Particulate matter-induced atmospheric skin aging is aggravated by UVA and inhibited by a topical l-ascorbic acid compound.

Ambient particulate matter (PM) is a major contributor to environmental air pollution-associated skin damage. However, most published studies are observational or epidemiologic and have not mechanistically investigated the effects of air pollutants on cellular senescence and aging, particularly in combination with ultraviolet (UV) radiation. Herein, we analyzed whether UVA aggravates the PM-induced inflammatory cascade, which contributes to the aging of skin-derived cells. We hypothesized that cellular senescence is involved in PM&UVA-induced aging and tested whether an l-ascorbic acid compound (LAC), containing vitamin E and ferulic acid, can inhibit PM&UVA-induced aging. PM&UVA-exposed HDFs showed further elevated reactive oxygen species (ROS) levels detected by flow cytometry. We then demonstrated that PM induces MAPK signaling activation and the expression of AhR and NF-κB, responses that are both exacerbated by UVA. The levels of inflammatory cytokines, IL-1ß and IL-6, were significantly higher in the PM&UVA-exposed group which resulted in increased transcription of MMPs, causing downregulation of type I collagen. Meanwhile, treatment with LAC reduced the levels of ROS and inflammatory cytokines. Additionally, PM&UVA-induced SA-ß-gal production (staining assay) was reduced by LAC. These findings suggest a role of atmospheric pollution and UVA radiation in cellular senescence induction. Our findings also suggest a possible role of AhR inhibition by topical antioxidants to prevent atmospheric pollution-induced skin aging.

Treatment of Human Immunodeficiency Virus-Associated Facial Lipoatrophy With Hyaluronic Acid Filler Mixed With Micronized Cross-Linked Acellular Dermal Matrix.

BACKGROUND: Human immunodeficiency virus (HIV)-associated facial lipoatrophy (FLA) is a stigmatizing side effect associated with the use of highly active antiretroviral therapy. We sought to evaluate the safety and efficacy of the hyaluronic acid filler mixed with micronized cross-linked acellular dermal matrix (HA/MADM) in HIV-associated FLA. METHODS: We conducted an open-label safety and efficacy study in patients with HIV-associated FLA. Fourteen patients received single injection of the HA/MADM, and 13 patients completed the 24-week follow-up evaluation. Treatment efficacy, safety, and patient and physician satisfaction were evaluated. Repeated measure analysis of variance with post-hoc analysis with the Wilcoxon signed rank test was performed to compare and incorporate parameters at each time point. RESULTS: All 13 patients maintained a significant improvement of the Carruthers Lipoatrophy Severity Scale grade throughout the study period, along with improvement of the depressed volume due to lipoatrophy measured using a three-dimensional camera system. More than 80% of patients and physicians were satisfied with the treatment, and no treatment-related adverse events were reported, except for one case of transient subcutaneous nodule formation. CONCLUSION: Our study findings suggest that injectable HA/MADM is a potentially effective and safe treatment option for treating HIV-positive patients with FLA.

Bactericidal effect on S. mutans using N-TiO2 with combined treatment of low concentration H2O2 and visible light.

PURPOSE: To test the feasibility of nitrogen-doped TiO2 nanoparticles in the killing of Streptococcus mutans (S. mutans) for short term treatment. METHODS: For the study, S. mutans were treated with the combinations of N-TiO2, visible light, and without/with 0.5% H2O2 inclusion. Visible light was irradiated for 3 minutes one time. RESULTS: Methylene blue solution was degraded (bleached) 5-30% by one of N-TiO2 (or TiO2) + visible laser (405 or 660 nm) +0.5% H2O2 conditions owing to almost linearly producing free radicals through photocatalysis. Antibacterial outcomes treated with N-TiO2 were slightly better than those by TiO2 regardless of test condition. Also, killing of S. mutans treated with 405 nm laser was slightly better than those by 660 nm laser. CLINICAL SIGNIFICANCE: S. mutans can be eliminated using N-TiO2 with clinically acceptable light (wavelength, intensity) and low concentration H2O2 condition under short term treatment.

Autofluorescence spectra and image to differentiate restorative dental resins from the tooth.

PURPOSE: To compare the autofluorescence (AF) spectra of resin products with teeth to determine if this type of non-invasive testing is feasible for differentiating resin products from teeth during resin repair. METHODS: For the study, 11 methacrylate-based resin products were chosen. A 405 nm laser was used to induce AF, and a spectrophotometer and a qualitative laser-induced fluorescence (QLF) camera were used to obtain AF spectra and images, respectively. RESULTS: Resin products and teeth showed one or two emission peak(s) at 435-465 nm and 475-480 nm, respectively. Other resin constituents produced weak emission peaks beyond the 435-475 nm range. Resin products with high emission intensities produced bright images. When layered, surface resins (0.2 mm-thick) were different from underlying base resins and teeth. CLINICAL SIGNIFICANCE: During resin repair, a restored resin can be readily removed if AF spectroscopy is used alone or in combination with QLF imaging.

Skin-resident natural killer T cells participate in cutaneous allergic inflammation in atopic dermatitis.

BACKGROUND: Natural killer T (NKT) cells are unconventional T cells that bridge innate and adaptive immunity. NKT cells have been implicated in the development of atopic dermatitis (AD). OBJECTIVE: We aimed to investigate the role of NKT cells in AD development, especially in skin. METHODS: Global proteomic and transcriptomic analyses were performed by using skin and blood from human healthy-controls and patients with AD. Levels of CXCR4 and CXCL12 expression in skin NKT cells were analyzed in human AD and mouse AD models. By using parabiosis and intravital imaging, the role of skin CXCR4+ NKT cells was further evaluated in models of mice with AD by using CXCR4-conditionally deficient or CXCL12 transgenic mice. RESULTS: CXCR4 and its cognate ligand CXCL12 were significantly upregulated in the skin of humans with AD by global transcriptomic and proteomic analyses. CXCR4+ NKT cells were enriched in AD skin, and their levels were consistently elevated in our models of mice with AD. Allergen-induced NKT cells participate in cutaneous allergic inflammation. Similar to tissue-resident memory T cells, the predominant skin NKT cells were CXCR4+ and CD69+. Skin-resident NKT cells uniquely expressed CXCR4, unlike NKT cells in the liver, spleen, and lymph nodes. Skin fibroblasts were the main source of CXCL12. CXCR4+ NKT cells preferentially trafficked to CXCL12-rich areas, forming an enriched CXCR4+ tissue-resident NKT cells/CXCL12+ cell cluster that developed in acute and chronic allergic inflammation in our models of mice with AD. CONCLUSIONS: CXCR4+ tissue-resident NKT cells may form a niche that contributes to AD, in which CXCL12 is highly expressed.

Consensus Statement on Robotic Mastectomy-Expert Panel From International Endoscopic and Robotic Breast Surgery Symposium (IERBS) 2019.

OBJECTIVES: To achieve a consensus statement on robotic mastectomy. BACKGROUND: Robotic-assisted surgery has gained much attention especially the results of few case series reporting on the technical feasibility, safety and early oncologic outcomes of robotic-assisted mastectomy in a few centers worldwide. The aim of this consensus statement was to develop and provide standardized guidelines on robotic mastectomy based on consensus statement by a panel of experts from indications to outcome measures and indicators, thereby providing a valuable guide for breast surgeons worldwide. METHODOLOGY: An internationally representative expert panel of 10 surgeons was invited to participate in the generation of a consensus statement. 52 statements were created in 6 domains: indications, contraindications, technical considerations, patient counseling, outcome measures and indicators, training and learning curve assessment. Experts were asked to vote if they agree, disagree or of the opinion that the statement should be rephrased. Two electronic rounds via online survey of iterative rating and feedback were anonymously completed, followed by a final round of in-person meeting during the inaugural International Endoscopic and Robotic Breast Surgery Symposium 2019 from May 24 to 25, 2019. Consensus was reached when there was at least 80% agreement on each statement. RESULTS: A total of 53 statements with at least 80% agreement were generated after 3 rounds of voting; 21 statements from first round of voting, 20 statements from second round of voting and 12 statements from the final round of in-person meeting. All experts agreed that the consensus statement served as expert recommendations but not mandatory for a successful and safe practice of robotic mastectomy. CONCLUSION: Robotic mastectomy is a promising technique and could well be the future of minimally invasive breast surgery whereas proving to be safe and feasible. The first consensus statement on robotic mastectomy from an international panel of experts serves as an extremely important milestone and provides recommendations for breast surgeons keen to embark on this technique.

Tissue-remodelling M2 Macrophages Recruits Matrix Metallo-proteinase-9 for Cryotherapy-induced Fibrotic Resolution during Keloid Treatment.

Cryotherapy is used to treat keloid scars; however, the molecular and pathological mechanisms are not clearly understood. This study retrospectively evaluated the efficacy of combined treatment with cryotherapy and intralesional triamcinolone injection (Cryo+TA) or intralesional TA monotherapy (TA) in 40 Asian patients with keloid scars. Scar improvement was assessed using the Vancouver Scar Scale and Global Improvement Scale. Clinical improvement in scars, especially reduced vascularity and redness, was significantly greater in the Cryo+TA group than in the TA group. Cryotherapy-treated and untreated keloid tissue was collected from six patients for analysis. Histo-logically, collagen bundles from cryotherapy-treated keloid tissue were more fibrillar and abnormal thickness was reduced. Immunohistochemical staining showed a reduced number of dermal vessels after cryotherapy. Moreover, CD163+ M2 macrophages and matrix metalloproteinase-9 (MMP-9) were significantly increased in cryotherapy-treated tissue. Double immunofluorescence staining revealed co-expression of CD163 and MMP-9. These data indicate that cryotherapy recruits tissue-remodelling M2 macrophages with accompanying MMP-9, suggesting that cryotherapy-recruited M2 macrophages function in fibrotic resolution during keloid treatment.

Postoperative Cancer Surveillance Following Oncoplastic Surgery with Latissimus Dorsi Flap: a Matched Case-Control Study.

BACKGROUND: The latissimus dorsi (LD) myocutaneous flap is a widely used local option in oncoplastic surgery for avoiding breast deformities; however, concerns exist regarding its influence in monitoring recurrence. In this study, we evaluated the impact of this flap on postoperative cancer surveillance. METHODS: Each patient receiving oncoplastic surgery with LD flap after partial mastectomy were matched in age, cancer stage, and body mass index with patients receiving partial mastectomy alone. Twenty-nine patients with the oncoplastic LD flap received 99 mammograms and 139 ultrasonograms, while 29 patients with partial mastectomy alone underwent 92 mammograms and 129 ultrasonograms. Mammographic and ultrasonographic findings were classified by Breast Imaging Reporting and Data System (BI-RADS) category and reviewed. Any recommendations for additional evaluation and recurrence were documented. RESULTS: During an average follow-up period of 44 months, although the oncoplastic group demonstrated more newly developed benign calcifications (control 14% vs. oncoplastic 41%; p = 0.019) on mammography, the percentage of recall for additional imaging in category 0, and the short-interval follow-up in category 3, was not different between the control and oncoplastic group. Regarding ultrasonography, BI-RADS category was also not different between the two groups; however, the control group showed more fluid collections than the oncoplastic group (control 21% vs. oncoplastic 0%; p = 0.023). One case of local recurrence was observed in the control group. CONCLUSION: Although there was an increase in benign calcifications in the oncoplastic group, there were no additional abnormal findings requiring further intervention. We concluded that the LD flap for oncoplastic surgery does not interfere with cancer surveillance, and even decreases the rate of fluid collection.

Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients.

BACKGROUND: The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume. METHODS: A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI. RESULTS: A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019). CONCLUSION: These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap.

Ultra Gas-Proof Polymer Hybrid Thin Layer.

Hermetic sealing is an important technology for isolating and protecting air-sensitive materials and is key in the development of foldable and stretchable electronic devices. Here we report an ultra gas-proof polymer hybrid thin layer prepared by filling the free volume of the polymer with Al2O3 using gas-phase atomic layer infiltration. The high-density polymer-inorganic hybrid shows extremely low gas transmission rate, below the detection limit of the Ca corrosion test (water vapor transmission rate <10-7 g m-2 day-1). Furthermore, because of the remarkable nanometer-scale thinness of the complete polymer-inorganic hybrid, it is highly flexible, which makes it useful for hermetic sealing of stretchable and foldable devices.

Hypoxia-Induced Epithelial-To-Mesenchymal Transition Mediates Fibroblast Abnormalities via ERK Activation in Cutaneous Wound Healing.

Previous studies described the involvement of extracellular signal-related kinase (ERK) in systemic fibrotic diseases, but the role of ERK in cutaneous scarring is unknown. Although hypoxia drives tissue fibrosis by activating hypoxia-inducible factor-1α (HIF-1α), the specific roles of hypoxia and associated ERK phosphorylation in abnormal fibroblast activity during cutaneous scarring are unclear. Here, we investigated whether pathologic myofibroblast-like keloid fibroblast activity is promoted by hypoxia-induced epithelial-mesenchymal transition mediated by ERK activation. ERK phosphorylation was significantly increased in keloid tissue and fibroblasts. Human dermal fibroblasts cultured under hypoxia (1% O2) expressed phosphorylated ERK and exhibited activation of p38 mitogen-activated protein kinase signaling. Hypoxic human dermal fibroblasts showed increased protein and mRNA levels of epithelial-mesenchymal transition markers. Furthermore, administration of an ERK inhibitor (SCH772984) reduced the hypoxia-induced elevation of collagen type I levels in human dermal fibroblasts. Therefore, ERK may be a promising therapeutic target in profibrogenic diseases.

Evaluation of the Relationship Between Flap Tension and Tissue Perfusion in Implant-Based Breast Reconstruction Using Laser-Assisted Indocyanine Green Angiography.

BACKGROUND: For implant-based breast reconstruction, inadequate tissue perfusion may cause devastating complications. Tissue tension by inadequate implant volume may reduce tissue perfusion by stretching and collapsing the capillaries. The SPY system is used to perform intraoperative fluorescence angiography with indocyanine green to assess visually the blood flow and evaluate tissue perfusion. However, there is no report yet about how mastectomy flap perfusion changes with the expander-filling volume. Therefore, to analyse the changes of tissue perfusion of the mastectomy flap according to the tension level, we used the SPY system and adjusted the filling volume of the tissue expander to change the tension on the skin flap. METHODS: Ten breasts of ten patients who underwent immediate two-stage, implant-based breast reconstructions were included. The expander-filling volume just before mastectomy flap blanching was set as 100%. Based on this, the expander-filling volume was reduced to 50% and increased to 150%. Ingress and egress rates were evaluated using the SPY system at each condition and analysed by a linear mixed model using least square means. RESULTS: The mean ingression rates were 138, 100, and 65%, and the mean egression rates were 145, 100, and 66% at 50, 100, and 150% inflation, respectively. CONCLUSIONS: It was objectively proven that tissue perfusion deteriorates as the tension applied on the flap increases. On the basis of this finding, we can control the amount of inflation volume of the expander or remove the skin in the pre-ischaemic condition to reduce complications of implant-based breast reconstruction.

The use of acellular dermal matrix in immediate two-stage prosthetic breast reconstruction provides protection from postmastectomy radiation therapy: a clinicopathologic perspective.

Although there is ample evidence showing that radiation therapy increases the risk of complications of breast reconstruction, the efficacy of human acellular dermal matrix (CGCryoDerm®) in immediate tissue expander breast reconstruction in the setting of postmastectomy radiation therapy has not been fully elucidated. In this study, we report our institutional experience with pertinent refined surgical technique, and determine whether acellular dermal matrices have a protective effect in this increasingly prevalent clinical setting. Twenty-six patients who underwent immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy with at least 2 years of follow-up were retrieved. Fifteen patents were reconstructed with ADM, whereas 11 patients were reconstructed without ADM. The occurrence of complications was assessed according to the reconstruction type (with ADM vs without ADM). Furthermore, in patients reconstructed with ADM (n = 15), immunohistochemistry was performed to analyze the breast capsule with ADM compared with that without ADM in the same patient, according to the expression of alpha-smooth muscle actin (α-SMA). The occurrence of complications was significantly associated with the reconstruction type (with ADM vs. without ADM, p = 0.015). On the basis of the results of α-SMA staining, α-SMA+ myofibroblasts were relatively highly expressed throughout the breast capsule without ADM. On the contrary, α-SMA+ myofibroblasts present at the breast capsule adjacent to the ADM were scarce and irregularly scattered. Use of an acellular dermal matrix may be recommended to patients who are concerned about complications after immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy.

Quantitative Mandibular Angle Ostectomy Facilitated by Oscillating-Blade Saw With Scalable Guide.

BACKGROUND: Although various techniques of mandibular angle ostectomy have been devised to correct overly prominent bony contours, none have incorporated methods to delineate the surgical line with precision. Herein, the authors describe one means of marking an ostectomy line more easily, using a specially designed oscillating-blade saw. METHODS: Between July 2013 and June 2014, a total of 75 patients underwent quantitative mandibular angle ostectomy using a custom oscillating-blade saw equipped with a scalable guide. Corticectomy, also done routinely to improve frontal appearance, called for a reciprocating saw only. Aesthetic outcomes gauged subjectively by the questionnaire about satisfaction and symmetry after postoperative 6 months. RESULTS: Satisfaction score was 4.9 and symmetric score was 4.7. No major complications, such as persistent nerve injury or fracture, were encountered. CONCLUSIONS: Use of an oscillating-blade saw equipped with a scalable guide facilitated quantitative mandibular angle ostectomy, enabling precise, and reproducible surgery with satisfactory outcomes with less complications.

Prospective 1-Year Follow-Up Study of Breast Augmentation by Cell-Assisted Lipotransfer.

BACKGROUND: Breast augmentation by cell-assisted lipotransfer (CAL) may achieve a more natural breast contour than silicone implants. Moreover, certain complications associated with these prosthetic devices can be avoided with CAL. Few prospective studies of CAL have been performed to examine long-term volume changes, effects on breast parenchymal tissue, and the effect of stromal vascular fraction (SVF) on graft survival. OBJECTIVES: In a 1-year prospective study of patients who underwent CAL, the authors examined changes in breast volume, effects on parenchymal tissue, and the impact of SVF on graft survival. METHODS: Following preoperative radiologic examination, patients underwent primary augmentation mammaplasty by CAL to both breasts. The SVF was characterized, and changes in breast volume were determined from magnetic resonance imaging studies performed postoperatively at 3 months and 1 year. A breast-imaging specialist reviewed all scans to detect changes in breasts. RESULTS: Five patients (10 breasts) were enrolled. Averagely 23% of grafted fat in volume was additionally harvested from each patient to isolate SVF cells. One year after CAL, breast volume had decreased to 47% of the initial postoperative volume. There was no parenchymal changes except small oil cysts. The ratio of SVF cell count to grafted fat volume showed no correlation with graft survival. Patterns of breast-volume decrease differed between older women with a history of breastfeeding and younger women without a history of breastfeeding. CONCLUSIONS: The addition of SVF cells did not appear to improve the retention of grafted fat in these patients. Skin tension may be an important factor influencing the absorption pattern of grafted fat. LEVEL OF EVIDENCE 4: Therapeutic.

Antifibrogenic effects of B16 melanoma-conditioned medium.

BACKGROUND: Some malignant cancers show high levels of local invasiveness by the secretion of soluble factors that can degrade adjacent tissues and suppress surrounding cell growth. We investigated the possibility of treating fibroproliferative scars based on these properties of malignant melanoma. MATERIAL AND METHODS: B16 melanoma-conditioned medium (B16 M-CM) was added to keloid fibroblasts (KFs), and proliferation, migration, and type I collagen production were measured. The cell cycle and signaling pathways were also analyzed. Proteins associated with cell proliferation were measured with Western blot analysis. Animal experiments using a rabbit ear model was performed to confirm the effect of B16 M-CM in vivo. RESULTS: B16 M-CM reduced proliferation, migration, and type I collagen production of KFs. This treatment also increased the number of cells in the subG1 phase and decreased phosphorylation levels of AKT, extracellular signal-regulated kinase1/2, cyclin D1, and c-Myc of KFs. Additionally, B16 M-CM reduced the thickness of rabbit ear scars in the rabbit ear model in vivo. CONCLUSIONS: B16 M-CM can suppress proliferation, migration, and type I collagen production of KFs. In addition, concentrated B16 M-CM reduced scar thickness in the rabbit ear model. The specific proteins involved should be identified in a future study.

Human Embryonic Stem Cell-Derived Endothelial Precursor Cell Conditioned Medium Reduces the Thickness of the Capsule Around Silicone Implants in Rats.

BACKGROUND: We postulated that the fibrotic capsule around a silicone implant could be induced by ischemic conditions, based on previous reports that hypoxia is an important microenvironmental factor in the development of tissue fibrosis. OBJECTIVE: This study aimed to determine the effect of human embryonic stem cell (hESC)-derived endothelial precursor cell (EPC) conditioned medium (CM), which has strong angiogenic potential, on the development of capsule around the silicone implant in a rat model. METHODS AND MATERIALS: Three groups had a mini-silicone implant with a smooth surface inserted. In 2 experimental groups, hESC-EPC CM was administered into the subcutaneous pocket either 1 or 2 times. After 2 months, the capsules were harvested and analyzed by histologic examination. RESULTS: There was a significant reduction in the thickness of the peri-implant capsules (P < 0.05) between the control and experimental groups. There is no tendency that hESC-EPC CM reduces inflammatory reaction in early postoperative periods. The experimental group showed increased angiogenesis compared to the control group (P < 0.05). CONCLUSIONS: Tissue hypoxia around the implant may be another cause for the peri-implant capsule. A preventive or therapeutic strategy to decrease capsular contracture by relieving the ischemic condition around the implant can be investigated in the future.

Hypoxia induces adipocyte differentiation of adipose-derived stem cells by triggering reactive oxygen species generation.

Generation of reactive oxygen species (ROS) by NADPH oxidase 4 (Nox4) induces the proliferation and migration of adipose-derived stem cells (ASCs). However, the functional role of mitochondrial ROS (mtROS) generation in ASCs is unknown. Therefore, we have investigated whether hypoxia induces the differentiation of ASCs via ROS generation. We also have tried to identify the cellular mechanisms of ROS generation underlying adipocyte differentiation. Hypoxia (2%) and ROS generators, such as antimycin and rotenone, induced adipocyte differentiation, which was attenuated by an ROS scavenger. Although Nox4 generates ROS and regulates proliferation of ASCs, Nox4 inhibition or Nox4 silencing did not inhibit adipocyte differentiation; indeed fluorescence intensity of mito-SOX increased in hypoxia, and treatment with mito-CP, a mtROS scavenger, significantly reduced hypoxia-induced adipocyte differentiation. Phosphorylation of Akt and mTOR was induced by hypoxia, while inhibition of these molecules prevented adipocyte differentiation. Thus hypoxia induces adipocyte differentiation by mtROS generation, and the PI3K/Akt/mTOR pathway is involved.

Under-through levator complex plication for correction of mild to moderate congenital ptosis.

PURPOSE: Congenital ptosis is most commonly of mild to moderate severity, with good to fair levator function. The appropriate procedures for this condition are levator resection or levator aponeurosis approaches. Among the latter, the levator plication method has received little attention because of a relatively high rate of ptosis recurrence secondary to weak adhesion. In this study, the authors described and retrospectively analyzed the results of an alternative plication technique, the "under-through levator complex plication" method. This method differs from conventional levator plication primarily by the posterior part of the levator complex being advanced to the tarsal plate to produce strong adhesion. METHODS: Five hundred and ten eyelids of 255 consecutive patients who underwent the under-through levator complex plication for congenital bilateral symmetrical ptosis were included in this study. Final outcomes were assessed at more than 5 months after surgery. RESULTS: The mean preoperative and postoperative marginal reflex distance 1 (MRD1) were 1.73 and 3.71 mm, respectively, and the mean amount of levator plication for every 1-mm increase in MRD1 was 3.31 mm. After the levator complex was plicated by the amount planned preoperatively, 65.1% of eyelids were at the target height. After subsequent intraoperative adjustments of the amount of plication, the overall surgery success rate was 94.5%. Recurrent ptosis due to relapse was not observed. CONCLUSIONS: The newly described surgical technique has overcome the limitations of conventional levator plication, by increasing the success rate and markedly reducing the relapse rate, while preserving the advantages of the conventional technique.

Transport distraction osteogenesis with recombinant human bone morphogenic protein-2 for large calvarial defect reconstruction.

BACKGROUND: Transport distraction osteogenesis (TDO) has been used in attempts to treat large calvarial defects but has, until now, lacked consistency and reliability. To achieve sufficient bone formation, the effect of TDO was compared to the effect of TDO combined with recombinant human bone morphogenic protein-2 (rhBMP-2). METHODS: Fourteen dogs were divided into 2 groups; 6 animals in the control group received TDO only, and 8 received TDO combined with rhBMP-2. A calvarial defect 33 × 35 mm in size was generated, and the drug-delivering internal distractor was applied. After a 5-day latency period, distraction with rhBMP-2 at 10 µg/day was initiated at a rate of 2 mm/day. This was followed by a consolidation period of 3 months, after which areas of osteogenesis and strength were measured and histologic examinations were conducted. RESULTS: The average area of osteogenesis was higher in the experimental group (P < 0.01). Regenerated bone of the experimental group showed increased strength (P < 0.05). Histological examination showed typical mature bone in the experimental group. Prominent osteoblastic rimming was observed in the bone marrow of the experimental group. CONCLUSIONS: TDO with an internal distraction device delivering rhBMP-2 can enhance bone regeneration of large calvarial defects in a dog model. These results suggest the potential for human clinical testing of TDO combined with rhBMP-2.