Angiotensin-Converting Enzyme Inhibitor, Captopril, Improves Scar Healing in Hypertensive Rats.

Pathological cutaneous scars, with aberrant extracellular matrix accumulation, have multiple origins. Antihypertensive medications, such as calcium channel blockers, have been used to treat pathological scars. However, a relationship between angiotensin-converting enzyme (ACE) inhibitors, pathological scars, and blood pressure (BP) has never been reported. Here, we aimed to compare the differences in scar development and the effects of the administration of systemic ACE inhibitor on scar tissue in a normotensive rat, the Wistar Kyoto rat (WKY), a hypertensive rat, and the spontaneously hypertensive rat (SHR). Using an 8-mm punch, we created two full-thickness skin defects in a total of 32 rats (16 WKY and 16 SHR) to obtain a total of 64 wounds. We established control WKY (n = 16), captopril-treated WKY (n = 16), control SHR (n = 16), and captopril-treated SHR (n = 16) groups and started captopril (100 mg/g per day) treatment on day 21 in the appropriate groups. The BP of all groups was measured at 0, 3, and 5 weeks. The scar area was measured by histopathological examination, and scarring was expressed in terms of scar area and fibroblast and capillary counts. The expression of heat shock protein (HSP) 47, type I and III collagens, alpha-smooth muscle actin (α-SMA), Ki67, and vascular endothelial growth factor (VEGF) was investigated using immunohistochemistry. The scar area and fibroblast count were significantly higher in control SHR than in control WKY. The scar area, fibroblast count, and capillary count were significantly smaller in captopril-treated SHR than in control SHR. Immunostaining for α-SMA, Ki67, and VEGF also showed a noticeable decrease in scarring in the treated SHR compared with that in control SHR. Thus, BP affects scar development in a rat model, and an ACE inhibitor is more effective at reducing scars in hypertensive rats than in normotensive rats.

Quadrangular Fixation of Pectus Bars to Prevent Displacement in Nuss Procedure.

BACKGROUND: Double pectus bars are sometimes inserted to correct pectus excavatum. Method of double-bar fixation to prevent bar displacement has been rarely reported. We have used quadrangular fixation of the double pectus bars. The objective of this study was to compare results of the quadrangular fixation procedure with those of the classic separate fixation procedure. METHODS: From September 2011 to January 2016, 86 patients underwent Nuss procedure with double-bar insertion. In 44 patients, each bar was fixed separately (group A). In 42 patients, quadrangular fixation of the bars was performed with metal plates (group B). Patient demographics, Haller index (HI), bar displacement index (BDI), and reoperation rate were compared between the two groups. RESULTS: The mean patient age was 17.2 years (range: 3-40 years) in group A and 17.8 years (range: 4-30 years) in group B. There was no significant difference in preoperative or postoperative HIs between the two groups (all p >0.05). Early complication rates were 15.9% in group A and 9.5% in group B (p > 0.05). In group A, three patients underwent surgery to correct bar displacement (6.8% of reoperation rate), whereas there was no corrective surgery in group B. BDIs of the two groups were significantly different (p < 0.01). CONCLUSIONS: When quadrangular fixation was performed with upper and lower pectus bars bilaterally fixed by connecting each bar with plates, bar displacement was prevented more effectively than separate fixation, thus minimizing reoperation.

Infraorbital Foramen Decompression Surgery for the Infraorbital Nerve Hypoesthesia in Patients With Isolated Fracture of Maxillary Sinus Anterior Wall.

Isolated fracture of maxillary sinus anterior wall is relatively uncommon. If the extent of fracture is minimal, only conservative care is amenable, however, there is no agreement on whether infraorbital nerve dysfunction can be used as an indication for surgical intervention. This study was conducted to verify the effect of decompression surgery of infraorbital foramen for recovery of hypoesthesia. A total of 26 patients with unilateral fracture of maxillary sinus anterior wall were enrolled. Ten who received only conservative therapy were allocated in the control group, while sixteen patients were assigned to the decompression group. Pre- and post-treatment sensory assessment using visual analogue scale (VAS) was recorded. Overall treatment satisfaction was also evaluated by means of global assessment scale (GAS). Both absolute VAS value and score increment showed statistical difference only at 4 weeks (P = 0.010 and P = 0.021, respectively), but no significant difference at 1, 12, and 24 weeks. GAS score also showed no statistical significance (P = 0.386). Decompression surgery of infraorbital foramen does not have a significant effect on hypoesthesia recovery in isolated fracture of maxillary sinus anterior wall. Therefore, it is not recommended to perform the operation when the infraorbital nerve hypoesthesia is the only indication for the open reduction.

Surgical Site Infection Caused by Mycobacterium Septicum Following Blepharoplasty.

BACKGROUND: M fortuitum and M chelonae are commonly reported in surgical site infections caused by nontuberculous mycobacterium, but M septicum is rarely known. Herein, the authors report the first case of surgical site infection caused by M septicum in an immunocompetent patient after blepharoplasty. METHODS: A 37-year-old woman had persisting bilateral masses on the upper eyelids at 3 months after a blepharoplasty. The excision and revision were performed in a local clinic with the administration of the empirical antibiotic (clarithromycin) for 2 months, but the masses recurred. The patient was referred to the authors' hospital after the steroid was injected. As the right eyelid skin was very thin with the pus pocket, curettage was performed, while the mass on the left eyelid was completely excised. A bacterial, Acid Fast Bacilli culture with antibiotic susceptibility testing, and a DNA-polymerase chain reaction test were performed. RESULTS: The polymerase chain reaction test identified M septicum. The antibiotic treatment was delayed to identify the susceptibility to antibiotics, but the Acid Fast Bacilli culture result showed no growth. In the meantime, the mass on the right eyelid recurred. Levofloxacin and clarithromycin were administered for 6 months in consultation with the Division of Infectious Diseases. Then the mass was excised. There was no recurrence after 1 year of follow-up. CONCLUSION: There are a few reports of M septicum catheter-related infection and pulmonary disease, but surgical site infection has not been reported. When a localized mass on a surgical site is found, surgeons should consider M septicum infection and find out the pathogen with its antibiotics susceptibility.

Identifying Preoperative Factors Associated with the Volume Discrepancy in Patients Undergoing Breast Reconstruction with the Extended Latissimus Dorsi Musculocutaneous Flap Coverage.

BACKGROUND: The latissimus dorsi (LD) flap is a versatile option for breast reconstruction. However, the indications are limited because of volume discrepancy between the breast and the flap. We conducted this study to identify preoperative factors associated with the volume discrepancy in patients undergoing breast reconstruction with the extended LD flap. METHODS: A retrospective study was performed in 69 patients (69 breasts) who underwent breast reconstruction with the extended LD flap between March 2015 and March 2018. We evaluated age, body weight, height, preoperative body mass index (BMI), postoperative BMI, breast skin defect size, breast volume, flap volume, and volume discrepancy [breast volume - flap volume]. RESULTS: Mean age, height, body weight, preoperative BMI, postoperative BMI, skin defect size, breast volume, flap volume, and volume discrepancy were 45.6 ± 7.1, 157.8 ± 0.1, 59 ± 8.1, 23.7 ± 3.2, 23.5 ± 3.3, 16.5 ± 9.3, 252.2 ± 107.1, 229.4 ± 95.6, and 32.6 ± 31.4, respectively. Spearman's rank correlation coefficients indicated significant positive linear correlations between volume discrepancy and preoperative BMI (correlation coefficient = 0.267, P = 0.027), volume discrepancy and breast volume (correlation coefficient = 0.472, P < 0.001), and between volume discrepancy and skin defect size (correlation coefficient = 0.609, P < 0.001). Stepwise multiple regression analysis yielded the following formula: predicted log volume discrepancy (ml) = 1.2891 + 0.0639 × skin defect size + 0.0025 × breast volume (R2 = 0.421). CONCLUSION: Skin defect size and breast volume were preoperative factors associated with volume discrepancy in patients who have undergone breast reconstruction with the extended LD flap. Considering these factors, we can predict the lack of volume and plan any necessary secondary procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Emerging Fixation Technique to Prevent Pectus Bar Displacement: Needlescope-Assisted 3-Point Fixation.

BACKGROUND: Bar flipping displacement is one of the most common complications after the Nuss procedure for pectus excavatum. We evaluated the results of a modified Nuss procedure with needlescope-assisted bar fixation. METHODS: The records of 41 patients with pectus excavatum who underwent single pectus bar insertion with the Nuss procedure between July 2011 and August 2014 were retrospectively reviewed. The patients were divided into two groups: those who did not undergo 3-point fixation (group A) and those who did undergo 3-point fixation (group B). RESULTS: There were 36 male patients and 5 female patients with a mean age of 10.7 ± 8.3 years (range: 3-36 years). The postoperative Haller index (HI) (2.61 ± 0.42) was significantly lower than the preoperative HI (3.91 ± 1.07; p < 0.01). The angle of the initial bar position was 5.59 ± 7.37 degrees in group A and 8.52 ± 9.61 degrees in group B, with no significant difference between the groups (p > 0.05). The rate of reoperation to correct bar displacement was lower in group B (3.3%) than in group A (9.1%). CONCLUSION: Needlescope-assisted 3-point fixation of the bar was performed without an additional skin incision and showed a low rate of reoperation to correct displacement of the pectus bar.

The effect of diabetes on the wound healing potential of adipose-tissue derived stem cells.

To investigate whether diabetes mellitus affects the wound-healing-promoting potential of adipose tissue-derived stem cells, we designed a wound-healing model using diabetic mice. We compared the degree of wound healing between wounds treated with normal adipose tissue-derived stem cells and wounds treated with diabetic adipose tissue-derived stem cells. We evaluated the wound-healing rate, the epithelial tongue distance, the area of granulation tissue, the number of capillary and the number of Ki-67-stained cells. The wound-healing rate was significantly higher in the normal adipose tissue-derived stem cells group than in the diabetic adipose tissue-derived stem cells group; it was also significantly higher in the normal adipose tissue-derived stem cells group than in the control group. Although the diabetic adipose tissue-derived stem cells group showed a better wound-healing rate than the control group, the difference was not statistically significant. Similar trends were observed for the other parameters examined: re-epithelisation and keratinocyte proliferation; granulation tissue formation; and dermal regeneration. However, with regard to the number of capillary, diabetic adipose tissue-derived stem cells retained their ability to promote neovasculisation and angiogenesis. These results reflect the general impairment of the therapeutic potential of diabetic adipose tissue-derived stem cells in vivo.

Subungual soft tissue chondroma with nail deformity in a child.

Soft tissue chondroma is a rare benign tumor of the cartilage. It occurs commonly in distal extremities of middle-aged patients. It is usually asymptomatic and grows slowly, making early diagnosis difficult. We report a 10-year-old patient with a 1-year history of a subungual soft tissue chondroma on her left fifth finger. The lesion arose from nail bed and distal nail matrix, resulting in nail dystrophy. Magnetic resonance imaging revealed a soft tissue tumor in the subungual region and soft tissue chondroma was diagnosed, based on histopathologic findings. Dermatologists should consider soft tissue chondroma in the differential diagnosis of subungual tumors of children.

Volume Measurement of Various Tissues Using the Image J Software.

Various methods have been introduced to assess the tissue volume because volumetric evaluation is recognized as one of the most important steps in reconstructive surgery. Advanced volume measurement methods proposed recently use three-dimensional images. They are convenient but have drawbacks such as requiring expensive equipment and volume-analysis software. The authors devised a volume measurement method using the Image J software, which is in the public domain and does not require specific devices or software packages. The orbital and breast volumes were measured by our method using Image J data from facial computed tomography (CT) and breast magnetic resonance imaging (MRI). The authors obtained the final volume results, which were similar to the known volume values. The authors propose here a cost-effective, simple, and easily accessible volume measurement method using the Image J software.

Identifying preoperative factors associated with the postoperative nasal synechia in patients undergoing closed reduction of the nasal bone fracture.

We conducted this study to identify preoperative factors that are associated with the postoperative nasal synechiae in patients with nasal bone fracture who underwent closed reduction.In the current single-center, retrospective study, we evaluated the fracture type, septal deviation angle (SDA), synechia scores (SSs) and visual analog scale (VAS) scores through a retrospective review of the medical records and computed tomography scans of 42 patients (n = 42) who had undergone closed reduction for nasal bone fracture at our medical institution during a period ranging from April to August 2013.The mean SS was significantly lower in the plane I group (n = 25) as compared with the plane II group (n = 17) (1.28 ± 1.77 vs 2.76 ± 1.89, P = 0.013). There was a significant positive correlation between the SDA and the SS with a formula of SS = 0.216SDA - 0.322 (r(2) = 0.532, P < 0.001) and between the SS and the VAS with a formula of VAS = 1.280SS + 0.612 (r(2) = 0.648, P < 0.001). Both the SS and VAS were significantly higher on the convex side as compared with the concave side of the nasal cavity.Our results indicate that patients with higher SDA or combined septal fractures might be at increased risks of developing the postoperative synechiae. Further large-scale, prospective studies are warranted to establish our results.

An analysis of pure blowout fractures and associated ocular symptoms.

Blowout fractures are one of the commonly occurring facial bone fractures and clinically important, as they may cause serious complications such as diplopia, extraocular movement limitation, and enophthalmos. The purpose of this study was to evaluate the current patient demographics and surgical outcomes of 952 pure blowout fractures from 2 hospitals of the Catholic University of Korea, from 2003 to 2011. The medical records were reviewed according to the cause, fracture site, ocular symptoms, time of operation, and sequela. Male patients outnumbered female patients, and blowout fractures were most often seen in 21- to 30-year-old men. The most common cause was violent assault (40.7%). The medial orbital wall (45.8%) was the most common site, followed by floor (29.4%) and inferomedial wall (24.6%). The most common ocular injury was hyphema. Diplopia was presented in 27.6%; extraocular movement limitation was detected in 12.8% patients, and enophthalmos was encountered in 3.4% patients. Diplopia, extraocular movement limitation, and enophthalmos were significantly improved by surgical repair (P < 0.05). Postoperative complications were persistent diplopia (1.6%) and enophthalmos (0.4%). We surveyed a large series of blowout fracture in the Republic of Korea and recommend this study to serve as an important guideline in treating pure blowout fractures.

The changes of distance between nipples following correction of women pectus excavatum.

The breasts in women pectus excavatum patients frequently appear to be slanting medially along the inclination of the distorted ribs. This study aims to evaluate changes in the distance between the nipples and to find out whether medially slanting breasts are corrected in women pectus excavatum patients following modified Nuss procedure. This case series analysis enrolled 22 young women patients with pectus excavatum between October 2011 and September 2020. We measured all the patients' distances from the sternal midline to the right and left nipples, based on chest computerized tomography. We calculated the distances between nipples as being the sum of the right and left distances. The mean age of patients was 16.50 ± 4.73 years, and the follow-up periods were 35.59 ± 20.23 months. The postoperative Haller indices (2.89 ± 0.43) were significantly lower than the preoperative Haller indices (5.14 ± 1.96) (p = 0.000). The distances between the nipples before and after Nuss procedure were 145.17 ± 17.73 mm and 172.29 ± 19.11 mm, which is a significant increase following surgery. (p = 0.000). Our results demonstrated that skeletal correction with modified Nuss procedure in pectus excavatum increased the distance between nipples, indicating that medially slanting breasts had been corrected.

Nuss procedure for combined pectus excavatum and carinatum in a patient with a history of congenital esophageal atresia repair surgery.

Cardiothoracic surgery usually causes tissue adhesion on the operation site which increases the risk of complications in the subsequent thoracic surgery including Nuss procedure. Disorders that require cardiothoracic surgery include chest wall deformities such as pectus excavatum, congenital heart diseases, lung diseases such as congenital cystic adenomatiod malformation and bronchopulmonary dysplasia, and congenital diaphragmatic hernia. Recently, we encountered a rare case of combined pectus excavatum and carinatum in a patient with a history of congenital esophageal atresia repair surgery. Commendably, despite tissue adhesion from the previous surgery, a modified Nuss procedure was performed successfully with no complications. We agree that the Nuss procedure is feasible for thoracic deformities in patients with a surgical history of cardiothoracic surgery.

Treatment of posttraumatic fingertip pain using a great toe pulp graft.

Complications of fingertip injury include pain, hyper- or dyssensitivity, cold intolerance, and fingertip atrophy. Especially in cases of soft-tissue defect or atrophy which result from crushing injury, fingertip pain often occurs when a finger touches the objects. To overcome this problem, several techniques including local flaps or free flaps were suggested. But these methods require intricate and multistaged procedures.Twelve patients who had fingertip pain with pulp atrophy were treated with pulp graft between March 2004 and March 2006. Under the local anesthesia, we made a fish-mouth incision at the most prominent portion of fingertip and elevated volar flaps. Composite tissue was harvested from the lateral aspect of great toe, and inserted between the previously elevated volar flaps. The harvested composite pulp tissue contained about 3- to 5-mm thick fat layer. Moisture dressing was performed. The visual analogue scale (VAS) was used to evaluate the degree of pain postoperatively. The follow-up period was in the range between the 12 and 24 months (average, 19 months). Pre- and postoperative differences in VAS scores were analyzed for statistical significance, using the Wilcoxon rank sum test. In addition, patients were asked about their level of satisfaction with the procedure. To evaluate the postoperative sensation of the graft, we performed the Semmes-Weinstein monofilament test, and static and dynamic 2-point discrimination test at 1 year postoperatively.The size of the graft was ranged from 276 mm (12 × 23 mm) to 750 mm (25 × 30 mm). At final follow-up review, 5 patients were very satisfied and 7 were satisfied. Atrophy of the fingertip was also improved. Fingertip pain reduced from 8.5 preoperative to 3.1 postoperative on VAS. These improvements were statistically significant. Semmes-Weinstein monofilament test was green (∼2.83) in 9 patients (75%) and blue (3.22-3.61) in 3 of 12 patients (25%). Static and dynamic 2-point discrimination test results came out as 6 and 5 mm, respectively.Composite graft applied to the fingertip is a simple technique, and gives few complications. This procedure can be performed under local anesthesia and gives a fairly high degree of satisfaction to patients. We believe this method is useful for treating fingertip pain with atrophy of pulp.

Effects of adipose-derived stromal cells and of their extract on wound healing in a mouse model.

In this study, the authors investigated the effects of adipose-derived stromal cells (ADSCs) and of their extract on wound healing. After creating wound healing splint model on the backs of mice, ADSCs and their extract were applied. Wound healing rates were calculated at 3, 5, 7, 10, and 14 days after the wounding, and tissues were harvested at 7 and 14 days for histological analysis. Wound healing rates were significantly higher at 7, 10, and 14 days in the cell group than in the control, but in the cell extract group wound healing rates were significantly decreased (P<0.05). Histological scores and capillary densities in the cell group were significantly higher at 2 weeks (P<0.05). In the cell group, thick inflammatory cell infiltration and many capillaries were observed at 1 week, and thick epithelium and numerous large capillaries were observed at 2 weeks. The present study suggests that ADSCs accelerate wound healing as known, and the effects of ADSCs on wound healing may be due to replacing insufficient cells by differentiation of ADSCs in the wound and secreting growth factors by differentiated cells, and not due to the effect of factors within ADSCs.

Extraskeletal chondroma in the auricle.

Extraskeletal chondroma is a rare benign tumor that develops in soft tissues, and histologically, it is a lobulated nodule surrounded by a fibrous capsule, and the inside consists of mature cartilage cells and diffuse hyalinized matrix. It occurs preferentially in the hand and foot area of adults, and the development in the head and neck area is very rare. We had a very rare case of extraskeletal chondroma that developed in the auricle and report the case together with a review of the literature.

Submuscular fibrolipoma of the forehead.

Fibrolipoma is a rare variant of lipoma with a mixture of fibrous connective tissue. Clinically, it presents as an asymptomatic, slowly growing mass with a smooth, firm, or soft consistency. Although fibrolipoma can occur in any part of the body, in the head region it mainly occurs in the oral cavity and sometimes in the lip, parotid gland, nose, and cheek. We present the first case of a 65-year-old man with a submuscular fibrolipoma of the forehead that showed no evidence of recurrence after excision.

Nodular fasciitis in the forehead.

Histologically, nodular fasciitis is observed as similar to sarcoma in soft tissues, and it is referred to as pseudosarcomatous fasciitis. Its histologic findings can be summarized as spindle-shaped fibroblasts, intercellular space between fibroblasts, red blood cells released to the extravascular area, and deposition of mucus within the interstitium. The lesion looks similar to sarcoma histologically and shows the characteristic of rapid growth, which in result is readily misdiagnosed as malignancy. It occurs preferentially in the upper extremities, whereas rarely occurring in the head and neck region. When we encounter subcutaneous nodules of the head and neck region, it is important to keep nodular fasciitis in mind as a differential diagnosis to avoid unnecessary wide resection. In this article, we report a rare case of nodular fasciitis on the forehead and some reviews of the literature.

In vivo cartilage formation using chondrogenic-differentiated human adipose-derived mesenchymal stem cells mixed with fibrin glue.

Human adipose-derived mesenchymal stem cells (MSCs) were differentiated into chondrogenic MSCs, and fibrin glue was used together to explore the feasibility of whether cartilages can be generated in vivo by injecting the differentiated cells. Mesenchymal stem cells extracted from human adipose were differentiated into chondrogenic MSCs, and such differentiated cells mixed with fibrin glue were injected subcutaneously into the back of the nude mouse. In addition to visual evaluation of the tissues formed after 4, 8, and 12 weeks, hematoxylin-eosin staining, Masson trichrome staining, measurement of glycosaminoglycan concentration using dimethylmethylene blue, agreecan through reverse transcriptase-polymerase chain reaction, type II collagen, and expression of SOX-9 were verified. Moreover, the results were compared with 2 groups of controls: 1 control group that received only injection of chondrogenic-differentiated MSC and the supporting control group that received only fibrin glue injection. For the experimental group, cartilage-like tissues were formed after 4, 8, and 12 weeks. Formation of cartilage tissues was not observed in any of 4, 8, and 12 weeks of the control group. The supporting control group had only a small structure formation after 4 weeks, but the formed structure was completely decomposed by the 8th and 12th weeks. The range of staining dramatically increased with time at 4, 8, and 12 weeks in Masson trichrome staining. The concentration of glycosaminoglycan also increased with time. The increased level was statistically significant with more than 3 times more after 8 weeks compared with 4 weeks and more than 2 times more after 12 weeks compared with 8 weeks. Also, in reverse transcriptase-polymerase chain reaction at 4, 8, and 12 weeks, all results expressed a cartilage-specific gene called aggrecan, type II collagen, and SOX-9. The study verified that the chondrogenic-differentiated MSCs derived from human adipose tissues with fibrin glue can proliferate and form new cartilage. Our findings suggest that formation of cartilages in vivo is possible.

Capsular flaps for the management of malpositioned implants after augmentation mammoplasty.

Among the reasons for reoperation after augmentation mammaplasty is the malpositioned implant, especially a lowered inframammary fold or symmastia, which is difficult to repair. The peri-implant capsule, a physiologic response to a foreign body, is naturally formed and suitable for use as a flap because of its high vascularity. In addition, it is sufficiently tough for suspension of the implant. The authors introduce the idea that the capsular flap is very useful for the correction of symmastia or a lowered inframammary fold. In such situations, the capsular flaps are used to prevent migration of the implant after raising of the inframammary fold or defining of the midline with capsulorrhaphy. This technique successfully corrected the malpositioned implants in this study, and all the patients were satisfied. There was no recurrence of a lowered inframammary fold or symmastia. These findings suggest that the capsular flap should be considered a safe and effective option for the management of malpositioned implants.