Anatomical Reconstruction of Extensive Inferomedial Blow-Out Fractures Involving the Inferomedial Orbital Strut Using a Single Fan-shaped Titanium-Reinforced Porous Polyethylene Plate.

Extensive inferomedial blow-out fractures involving the inferomedial orbit strut frequently result in severe ophthalmic complications. Therefore, anatomical reconstruction is essential but is still technically challenging. Thus, the authors have used a novel technique using a combination of single fan-shaped titanium-reinforced porous polyethylene (TR-PPE) implants and a bidirectionally extended transconjunctival approach. Herein, the authors describe our surgical technique and discuss its effectiveness. First, the transconjunctival approach was performed and was subsequently extended medially using the transcaruncular approach and laterally using lateral blepharotomy. After the origin of the inferior oblique muscle was identified, a trimmed fan-shaped TR-PPE implant was inserted into the orbital floor. It was subsequently rotated and bent at the site of origin of the IO muscle and moved upward to cover the superior bony ledge of the medial wall. Finally, the implant was fixed to the orbital rim. Anatomical orbital reconstruction was confirmed by a computed tomographic scan. The preoperative diplopia in 19 patients, resolved within 1 week in 16 patients and in 3 to 6 months in the remaining 3 patients. Preoperative enophthalmos >2 mm in all patients improved to <2 mm in 67 patients and 3 mm in 2 patients (>7 mm preoperatively). The postoperative course was uneventful, and no severe complications were observed. The authors believe that the placement of a fan-shaped TR-PEE implant into the orbit through the bidirectionally extended transconjunctival approach could be a viable option for the anatomical reconstruction of extensive inferomedial blow-out fractures involving the inferomedial orbital strut.

Highly Hydrophilic Polyurethane Foam Dressing Versus Early Hydrophilic Polyurethane Foam Dressing on Skin Graft Donor Site Healing in Patients with Diabetes: An Exploratory Clinical Trial.

OBJECTIVE: To compare the effects of early hydrophilic polyurethane (EHP) foam dressing and highly hydrophilic polyurethane (HHP) foam dressing on wound healing in patients with diabetes. METHODS: Twenty patients with diabetes with skin graft donor sites on the lateral thigh were enrolled in this study. Each donor site was divided into two equal-sized areas for the application of HHP or EHP foam dressing. The study endpoint was the time required for healing, defined as complete epithelialization of the donor site without discharge. All possible adverse events were also documented. MAIN RESULTS: Donor site healing was faster in 15 patients on the HHP half and 1 patient on the EHP half. In four patients, healing rates were the same between the HHP and EHP areas. Donor sites treated with HHP and EHP foam dressings healed in 17.2 ± 4.4 and 19.6 ± 3.7 days (P = .007), respectively. During the study period, no adverse event associated with the dressings occurred in either group. CONCLUSIONS: The HHP foam dressing might provide faster healing than EHP foam dressing for skin graft donor sites in patients with diabetes.

Septorhinoplasty for Destructed Septal L-Strut in Patients with Previously Applied Porous High-Density Polyethylene Implants (Medpor®).

BACKGROUND: Porous high-density polyethylene implants (Medpor®) have been extensively used for septal extension grafts in Asian rhinoplasty. However, studies on the long-term complications associated with Medpor® have not been reported. Therefore, the purpose of this study was to evaluate the long-term complications of septal extension grafts using Medpor® and present a reconstructive strategy for destructed septal L-struts. METHODS: We conducted a 12-year retrospective medical chart review of 428 patients who visited our center for septorhinoplasty. Among 428 patients, 43 patients had Medpor® for septal extension grafts previously applied at other clinics. The quadrangular cartilage was devoid or destructed in the area where Medpor® was previously applied. Therefore, all patients underwent secondary septorhinoplasty using autogenous cartilage grafts. Patient outcome was assessed to evaluate satisfaction, hardness of nasal tip, functional nasal obstruction symptom evaluation (NOSE) scores, and pain scores. Anthropometric analyses were carried out with patients' photographs. Postoperative complications were also evaluated. RESULTS: After septal L-strut reconstruction, 87% of patients were satisfied with their aesthetic results. Hardness of nasal tip, NOSE scores, and pain scores also improved after reconstruction. Anthropometric analyses demonstrated that increased nasal length and decreased columellar-labial angle were achieved in patients with short nose deformities. No postoperative complications related to the reconstruction were recorded for any patient. CONCLUSIONS: The devastated destruction of nasal support lines was found after the use of Medpor® for septorhinoplasty. Therefore, the use of Medpor® should be reduced. Autogenous cartilage grafts are the last resort for reconstruction of destructed septal L-struts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 .

Clinical Analysis of Nasal Bone Fracture in Patients Who Have Previously Undergone Dorsal Augmentation Using Silicone Implants: A Pilot Study.

BACKGROUND: There are no studies about the treatment of nasal bone fractures in patients with dorsal augmentations using silicone implants. We aimed to describe the characteristics of nasal bone fracture in patients who underwent rhinoplasty and compare the difference between closed reduction and conservative treatment of nasal bone fractures in patients with a history of rhinoplasty. METHODS: Between January 2013 and June 2018, a total of 463 patients were admitted to our center for nasal bone fracture; 17 patients with nasal bone fractures who underwent rhinoplasty were included, of which, five underwent closed reduction in the nasal bone and 12 underwent conservative treatment. Three of 12 patients who were initially treated conservatively underwent a secondary rhinoplasty for esthetic improvements. All patients were classified according to fracture site and the presence of a nasal septal fracture-in accordance with the modified Murray classification-and were analyzed for the correlation between fracture type and disease course. RESULTS: The nasal bone fracture types per computed tomography findings were unilateral (n = 13), bilateral (n = 4), septal (n = 1), and M-type (n = 1). No significant differences in fracture site (P > 0.05) and the presence of a nasal septal fracture (P > 0.05) were found between the groups. Fracture type did not significantly differ among patients who underwent closed reduction, conservative treatment without secondary rhinoplasty, and secondary rhinoplasty (P > 0.05). CONCLUSIONS: Despite risking traumatic capsular rupture, implant removal is seldom required and closed reduction is recommended if visible deviations are present; otherwise, only conservative treatment is recommended. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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.

Paranasal Augmentation Using Multi-Folded Expanded Polytetrafluorethylene (ePTFE) in the East Asian Nose.

BACKGROUND: Paranasal augmentation has commonly been performed utilizing alloplastic materials such as silicone or porous polyethylene. However, there are problems such as bone absorption, implant migration, and infection risk attributable to intraoral approaches. OBJECTIVES: The authors attempted anterior positioning of the alar crease junction as an adjunct method of rhinoplasty. The authors aimed to determine the long-term results of the intranasal approach for placement of multi-folded expanded polytetrafluorethylene (ePTFE). METHODS: A retrospective review was conducted of patients who underwent intranasal surgical approach for paranasal augmentation employing multi-folded ePTFE implants in 19 septorhinoplasties who were followed-up for 3 to 10 years. Patient charts were reviewed for demographic information, concomitant operations, and complications. Preoperative and postoperative photographs were utilized to evaluate operative outcomes. The photographs were reformatted to 2-dimensional images employing standard photographic methods. RESULTS: Of the 19 patients treated, 17 were female and 2 were male; ages ranged from 18 to 58 years. All patients reported improvement in their lateral profiles and were pleased at follow-up. There were no major complications, no nerve or vascular supply compromise, and no cases of implant malposition. The average increase in soft tissue outline near the alar crease junction was more than 3.2 mm (P < 0.001), but the alar base did not became wider. CONCLUSIONS: Paranasal augmentation with multi-folded ePTFE is a simple, safe, and effective method that can readily improve the lateral profile. In particular, the intranasal approach combined with rhinoplasty can synergistically improve outcomes and lead to greater patient satisfaction.

Effects of human umbilical cord blood-derived mesenchymal stromal cells and dermal fibroblasts on diabetic wound healing.

BACKGROUND AIMS: A previous study demonstrated that human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have superior wound-healing activity compared with fibroblasts in vitro. However, wound healing in vivo is a complex process that involves multiple factors. The purpose of this study was to compare the effects of hUCB-MSCs and fibroblasts on diabetic wound healing in vivo. This study especially focused on collagen synthesis and angiogenesis, which are considered to be the important factors affecting diabetic wound healing. METHODS: Porous polyethylene discs were loaded with either fibroblasts or hUCB-MSCs, and a third group, which served as a control, was not loaded with cells. The discs were then implanted in the back of diabetic mice. During the first and the second week after implantation, the discs were harvested, and collagen level and microvascular density were compared. RESULTS: In terms of collagen synthesis, the hUCB-MSC group showed the highest collagen level (117.7 ± 8.9 ng/mL), followed by the fibroblast group (83.2 ± 5.2 ng/mL) and the no-cell group (60.0 ± 4.7 ng/mL) in the second week after implantation. In terms of angiogenesis, the microvascular density in the hUCB-MSC group was 56.8 ± 16.4, which was much higher than that in the fibroblast group (14.3 ± 4.0) and the no-cell group (5.7 ± 2.1) in the second week after implantation. CONCLUSIONS: These results demonstrate that hUCB-MSCs are superior to fibroblasts in terms of their effect on diabetic wound healing in vivo.

In Vitro Evaluation of Betafoam, a New Polyurethane Foam Dressing.

BACKGROUND: A new polyurethane foam dressing impregnated with 3% povidone-iodine (Betafoam; Genewell, Seoul, Korea) was recently developed based on the hypothesis that its physical properties, including improved moisture-retention capacity and antimicrobial activity, are at least as good as those achieved with the current foam dressings that contain silver, but also associated with reduced cost and cytotoxicity to host cells. The purpose of this in vitro study was to evaluate the efficacy of Betafoam by comparing its physical properties, antimicrobial activity, and cytotoxicity with those of 3 silver foam dressings (Allevyn-Ag [Smith & Nephew, Hull, United Kingdom]; Mepilex-Ag [Mölnlycke Health Care, Gothenburg, Sweden]; and PolyMem-Ag [Ferris MFG Corp, Burr Ridge, Illinois]) used worldwide. METHODS: This study measured each dressing's pore size, fluid absorption time, fluid absorption capacity, fluid retention capacity, antimicrobial activity against Staphylococcus aureus and Pseudomonas aeruginosa, and cytotoxicity to mouse fibroblasts. RESULTS: Betafoam had the smallest pore size, the fastest fluid absorption time, greatest fluid absorption, and best retention capacities among the tested foam dressings. Antimicrobial activity was not significantly different among the dressings. However, Betafoam also demonstrated the lowest cytotoxicity to the fibroblasts. CONCLUSIONS: Betafoam may result not only in desirable rapid regulation of exudation but also antimicrobial activity with minimal cytotoxicity to host cells that are key requirements for wound healing.

Evaluation of the Efficacy of Highly Hydrophilic Polyurethane Foam Dressing in Treating a Diabetic Foot Ulcer.

OBJECTIVE: To demonstrate the efficacy of a highly hydrophilic polyurethane foam dressing in the treatment of diabetic ulcers. BACKGROUND: Diabetic foot ulcers often pose a difficult treatment problem. Polyurethane foam dressings have been used worldwide to accelerate wound healing, but only a few clinical studies demonstrate the effect of foam dressing on the healing of diabetic ulcers. METHODS: Medical records of 1342 patients with diabetic ulcers who were admitted and treated at the authors' institution were reviewed. A total of 208 patients met the study's inclusion criteria. Of these 208 patients, 137 were treated with a highly hydrophilic polyurethane foam dressing, and 71 were treated with saline gauze (control group). Except for the application of polyurethane foam dressing, the treatment method was identical for patients in both groups. The wound healing outcomes of the 2 groups were compared. RESULTS: Complete wound healing occurred in 87 patients (63.5%) in the polyurethane foam dressing group and in 28 patients (39.4%) in the control group within 12 weeks (P < .05, X test). The mean percentage of wound area reduction in both groups was statistically significant (P < .05, Mann-Whitney U test). The mean time required for complete closure in patients who achieved complete healing within 12 weeks was 6.2 (SD, 3.4) weeks and 7.3 (SD, 2.6) weeks in the polyurethane foam dressing and control groups, respectively (P < .05, Mann-Whitney U test). CONCLUSION: These results indicate that the highly hydrophilic polyurethane foam dressing may provide an effective treatment strategy for diabetic foot ulcers.

Injectable tissue-engineered soft tissue for tissue augmentation.

Soft tissue augmentation is a process of implanting tissues or materials to treat wrinkles or soft tissue defects in the body. Over the years, various materials have evolved to correct soft tissue defects, including a number of tissues and polymers. Autogenous dermis, autogenous fat, autogenous dermis-fat, allogenic dermis, synthetic implants, and fillers have been widely accepted for soft tissue augmentations. Tissue engineering technology has also been introduced and opened a new venue of opportunities in this field. In particular, a long-lasting filler consisting of hyaluronic acid filler and living human mesenchymal cells called "injectable tissue-engineered soft tissue" has been created and applied clinically, as this strategy has many advantages over conventional methods. Fibroblasts and adipose-derived stromal vascular fraction cells can be clinically used as injectable tissue-engineered soft tissue at present. In this review, information on the soft tissue augmentation method using the injectable tissue-engineered soft tissue is provided.

Myomucosal composite graft: A simple technique for full-thickness vermilion defects of the lower lip.

Reconstruction of vermillion defects of the lower lip requires careful consideration of functional and aesthetic aspects. Traditionally, various local flap methods involving tissue advancement from the corner of the mouth, lateral chin, and medial cheek have been commonly employed to fill lower lip defects. However, these approaches have inherent limitations, which include technical complexity, disruption of the orbicularis oris muscle, lip tightening, microstomia, and visible scarring. To overcome these limitations, we employed a free myomucosal composite graft from the lower lip to reconstruct small to medium vermilion defects. Our technique is based on a simple and reproducible surgical approach that facilitates natural volume rearrangement of tissues. Moreover, this method enables precise inset and tension-free repair, prevents lip tightening, and offers excellent aesthetic outcomes with no vertical scarring and appropriate color matching with surrounding tissues.

Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip Plasty in Asians.

BACKGROUND: The objective of this study was to illustrate a novel technique for lifting of the aging upper lip with nasal tip plasty in Asians. With this procedure, a shortening of the philtrum, an increase of the vermilion, and a natural and nicer mouth can be obtained, with increase of the tip of the nose simultaneously. METHODS: Thirty patients were the subjects of this study. Incisions were made bilaterally beginning at the alar fold, entering nostrils, and rising medially on the skin below the lower margin of the medial crura. Excess skin of the philtrum was eliminated in two separate pieces and the muscle was suspended to the base of the nose with interrupted stitches. RESULTS: All patients expressed a high degree of satisfaction. The average ratio between the L1 reference line and the height of the upper lip measurement preoperatively was 0.43 ± 0.05. This ratio was improved postoperatively to an average of 0.32 ± 0.05. The nasolabial angle was 91.31 ± 4.19 degrees before surgery and 105.62 ± 5.04 degrees after surgery. The angle of the upper lip was 48.97 ± 2.41 degrees before surgery and 38.21 ± 3.34 degrees after surgery. CONCLUSIONS: Lip lift is an effective tool for correcting a natural tendency of the upper lip to cover the upper teeth during aging. There is a dramatic improvement in the patient's facial aesthetic appearance during smiling and at rest. The authors strongly recommend this technique as part of the surgical procedure to achieve a youthful face. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Potential of Allogeneic Adipose-Derived Stem Cell-Hydrogel Complex for Treating Diabetic Foot Ulcers.

Mesenchymal stem cells (MSCs) may hold great promise for treating diabetic wounds. However, it is difficult for a clinician to use MSCs because they have not been commercialized. Meanwhile, a new commercial drug that contains adipose-derived stem cells (ASCs) has been developed. The purpose of this study was to examine the potential of allogeneic ASC sheets for treating diabetic foot ulcers. Fifty-nine patients with diabetic foot ulcers were randomized to either the ASC treatment group (n = 30) or a control group treated with polyurethane film (n = 29). Either an allogeneic ASC sheet or polyurethane film was applied on diabetic wounds weekly. These wounds were evaluated for a maximum of 12 weeks. Complete wound closure was achieved for 73% in the treatment group and 47% in the control group at week 8. Complete wound closure was achieved for 82% in the treatment group and 53% in the control group at week 12. The Kaplan-Meier median times to complete closure were 28.5 and 63.0 days for the treatment group and the control group, respectively. There were no serious adverse events related to allogeneic ASC treatment. Thus, allogeneic ASCs might be effective and safe to treat diabetic foot ulcers.

Advantages of the presence of living dermal fibroblasts within restylane for soft tissue augmentation.

For the elimination of facial wrinkles and skin contour defects, injectable filler substances composed of commercially prepared nonanimal stabilized hyaluronic acid (Restylane) are now widely used. Although this method of suspension has been shown to be relatively safe and convenient, varying degrees of resorption have required repeated percutaneous injections. This study was undertaken to evaluate the feasibility of Restylane, which is a modified hyaluronic acid, combined with cultured human dermal fibroblasts, to enhance the longevity of injected implants. The histologic changes of the injected implants were also evaluated. For the test group, fibroblasts from the dermis of healthy adults were isolated and cultivated. The cultured fibroblasts were measured with a hemocytometer. Five x 105 fibroblasts suspended in 200 microl of Dulbecco phosphate-buffered saline (DPBS) were then dispersed in 200 microl of Restylane to form a 400-microl human fibroblast-Restylane mix. For the control group, 200 microl of DPBS without fibroblasts were mixed with 200 microl of Restylane. These implants were subcutaneously injected into the back of an athymic nude mouse at 6 sites, the 3 left sites composing the control group and the 3 right sites composing the test group. Twelve nude mice were injected for a total of 36 injections per group. The nodular swellings that resulted from the injections were excised to include skin beyond the swelling points down to the panniculus carnosus layer using 5-mm punches, and the weights were measured at 1, 2, 4, 8, 12, and 16 weeks after the injections. Histologic comparisons were also performed to confirm the presence of human collagen in the fibroblast-mixed Restylane group using immunohistochemical study with antihuman collagen type I polyclonal antibody. The mean weight of the control group nodules decreased throughout the examination period. The mean weight at the 16th week was 60% of the weight at the first week. On the other hand, the mean weight of the test-group nodules decreased only over the first 2 weeks. Beyond 2 weeks, there was no further significant weight change. The mean weight at the 16th week was 91% of the weight measured at the first week. Histologic examinations of the control group exhibited negative immunohistochemical staining for human collagen at each examination period. The test group exhibited positive staining after 2 weeks, indicating the presence of human collagen. These results indicate that Restylane mixed with cultured human dermal fibroblasts may be successfully injected as living grafts for long-term retention of implants.