND: The Clavien-Dindo (CD) classification is used to evaluate the severity of surgical complications. However, its usefulness in esophageal reconstruction has not been reported. To address this, this case series study used the CD classification to evaluate the complications after cervical esophageal reconstruction with free jejunum transfer or supercharged pedicled intestinal transfer. METHODS: All consecutive patients who underwent esophageal cancer surgery with larynx-preserving free jejunum or pedicled ileocolic transfer in June 2012-December 2015 were identified. The postoperative complications were classified using the CD classification. RESULTS: In total, 22 patients (20 men and 2 women; mean age, 63.3 years) underwent esophageal cancer reconstruction with larynx-preserving free jejunum transfer (n = 9) and supercharged pedicled intestinal transfer (n = 13). Seven patients underwent prophylactic tracheotomy. Four patients underwent emergent tracheotomy 1 or 5 days after surgery. The most frequent complication was recurrent nerve paralysis (RNP) (n = 8). Of these 8 RNP cases, 6 and 2 were classified as CD I and III complications, respectively. Pneumonia was the next most common complication (n = 7). Of these 7 pneumonia cases, 5 and 2 were classified as CD II and III, respectively. There were 2 cases of intestinal anastomosis leakage (CD II and III). On average, patients were able to start oral alimentation 15.1 (9-35) days after surgery. CONCLUSIONS: Our analysis with the CD classification suggested that vascularized free jejunum transfer or supercharge-drainage pedicled ileocolic transfer prevents postoperative intestinal anastomosis leakage and that prophylactic tracheotomy is especially indicated in cases with significant surgical damage in the cervical region.

Examination of Epithelial Mesenchymal Transition in Keloid Tissues and Possibility of Keloid Therapy Target.

BACKGROUND: Keloid is a fibroproliferative skin disorder that is characterized by collagen accumulation and blood vessel proliferation in the reticular layer of the dermis. It is caused by prolonged inflammation after cutaneous injury. Several studies suggested recently that epithelial mesenchymal transition (EMT) is involved in the development of fibrosis. This study assessed whether EMT also participates in keloid development and/or aggravation. METHODS: Resected keloid (n = 19) and normal skin (n = 13) samples were subjected to immunohistochemical, immunofluorescent, and Western blot analyses of their expression of epidermal (E-cadherin) and mesenchymal (vimentin) proteins. RESULTS: Immunohistochemical analysis showed that the keloid tissues had more vimentin-positive cells in the epidermis than the normal tissues. When normal primary keratinocytes were cultured with proinflammatory cytokines, the cobblestone-shaped cells changed to a spindle shape and many vimentin-positive cells were detected. When immortalized HaCaT keratinocytes were cocultured in split-well plates with normal or keloid-derived fibroblasts, they also underwent EMT, as indicated by their greater vimentin expression on Western blot analysis compared with HaCaT cells that were cultured alone. CONCLUSIONS: EMT was observed in keloid specimens. EMT was induced by inflammatory cytokines and fibroblasts. EMT may be involved in keloid generation and/or aggravation and may have potential as a keloid treatment target.

Using a Vibration Device to Ease Pain During Facial Needling and Injection.

OBJECTIVE: In general, needling and injection are painful procedures, especially when the face is the target. Although local anesthetics (cream or tape) can be used to reduce the pain, they are not sufficiently effective. It has been suggested that vibration can reduce pain. The aim of this case study was to determine whether application of a vibration device to an area adjacent to the facial target area to be injected/needled would relieve pain. METHODS: Consecutive women scheduled to undergo facial injection with hyaluronic acid or botulinum toxin were recruited. Half of the face was injected with concomitant vibration, whereas the other half was injected without vibration. The pain experienced by the women during both procedures was assessed using the Numeric Rating Scale. The safety of injection with vibration was also assessed. RESULTS: Of the 32 patients, 28 indicated that vibration relieved the pain, 3 stated that it had no effect, and 1 (who received deep botulinum toxin injections to the masseter muscle) complained that it made the pain worse. Vibration did not affect the safety of the injections. The average Numeric Rating Scale scores for the no-vibration and vibration injections were 4.5 ± 1.5 and 2.3 ± 0.9, respectively (P < .001). CONCLUSIONS: The Gate Control Theory of Pain explains why vibration reduces pain.

Production of protocatechuic acid by Corynebacterium glutamicum expressing chorismate-pyruvate lyase from Escherichia coli.

Protocatechuic acid (3,4-dihydroxybenzoic acid; PCA) serves as a building block for polymers and pharmaceuticals. In this study, the biosynthetic pathway for PCA from glucose was engineered in Corynebacterium glutamicum. The pathway to PCA-employed elements of the chorismate pathway by using chorismate-pyruvate lyase (CPL) and 4-hydroxybenzoate hydroxylase (4-HBA hydroxylase). As C. glutamicum has the potential to synthesize the aromatic amino acid intermediate chorismate and possesses 4-HBA hydroxylase, we focused on expressing Escherichia coli CPL in a phenylalanine-producing strain of C. glutamicum ATCC21420. To secrete PCA, the gene (ubiC) encoding CPL from E. coli was expressed in C. glutamicum ATCC 21420 (strain F(UbiC)). The formation of 28.8 mg/L of extracellular 4-HBA (36 h) and 213 ± 29 mg/L of extracellular PCA (80 h) was obtained by the C. glutamicum strain F(UbiC) from glucose. The strain ATCC21420 was also found to produce extracellular PCA. PCA fermentation was performed using C. glutamicum strain F(UbiC) in a bioreactor at the optimized pH of 7.5. C. glutamicum F(UbiC) produced 615 ± 2.1 mg/L of PCA from 50 g/L of glucose after 72 h. Further, fed-batch fermentation of PCA by C. glutamicum F(UbiC) was performed with feedings of glucose every 24 h. The maximum production of PCA (1140.0 ± 11.6 mg/L) was achieved when 117.0 g/L of glucose was added over 96 h of fed-batch fermentation.

A case of obesity hypoventilation syndrome with respiratory failure that improved with abdominoplasty.

We report on a 70-year-old man with severe respiratory failure caused by obesity hypoventilation syndrome due to abdominal adiposis. Obesity hypoventilation syndrome is a severe condition that is diagnosed when all of the following criteria are satisfied: body-mass index >30 kg/m(2); apnea hypopnea index >30; PaCO2 >45 mm Hg (in the daytime); and marked daytime somnolence. Abdominoplasty, which is generally used for abdominal laxness, striae, and rectus muscle diastases and for women in the postpartum period, was performed for this patient to facilitate ventilator weaning and produced a satisfactory result.

[A case of complete response to multiple liver metastasis of gastric cancer after discontinuation of S-1 administration].

An 80-year-old man was diagnosed with advanced gastric cancer and underwent distal gastrectomy. Although the pathological Stage of the cancer was III A, he refused adjuvant chemotherapy. One year later, CT revealed multiple liver metastases. Therefore, he was started with S-1 administration and a complete response was obtained at 10 months after starting S-1 administration. He has maintained a complete response for 22 months after S-1 discontinuation.

Sentinel node biopsy versus elective lymph node dissection in patients with cutaneous melanoma in a Japanese population.

BACKGROUND: In Japan, elective lymph node dissection (ELND) has been the standard treatment for patients with possible nodal melanoma. Sentinel node biopsy (SNB) has now replaced ELND, not only in Japan but also worldwide. The objective of this study was to compare the interim outcomes of SNB and ELND. METHODS: A retrospective study was conducted among patients with clinically node-negative disease treated at our institute with either SNB (n = 30) or ELND (n = 72). RESULTS: The background was similar in the two groups. Nodal metastases were found in 40.0% of patients in the SNB group, but in only 26.4% in the ELND group (P = 0.173). The median follow-up was 31.5 months for the SNB group and 82 months for the ELND group. The incidence of locoregional recurrence and distant metastasis in the SNB group was 10.0% and 16.7%, respectively, and for the ELND group the incidence was 5.6% and 31.9%, respectively. The 3-year disease-free survival rate was similar in the two groups (P = 0.280), and the 3-year disease-free survival rates for node-positive patients were also similar in the two groups (P = 0.90), as were the 3-year disease-free survival rates for node-negative patients (P = 0.193). CONCLUSION: This interim result in a Japanese melanoma population with clinically node-negative disease demonstrated that SNB identified more nodal micrometastases than ELND. This increase in accurate staging likely resulted from the reliable identification of the lymph node field by lymphoscintigraphy, as well as the more detailed pathologic examination of the nodes removed in SNB. It is quite reasonable to perform SNB instead of ELND in this population.