Postoperative electron beam irradiation to prevent recurrence of refractory subungual exostosis: a case report.

Background: Subungual exostosis is a type of heterotopic ossification, which often has unclear margins. Therefore, marginal resection may cause recurrence and wide resection is sometimes required to achieve a complete cure. However, wide resection may cause postoperative nail deformity and revision of this deformity is generally difficult. The primary treatment of subungual exostosis is surgical treatment, and there have been no comprehensive reports on the efficacy of adjunctive treatments. Although postoperative electron beam irradiation has been successfully used after heterotopic ossification excision to prevent recurrence, there are no reports on the use of this procedure following subungual exostosis resection. Case Description: Herein, we report a case of refractory subungual exostosis that developed as a result of chronic irritation and inflammation caused by an ingrown nail and recurred after initial resection. We performed marginal resection of the lesion to preserve the nail matrix and nail bed as possible, a two-stage skin grafting procedure, and electron-beam irradiation to prevent recurrence. Conclusions: Excellent results were achieved both in terms of complete cure and cosmetic appearance, suggesting that electron-beam irradiation following refractory subungual exostosis excision may help prevent its recurrence. We expect a further study including many cases of subungual exostosis treated with postoperative electron-beam irradiation to be conducted.

Flap Monitoring Using Interstitial Fluid Glucose Measurements.

Background: Various flap monitoring techniques have been used in the early detection of anastomotic thrombus; however, the use of automatic and continuous monitoring methods is presently uncommon. The purpose of this study was to investigate trends in interstitial fluid glucose concentration (IFG) in flap monitoring by measuring IFG automatically and continuously. Methods: Nine patients underwent unilateral breast reconstruction using a transverse rectus abdominis myocutaneous flap with vascular anastomosis. Two IFG measuring devices were attached to each patient. One device was attached to the flap (flap IFG) and the other to the healthy breast (control IFG). In each case, flap IFG, control IFG, and IFG ratio (flap IFG/control IFG) were recorded in the initial 72 h post-surgery (first half) and also in the subsequent 72 h (second half). In all of the cases, the mean values recorded in the first half and those in the second half were compared. Results: All flaps survived. The flap IFG didn't fall below 40 mg/dL in the first half. The minimum flap IFG and IFG ratio were 42 mg/dL and 0.55 in the first half. The flap IFG was significantly higher in the first half than in the second half in all cases, and the IFG ratio was similar in 8 cases. Furthermore, mean flap IFG and mean IFG ratio in all cases in the first half were significantly higher than in the second half. Conclusions: IFG measurements may complement conventional flap monitoring, particularly in the early postoperative period.

Historique: Diverses techniques de surveillance du lambeau sont utilisées pour favoriser le dépistage précoce du thrombus anastomotique, mais peu de méthodes de surveillance automatique et continue sont utilisées en ce moment. La présente étude visait à examiner les tendances du glucose interstitiel (GI) lors de la surveillance du lambeau par une mesure automatique et continue. Méthodologie: Neuf patientes ont subi une reconstruction mammaire unilatérale au moyen d'un lambeau myocutané du grand droit transverse avec anastomose vasculaire. Chaque patiente était dotée de deux dispositifs de mesure du GI. L'un d'eux était fixé au lambeau (GI du lambeau) et l'autre au sein en bonne santé (GI témoin). Dans chaque cas, les chercheurs ont enregistré le GI du lambeau, le GI témoin et le ratio du GI (GI du lambeau/GI témoin) pendant les 72 premières heures suivant l'opération (première moitié), puis pendant les 72 heures suivantes (deuxième moitié). Dans tous les cas, les chercheurs ont comparé les valeurs moyennes enregistrées pendant la première moitié à celles enregistrées pendant la deuxième moitié. Résultats: Tous les lambeaux ont survécu. Le GI du lambeau n'a pas chuté sous 40 mg/dl pendant la première moitié. Le ratio minimal du GI était de 42 mg/dl et 0,55 pendant la première moitié. Dans tous les cas, le GI du lambeau était beaucoup plus élevé pendant la première moitié que pendant la deuxième moitié, et le ratio du GI était semblable dans huit cas. De plus, dans tous les cas, le GI moyen du lambeau et le ratio moyen du GI était beaucoup plus élevé pendant la première moitié que la deuxième. Conclusions: Les mesures de GI peuvent compléter la surveillance habituelle du lambeau, notamment au début de la période postopératoire.

Pediatric-acquired Idiopathic Blepharoptosis with the Eyelids Being Habitually Opened Using the Frontalis Muscle.

Pediatric-acquired idiopathic blepharoptosis is rare, and no studies on surgery for the disease have been reported. We present a case of the disease with an atypical postoperative course. The patient initially underwent levator aponeurosis advancement. However, she cannot sufficiently open the affected eyelid without conscious effort and has developed a habit of opening the eyelids using the frontalis muscle. She underwent secondary frontalis suspension with the fascia latae, and then she was able to open her eyelids well all the time. When the disease duration in pediatric-acquired blepharoptosis is long, the habit of opening the eyelids using the frontalis muscle may be difficult to break. In such cases, we believe that frontalis suspension is the best operation.

False-positive diagnoses of damaged breast implants on imaging: a report of two cases.

Background: Silicone breast implants (SBIs), used in breast reconstruction, are durable and resistant to breakage and internal gel leakage. However, regular imaging examinations are crucial, as symptoms may not be apparent even if the implant ruptures. There are several known imaging findings that suggest SBI failure. Although artifacts such as moisture and air bubbles or substances similar to the gel extending outside the shell may appear on imaging, no reports have demonstrated false-positive diagnoses of damaged SBIs in detail. Hence, we present two cases in which failure was suspected based on the imaging results but not confirmed. Case Description: In case 1, at the 4-year follow-up after implant-based breast reconstruction, ultrasonography revealed a stepladder sign, and magnetic resonance imaging (MRI) revealed the salad oil sign. Although SBI failure was suggested, intraoperative examination revealed only a small amount of fluid retention within the capsule and no SBI fractures. Consequently, the imaging results were proved to be artifacts. In case 2, at the 7-year follow-up after implant-based breast reconstruction, ultrasonography revealed a subcapsular line sign, and MRI confirmed a keyhole sign. Although SBI failure was suggested, intraoperative examination revealed no implant fractures. Hematogenous serous effusion was found within the capsule, and blood clots and a large amount of fibrinous mass were found deposited at the bottom of the capsule. These findings caused false-positive diagnoses on imaging. Conclusions: In cases of suspected fractures, patients may opt for either observation or surgical removal, or replacement of the implant. When choosing the latter, it is important to inform patients of the possibility of an unbroken implant.

Reconstructive surgery for severe breast asymmetry post-paediatric cardiovascular operation by anterolateral thoracotomy.

Breast maldevelopment is a troublesome long-term complication of anterolateral thoracotomies, and several cases of this event have been reported. However, breast reconstruction in such cases has not yet been reported in detail, and solutions for managing this event remain unexplained. Herein, we present a case of breast maldevelopment after anterolateral thoracotomy, in which symmetrical breasts were successfully obtained by breast reconstruction based on autologous tissue transfer. The surgical approach prior to pleurotomy in anterolateral thoracotomy, particularly when performed on female infant patients, must be modified to prevent postoperative breast malformation.

A Novel Dissection Method of the Internal Mammary (Thoracic) Artery: Anastomotic Vessel of the DIEP Flap.

Deep inferior epigastric perforator flaps are commonly used for breast reconstruction using autologous tissue. For such free flaps, the internal mammary artery provides stable blood flow as the recipient for anastomosis. We report a novel dissection method of the internal mammary artery. First, the perichondrium and costal cartilage of the sternocostal joint are dissected with electrocautery. Then, the incision on the perichondrium is extended along the cephalic and caudal ends. Next, this C-shaped superficial layer of perichondrium is elevated from the cartilage. The cartilage is incompletely fractured with electrocautery, with the deep layer of perichondrium intact. Then, the cartilage is completely fractured by leverage and removed. The remaining deep layer of perichondrium is incised at the costochondral junction and shifted aside, revealing the internal mammary artery. The preserved perichondrium creates a rabbet joint to protect the anastomosed artery. This method not only enables a more reliable, safer dissection of the internal mammary artery, but also allows reusage of the perichondrium as underlayment in the setting of anastomosis, and coverage for the incised rib edge, protecting the anastomosed vessels.

A Case of Refractory Heel Ulcer Complicated by Moderate Osteomyelitis and Cellulitis Successfully Treated with Rheocarna.

Revascularization surgery was first considered for the treatment of ulcers in patients with critical limb ischemia (CLI). However, it may not be indicated for patients with severe infections or peripheral vascular occlusions. Although blood purification therapy is adjuvant therapy for such patients, it is not yet widely used due to insurance coverage. We report a case of a refractory heel ulcer with moderate osteomyelitis and cellulitis that was not amenable to revascularization. Treatment with the adsorptive blood purifier rheocarna® (Kaneka Corporation; Osaka, Japan) resulted in complete epithelialization of the ulcer and control of inflammation. Although this case required careful follow-up, we believe rheocarna might be a promising treatment option for patients with CLI who do not respond to revascularization. Rheocarna could improve peripheral blood flow and control inflammation by improving antibiotic drug delivery.

Successful management of a mediastinum abscess with sternum destruction caused by MSSA bloodstream infection.

BACKGROUND: Multiple deep organ abscesses associated with Staphylococcus aureus bloodstream infection (SAB) have a high mortality rate, requiring rapid removal or drainage of infective foci with long-term appropriate antimicrobial therapy. Cases in which infective foci cannot be completely removed are challenging for their management. CASE PRESENTATION: A 77-year-old man developed multiple deep organ abscesses associated with SAB. The left anterior chest subcutaneous abscess continued into the right anterior mediastinum and had extensively destroyed the sternum. Necrotizing fasciitis was observed in the bilateral feet. The anterior mediastinum abscess was drained percutaneously, and the chest wall abscess was incised cautiously without causing an external pneumothorax. On the next day, right-sided pyothorax had developed, requiring pleural drainage. On the third day, debridement of anterior chest wall abscess followed by concurrent thoracoscopic pleural curettage and debridement of bilateral feet were performed. Thorough sternal debridement was not performed, considering the risk of respiratory failure due to the sternal defects. On the 24th day, sternum debridement and incisional drainage of sciatic rectus fossa abscess, which had been present since the time of admission, were performed to control persistent infection. The caudal half of the sternal body was resected, leaving the costal cartilage attachments. The general condition further improved without postoperative respiratory failure after the second surgery, leading to a transfer to the general ward on the 43rd day. CONCLUSIONS: We successfully treated the severe multiple deep organ abscesses, including a mediastinum abscess with sternum destruction, by repeated removal of the infective foci while avoiding respiratory failure due to excessive debridement of the anterior chest wall, including the sternum.

EGFR-mediated epidermal stem cell motility drives skin regeneration through COL17A1 proteolysis.

Skin regenerative capacity declines with age, but the underlying mechanisms are largely unknown. Here we demonstrate a functional link between epidermal growth factor receptor (EGFR) signaling and type XVII collagen (COL17A1) proteolysis on age-associated alteration of keratinocyte stem cell dynamics in skin regeneration. Live-imaging and computer simulation experiments predicted that human keratinocyte stem cell motility is coupled with self-renewal and epidermal regeneration. Receptor tyrosine kinase array identified the age-associated decline of EGFR signaling in mouse skin wound healing. Culture experiments proved that EGFR activation drives human keratinocyte stem cell motility with increase of COL17A1 by inhibiting its proteolysis through the secretion of tissue inhibitor of metalloproteinases 1 (TIMP1). Intriguingly, COL17A1 directly regulated keratinocyte stem cell motility and collective cell migration by coordinating actin and keratin filament networks. We conclude that EGFR-COL17A1 axis-mediated keratinocyte stem cell motility drives epidermal regeneration, which provides a novel therapeutic approach for age-associated impaired skin regeneration.

Complications and Surgical Treatment of Breast Augmentation Using Autologous Fat Transfer and Fillers.

BACKGROUND: Breast augmentation with autologous fat grafting or hyaluronic acid injection requires minimal loss of healthy tissue. With an increasing trend of breast augmentation with these fillers, accompanying complications have also increased. Patients with complications often complain of induration, cyst formation, calcification, and infection, which require surgical treatment. We will discuss these complications and their surgical treatment through our experience of cases. METHODS: This retrospective study included 20 patients who all required surgical treatment due to breast augmentation complications such as induration, cyst formation, calcification, and infection, and who visited us between May 2007 and June 2018. The patients' ages ranged from 25 to 63, and the mean age was 39.9. The material used for breast augmentation was fat for 17 cases, and hyaluronic acid, paraffin, and silicon for one case each. The results were analyzed through plastic surgeons at our hospital. RESULTS: We performed a zigzag incision in the peri-areola margin to 17 of 18 patients for complications of autologous fat grafting and hyaluronic acid injection. The one excluded patient required an adipo-fascial flap from an inframammary fold incision. For one patient with silicon injection complication and one patient with paraffin injection complication, each required mammary gland resection. CONCLUSIONS: A zigzag incision in the peri-areolar margin was useful for treating complications of breast augmentation with autologous fat grafting and hyaluronic acid injection. All cases resulted in inconspicuous fine scars, with high patient satisfaction. However, this incision was insufficient to remove injected silicon and paraffin.

Changes in the expression of epidermal differentiation markers at sites where cultured epithelial autografts were transplanted onto wounds from burn scar excision.

This study investigated the recovery process during which grafted cultured epithelium formed normal epidermis. The subjects were 18 patients whose burn scars were excised at a depth not exposing the fat layer and who subsequently received cultured epithelial autografts. A total of 24 samples were obtained from the grafted sites: 6 samples within 6 weeks (stage 1), 5 samples after 6 weeks and within 6 months (stage 2), 6 samples after 6 months and within 18 months (stage 3) and 7 samples beyond 18 months (stage 4) after transplantation. These samples were stained for monoclonal antibodies against filaggrin, transglutaminase (TG), cytokeratin 6 and involucrin. Their expressions were examined in the epidermis. The expression patterns were classified using a six-grade scale. The grades of filaggrin and TG were significantly higher at stage 3 and 4 compared with stage 1. There was a marginally significant increase in the grade of cytokeratin 6 at stage 3 and it was significantly higher at stage 4 compared with stage 1. These results showed that wound healing continued at a molecular level until the end of stage 3. The recovery of involucrin was delayed compared with that of other markers. TG and involucrin are thought to be regulated independently at the grafted sites.

A rare case of a broken dental bur perforating the medial orbital wall without damaging the eye.

Rotating instruments used in the fields of dentistry and oral surgery operate at high speeds. Therefore, if small particles are projected and strike the orbit, injuries of varying severity can occur. We report here a case in which a broken dental bur pierced into the orbit. The bur fortunately did not damage the eyeball and stopped after penetration of the medial orbital wall. The subject was a 27-year-old dental assistant and not wearing protective eyewear. A foreign body had penetrated the medial wall of the right orbit and the tip had reached the ethmoid sinus. The medial orbital wall was exposed subperiosteally after dissection of the medial canthal ligament, and the foreign body was removed. Although the importance of protective eyewear had been advocated, eye protection compliance differed by region and dental personnel. Eye protection use needs to increase in not only dentists but also other dental personnel.

Treatment of vitiligo with autologous cultured keratinocytes in 27 cases.

BACKGROUND: Vitiligo is an acquired depigmentation of the skin characterized by white spots with well-defined margins, causing psychological stress in patients due to cosmetic concerns. We examined 27 patients who underwent vitiligo treatment using autologous cultured keratinocytes. METHODS: The study comprised 20 patients with segmental vitiligo and seven patients with generalized vitiligo, and they were followed up for at least 1 year postoperatively. In all 27 cases, topical steroid or ultraviolet therapy had been previously performed by dermatologists, but this treatment had been ineffective. The patients' vitiligo had stabilized. The patients were treated using keratinocytes obtained from primary culture using Green's techniques or from first passage. Dispase treatment was used to detach the stratified cultured epithelial sheets from their culture dishes. The detached sheets shrank to approximately one half to two thirds of their original size on the culture dish. After the recipient site was completely epithelialized, the skin was exposed to sunlight. RESULTS: For patients with segmental vitiligo, 12 had a good therapeutic outcome (90 % or more repigmentation) after the first surgery. This number increased to 14 when patients with multiple surgeries were included. There were six patients with fair outcomes (50-90 % repigmentation), and no patients with poor outcomes (50 % or less repigmentation). For patients with generalized vitiligo, no patients had a good outcome despite multiple surgeries. There were three patients with fair outcomes, and four patients with no change outcomes. CONCLUSIONS: Cultured keratinocyte grafting was a more effective treatment for segmental vitiligo than for generalized vitiligo. Level of Evidence: Level IV, therapeutic study.

Wound treatment and pain management: a stressful time.

This review and case study report considers the evidence to indicate that the progress of wound healing is negatively affected by the presence of stressors and in circumstances where patients are in pain. It considers the relationship between perceptions of pain, stress and delayed wound healing with a specific focus on guidance for clinical practice. It is appreciated that although the literature has examined these issues in the management of acute wounds, demonstrating that psychological stress can have detrimental effects on the wound-healing process, the evidence to support this link in relation to chronic wounds is limited. The review considers evidence indicating that punch biopsy wounds heal more slowly in subjects under stress on account of caring for family members with long-term illnesses and also considers briefly the relationship between cortisol secretion in response to stress and the consequent influences on cytokine levels and the wound-healing process.

Diabetic foot wounds in haemodialysis patients: 2-year outcome after percutaneous transluminal angioplasty and minor amputation.

Critical limb ischaemia (CLI) is known to be associated with high mortality. In some patients, surgery cannot be performed due to high risk of perioperative death and complications. In other cases, there is only pain at rest but no wound. Therefore, it is difficult to accurately predict the prognosis of individual patients. We examined the prognosis of CLI cases in which therapeutic footwear was made for ambulation after wounds healed. The subjects were 31 haemodialysis patients with diabetic foot wounds, which were treated with percutaneous transluminal angioplasty and minor amputation. The subjects were 22 men and 9 women. Female patients were significantly older than male patients (P = 0.046). Two-year postoperative outcomes were survival in 19 patients and death in 12 patients. Eight of twelve deceased patients had a history of coronary intervention. There were 8 deaths among 13 patients with such history, indicating a marginally significant increase in the mortality rate (P = 0.060). Re-amputation was performed in 6 of 19 patients who survived. Two years postoperatively, 41.9% of patients overall survived without re-amputation. It is important to increase the number of cases for further study to improve the well-being of CLI patients and to examine medical economics.

Treatment of inverted nipple with subareolar abscess: usefulness of high-resolution MRI for preoperative evaluation.

Background. Inverted nipples with subareolar abscesses can recur due to insufficient resection. It is important to provide reliable curative treatment after determination of the extent of resection by preoperative imaging evaluation. Methods. Ten patients were treated for inverted nipples with subareolar abscess. Sonography and high-resolution MRI were used as preoperative imaging modalities. The endpoints of preoperative imaging evaluation were defined as the identification of the abscess site, isolated fistula site, and extent of inflammation. Results. In all patients, sonography confirmed the presence of abscesses but their locations could not be identified. Sonography could not confirm the presence of isolated fistula or inflammation. In contrast, high-resolution MRI not only confirmed the presence of abscesses but also revealed their positional relationships with the nipples. In addition, high-resolution MRI confirmed the presence of isolated fistulas and inflammation as well as revealed their positional relationships with the nipples. In all patients, no recurrence was observed, and satisfactory surgical results were obtained. Conclusion. High-resolution MRI is useful in determination of the extent of resection of subareolar abscess associated with inverted nipple.

Application for regenerative medicine of epithelial cell culture-vistas of cultured epithelium.

This review describes culture techniques for the epithelial system as well as trends in the clinical application of cultured keratinocytes in our department and the possibility of applying the techniques to other organs. Cultured epithelium and cultured dermis in particular have considerably preceded regeneration of other organs in the field of regenerative medicine. Since 1988 we have grafted cultured keratinocytes by the Rheinwald-Green modified method in at least 500 patients with large skin defects. As a result of the establishment of a culture technique for individual patients, it is now possible to prepare enough regenerated epithelium to cover the body surface area of as many as 10 adult patients in approximately three weeks after collecting 1 cm(2) of skin, and then remaining cultured keratinocytes can be cryo-preserved for two-stage dermatoplasty at another site. This procedure makes it possible to avoid frequent skin collection from the same patient and thereby improves patients' quality of life and activities of daily living. On the other hand, to solve the problem of regenerated epithelium shrinking and problems with graft efficiency on dermis defect lesion, we have developed a proteinase-resistant regenerated dermis by mixing a certain protein with a fibrin scaffold. Recently we also took the initiative in grafting hybrid-type regenerated trachea in an animal experiment by using the epithelial and dermal cell culture technique, and some results of the graft were obtained.

Re-epithelialisation and the possible involvement of the transcription factor, basonuclin.

This article briefly summarises the basic mechanism of re-epithelialisation and discusses the possible role of the cell-type-specific transcription factor, basonuclin. Re-epithelialisation is initiated by a signal resulting from the absence of neighbouring cells at the wound edge. Basal cells at the wound edge become flattened and lose their intercellular desmosomes and substratum attachment. The amount of cytoplasmic actinomyosin filaments that insert into the new adhesion complexes is increased, and contraction of those filaments produces cell movement. The epithelial cells at the wound edge migrate on a provisional matrix using the newly expressed integrin receptors. Once re-epithelialisation is complete, the epithelial cells revert to the normal phenotype of basal epidermal cells, firmly attach to the newly developed basement membrane zone through hemidesmosomes and resume standard differentiation. Protein synthesis increases in the epidermal cells at the wound edge during re-epithelialisation. Active protein synthesis requires accelerated transcription of ribosomal RNA genes. The transcription factor basonuclin binds to the ribosomal RNA gene promoter and increases the transcription of the genes. Therefore, it is speculated that basonuclin in epithelial cells is required in the process of re-epithelialisation.