Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018.

There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.

The rare sugar D-allose has a reducing effect against ischemia-reperfusion injury on the rat abdominal skin island flap model.

BACKGROUND: Recently, one of the rare sugars, D-allose, has received attention from many researchers because of its availability for mass production and its various physiological functions. Among these, an antioxidative effect has been strongly suggested. In this study, we investigated whether this effect is also applicable to the field of skin surgery. METHODS: In ischemia-reperfusion injury model using the rat abdominal skin island flap (male Wistar rats, n = 110), D-allose was injected intravenously 15 min before 8-h ischemia. The survival area (%) was measured by digital photographic assessment 1 wk after surgery, and multiple comparisons (Fisher's protected least significant difference) were carried out. Histopathological examination (neutrophilic infiltration into dermis in hematoxylin and eosin stain) and immunostaining (of ectodermal dysplasia-1 (ED1)-positive cells/flap) were assessed. Myeloperoxidase (MPO) activity in the skin flap (sampling at the time of 8 h after reperfusion) was measured spectrophotometrically, and Student t-test was performed. RESULTS: D-allose extended the survival of the remaining flaps, and a dose greater than 30 mg (0.1 mg/g) was necessary to be effective. The flap survival rates in the 30, 60, and 150 mg groups were significantly higher than that in the control (saline) group: 75.87 ± 5.90, 79.27 ± 7.81, and 77.87 ± 6.20 versus 50.53 ± 9.66, respectively (P < 0.05). ED1-positive cells/flap in 60 mg of D-allose and control (saline) were 78 ± 25.7 versus 124 ± 15.8, respectively (P = 0.08). The MPO activity in the D-allose 60 mg group was 0.40 ± 0.04, and that in the control (saline) was 0.72 ± 0.12. D-allose significantly reduced the skin tissue MPO activity (P < 0.05) compared with that in the control (saline) group. CONCLUSIONS: We proved that D-allose has a reducing effect against ischemia-reperfusion injury on the skin island flap model, and the mechanism is related to inhibiting the activity of neutrophils in the skin tissues. Compared with chemo-synthetic materials, rare sugars are safer for our bodies as well as the environment; therefore, this rare sugar project is expected to lead to the development of a safer antioxidant for skin flap surgery.

Keloids can be forced into remission with surgical excision and radiation, followed by adjuvant therapy.

We have treated keloids using a combination of surgical excision and postoperative irradiation. The objective of this study was to evaluate the results of our treatment over 12 years. From 1995 until 2006, we treated keloids using the aforementioned treatment. If we identified a sign of recurrence during the follow-up period, we started an intralesional injection of triamcinolone acetonide immediately. We selected 91 keloids for which we had more than 2 years of follow-up data for this study and assessed the results according to our original scale (Kyoto scar scale) based on objective and subjective symptoms. In all, 51 keloids (56.0%) were cured completely by a combination of surgical excision and postoperative irradiation without additional treatment, and finally 81 keloids (89.0%) showed good results with additional treatment. Keloids are a controllable condition when treated with combination therapy, involving surgical excision with postoperative irradiation and early conservative treatment after the detection of recurrence.

Indication for skin-sparing mastectomy with or without nipple preservation for primary breast cancer.

Skin-sparing mastectomy (SSM) is one of the available operation methods for breast cancer. We discuss here indications for SSM for primary breast cancer. We carried out SSM for 28 patients with breast cancer. Their clinical features were compared with those in patients who underwent breast-conserving treatment (BCT). Fifteen of the 28 patients received SSM according to schedule. The remaining 13 patients who were scheduled to undergo BCT received SSM because of involvement of the surgical margin. Clinical features indicating suitability for SSM included extensive intraductal cancer growth and multicentricity. The length of intraductal cancer growth in these patients was significantly greater than that in 24 patients who received BCT (2.28 versus 0.571 cm; P = 0.000078). Tumor size and tumor-nipple distance were not indicating factors for this treatment. SSM, which is advantageous in terms of aesthetic outcome and oncologic safety, may be widely indicated after careful evaluation by magnetic resonance imaging or pathologic examination.

Obliteration of empyema space by vascularized anterolateral thigh flaps.

Closure of the fistula and an appropriate choice of obliterating agents are crucial for the treatment of empyema with bronchopleural fistula. The choice of the material to be used for obliteration of the pleural space is a difficult one in some patients, such as those with empyema, developing after omentectomy, laparotomy, posterolateral thoracotomy, and so forth. The use of free anterolateral thigh flaps for obliteration of the pleural space generally needs a satisfactory vascular network around the thorax. We report two successfully treated cases of empyema with bronchial fistula, which were otherwise difficult to manage, in which a free anterolateral thigh musculocutaneous flap anastomosed to the superior thyroid vessels used to obliterate the pleural space.

Dissociation of sexual function and sexual bother following autologous sural nerve grafting during radical prostatectomy.

AIM: We prospectively investigated health-related quality of life (HR-QOL), including sexual function and sexual bother, in patients who underwent nerve grafting during a radical prostatectomy in comparison with those who underwent a non-nerve-sparing radical prostatectomy. METHODS: Between August 2001 and May 2004, radical prostatectomies were performed on 69 patients with clinical T1-T2N0/M0 prostate cancer. Of these, 66 patients (22: nerve-grafting patients, 44: non-nerve-sparing and non-nerve-grafting patients) were enroled into this study. The observation periods ranged from 12-46 months (median: 29 months). The general HR-QOL was measured with the SF-36 General Health Survey and disease-specific HR-QOL was measured with the University of California Los Angeles-Prostate Cancer Index. RESULTS: Penile tumescence was observed in 11 out of 15 (73.3%) prostate-specific antigen failure-free patients who underwent unilateral nerve grafting with contra-lateral nerve-sparing or bilateral nerve grafting. Vaginal penetration was observed in six out of 15 (40.0%) patients. The time for partial erection and for intercourse, respectively, ranged from 3-21 months (median = 6 months) and 6-36 months (median = 13.5 months). There were no significant differences in general HR-QOL changes over time between the nerve-grafting patients and the patients without any nerve-preserving procedures. The sexual function score was significantly better in the nerve-grafting (bilateral nerve graft or unilateral nerve graft with contra-lateral nerve-sparing) patients than in the non-nerve-sparing/non-nerve-grafting patients. The sexual bother score, however, was more serious for the patients who underwent nerve-grafting surgery than for the non-nerve-sparing/non-nerve-grafting patients. CONCLUSION: Sexual bother is serious for patients who attempt to maintain sexual function after special surgical procedures, such as nerve-grafting surgery. We should be aware that careful counseling is needed to avoid impatient and excessive hope for the recovery of sexual function.

Japanese family with Greig cephalopolysyndactyly syndrome, including bilateral seven toes, and esotropia, over three generations.

We report a Japanese family with Greig cephalopolysyndactyly syndrome (GCPS), in which the grandmother, mother, and daughter were affected. They each had the same characteristics including bilateral seven toes, hypertelorism, and esotropia. Bilateral seven toes and esotropia had followed over three generations and have not previously been reported in this syndrome. The present case with bilateral seven toes and esotropia may be a new type.

Long-term outcome of intralesional injection of triamcinolone acetonide for the treatment of keloid scars in Asian patients.

We studied the long-term outcome of injection of triamcinolone acetonide into keloid scars in Asian patients. Between 1985 and 2003, we treated 109 keloid scars in 94 patients by injecting 1 to 10?mg of triamcinolone acetonide depending on the size of the lesion at four week intervals. There was little morbidity. Thirty-one patients gave up treatment within 10 injections because of pain and lack of immediate improvement. Improvement in subjective symptoms was seen in 52 of the remaining 63 patients (82%). In objective symptoms, fair or better results were seen in 40 of 63 (63%), and good or better results in 25 of 63 (39%). The treatment method required 20-30 injections over three to five years. Although we did not achieve as good results as other authors, we think it was safer because we used a smaller dose of a steroid.

Postoperative complications and long-term prognosis of microsurgical reconstruction after total maxillectomy.

Between 1986-2004, 13 patients (11 males and 2 females; mean age, 63.9 years) underwent microsurgical reconstruction after total maxillectomy in our hospital. Reconstructions using a rectus abdominis musculocutaneous flap were primarily carried out in our hospital by emphasizing soft-tissue filling. No postoperative complication related to a vascular anastomosis (such as thrombosis) was noted (success rate, 100%). In 3 cases, fistula formation was observed postoperatively (23.0%). In one case reconstructed with a scapular flap with a vascularized scapula, atelectasis followed by serious pneumonia was observed, and the patient temporarily fell into a life-threatening condition. Five patients died after 1-2 years due to recurrence of maxillary sinus carcinoma, and 2 died after 3-4 years due to another tumor (lung and esophageal). The disease-specific 5-year survival rate of all 40 patients with maxillary sinus carcinoma treated in our hospital by the Kaplan-Meier method was 54.6%, and the overall survival rate was 45.8%. As the prognosis of maxillary sinus carcinoma is poor, we consider that priority should be given to filling of defects with soft tissues, and we also consider that this study is significant to reevaluate strategies for maxillary reconstruction.

Aluminum foil treatment combined with basic fibroblast growth factor (bFGF) for gangrene of the fingertip caused by collagen disease.

Although basic fibroblast growth factor (bFGF) is used for the treatment of various intractable ulcers, there have been no reports of using it for gangrene of the fingertips caused by collagen diseases. We successfully treated gangrene as a result of malignant rheumatoid arthritis with aluminum foil combined with bFGF.

Cavernous nerve reconstruction during radical prostatectomy by sural nerve grafting: surgical technique in nerve harvesting and grafting.

The authors performed cavernous nerve reconstruction by nerve grafting in 22 patients (unilateral-16, bilateral-6) between August 2001 and June 2004. Harvesting of the sural nerve was unexpectedly more difficult than nerve grafting in the extremities or the head and neck, because a knee and lumbar bending position was impossible due to the pelvic surgical field. Suture of the grafted nerve on the distal side required great effort, because there was only sufficient space for one hand at the maximum in a deep region of the pelvic cavity, and the nerve ends easily become invisible by inflow of even a small amount of urine or blood. The mean time of the nerve harvesting and grafting was 1 hr 50 min for unilateral grafting and 2 hr 40 min for bilateral grafting. Recovery of erectile function was observed in about half the patients who had undergone surgery nearly 1 year before. Since harvesting of the sural nerve and nerve grafting were more difficult than expected, modification and improvement of many surgical elements, such as improvement of surgical devices and application of endoscopic techniques, are necessary.

Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound.

For vulvar reconstruction following radical vulvectomy in a 71-year-old woman with a large vulvar cancer, we applied the deep inferior epigastric perforator flap (DIEP flap), a typical perforator flap, which could be performed by utilizing an abdominal incision wound without producing another surgical scar and had less donor site morbidity because of a minimal sacrifice of muscles. The surgical procedures were less invasive and simple, and morphologically and functionally satisfactory results were obtained: no recurrence of cancer, a well-preserved vulvar morphology with less donor site scarring, and no functional disturbance such as dysuria and abdominal hernia. We consider that the DIEP flap is the first choice for vulvar reconstruction following radical vulvectomy. Even in radical vulvectomy without an abdominal incision wound, the DIEP flap with an anatomically reliable vascular pedicle can be an effective option.

Nonmicrosurgical replantation using a subcutaneous pocket for salvage of the amputated fingertip.

PURPOSE: The pocket principle suggested by Brent in 1979 is an alternative method for use when microsurgical replantation is not feasible. The application and the amputation level for which the method is available, however, have not been well examined. METHODS: Between 1999 and 2003 we treated 6 patients (7 fingers) by nonmicrosurgical replantation using a subcutaneous pocket (the Brent technique). All patients had sustained complete fingertip amputations across or proximal to the lunula in digits other than the thumb. In every case the amputation was a crush or avulsion-type injury and microsurgical replantation was not feasible; however, cosmetic symmetry was desired strongly by the patient. RESULTS: Of the 7 fingers only one survived completely but became atrophic after 4 months. One finger developed necrosis involving less than half of the replant but a hooked nail deformity developed. Two fingers developed partial necrosis involving more than half of the replant but both fingers were missing the fingernail and the cosmetic results were not acceptable. Three fingers developed total necrosis. In addition a slight flexion contracture not improved with therapy in the digits was noted in 4 patients. CONCLUSIONS: The Brent technique should be performed scrupulously for fingertip amputation across or proximal to the lunula because of the poor survival rate and the possibility of contracture in the digits or other proximal joints.

Rubinstein-Taybi syndrome (RTS) with postaxial polydactyly of the foot: 4-year follow-up until improvement of dysbasia.

Rubinstein-Taybi syndrome (RTS), also known as 'broad thumbs syndrome' or 'broad thumb-hallux syndrome', is a malformation syndrome characterized by the triad of broad thumbs or first toes, a peculiar facial expression called 'comical face' and mental retardation. Although various malformations are combined with the triad, polydactyly is rare. We treated a male patient with RTS complicated by postaxial polydactyly of the foot. His clinical course was different from typical patients with polydactyly, especially in the aspect of walking development. Osteoplasty-combined surgery, which was ideal for anatomical reconstruction, was performed on the patient at 2 years and 11 months of age. A 4-year follow-up period was required until there was an improvement of dysbasia.

The PNB classification for treatment of fingertip injuries: the boundary between conservative treatment and surgical treatment.

The PNB classification, which was advocated by Evans and Bernadis, separates the injuries into their effects on 3 components of the fingertip: pulp, nail, and bone. Because each component is subdivided into 7 or 8 items, this can describe fingertip injuries more precisely. Between 1997 and 2003, we treated 381 fingertip injuries (279 males, 102 females; average age, 41.2 years) in our facilities. A 3-digit number was provided for each of the 381 cases in accordance with the PNB classification. We extracted patients in whom amputated tissues did not exist, and predicted the boundary between conservative treatment and surgical treatment by individually comparing the curative results of the same type of injuries. In conclusion, PNB 355-366 and PNB 455-466 were most suitable for surgical treatment, and the boundaries between surgical treatment and conservative treatment were PNB 386 and 666 and 700. The results, which are the criteria for surgical treatment, are summarized as follows; 1) More than two thirds of the distal phalanx remains. 2)The nail bed defect ranges from one third to half. If the defect is more or less than the criteria, the surgical treatment is less significant. Recognition of the boundary and prevention from unnecessary surgical treatment leads to minimum invasive surgery for fingertip injuries.

Rhomboid perforator flap for a large skin defect due to lumbosacral meningocele: a simple and reliable modification.

To date, very few studies have reported the use of perforator flaps in newborn infants with an immature vascular system. Therefore, it is not clear whether perforator flaps can be used in newborns, as in adults. In this study, we applied the perforator flap procedure to a newborn infant, who had a large skin defect due to lumbosacral meningocele. We used the rhomboid perforator flap, which was a combination of using a rhomboid flap reported by Ohtsuka et al and preserving paraspinal perforator vessels according to Thomas. Although perforator vessels were so thin as to necessitate careful dissection and flap design, a good result was obtained by this procedure. We consider that the rhomboid perforator flap is a simple and reliable procedure for the treatment of lumbosacral meningocele.