In the face and neck, keloid scar distribution is related to skin thickness and stiffness changes associated with movement.

Keloid scars tend to occur in high-tension sites due to mechanical stimuli that are involved in their development. To date, a detailed analysis of keloid distribution focused specifically on facial and neck areas has not been reported, and limited literature exists as to the related mechanical factors. To rectify this deficiency of knowledge, we first quantified the facial and neck keloid distribution observed clinically in 113 patients. Subsequently, we performed a rigorous investigation into the mechanical factors and their associated changes at these anatomic sites in healthy volunteers without a history of pathologic scarring. The association between keloid-predilection sites and sebaceous gland-dense and acne-prone sites was also examined. To assess skin stretch, thickness and stiffness, VECTRA, ultrasound and indentometer were utilised. Baseline skin stiffness and thickness were measured, as well as the magnitude of change in these values associated with facial expression and postural changes. Within the face and neck, keloids were most common near the mandibular angle (41.3%) and lateral submental (20.0%) regions. These areas of increased keloid incidence were not associated with areas more dense in sebaceous glands, nor linked consistently with acne-susceptible regions. Binomial logistic regression revealed that changes in skin stiffness and thickness related to postural changes significantly predicted keloid distribution. Skin stiffness and thickness changes related to prolonged mechanical forces (postural changes) are most pronounced at sites of high keloid predilection. This finding further elucidates the means by which skin stretch and tension are related to keloid development. As a more detailed analysis of mechanical forces on facial and neck skin, this study evaluates the nuances of multiple skin-mechanical properties, and their changes in a three-dimensional framework. Such factors may be critical to better understanding keloid progression and development in the face and neck.

The effects of systemic diseases, genetic disorders and lifestyle on keloids.

Keloid are a fibroproliferative disorder caused by abnormal healing of skin, specifically reticular dermis, when subjected to pathological or inflammatory scars demonstrating redness, elevation above the skin surface, extension beyond the original wound margins and resulting in an unappealing cosmetic appearance. The severity of keloids and risk of developing keloids scars are subjected to elevation by other contributing factors such as systemic diseases, general health conditions, genetic disorders, lifestyle and natural environment. In particular, recently, daily physical work interpreted into mechanical force as well as the interplay between mechanical factors such as stress, strain and stiffness have been reported to strongly modulate the cellular behaviour of keloid formation, affect their location and shape in keloids. Herein, we review the extensive literature on the effects of these factors on keloids and the contributing predisposing mechanisms. Early understanding of these participating factors and their effects in developing keloids may raise the patient awareness in preventing keloids incidence and controlling its severity. Moreover, further studies into their association with keloids as well as considering strategies to control such factors may help clinicians to prevent keloids and widen the therapeutic options.

The Square-Plus Flap: A Modification to Release Long Postburn Scar Contractures.

The square flap method has been successful in releasing contracture bands at various body regions. However, the original square flap method alone may not be efficient in releasing long contracture bands. We, therefore, proposed an extended design to the traditional design, which is called the "square-plus flap." A 4-year-old girl presented with a postburn web-like contracture band over the right axilla. We marked a square flap technique at the center of the contracture band and then two additional Z-plasties were placed on both edges of the flap. After the release and securing of the square flap, the adjacent distal Z-plasty was then transposed and sutured in their new locations. We do not need to incise the proximal Z-plasty as we could achieve complete relaxation of the contracture band. This novel modification can be added to the plastic surgeon's armamentarium for releasing long postburn contracture bands involving distinct body regions.

Posterior Auricle Bilobed Cartilage-skin Flap for Reconstructing the Earlobe: A Case Report.

Because the auricle plays an important role in facial aesthetics, all earlobe operations must seek to limit postoperative ear deformity. This report describes the single-stage posterior-auricle bilobed cartilage-skin flap technique for reconstructing the earlobe. A 31-year-old man incurred a left earlobe deficiency due to a human bite. Earlobe reconstruction was conducted 102 days later. A bilobed flap was designed on the posterior-auricular skin. Both flaps were pedicled in the caudal posterior-auricular area. The first incision raised the upper lobe, which consisted of posterior-auricle skin and conchal cartilage. The skin was sutured to the auricle base so that it formed the anterior earlobe. The cartilage was then cut to separate and processed to the natural curve. The second incision elevated the second flap from the caudal posterior-auricular area. This was sutured to the first flap so that it formed the posterior earlobe. The donor sites were closed with simple sutures. The reconstructed earlobe had no obvious contracture after surgery. Most donor-site scarring was hidden behind the auricle. At 9 months postoperative, the patient was satisfied with the result. Our technique allows us to harvest cartilage from the same operative field, perform a single-stage reconstruction, and recreate a relatively large earlobe with good size and shape. The posterior auricle bilobed cartilage-skin flap technique is useful for earlobe reconstruction.

Ear Keloid as an Unusual Complication of Prolonged Mask Use during the COVID-19 Pandemic.

The recent COVID-19 pandemic required many people to wear ear-loop face masks (ELFMs) for protracted periods, and ear injuries have been reported. Here, we report a rare case of a keloid on the right posterior ear that appeared to arise from prolonged ELFM use. A 76-year-old Japanese man presented with a 7.3 × 2.2 × 1.4-cm keloid running from the medial retroauricular sulcus to the posterior lobule. The lack of keloid history suggested the absence of genetic risk factors. The patient reported extensive mask-wearing habits that were augmented by the pandemic. The keloid developed from an ear injury. Although it healed well, it started thickening 2 months later. Because local mechanical forces (eg, pressure/friction) can promote keloid growth, the ELFM may have provoked the keloid. The patient disclosed a history of uncontrolled hypertension and diabetes mellitus, which associate with severe keloids. The whole keloid was removed via total excision, and the defect was closed primarily and subjected to 15Gy/2Fr radiotherapy. The patient was advised to use a different mask type. Twelve months later, the scar had healed without complications or recurrence and with good cosmetic outcomes. Thus, ELFMs can promote retroauricular keloid formation, possibly by imposing local pressure/friction. ELFMs may also raise local skin temperatures and humidity, thereby fostering infection, which can trigger keloids. Hypertension/diabetes may further elevate the risk of EFLM-induced keloid. Thus, an auricular keloid is an unusual complication of prolonged ELFM use. Combination therapy can have excellent outcomes. Patients with keloid risk factors should be advised to use face masks without ear loops.

Cheek Reconstruction with a Nasolabial External-Rotation Flap.

It remains difficult to reconstruct large preauricular defects in a single step with good cosmetic outcomes. We describe here the nasolabial external-rotation (NER) flap, which was combined with a cervical-rotation flap to reconstruct a large skin defect on the preauricular area that included the malar prominence. The patient in case 1 was a 91-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Three weeks after excision, the 6.5 × 5.5 cm defect was covered with a 5 × 3 cm NER flap, which had a cephalad base and was rotated so its caudal tip covered the malar prominence. The resulting nasolabial defect and the remaining defect occupied the entire buccomandibular area, which was then covered with a 13 × 10 cm cervical-rotation flap. Revision surgery has not been needed for 8.5 months and the cosmetic outcomes are good. The patient in case 2 was a 90-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Four weeks after excision, the 4.7 × 4 cm defect was covered with an 8 × 3 cm NER flap. The buccomandibular defect was covered with a 9.5 × 5 cm cervical-rotation flap. The flaps survived completely. The NER flap is unique because the flap is moved from the midface to the lateral face. It can reconstruct the malar prominence with thick skin tissue, and it is particularly suitable for older patients. Combining it with a cervical-rotation flap allows for natural subunit reconstruction in a relatively minimally invasive manner with good aesthetic outcomes.

168 Cases of aneurysmal dermatofibroma and 29 cases of hemosiderotic dermatofibroma: A clinicopathologic study.

OBJECTIVES: Aneurysmal dermatofibroma (ADF) and hemosiderotic dermatofibroma (HDF) are rare variants of dermatofibroma (DF) characterized by distinct histologic features. While HDF is traditionally considered a precursor to ADF, supporting evidence is limited, and the etiology remains unclear. A retrospective analysis of 2128 DF cases (2016-2019) was conducted to investigate the clinicopathologic characteristics of ADF, HDF, and other DFs. METHODS: Histopathologically diagnosed DF cases were examined for ADF and HDF. Univariate analyses were performed to compare clinicopathologic features. RESULTS: Among the cases, 168 (7.9%) were ADF and 29 (1.4%) were HDF. Aneurysmal dermatofibroma and HDF shared several common characteristics, including lower occurrence in females, larger size, and increased cellularity (all P < .0001). Notably, 29% of ADFs lacked hemosiderin deposition. Aneurysmal dermatofibroma primarily manifested on exposed areas (face and forearm, both P < .001). In contrast, 41% of HDFs occurred on the lower leg (P = .018), and all lower leg HDFs exhibited signs of venous stasis, distinguishing them from other HDFs (P < .0001). CONCLUSIONS: Our findings indicate a potential close relationship between ADF and HDF. Contrary to conventional beliefs, we also presented the possibility of ADF progressing into HDFs. Physical trauma may induce ADF, and HDFs may emerge from ADFs in conjunction with venous stasis in the lower extremities.

Continuous glucose monitoring metrics following sub-Tenon's injection of triamcinolone acetonide for diabetic macular edema.

PURPOSE: This pilot study aims to comprehensively evaluate the effects of sub-Tenon's injection of triamcinolone acetonide (STTA) on glycemic control in patients with diabetic macular edema (DME) using professional continuous glucose monitoring (CGM). METHODS: This retrospective study analyzed changes in glycemic control in 20 patients with type 2 mellitus and DME following single STTA (20 mg/0.5 mL) using The FreeStyle Libre Pro system. Professional CGM provides core CGM metrics such as the percentage of time that glucose levels fall within a target range and include the time in range (TIR) (70-180 mg/dL), time above range (TAR) (> 180 mg/dL), and time below range (TBR) (< 70 mg/dL). Outcome measures were the changes in CGM metrics (TIR, TAR and TBR) and the percentage of patients in whom TAR increased by at least 10 percentage points (ppt) 4 days before to 4 days after STTA administration. RESULTS: The mean CGM metrics (TIR/TAR/TBR) were 75.5%/19.9%/4.4% 4 days before STTA and 73.7%/22.4%/3.5% 4 days after STTA; the metrics 4 days before and 4 days after STTA were not significantly different (P = 0.625 for TIR, P = 0.250 for TAR, and P = 0.375 for TBR). TAR increased by more than 10 ppt in four (20%) patients treated with sulfonylurea and/or insulin. CONCLUSION: Although there were no significant changes in the CGM metrics, four patients developed CGM-measured hyperglycemia after STTA for DME.

The HEDGEHOG-GLI1 pathway is important for fibroproliferative properties in keloids and as a candidate therapeutic target.

Keloids are benign fibroproliferative skin tumors caused by aberrant wound healing that can negatively impact patient quality of life. The lack of animal models has limited research on pathogenesis or developing effective treatments, and the etiology of keloids remains unknown. Here, we found that the characteristics of stem-like cells from keloid lesions and the surrounding dermis differ from those of normal skin. Furthermore, the HEDGEHOG (HH) signal and its downstream transcription factor GLI1 were upregulated in keloid patient-derived stem-like cells. Inhibition of the HH-GLI1 pathway reduced the expression of genes involved in keloids and fibrosis-inducing cytokines, including osteopontin. Moreover, the HH signal inhibitor vismodegib reduced keloid reconstituted tumor size and keloid-related gene expression in nude mice and the collagen bundle and expression of cytokines characteristic for keloids in ex vivo culture of keloid tissues. These results implicate the HH-GLI1 pathway in keloid pathogenesis and suggest therapeutic targets of keloids.

Scars.

Wound healing occurs as a response to disruption of the epidermis and dermis. It is an intricate and well-orchestrated response with the goal to restore skin integrity and function. However, in hundreds of millions of patients, skin wound healing results in abnormal scarring, including keloid lesions or hypertrophic scarring. Although the underlying mechanisms of hypertrophic scars and keloid lesions are not well defined, evidence suggests that the changes in the extracellular matrix are perpetuated by ongoing inflammation in susceptible individuals, resulting in a fibrotic phenotype. The lesions then become established, with ongoing deposition of excess disordered collagen. Not only can abnormal scarring be debilitating and painful, it can also cause functional impairment and profound changes in appearance, thereby substantially affecting patients' lives. Despite the vast demand on patient health and the medical society, very little progress has been made in the care of patients with abnormal scarring. To improve the outcome of pathological scarring, standardized and innovative approaches are required.

A Case of Axillary Fibroadenoma That Grew Rapidly from Axillary Accessory Breast Tissue over 40 Days.

Axillary accessory breast (AAB) occurs in 2%-6% of women. Like normal breast tissue, ABB can undergo changes, including periodic enlargement that can result in a palpable axillary mass. Fibroadenoma is the most common benign subcutaneous tumor of the breast: it occurs in approximately 25% of women and accounts for 50% of all breast biopsies. However, fibroadenoma in AAB is rare (2.6%). Here, we describe the case of a patient who was diagnosed first with left AAB on the basis of clinical and magnetic imaging resonance findings, and then 40 days later with fibroadenoma in left AAB by histopathology of the resected mass. The tumor, which had been undetectable at the initial visit, had transformed into a clinically obvious, hard, protruding mass at surgery. Thus, fibroadenomas originating from AAB can grow quickly, and imaging-based diagnosis should be confirmed with histology. Treatment should involve complete excision of the fibroadenoma and surrounding AAB.

Utilizing 3D Printing for the Surgical Management of Orbital Floor Fractures.

We present a technique for treating orbital floor fractures using three-dimensional (3D) printing technology and a preoperative template based on the mirror image of the unaffected orbit. Our patient, a 56-year-old man, experienced persistent diplopia in the upward direction and left enophthalmos after previous open reduction internal fixation surgery. To address these complications, we used a simulation of the ideal orbital floor from computed tomography images and used a 3D printer to create a template. Subsequently, an absorbable plate was molded intraoperatively based on this template. Notably, the plate fit seamlessly into the fracture site without requiring any adjustment, reducing the operation time. Postoperative computed tomography scans confirmed successful reduction, improved visual function, and the absence of complications. Our method offers a precise and efficient approach to reconstructing fractured orbital floors. By leveraging 3D printing technology and preoperative templates, surgeons can enhance postoperative outcomes and minimize patient burden. Further investigations are warranted to assess the long-term effectiveness and cost-effectiveness of this technique. Our findings highlight the potential of this approach to improve treatment strategies for patients with orbital floor fractures.

Adherent Abdominal Scar Revision Does Not Require Total Scar Removal.

Abdominal surgery can cause notable scars that adhere to the abdominal tissues below. Full scar removal is generally not recommended due to the risk of intestinal damage and delayed wound healing. Here, we describe a surgical scar-revision procedure for adherent abdominal scars that does not involve either opening the abdominal cavity or total scar removal. A 58-year-old woman exhibited an aesthetically displeasing hypertrophic adherent abdominal scar that extended from the umbilical fold to the pubic area and distorted the umbilicus. It arose from multiple laparotomies for hernia repair and subsequent complications. Pain/discomfort and functional impairment were absent. Scar-revision surgery was conducted under general anesthesia. The skin around the adherent scar was excised down to the subcutaneous layer with a minimal margin. However, only the epidermis and superficial dermal layer of the adherent scar were removed; the deep scar dermis remained. The skin flaps on either side of the midline were then advanced and sutured over the remnant dermis. One year after surgery, the aesthetic and functional outcomes were excellent. Furthermore, no hypertrophic scars or epidermal cysts were found. This technique is effective, efficient, does not involve intraabdominal procedures, provides a vascularized tissue layer, and results in an aesthetically pleasing scar.

Geometric Wire-frame Fixation of Skin Grafting for Lip Reconstruction.

Postoperative fixation is required for skin grafts on mobile sites. External wire-frame fixation technique has demonstrated a beneficial role for grafts in specific areas such as lips, eyelids, and fingers. Although this technique is sufficient in most cases, patients with psychosis fail to maintain the lip in resting position, which led us to consider using a more rigid fixation method, known as "Geometric wire-frame fixation." Surgical technique included fixing a perimeter frame around skin graft similar to the conventional external wire-frame fixation. In addition, a geometric frame was prepared to divide the area of the graft geometrically. Then, it was placed on gauze to compress the grafted skin, and connected to the perimeter frame. In case 1, a 33-year-old man with a history of schizophrenia and presenting with flame burn injury sustained while attempting suicide was admitted. The scar on the lips was excised, and an external wire-frame fixation was performed. However, postoperative vigorous mouth movements caused incomplete survival of the skin graft. Geometric wire-frame fixation was performed in the next operation, and the graft fully survived. The patient in case 2 was a 62-year-old man who developed a facial scar contracture after chemical injury by sulfuric acid. We performed geometric wire-frame fixation with contracture release of the upper lip, and the skin graft was fully taken. The geometric wire-frame fixation method allows for rigid fixation of the skin graft and can be considered as a valuable option, especially for lip reconstruction in poorly compliant patients who are unable to maintain proper resting lips.

A Case of Takotsubo Cardiomyopathy after Dermal Burn on the Face and Hands.

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or broken heart syndrome, generally has a good prognosis but occasionally causes serious complications. It is often triggered by physical and emotional stressors. Burns have been associated with takotsubo cardiomyopathy in six cases in the literature. We report here the seventh case. The patient, an 86-year-old woman with burn injuries to her face and hands due to a fire in her home, developed takotsubo cardiomyopathy. The condition was suspected soon after presentation due to precautionary electrocardiogram and then laboratory findings of elevated myocardial biomarkers. The diagnosis was then confirmed by left ventriculography. The cardiomyopathy resolved spontaneously without complications. The burn in our patient affected only 5% of total body surface area, but its impact may have been augmented by emotional stress caused by the patient losing her home in the fire. Our review of the six burn-related takotsubo cardiomyopathy cases in the literature showed that two of the cases also had small burns in combination with severe emotional stress. Since all six cases developed serious complications, the possibility of takotsubo cardiomyopathy should be suspected, even with small burns.

Combined thoraco-laparoscopic hepatectomy concomitant with resection of the diaphragm for solitary peritoneal seeding from cervical cancer: A case report.

Combined thoraco-laparoscopic resection can aid in precise resection of an invasive tumor of the diaphragm. A 44-year-old woman was referred to our department for resection of solitary peritoneal seeding from cervical cancer following systemic chemotherapy. The tumor was located in the right diaphragm with an ill-defined border of the liver. Combined thoraco-laparoscopic resection was proposed. Laparoscopy portrayed that the right diaphragm was partially attached to the liver, and the depth of tumor invasion to the diaphragm was ambiguous. Observation from the thoracic cavity indicated a white-colored distortion following the location of peritoneal seeding. Partial resection and repair of the diaphragm were made using the thoracoscopic-assisted approach, followed by laparoscopic hepatectomy. The postoperative course was uneventful, and pathological findings revealed that peritoneal metastases of the diaphragm and surgical margin was negative for cancer. Combined thoraco-laparoscopic resection can cover the drawbacks of each approach and is among the options for minimally invasive surgery for invasive tumor of the diaphragm.

Lumbar Sympathetic Ganglion Block Facilitates Wound Healing in a Rat Ischemic Hindquarter Model.

Lumbar sympathetic nerve block (LSNB) improves blood flow in the lower limbs and relieves pain involving the sympathetic afferents. This study examines the use of LSNB, but there are no reports of its use for the purpose of wound healing. Therefore, the authors planned the following study. Methods: An ischemic limb ulcer was created on both lower limbs using a rat model (N = 18). The rats were divided into three groups, namely, A, B, and C. Group A received LSNB on one side (N = 6). Group B was sprayed with basic fibroblast growth factor preparation (trafermin/fiblast) on one side (N = 6). Group C was used as a control (N = 6). Lower limb temperature and the ulcer area were measured over time in each group. Furthermore, the correlation between the ulcer temperature and the ulcer area reduction rate was analyzed. Results: Group A had higher skin temperature on the LSNB-treated side than on the nontreated side (P = 0.0022 < 0.05). Regarding the correlation between the average temperature and the ulcer area reduction rate, the correlation coefficient was as high as 0.691 in group A. Conclusions: In the LSNB group, the skin temperature increased and the ulcer area decreased significantly. Conventionally, LSNB has been used for pain relief purposes, although the authors consider that it will be useful in the treatment of ischemic ulcers and that it is a potential treatment option for future chronic limb ischemia/chronic limb-threatening ischemia cases.

Applied Usage and Tips of High Stretch Fixation NPWTi-d for Sternal Osteomyelitis.

Sternal osteomyelitis is a rare but devastating complication of median sternotomy. To achieve good outcomes, it should be diagnosed early and treated appropriately. Standard treatment involves antibiotics, debridement, and reconstruction with flaps. To prevent flap complications and recurrence, the wound bed must be prepared carefully. One approach, a recent development, is negative pressure wound therapy with instillation and dwell time (NPWTi-d), where suction cycles are interspersed with wound instillation with solutions. NPWTi-d is currently cautioned against for large trunk wounds and cavities because it might alter core body temperature. Here, we report a new NPWTi-d dressing technique that is associated with successful reconstruction in two severe sternal osteomyelitis cases with wound sizes of 29 × 10 and 28 × 8 cm. This "delay-dressing technique" involves manually pulling the wound edges together; inserting a thin strip of dressing foam; applying dressing film strips from one side of the chest wall to the other, thus placing strong stretching tension on the normal skin around the wound; and then applying NPWTi-d. In our cases, we used the V.A.C. Ulta system for 20 and 17 days. The successful reconstruction in both cases may reflect good wound bed preparation and flap preconditioning due to the mechanical stress imposed by NPWTi-d. Thus, this dressing technique with the V.A.C. Ulta system may be an effective treatment option for sternal osteomyelitis cases.

Congress Report on the Second World Congress of Global Scar Society with Scar Academy and Japan Scar Workshop.

Pathological scars (including keloids, hypertrophic scars, and scar contractures) are present with high severity among certain populations, particularly in Asians and Africans who are highly prone to develop scars. Understanding the patho-mechanism that underlies scarring, such as mechanosignaling, systemic, and genetic factors, as well as optimal surgical techniques and integrated noninvasive therapeutic methods can guide clinicians to develop treatment protocols that can overcome these issues. This report summarizes a congress at Pacifico Yokohama (Conference Center) on December 19, 2021 involving researchers and clinicians from diverse disciplines who convened to discuss current clinical, preclinical, and most recent research advances in understanding pathological scarring, keloid and hypertrophic scar management, and research progress in wound healing. Presenters described the advances in scar therapies, understanding scarring mechanisms, and scar prevention and assessments tools. Moreover, presenters addressed the challenges during the COVID-19 pandemic and using telemedicine in management of scar patients.

Factors affecting polyglycolic acid sheet engraftment success for covering mucosal defects from head and neck surgery.

BACKGROUND: Polyglycolic acid (PGA) sheets have been used with fibrin glue to cover extensive mucosal defects in oral and pharyngeal surgery; however, the sheets can fall off before wound healing is completed. Hence, prolonged fasting is often recommended in such patients. However, there are few studies on the factors that shape PGA sheet engraftment. We studied sheet engraftment rates considering these factors. METHODS: All consecutive cases of oral surgery in 2013-21 in which the defect was covered with fibrin glue and Neoveil® or Neoveil Nano® PGA sheets were identified. The loss of all sheets was defined as an engraftment failure. Multiple logistic regression analysis was conducted to identify whether the PGA-sheet type, application site, defect size and postoperative fasting duration predicted engraftment. RESULTS: Overall, 137 patients were identified (mean age, 73 years; 57% male). The surgeries were conducted with Neoveil® in 66% of the patients; the most common site was the buccal mucosa (25%), and the mean defect size and fasting duration were 709 mm2 and 4 days, respectively. The engraftment rate was 76%. Neoveil Nano® PGA sheets were associated with a 2.8-fold better engraftment rate than Neoveil® (univariate: 87 vs. 70%, P = 0.032; multivariate: 95% confidence intervals = 1.067-7.410, P = 0.036). Other variables, including fasting duration, were not predictive of engraftment. CONCLUSIONS: This is the largest case series of patients with head and neck cancer who underwent fibrin glue-PGA sheet defect coverage. The fasting duration did not influence engraftment. Therefore, early oral intake is not contraindicated in such patients.