Rotating suture technique combined with lid margin split and lower eyelid retractor disinsertion for epiblepharon.

Epiblepharon is an eyelid disease affecting 46-52.5% of Asian children. The Hotz procedure was commonly used for the treatment. However, the currently preferred technique is the rotating suture technique. This study aimed to report the recurrence rate and the complications of using the rotating suture technique combined with lid margin split and lower eyelid retractor (LER) disinsertion of epiblepharon. This was a retrospective study of the procedures performed between January 2017 and December 2020. This study included 64 eyelids of 37 patients who underwent the consecutive rotating suture technique, lid margin split, and LER disinsertion simultaneously for lower eyelid epiblepharon and were followed up for at least 6 months. The mean age of the patients who underwent surgery was 9.5 (5-28) years. The mean observation period was 8.3 (6-27) months. Recurrence was observed in one eyelid (1.6%). The complications included an ectopic eyelash on one eyelid (1.6%). LER disinsertion performed in this study had two advantages. First, the imbalance between the anterior and posterior lamellae was corrected. Disinserting the LER, the tarsal plate could be repositioned cranially, effectively addressing this imbalance. Second, LER disinsertion ensured direct exposure of the lower margin of the tarsal plate, facilitating the implementation of a reliable rotating suture. In conclusion, promising results were achieved by combining the rotating suture technique with LER disinsertion and lid margin splitting.

The Prospective Natural History Study of Patients with Intractable Venous Malformation and Klippel-Trenaunay Syndrome to Guide Designing a Proof-of-Concept Clinical Trial for Novel Therapeutic Intervention.

Background: The natural history of venous malformation (VM) and Klippel-Trenaunay Syndrome (KTS) has not been quantitatively studied. To obtain benchmarks to guide designing clinical trials to assess safety and efficacy of novel drug candidates, the clinical course of the patients was followed for 6 months. Methods and Results: This is a multicenter prospective observational study evaluating the change rate in lesion volume from baseline with magnetic resonance images, as the primary endpoint. In addition, disease severities, performance status (PS), pain visual analog scale (VAS) score, quality of life (QoL), infections, and coagulation markers were also evaluated. Thirty-four patients (VM = 17, KTS = 17, 1-53 of age; median 15.9 years) with measurable lesion volume were analyzed. There was no statistically significant difference in the lesion volume between baseline and day 180, and the mean change rate (standard deviation) was 1.06 (0.28). There were no baseline characteristics that affected the change in lesion volume over 6 months. However, there were patients who showed more than 20% volume change and it was suggested that the lesion volume was largely impacted by local infection. There were no statistically significant changes in pain VAS score, severity, PS, QoL score, D-dimer, and platelet count over 6 months within all patients analyzed. Conclusion: The results showed the representative natural course of VM and KTS for a 6-month period with objective change of lesion volume and other factors, suggesting that it is scientifically reasonable to conduct a Phase 2 proof-of-concept study without a placebo arm, using the results of this study as the control. Clinical Trial Registration: NCT04285723, NCT04589650.

Comparison of postoperative recurrence rates between percutaneous and transconjunctival approaches for involutional entropion.

Lower eyelid entropion is the second most common disease seen after ptosis in oculoplastic outpatients. In this study, we performed percutaneous and transconjunctival shortening of the anterior and posterior layers of the lower eyelid retractor (LER) to treat lower eyelid involutional entropion. This study aimed to examine the recurrence rate and complications of the percutaneous and transconjunctival approaches. This was a retrospective study of procedures conducted from January 2015 to June 2020. The LER shortening was performed for lower eyelid involutional entropion on 103 patients (116 eyelids). From January 2015 to December 2018, LER shortening using the percutaneous approach was implemented; from January 2019 to June 2020, the transconjunctival approach was used to shorten the LER. All patient charts and photographs were retrospectively reviewed. Recurrence occurred in 4 patients (4.3%) in the percutaneous approach. No recurrence was observed in any patient in the transconjunctival approach. Temporary ectropion occurred in 6 patients (7.6%) when the percutaneous approach was used; all cases healed within 3 months after surgery. The study did not reveal any statistically significant difference in recurrence rates between the percutaneous and transconjunctival approaches. We achieved results equal to or better than percutaneous LER shortening by combining transconjunctival LER shortening with horizontal laxity shortening, such as lateral tarsal strip, pentagonal resection, and orbicularis oculi muscle resection. However, it is necessary to be careful about temporary ectropion after surgery when percutaneous LER shortening alone is performed for lower eyelid entropion.

Potential of an artificial nerve graft containing Schwann cells for the treatment of a 20-mm nerve defect in rats.

OBJECTIVE: In a previous study, the authors showed that the migration of Schwann cells (SCs) through end-to-side (ETS) neurorrhaphy promotes axonal regrowth within an acellular nerve graft. In the present study, the authors investigated whether a similar strategy using an artificial nerve (AN) would allow reconstruction of a long nerve gap (20 mm) in rats. METHODS: Forty-eight 8- to 12-week-old Sprague Dawley rats were divided into control (AN) and experimental (SC migration-induced AN [SCiAN]) groups. Prior to the experiment, the ANs used in the SCiAN group were populated in vivo with SCs over a 4-week period by ETS neurorrhaphy onto the sciatic nerve. In both groups, a 20-mm sciatic nerve defect was reconstructed in an end-to-end fashion using 20-mm ANs. Sections from the nerve graft and distal sciatic nerve in both groups underwent assessments at 4 weeks for SC migration by immunohistochemical analysis and quantitative reverse transcription-polymerase chain reaction. At 16 weeks, axonal elongation was assessed by immunohistochemical analysis, histomorphometry, and electron microscopy. The number of myelinated fibers was counted, the g-ratio was calculated, and myelin sheath thickness and axon diameter were measured. Furthermore, functional recovery was evaluated at 16 weeks using the Von Frey filament test for sensory recovery and by calculating the muscle fiber area for motor recovery. RESULTS: The area occupied by SCs at 4 weeks and by axons at 16 weeks was significantly larger in the SCiAN group than in the AN group. Histomorphometric evaluation of the distal sciatic nerve revealed a significantly greater number of axons. At 16 weeks, plantar perception in the SCiAN group was significantly better, demonstrating improvement in sensory function. However, no tibialis anterior muscle motor improvement was observed in either group. CONCLUSIONS: The induction of SC migration into an AN by ETS neurorrhaphy is a useful technique for repairing 20-mm nerve defects in rats, with better nerve regeneration and sensory recovery. No motor recovery was observed in either group; however, motor recovery might require a longer period of time than the lifespan of the AN used in this study. Future studies should investigate whether structural and material reinforcement of the AN, to lower its decomposition rate, can improve functional recovery.

A Case of a Refractory Bleeding Giant Vaginal Wall Cavernous Hemangioma Successfully Managed with Sclerotherapy.

BACKGROUND Vaginal wall hemangiomas are extremely rare, benign, vascular tumors of the female genitalia. Most cases occur in childhood, but a few cases can be acquired; however, the mechanism of hemangioma formation remains unknown. Most hemangiomas involving female genital organs are small and asymptomatic. However, huge hemangiomas can cause irregular genital bleeding, infertility, and miscarriage. Surgical excision and embolization are the most common treatment options. We reveal that sclerotherapy achieved good outcomes in a patient with an intractable huge vaginal wall hemangioma. CASE REPORT A 71-year-old woman visited a local doctor with concerns of frequent urination. A ring pessary was inserted after a diagnosis of pelvic organ prolapse. However, symptoms did not improve, and the patient consulted another hospital. The previous physician diagnosed vaginal wall tumors and prolapse and performed a colporrhaphy. However, she was referred to our hospital with heavy intraoperative bleeding. Imaging examination revealed a huge hemangioma on the vaginal wall, which was histologically diagnosed as a cavernous hemangioma. Angiography revealed hemorrhage in the right peripheral vaginal artery. Owing to concerns regarding extensive vaginal wall necrosis caused by arterial embolization, sclerotherapy using monoethanolamine oleate was selected. Hemostasis was achieved 1 month after sclerotherapy, and postoperative imaging showed the lesion had shrunk in size. No recurrence of hemangioma was observed 19 months after surgery. CONCLUSIONS We report a case of a large vaginal wall intractable bleeding hemangioma. Sclerotherapy can be a suitable treatment option for large vaginal hemangiomas that are too extensive to be treated using surgery or arterial embolization.

Modified Lengthening Temporalis Myoplasty Using an Intraoral Approach.

BACKGROUND: Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves inserting the whole temporal tendon directly into the nasolabial fold. However, the nasolabial fold incision remains one of the difficulties of this procedure, particularly in young or female patient. To avoid the need for this incision, the authors developed an intraoral approach to manipulate the temporal muscle tendon toward the nasolabial fold. in this study, we describe the details of this procedure. METHOD: The authors performed their intraoral approach procedure in 5 patients with established complete facial paralysis. instead of making an incision at the nasolabial fold to approach the coronoid process, the authors made the incision at the buccal mucosa. The results were evaluated both subjectively and objectively. RESULTS: The authors achieved facial reanimation without leaving any obvious scar on the face or neck and the effect of static reconstruction is obvious, even immediately after the surgery. All the patients obtained good facial movement within 4 months (2.5 months in average), and improved all evaluated parameters postoperatively. No infections or other major complications were reported following surgery; however, 1 patient developed a slight dimple that required revision. DISCUSSION: The authors could advance temporal tendon toward nasolabial fold firmly obtaining sufficient surgical field similar to that of nasolabial fold incision, and achieved fairly good results without an obvious scar on the face.Establishing LTM without nasolabial fold incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reanimation in all generation.

Sliding Flap for the Wide Upper Eyelid Margin Defect After Cancer Removal.

BACKGROUND: Reconstruction of eyelid margin defects following resection of upper-eyelid skin malignancies is typically performed using a lower eyelid switch flap, including eyelash reconstruction. However, a subsequent procedure for flap separation, and prolonged swelling of the flap may occur as a complication. OBJECTIVE: The authors performed anterior lamellar reconstruction using a sliding flap with excess upper eyelid skin, a procedure that is a less invasive and simpler. MATERIALS AND METHODS: The authors performed anterior lamellar reconstruction using a sliding flap in 7 patients with full-thickness upper eyelid margin defect after skin cancer resection. The mean age of the patients was 76.0 years. The horizontal width of the defect in our cohort ranged from 11 to 25 mm and the vertical width ranged from 5 to 10 mm. RESULTS: All the flaps and mucosal grafts were well taken, and none of the patients complained of lack of eyelash reconstruction. However, eyelid margin irregularity, possibly due to flap or mucosal graft contraction, was observed in 2 patients, and 1 patient developed keratoconjunctivitis. CONCLUSIONS: The sliding flap technique is a minimally invasive and simple procedure for wide eyelid margin reconstruction. However, 2 patients developed eyelid margin irregularities and 1 patient developed keratoconjunctivitis. Those complications might have occurred owing to the condition of posterior lamellar reconstruction. Therefore, for the successful use of a sliding flap for anterior lamellar reconstruction, the form of the eyelid edge and the choice of posterior lamellar reconstruction are key considerations. In future, we plan to establish a better reconstructive technique by accumulating more evidence.

Adenoid Cystic Carcinoma Developed from the Parotid Gland to the Ear Lobe of a Young Woman.

Adenoid cystic carcinoma (ACC) is a relatively rare malignant tumor. It is more common in women than in men and typically develops in the lacrimal, salivary, and breast glands. ACC of the external auditory canal (EAC) is exceedingly rare, and its invasion into the ear lobe is even more unusual. In this report, we present a case of ACC that presented as a mass on the surface of the ear lobe in a 28-year-old woman and was initially diagnosed as infected atheroma. For wide resection of the tumor, half of the entire auricula was resected and superficial parotidectomy was performed. After confirming no tumor cells on the surface of the facial nerve, the defect was reconstructed by the combination of platysma muscle flap to prevent Frey syndrome and free forearm flap for the ear lobe form. There was no recurrence or metastasis of the tumor, and Frey syndrome did not occur at 2 years and 8 months after surgery. The patient was satisfied with the result, oncologically and cosmetically. Even in young patients, comprehensive treatments (including diagnosis, resection, and reconstruction) are important in painful ear lobe masses.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence-based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese Dermatological Association Guidelines: outlines of guidelines for cutaneous melanoma 2019

With consideration of the ongoing developments in treatment options for cutaneous melanoma, the Japanese Skin Cancer Society published the first guidelines for cutaneous melanoma in 2007 and later revised them in 2015. Here, we report on an English version of the 2019 Japanese Melanoma Guidelines. In this latest edition, all processes were carried out according to the Grading of Recommendations, Assessment, Development and Evaluation system. A comprehensive published work search, systematic review and determination of recommendations in each clinical question were performed by a multidisciplinary expert panel consisting of dermatologists, a plastic and reconstructive surgeon, and a radiation oncologist. The advent of novel agents, such as immune checkpoint inhibitors and molecular-targeted agents, has drastically changed the nature of treatment for adjuvant and advanced-stage diseases among melanoma patients worldwide. Additionally, recent reports of clinical trials regarding surgical procedures and a better understanding of molecular biology and tumor immunology in clinical types of melanoma have had an impact on clinical practise. Based on these viewpoints, eight relevant clinical questions were raised in this report that aim to help clinicians select the appropriate therapeutic approach.

Japanese Dermatological Association Guidelines: Outlines of guidelines for cutaneous melanoma 2019.

With consideration of the ongoing developments in treatment options for cutaneous melanoma, the Japanese Skin Cancer Society published the first guidelines for cutaneous melanoma in 2007 and later revised them in 2015. Here, we report on an English version of the 2019 Japanese Melanoma Guidelines. In this latest edition, all processes were carried out according to the Grading of Recommendations, Assessment, Development and Evaluation system. A comprehensive published work search, systematic review and determination of recommendations in each clinical question were performed by a multidisciplinary expert panel consisting of dermatologists, a plastic and reconstructive surgeon, and a radiation oncologist. The advent of novel agents, such as immune checkpoint inhibitors and molecular-targeted agents, has drastically changed the nature of treatment for adjuvant and advanced-stage diseases among melanoma patients worldwide. Additionally, recent reports of clinical trials regarding surgical procedures and a better understanding of molecular biology and tumor immunology in clinical types of melanoma have had an impact on clinical practise. Based on these viewpoints, eight relevant clinical questions were raised in this report that aim to help clinicians select the appropriate therapeutic approach.

Oncoplastic Lower Eyelid Reconstruction Analysis.

BACKGROUND: Oncoplastic lower eyelid reconstruction is a challenging task due to the complicated structure of the eyelid and requirement of high operative accuracy. Poorly treated defects result in ectropion and ptosis which may lead to keratitis and corneal ulceration. Previous related studies do not include a detailed comparison of the common reconstructive methods of the lower eyelid in terms of results and complication rates. OBJECTIVE: The authors aim to demonstrate whether the choice of reconstruction affects the aesthetic and functional outcome of oncoplastic lower eyelid reconstruction. METHODS & MATERIALS: The authors performed a 10-year retrospective review of all oncoplastic lower eyelid reconstructions carried out in our hospital. Information on patient background, diagnosis and the choice of reconstructive method were evaluated. Postoperative photographs of each patient were then subjectively evaluated for color match, cosmesis, quality of shape, symmetry, and overall appearance. The authors hypothesized that the outcome is related to the main trajectory of the flap. Patients treated with local flaps of horizontal and vertical trajectories were then compared in terms of outcome and complication rates. RESULTS: Reconstructions based on a horizontal trajectory compared with a vertical trajectory resulted with lower rates of ectropion and ptosis occurrence. The results were statistically significant.

Split-skin Paddle Anterolateral Thigh Flap for Reconstruction of Giant Dermatofibrosarcoma Protuberans in Groin.

Dermatofibrosarcoma protuberans (DFSP) is a slow-growing superficial sarcoma. Due to its high late local recurrence, thin skin graft is usually recommended for reconstruction after resection of the tumor. In this report, we present a case of giant DFSP in the groin region of young woman. Reconstruction of large groin defect after DFSP resection was performed by "split-skin paddle anterolateral thigh flap" instead of skin graft considering that the patient was a 29-year-old woman. This method enabled the primary closure of the donor site and provided the positive functional and esthetic outcomes. In the present case, the surgical scar is less conspicuous and the patient can climb and descend stairs without any trouble at 4 years after the surgery. With careful monitoring of the tumor recurrence, this technique may become a reliable reconstruction option for patients with large groin defect after resection of the malignant tumor.

Quality-Quantity Control Culture Enhances Vasculogenesis and Wound Healing Efficacy of Human Diabetic Peripheral Blood CD34+ Cells.

Autologous endothelial progenitor cell (EPC) therapy is commonly used to stimulate angiogenesis in ischemic repair and wound healing. However, low total numbers and functional deficits of EPCs make autologous EPC therapy ineffective in diabetes. Currently, no known ex vivo culture techniques can expand and/or ameliorate the functional deficits of EPCs for clinical usage. Recently, we showed that a quality-quantity culture (QQc) system restores the vasculogenic and wound-healing efficacy of murine diabetic EPCs. To validate these results and elucidate the mechanism in a translational study, we evaluated the efficacy of this QQc system to restore the vasculogenic potential of diabetic human peripheral blood (PB) CD34+ cells. CD34+ cells purified from PB of diabetic and healthy patients were subjected to QQc. Gene expression, vascular regeneration, and expression of cytokines and paracrine mediators were analyzed. Pre- or post-QQc diabetic human PB-CD34+ cells were transplanted into wounded BALB/c nude mice and streptozotocin-induced diabetic mice to assess functional efficacy. Post-QQc diabetic human PB-CD34+ cell therapy significantly accelerated wound closure, re-epithelialization, and angiogenesis. The higher therapeutic efficacy of post-QQc diabetic human PB-CD34+ cells was attributed to increased differentiation ability of diabetic CD34+ cells, direct vasculogenesis, and enhanced expression of angiogenic factors and wound-healing genes. Thus, QQc can significantly enhance the therapeutic efficacy of human PB-CD34+ cells in diabetic wounds, overcoming the inherent limitation of autologous cell therapy in diabetic patients, and could be useful for treatment of not only wounds but also other ischemic diseases. Stem Cells Translational Medicine 2018;7:428-438.

Mammary Analogue Secretory Carcinoma Arising in the Parotid Gland of Child.

Mammary analogue secretory carcinoma (MASC) of salivary glands is a newly recognized tumor entity. We report a child who was initially diagnosed with lymphangioma and referred to our institute for sclerotherapy, only to find out that the tumor was in fact MASC after excision. This case of MASC is in a 7-year-old boy, the youngest case so far reported. He referred to his primary care physician with a infra-auricular swelling, and it was diagnosed as lymphatic malformation he was referred to our institution for sclerotherapy. For Doppler and ultrasound magnetic resonance imaging, there was a distinct cystic lesion with a heterogeneous solid lesion inside. Minimally invasive treatment such as sclerotherapy was thought to be more desirable due to a pediatric case, the risk of postoperative facial paralysis and scar. However, even the successful treatment of cystic lesion with sclerotherapy, solid lesion of the tumor could be remained without pathological findings. Otolaryngologist also thought the importance of pathological diagnosis, and we finally chose surgical excision. The tumor was ultimately diagnosed as MASC considering histological and genetic findings. For child case, we tend to treat patient less invasively, and it might bring a risk of MASC being incorrectly treated nonsurgically such as with sclerotherapy. This could lead to tumor progression and wider radical excision at last. We believe that histological diagnosis should become the priority in similar cases of mixed solid and cystic tumors to avoid incorrect treatment, and we need to choose surgical excision by understanding the character of salivary gland tumor occurring in childhood.

The Relationship between Neurite Density Measured with Confocal Microscopy in a Cleared Mouse Brain and Metrics Obtained from Diffusion Tensor and Diffusion Kurtosis Imaging.

PURPOSE: Diffusional kurtosis imaging (DKI) enables sensitive measurement of tissue microstructure by quantifying the non-Gaussian diffusion of water. Although DKI is widely applied in many situations, histological correlation with DKI analysis is lacking. The purpose of this study was to determine the relationship between DKI metrics and neurite density measured using confocal microscopy of a cleared mouse brain. METHODS: One thy-1 yellow fluorescent protein 16 mouse was deeply anesthetized and perfusion fixation was performed. The brain was carefully dissected out and whole-brain MRI was performed using a 7T animal MRI system. DKI and diffusion tensor imaging (DTI) data were obtained. After the MRI scan, brain sections were prepared and then cleared using aminoalcohols (CUBIC). Confocal microscopy was performed using a two-photon confocal microscope with a laser. Forty-eight ROIs were set on the caudate putamen, seven ROIs on the anterior commissure, and seven ROIs on the ventral hippocampal commissure on the confocal microscopic image and a corresponding MR image. In each ROI, histological neurite density and the metrics of DKI and DTI were calculated. The correlations between diffusion metrics and neurite density were analyzed using Pearson correlation coefficient analysis. RESULTS: Mean kurtosis (MK) (P = 5.2 × 10-9, r = 0.73) and radial kurtosis (P = 2.3 × 10-9, r = 0.74) strongly correlated with neurite density in the caudate putamen. The correlation between fractional anisotropy (FA) and neurite density was moderate (P = 0.0030, r = 0.42). In the anterior commissure and the ventral hippocampal commissure, neurite density and FA are very strongly correlated (P = 1.3 × 10-5, r = 0.90). MK in these areas were very high value and showed no significant correlation (P = 0.48). CONCLUSION: DKI accurately reflected neurite density in the area with crossing fibers, potentially allowing evaluation of complex microstructures.