Zinc-Alpha-2-Glycoprotein Peptide Downregulates Type I and III Collagen Expression via Suppression of TGF-ß and p-Smad 2/3 Pathway in Keloid Fibroblasts and Rat Incisional Model.

BACKGROUND: Keloids and hypertrophic scars result from abnormal collagen accumulation and the inhibition of its degradation. Although the pathogenesis remains unclear, excessive accumulation of the extracellular matrix (ECM) is believed to be associated with the TGF-ß/SMAD pathway. Zinc-alpha-2-glycoprotein (ZAG) inhibits TGF-ß-mediated epithelial-to-mesenchymal transdifferentiation and impacts skin barrier functions. In this study, we investigated the potential of a small ZAG-derived peptide against hypertrophic scars and keloids. METHODS: The study examined cell proliferation and mRNA expression of collagen types I and III in human dermal fibroblast (HDF) cell lines and keloid-derived fibroblasts (KF) following ZAG peptide treatment. A rat incisional wound model was used to evaluate the effect of ZAG peptide in scar tissue. RESULTS: Significantly lower mRNA levels of collagen types I and III were observed in ZAG-treated fibroblasts, whereas matrix metalloproteinase (MMP)-1 and MMP-3 mRNA levels were significantly increased in HDFs and KFs. Furthermore, ZAG peptide significantly reduced protein expression of collagen type I and III, TGF-ß1, and p-Smad2/3 complex in KFs. Rat incisional scar models treated with ZAG peptide presented narrower scar areas and reduced immature collagen deposition, along with decreased expression of collagen type I, α-SMA, and p-Smad2/3. CONCLUSION: ZAG peptide effectively suppresses the TGF-ß and p-Smad2/3 pathway and inhibits excessive cell proliferation during scar formation, suggesting its potential therapeutic implications against keloids and hypertrophic scars.

Reaching New Heights: A Comprehensive Study of Hand Transplantations in Korea after Institutionalization of Hand Transplantation Law.

PURPOSE: With the revision of the Organ and Transplantation Act in 2018, the hand has become legal as an area of transplantable organs in Korea. In January 2021, the first hand allotransplantation since legalization was successfully performed, and we have performed a total of three successful hand transplantation since then. By comparing and incorporating our experiences, this study aimed to provide a comprehensive reconstructive solution for hand amputation in Korea. MATERIALS AND METHODS: Recipients were selected through a structured preoperative evaluation, and hand transplantations were performed at the distal forearm level. Postoperatively, patients were treated with three-drug immunosuppressive regimen, and functional outcomes were monitored. RESULTS: The hand transplantations were performed without intraoperative complications. All patients had partial skin necrosis and underwent additional surgical procedures in 2 months after transplantation. After additional operations, no further severe complications were observed. Also, patients developed acute rejection within 3 months of surgery, but all resolved within 2 weeks after steroid pulse therapy. Motor and sensory function improved dramatically, and patients were very satisfied with the appearance and function of their transplanted hands. CONCLUSION: Hand transplantation is a viable reconstructive option, and patients have shown positive functional and psychological outcomes. Although this study has limitations, such as the small number of patients and short follow-up period, we should focus on continued recovery of hand function, and be careful not to develop side effects from immunosuppressive drugs. Through the present study, we will continue to strive for a bright future regarding hand transplantation in Korea.

Contrast-enhanced ultrasonography as an adjunctive method to ICG lymphography for functional lymphaticovenous anastomosis.

BACKGROUND AND OBJECTIVES: Indocyanine green (ICG) lymphography is the reference standard for evaluating lymphedema stage and identifying lymphatic vessels. However, the penetration depth was limited to 1-2 cm from the skin surface. This prospective study compares clinical outcomes following lymphaticovenous anastomoses (LVA) in patients with upper and lower limb lymphedema using contrast-enhanced ultrasonography (CEUS) with ICG as a preoperative imaging modality. METHODS: Under general anesthesia, Sonazoid® was injected subcutaneously to visualize functional lymphatic channels via CEUS. We analyzed the changes in limb circumference and inter-limb ratio (ILR) using bioimpedance to measure electrical resistance between the CEUS plus ICG group and the ICG-only group to see the effect of CEUS-assisted LVA. RESULTS: No significant demographic differences existed between the two groups (CEUS plus ICG group vs. ICG-only group). The ILR decrease of the Z1 value measured using bioimpedance was statistically significant (p = 0.042 for the upper limb, p = 0.002 for the lower limb)- CONCLUSIONS: CEUS allowed us to identify deep-lying, functional, and large lymphatic channels. In conclusion, the combination of CEUS and ICG for identifying lymphatic channels has the potential to lead to a more functional lymphovenous anastomosis.

A bipedicled keystone perforator island flap: Pedicle division technique with enhanced advancement potential for chronic wound coverage.

Since the first description of the keystone perforator island flap (KPIF) in 2003, several modifications have been suggested to enhance its coverage ability. However, locoregional flaps have limited its use in chronic wounds due to decreased elasticity around the defect. We investigated the use of a bipedicled KPIF (bKPIF), which covers a defect while completely elevating the median part of the flap from the fascia. A retrospective chart review of 20 consecutive patients who underwent classical type I KPIF (n = 10) or bKPIF (n = 10) reconstruction from June 2020 to December 2022 was performed. Baseline characteristics, indications, operative details, healing time, and complications were analyzed and compared between the two groups. The average defect size was 30 cm2 in type I KPIF and 36.6 cm2 in bKPIF, and an average flap size of 86.5 cm2 was covered in type I KPIF, larger than bKPIF at 73.8 cm2. The flap/defect ratio was significantly lower in the bKPIF group (p < 0.02), with an average of only 55% pedicular area. The average advancement distance in the bKPIF group was 1.85 cm (standard deviation 0.78) greater than that in the type 1 KPIF group. There was no significant difference between the groups in terms of operation time, complete healing time, and complications. All ten bKPIFs were successful without any flap necrosis. Even though the mean pedicular area in the bKPIF group was nearly half compared with that in the type I KPIF group, it was sufficient to perfuse the entire flap without any major complications. This novel technique using bKPIF has potential clinical relevance, as evidenced by the enhanced ability to cover chronic defects with severe scarring. Lateralizing the hotspots to the bilateral corners of the flap is the mechanism that facilitates this potential.

Silibinin Downregulates Types I and III Collagen Expression via Suppression of the mTOR Signaling Pathway.

Keloid scars are fibro-proliferative conditions characterized by abnormal fibroblast proliferation and excessive extracellular matrix deposition. The mammalian target of the rapamycin (mTOR) pathway has emerged as a potential therapeutic target in keloid disease. Silibinin, a natural flavonoid isolated from the seeds and fruits of the milk thistle, is known to inhibit the mTOR signaling pathway in human cervical and hepatoma cancer cells. However, the mechanisms underlying this inhibitory effect are not fully understood. This in vitro study investigated the effects of silibinin on collagen expression in normal human dermal and keloid-derived fibroblasts. We evaluated the effects of silibinin on the expressions of collagen types I and III and assessed its effects on the suppression of the mTOR signaling pathway. Our findings confirmed elevated mTOR phosphorylation levels in keloid scars compared to normal tissue specimens. Silibinin treatment significantly reduced collagen I and III expressions in normal human dermal and keloid-derived fibroblasts. These effects were accompanied by the suppression of the mTOR signaling pathway. Our findings suggest the potential of silibinin as a promising therapeutic agent for preventing and treating keloid scars. Further studies are warranted to explore the clinical application of silibinin in scar management.

One Year Experience of the Hand Allotransplantation First Performed after Korea Organ Transplantation Act (KOTA) Amendment.

The revision of the Korea Organ Transplantation Act (KOTA) in 2018 included hand/arm among the organs that can be transplanted. The first hand transplantation since the revision of KOTA took place in January 2021. A 62-year-old male patient experienced hand amputation on July 13, 2018, by a catapult injury. The patient first visited our institute 3 months after the injury. After serial interviews and an overall evaluation, the patient was registered on the hand transplantation waiting list in January 2020. On January 9, 2021, the patient underwent hand transplantation at the right distal forearm level. The total operation time was 17 hours 15 minutes, and the cold ischemic time was 4 hours 9 minutes. Postoperative immunosuppression was administered based on the protocol used for kidney transplantation. Two acute rejection episodes occurred, on postoperative days 33 and 41. Both rejection episodes were reversible with rescue therapy of a higher tacrolimus trough level, steroid pulse therapy, and topical immunosuppressants. Controlled passive range of motion exercise was started on postoperative day 10. Dynamic splint was applied on postoperative day 18. At 1 year, graft maintenance and functional improvement were satisfactory, and the patient showed a Disabilities of Arm, Shoulder and Hand score of 25.8. We successfully performed the first hand transplantation surgery under the KOTA amendment. It came from the organic and effective cooperation of plastic, orthopaedic, and transplantation departments and we believe it will guarantee the future ongoing success.

Breast Tissue Reconstruction Using Polycaprolactone Ball Scaffolds in a Partial Mastectomy Pig Model.

BACKGROUND: Breast cancer patients suffer from lowered quality of life (QoL) after surgery. Breast conservancy surgery (BCS) such as partial mastectomy is being practiced and studied as an alternative to solve this problem. This study confirmed breast tissue reconstruction in a pig model by fabricating a 3-dimensional (3D) printed Polycaprolactone spherical scaffold (PCL ball) to fit the tissue resected after partial mastectomy. METHODS: A 3D printed Polycaprolactone spherical scaffold with a structure that can help adipose tissue regeneration was produced using computer-aided design (CAD). A physical property test was conducted for optimization. In order to enhance biocompatibility, collagen coating was applied and a comparative study was conducted for 3 months in a partial mastectomy pig model. RESULTS: In order to identify adipose tissue and fibroglandular tissue, which mainly constitute breast tissue, the degree of adipose tissue and collagen regeneration was confirmed in a pig model after 3 months. As a result, it was confirmed that a lot of adipose tissue was regenerated in the PCL ball, whereas more collagen was regenerated in the collagen-coated Polycaprolactone spherical scaffold (PCL-COL ball). In addition, as a result of confirming the expression levels of TNF-a and IL-6, it was confirmed that PCL ball showed higher levels than PCL-COL ball. CONCLUSION: Through this study, we were able to confirm the regeneration of adipose tissue through a 3-dimensional structure in a pig model. Studies were conducted on medium and large-sized animal models for the final purpose of clinical use and reconstruction of human breast tissue, and the possibility was confirmed.

Prediction of Enophthalmos in Medial Orbital Wall Fracture: Suggested Coordinate Plane for Making Surgical Decisions.

BACKGROUND: Enophthalmos is one of the most distressing complications of blowout orbital fractures. Although several studies have been conducted on the topic of indications of early surgical correction, none have been performed using a set of measurable parameters. METHODS: The study quantitatively examined orbital fracture areas (OFA) and volumes (OFV) retrospectively of 242 patients with isolated medial orbital wall fractures that were treated conservatively during a 12-year period (from 2009 to 2021). Three plastic surgeons measured enophthalmos >6 months after trauma. The correlations between parameters and enophthalmos in the study cohort were analyzed. In addition, patients treated operatively, and nonoperatively were compared with assess the suitability of the predictive model. RESULTS: Significant correlations were observed between several parameters and late enophthalmos. Total 2.59 cm 2 of OFA (ie, OFA >2.59 cm 2 ) or 1.45 cm 3 of OFV (ie, OFV >1.45 cm 3 ) corresponds to 2 mm of enophthalmos. Multiple regression analysis revealed the following coefficients: -0.208 is a constant ( P <0.001), with 0.695 and 0.372 for OFA and OFV, respectively ( P <0.001 for both OFA and OFV). CONCLUSIONS: The study shows that enophthalmos can be more accurately predicted when OFA and OFV are simultaneously considered in patients with isolated medial wall fractures. Finally, an algorithm and a "blowout fracture coordinate plane" was proposed to aid treatment decision-making in isolated medial wall fractures.

Association between Immediate Breast Reconstruction and the Development of Breast Cancer-Related Lymphedema.

BACKGROUND: With the increasing number of patients undergoing immediate breast reconstruction after mastectomy, the impact of immediate breast reconstruction on the risk of breast cancer-related lymphedema has become an emerging area of interest. This study aimed to identify the association between immediate breast reconstruction and postoperative lymphedema. METHODS: A retrospective cohort study was conducted from 2006 to 2016 with 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without immediate breast reconstruction. After excluding patients with synchronous contralateral breast cancer, lymphedema before mastectomy, history of procedures performed in the axillary region, and follow-up data of less than 1 year, the cumulative incidence of lymphedema after immediate breast reconstruction and after no reconstruction was calculated and compared using multivariate Cox regression analysis. RESULTS: Overall, 5497 patients (mean age, 51.7 years) were included, and 630 developed lymphedema. The 5-year cumulative incidence rate of lymphedema was significantly reduced in patients who underwent immediate breast reconstruction versus control patients (9.6% versus 12.2%; P = 0.02). In the multivariate analysis, immediate breast reconstruction status (hazard ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = 0.042) was an independent predictor for lymphedema. Similar significant associations were observed in the subgroup analyses of patients with a body mass index less than 30 kg/m2 (P = 0.024), in those with fewer than 10 dissected lymph nodes (P = 0.042), or in those with adjuvant radiotherapy (P = 0.048). CONCLUSIONS: Immediate breast reconstruction was associated with a reduced risk of lymphedema. These results may be used for predicting the development of lymphedema following breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Prophylactic intraoperative wound irrigation with antibiotic solution for the prevention of surgical incisional wound infections: Systematic literature review and meta-analysis.

BACKGROUND: There is no consensus on the use of prophylactic intraoperative wound irrigation (pIOWI) for reducing surgical-site infections (SSIs), particularly surgical incisional wounds, and opinions are divided on whether an antibiotic should be mixed with the solution used for incisional wound irrigation. No large, reliable cohort studies or meta-analyses of pIOWI for surgical incisional wounds were found in PubMed or Embase. METHODS: We searched the PubMed, Embase, Cochrane Library, Insight, Scopus, and Web of Science databases for primary research articles investigating the relevance of pIOWI with antibiotics for SSIs. The initial search was limited to human studies published before January 2022, which were indexed as randomized controlled trials (RCTs); clinical trials; or observational, cross-sectional, or cohort studies. We used R statistical software version 4.1.2 for this meta-analysis. RESULTS: The odds ratio of the random-effects model was 0.519 [95% confidence interval (CI); 0.311, 0.864, P-value < 0.0117], indicating that the intervention had a statistically significant effect on surgical complications. To examine the heterogeneity of the entire study, we performed statistical analysis (τ2 (tau square) = 0.4175 [0.0732; 2.8178]; τ (tau) = 0.6461 [0.2706; 1.6786]; Higgins' I2 = 64.0% [34.8%; 80.1%]; and H = 1.67 [1.24; 2.24]). CONCLUSIONS: Many studies have shown that inclusion of antibiotics in the irrigation solution significantly lowers the rate of soft-tissue-related SSIs, but those studies contain both heterogeneity and many biases. Further large, prospective RCTs only limited to incisional SSIs and excluding other variables and biases in the field of plastic surgery are needed.

Breast Tissue Restoration after the Partial Mastectomy Using Polycaprolactone Scaffold.

As breast conserving surgery increases in the surgical treatment of breast cancer, partial mastectomy is also increasing. Polycaprolactone (PCL) is a polymer that is used as an artifact in various parts of the human body based on the biocompatibility and mechanical properties of PCL. Here, we hypothesized that a PCL scaffold can be utilized for the restoration of breast tissue after a partial mastectomy. To demonstrate the hypothesis, a PCL scaffold was fabricated by 3D printing and three types of spherical PCL scaffold including PCL scaffold, PCL scaffold with collagen, and the PCL scaffold with breast tissue fragment were implanted in the rat breast defect model. After 6 months of implantation, the restoration of breast tissue was observed in the PCL scaffold and the expression of collagen in the PCL scaffold with collagen was seen. The expression of TNF-α was significantly increased in the PCL scaffold, but the expression of IL-6 showed no significant difference in all groups. Through this, it showed the possibility of using it as a method to conveniently repair tissue defects after partial mastectomy of the human body.

Cranioplasty and temporal hollowing correction with a three-dimensional printed bioresorbable mesh and double vertical suture anchor muscle sling: a case report.

Postoperative temporal hollowing is a common complication of craniotomy. Damage and repositioning of the temporalis muscle can lead to a depression in the temporal side of the skull with inferior bulging, worsening aesthetic outcomes. We report a case of cranioplasty with three-dimensional (3D) printed mesh involving an additional correction using a temporalis muscle sling to help address this problem. A 3D-printed bioabsorbable mesh was prepared based on preoperative facial computed tomography, and was fixed to the hollowed area for tissue augmentation. The temporalis muscle was elevated and fanned out to its original position, and a sling was attached to a screw that was fixed to the mesh. For reinforcement, an additional sling was attached to another screw fixed to the mesh 2-3 cm vertically above the first screw. Aesthetic results were confirmed immediately after surgery and later during outpatient follow-up. Both depression and lateral bulging were resolved, and there was no delayed drooping of the temporalis muscle on 6-month follow-up. There were no complications, and the patient was satisfied with the appearance. This is a simple yet effective technique with a low risk of complications, and should be considered for postoperative temporal hollowing patients, especially those with severe lateral bulging.

Methodology in Conventional Head and Neck Reconstruction Following Robotic Cancer Surgery: A Bridgehead Robotic Head and Neck Reconstruction.

PURPOSE: Robotic head and neck surgery is widespread nowadays. However, in the reconstruction field, the use of robotic operations is not. This article aimed to examine methodologies for conventional head and neck reconstruction after robotic tumor surgery in an effort to obtain further options for future reconstruction manipulations. MATERIALS AND METHODS: A retrospective review of all patients who received head and neck robot surgery and conventional reconstructive surgery between October 2016 and September 2021. RESULTS: In total, 53 cases were performed. 67.9% of the tumors were greater than 4 cm. Regarding defect size, 47.2% of the lesions were greater than 8 cm. In terms of TNM stage, stage 3 disease was recorded in 26.4% and stage 4 in 52.8%. To make a deep and narrow field wider, we changed the patient's posture in pre-op field, additional dissection was done. We used radial forearm flap mostly (62.2%). CONCLUSION: Conventional head and neck reconstruction after robotic ENT cancer surgery is possible. One key step is to secure additional space in the deep and narrow space left after robotic surgery. For this, we opted for a radial forearm flap mostly. This can be performed as a bridgehead to perform robotic head and neck reconstruction.

Effect of Mortalin on Scar Formation in Human Dermal Fibroblasts and a Rat Incisional Scar Model.

Wound healing is a complicated cascading process; disequilibrium among reparative processes leads to the formation of pathologic scars. Herein, we explored the role of mortalin in scar formation and its association with the interleukin-1α receptor using in vitro and in vivo models. To investigate the effects of mortalin, we performed an MTT cell viability assay, qRT-PCR, and Western blot analyses, in addition to immunofluorescence and immunoprecipitation studies using cultured fibroblasts. A rat incisional wound model was used to evaluate the effect of a mortalin-specific shRNA (dE1-RGD/GFP/shMot) Ad vector in scar tissue. In vitro, the mortalin-treated human dermal fibroblast displayed a significant increase in proliferation of type I collagen, α-smooth muscle actin, transforming growth factor-ß, phospho-Smad2/3-complex, and NF-κB levels. Immunofluorescence staining revealed markedly increased mortalin and interleukin-1α receptor protein in keloid tissue compared to those in normal tissue, suggesting that the association between mortalin and IL-1α receptor was responsible for the fibrogenic effect. In vivo, mortalin-specific shRNA-expressing Ad vectors significantly decreased the scar size and type-I-collagen, α-SMA, and phospho-Smad2/3-complex expression in rat incisional scar tissue. Thus, dE1-RGD/GEP/shMot can inhibit the TGF-ß/α-SMA axis and NF-κB signal pathways in scar formation, and blocking endogenous mortalin could be a potential therapeutic target for keloids.

Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers.

INTRODUCTION: Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique. MATERIALS AND METHODS: From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated. RESULTS: The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m2; p = 0.183). CONCLUSION: The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.

The effect of early arm exercise on drainage volume after total mastectomy and tissue expander insertion in breast cancer patients: a prospective study.

BACKGROUND: In prosthesis-based breast reconstruction patients, the drain tends to be kept in place longer than in patients who undergo only mastectomy. Postoperative arm exercise also increases the drainage volume. However, to preserve shoulder function, early exercise is recommended. In this study, we investigated the effect of early exercise on the total drainage volume and drain duration in these patients. METHODS: We designed a prospective randomized trial involving 56 patients who underwent immediate breast reconstruction following mastectomy using tissue expanders. In each group, the patients were randomized either to perform early arm exercises using specific shoulder movement guidelines 2 days after surgery or to restrict arm movement above the shoulder height until drain removal. The drain duration and the total amount of drainage were the primary endpoints. RESULTS: There were no significant differences in age, height, weight, body mass index, or mastectomy specimen weight between the two groups. The total amount of drainage was 1,497 mL in the early exercise group and 1,336 mL in the exercise restriction group. The duration until complete removal of the drains was 19.71 days in the early exercise group and 17.11 days in the exercise restriction group. CONCLUSIONS: Exercise restriction after breast reconstruction did not lead to a significant difference in the drainage volume or the average time until drain removal. Thus, early exercise is recommended for improved shoulder mobility postoperatively. More long-term studies are needed to determine the effect of early exercise on shoulder mobility in prosthesis-based breast reconstruction patients.

Outcomes of grafted skin on the dorsum of the foot after car-tire friction injuries.

BACKGROUND: A car-tire friction injury on the dorsum of a child's foot often results in hypertrophic scarring of the wound margins. This study describes the clinical appearance of the injured areas and surgical complications that occurred during the follow-up period in a series of children with car-tire friction injuries who were treated with split-thickness skin grafts (STSGs). We describe the clinical features that we believe need to be highlighted when initially treating car-tire injuries in children. METHODS: From May 2003 to June 2016, our retrospective study included 15 patients with car-tire injuries on the dorsum of the foot who were treated with surgical excision and STSG to cover the wound. RESULTS: A total of 15 patients with car-tire injuries were treated. The average age was 6.26 years old. The average injury grade was 3.26. Two patients were treated using delayed repair, and 13 patients received STSG for initial management. Four patients experienced no complications, while 11 patients had hypertrophic scars and/or scar contracture after surgery. CONCLUSIONS: A car-tire friction injury on the dorsum of a child's foot often results in hypertrophic scar formation or scar contracture even if proper management is undertaken. Since the occurrence of these complications in childhood can lead to a secondary deformity, it is important to properly treat car-tire friction wounds, inform patients and caregivers about potential complications, and ensure regular follow-up evaluations over a 12-month period following the initial surgery.

Anterior skull base reconstruction using an anterolateral thigh free flap.

BACKGROUND: Galeal or temporalis muscle flaps have been traditionally used to reconstruct skull base defects after tumor removal. Unfortunately, these flaps do not provide sufficient vascularized tissue for a dural seal in extensive defects. This study describes the successful coverage of large skull base defects using anterolateral thigh (ALT) free flaps. METHODS: This retrospective study included five patients who underwent skull base surgery between June 2018 and June 2021. Reconstruction was performed using an ALT free flap to cover defects that included the intracranial space and extended to the frontal sinus and cribriform plate. RESULTS: There were no major complications, such as ascending infections or cerebrospinal leakage. Postoperative magnetic resonance imaging showed that the flaps were well-maintained in all patients. CONCLUSION: Successful reconstruction was performed using ALT free flaps for large anterior skull base defects. In conclusion, the ALT free flap is an effective option for preventing communication between the nasal cavity and the intracranial space.

Synergistic Effect of 300 µm Needle-Depth Fractional Microneedling Radiofrequency on the Treatment of Senescence-Induced Aging Hyperpigmentation of the Skin.

Aging-associated dermatological pigmentary diseases are associated with accumulation of senescence cells and the disruption of basement membrane due to chronic ultraviolet radiation (UVR) exposure. Our study is on the synergistic effect of the novel 300 µm needle-depth fractional microneedling radiofrequency (FMR) treatment and conventional Q-switched ND:YAG laser on aging-associated hyperpigmentation of the skin. The prospective controlled clinical trial of 25 Asian women revealed significantly higher improvements not only on wrinkles, but also on hyperpigmentation. Additional ex vivo study revealed significant reduction of pro-melanogenic markers as well as senescent keratinocytes, while increased expression of collagen type IV on the epidermal basement membrane, after additional FMR treatment on UV-irradiated human tissues. These results demonstrate that 300 µm needle-depth FMR might effectively remove senescent keratinocytes that secrete pro-melanogenic markers, and repair disrupted basement membrane, therefore preventing constant hyperpigmentation of the aged skin.