Peri-implant atypical femoral fracture after nail or plate osteosynthesis.

BACKGROUND: A lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. METHODS: We identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. RESULTS: The PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. CONCLUSIONS: PI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.

Versajet-Assisted Hydraulic Epilation Through Small Incisions for Axillary Osmidrosis.

BACKGROUND: Osmidrosis is a malodorous disease caused by the breakdown of sweat secreted from the apocrine glands by surface bacteria. The aim of this study was to evaluate the effect of Versajet-assisted hydraulic epilation for the treatment of axillary osmidrosis. METHODS: Thirty-two patients with axillary osmidrosis (64 axillae) underwent Versajet-assisted hydraulic epilation between January 2016 and January 2017. Subjective assessments were evaluated by a patient survey at least 3 months after the procedure. RESULTS: There were no complications other than one mild pigmentation in the axilla at 3 months after the procedure. Thirty-two patients evaluated malodor elimination as good. No patients evaluated it as fair or poor. There were no recurrences. CONCLUSION: Versajet-assisted hydraulic epilation is an ideal surgical procedure for the treatment of axillary osmidrosis that decreases complications and recurrence. NO LEVEL ASSIGNED: 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 .

The effects of botulinum toxin A on survival of rat TRAM flap with vertical midline scar.

The transverse rectus abdominis musculocutaneous (TRAM) flap has been widely used in various reconstructive surgeries. Recently, there have been reports regarding the positive effect of botulinum toxin A (BoTA) on flap survival. We hypothesized that pretreatment with BoTA could augment the survival of pedicled TRAM flaps with a vertical midline scar. Twenty-four Sprague-Dawley rats were randomly divided into 2 groups, namely, control group and BoTA group. Five days after a vertical midline incision, the BoTA group was pretreated with BoTA, whereas the control group was pretreated with normal saline. Ten days after the initial incision, the TRAM flap was harvested. We evaluated the gross flap survival and analyzed the overall histologic change, lumen area of pedicle, and microvessel density with immunohistochemistry. Reverse transcription polymerase chain reaction was performed for the evaluation of angiogenesis-related factors. In the BoTA group, the gross flap survival rate was significantly higher than that in the control group on both ipsilateral and contralateral sides (P < 0.001). In the BoTA group, a significant increase in pedicle lumen area was observed (P < 0.001). In the control group, mild to moderate epidermal necrosis was seen; microvessels were relatively small compared with those of the BoTA group. According to immunohistochemistry, the number of CD31 positively stained vessels was significantly higher on the contralateral side in the control group compared to that in the BoTA group (P < 0.001). The relative messenger RNA (mRNA) expression of CD31 was significantly lower in the BoTA group than that in the control group on both ipsilateral and contralateral sides (P < 0.001). Meanwhile, the relative mRNA expression of VEGF was significantly higher in the BoTA group than in the control group on both ipsilateral and contralateral sides (P < 0.001).We believe that preoperative BoTA therapy is a feasible method to improve circulation of the rat TRAM flap with a vertical midline incision scar.

The effects of sterilization methods on lyophilized cartilage grafts in an experimental model.

BACKGROUND: Cartilage graft is an effective method for reconstructing the bony framework of the face and covering the bony defect site. As a process method of cartilages, lyophilization has the advantages of long-term storage and easy handling. We hypothesized that the type of procedure used to sterilize lyophilized cartilage may affect outcomes after implantation into the body. We compared the effects of ethylene oxide (EO) gas, γ-irradiation, and autoclaving methods on cartilage grafts. METHODS: After sterilization, lyophilized human rib cartilage was inserted into subperiosteal pockets created in New Zealand white rabbit skulls. We assessed the weights and ratios of the remaining cartilage and examined histologic changes throughout the implantation period. RESULTS: Over a 5-week period, the γ-irradiated grafts remained more than the other grafts, but after more than 5 weeks, there were no significant differences between γ-irradiated and EO gas-sterilized cartilages. Autoclave-sterilized cartilages were totally resorbed at 10 weeks. CONCLUSIONS: Over 10 weeks of follow-up, based on persistence measurements and histologic appearance, there was little difference between γ-irradiated and EO gas-sterilized lyophilized cartilage used in experimental bone grafts.

Analysis of 15 cases of auricular keloids following conchal cartilage grafts in an asian population.

BACKGROUND: Recently, rhinoplasty techniques have advanced significantly and are frequently combined with columellar struts using conchal cartilage grafts to sufficiently reshape the nasal tip. For this reason, auricular keloids following harvesting of conchal cartilage grafts are expected to occur with greater frequency. The aim of this study was to share our experiences with auricular keloids and to suggest possible risk factors. METHODS: We conducted a retrospective review of patients with pathologically confirmed auricular keloids that were surgically excised with primary closure after conchal cartilage grafts were harvested. Starting between days 21 and 28 postoperatively, patients were instructed to use magnets for approximately 12 h a day for 6 months until adjuvant pressure therapy was completed. Recurrence after treatment was recorded. In all patients, a follow-up period of 18 months was required. RESULTS: Auricular keloids were successfully treated in 93.3 % of the cases and 6.7 % of the cases had recurrence. The postoperative course was uneventful without exception. There was a male predominance of auricular keloids after conchal cartilage graft harvesting. In addition, a high growth rate as a result of the short duration of the keloid before treatment was seen. CONCLUSIONS: Adjuvant pressure therapy using magnets is useful for treating auricular keloids following conchal cartilage graft harvesting. In addition, surgeons should be careful when performing conchal cartilage harvest to avoid needless injury to the adjacent skin flap. 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 .

Earlobe keloids: classification according to gross morphology determines proper surgical approach.

BACKGROUND: A previous study described the outcomes of a treatment protocol using a prospective design and identified three clinical risk factors for recurrent keloids. OBJECTIVE: To introduce a novel classification of earlobe keloids through a retrospective study and describe the appropriate surgical methods according to this new classification. METHODS: One thousand twenty-seven earlobe keloids were treated at Kangbuk Samsung Hospital from March 2001 to February 2011. All cases were studied retrospectively and classified. RESULTS: The earlobe keloids were classified into five groups. The frequency of earlobe keloids in descending order were a sessile type, single nodular pattern; pedunculated type; sessile type, multinodular pattern; buried type; and mixed type. Different surgical methods were used based on the Chang-Park classification according to gross morphology, including core extirpation using a penetrating technique, standard keloidectomy, radical keloidectomy, keloidectomy with core extirpation, and a combination of these. All cases were closed primarily without skin grafting or sacrifice of the surrounding tissue. CONCLUSIONS: This novel classification for earlobe keloids can lead to a better understanding of the different types of earlobe keloids and inform decisions regarding surgical methods.

Clinical experience with polymethylmethacrylate microsphere filler complications.

Polymethylmethacrylate (PMMA) filler is widely used for the correction of wrinkles because of its relative long-lasting cosmetic improvements and the rarity of reported complications. However, early and delayed complications, ranging from minor to severe, can occur following PMMA filler injection. We evaluated and treated 13 cases of PMMA filler-related complications that were referred to our institution from July 2005 to June 2010. Of these patients, 92.3% were female and 7.7% were male. Complications were roughly classified as (1) nodular masses, (2) inflammation, (3) allergic reactions, and (4) discoloration. Affected locations were the lips, periocular wrinkles, nasolabial folds, forehead, marionette wrinkles, and cheeks. As there is no standard treatment modality for PMMA filler complications, patients were managed with various treatments aimed at minimizing morbidity. In the cases of lip granuloma, we recommended intralesional steroid injection first, followed by surgical excision, including lip mucosa and orbicularis oris muscle in intractable cases. Additional studies should be conducted to determine the safety of PMMA injection, reduce the occurrence of adverse reactions, and identify risk factors that are associated with higher complication rates.

Clinical characteristics of facial keloids treated with surgical excision followed by intra- and postoperative intralesional steroid injections.

BACKGROUND: The physiopathogenesis of keloid scars is not well understood. This report aims to present the authors' experiences with facial keloids, to evaluate their treatment outcomes via a prospective study, and to identify risk factors involved in facial keloid recurrence. METHODS: Patients with facial keloids were treated with surgical excision followed by intra- and postoperative intralesional steroid injections at Kangbuk Samsung Hospital between July 2005 and June 2010. Of 15 keloids, 8 (53.3%) had previously been treated unsuccessfully at other hospitals. The follow-up period was 18 months, and therapeutic outcomes were evaluated based on recurrence or nonrecurrence. RESULTS: The study evaluated 17 facial keloids in 15 patients. The overall recurrence-free rate was 76.5% after a follow-up period of 18 months. The authors hypothesized that the recurrence of keloids on the face is associated with both previous treatment and anatomic location. CONCLUSIONS: The authors' protocol resulted in successful outcomes for the treatment of facial keloids. Patients with a history of previous treatment and keloids in the perioral region should be monitored closely for signs of recurrence and managed cautiously during treatment.

Three-dimensional circumferential liposuction of the overweight or obese upper arm.

UNLABELLED: Due to recent trends in liposuction, anatomic consideration of the body's fatty layers is essential. Based on this knowledge, a circumferential approach to achieving maximal aesthetic results is highlighted. In the upper arm, aspiration of fat from only the posterolateral region can result in skin flaccidity and disharmony of the overall balance of the upper arm contour. Different suction techniques were applied depending on the degree of fat accumulation. If necessary, the operation area was extended around the axillary and scapular regions to overcome the limitations of the traditional method and to achieve optimal effects. To maximize skin contracture and redraping, the authors developed three-dimensional circumferential liposuction (3D-CL) based on two concepts: circumferential aspiration of the upper arm, to which was applied different fluid infiltration and liposuction techniques in three anatomic compartments (anteromedial, anterolateral, and posterolateral), and extension of liposuction to the periaxillar and parascarpular areas. A total of 57 female patients underwent liposuction of their excess arm fat using this technique. The authors achieved their aesthetic goals of a straightened inferior brachial border and a more slender body contour. Complications occurred for five patients including irregularity, incision-site scar, and transient pigmentation. Through 3D-CL, the limitations of traditional upper arm liposuction were overcome, and a slender arm contour with a straightened inferior brachial border was produced. 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 at http://www.springer.com/00266.

Reconstructive challenge of dermatofibrosarcoma protuberans in the female breast.

Dermatofibrosarcoma protuberans is an uncommon locally aggressive malignant neoplasm that most frequently appears in the trunk, followed by the extremities, head, and neck. But occurrence in the breast is extremely rare. We present a case of a 28-year-old woman, who had a history of trauma 5 years previously and excision 1 year before presentation at our clinic. We performed wide excision, together with microscopic and immunohistochemical analysis. No postoperative oncologic treatment was used and she remains disease-free 1 year after the surgery without any tumor recurrence. Here, we report a case of dermatofibrosarcoma protuberans in the female breast and present a detailed discussion of the diagnosis and treatment with reference to available literatures.

The Lazy S Design: A Novel Skin Closure Design in Skin-Sparing Mastectomy for Implant-Based Breast Reconstruction.

Preservation of the breast skin envelope during immediate implant-based breast reconstruction is important for producing symmetrical and natural-looking breasts. We propose the lazy S design for the closure of round-shaped wounds with the hope of improving the aesthetic outcomes and reducing the tension on the wound by preserving the skin. Additionally, the direction of tension is dispersed due to the shape of this design. Patients undergoing implant reconstruction after skin-sparing mastectomy may benefit from the lazy S design.

Reconstruction of the Foot Using a Superficial Inferior Epigastric Artery Free Flap.

When foot reconstruction is performed in the pretibial area, the ankle, or the dorsum of the foot, the need for a reliable flap remains a challenge. We found that the superficial inferior epigastric artery (SIEA) free flap can be used as an alternative tool for this purpose, as it helps to solve the problems associated with other flaps. We describe 2 cases in which we reconstructed the foot using an SIEA free flap, which was pliable enough to fit the contours of the area. Postoperatively, the flaps were intact and showed excellent aesthetic results. Thus, the SIEA free flap can be an alternative tool for patients with a low body mass index who undergo reconstructive surgery involving the pretibial area, ankle, knee, or dorsum of the foot, all of which require a soft and flexible flap.

Deep-Plane Lipoabdominoplasty in East Asians.

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Methylene blue dye-induced skin necrosis in immediate breast reconstruction: evaluation and management.

BACKGROUND: For early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported. METHODS: Immediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation. RESULTS: Six cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction. CONCLUSIONS: The complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.

Histologic changes of implanted gore bio-a in an experimental animal model.

Gore Bio-A has been reported to be an ideal synthetic bioabsorbable scaffold material for hernia repair. The purpose of this study was to determine the effectiveness of Gore Bio-A in soft tissue augmentation. Six New Zealand white rabbits were used in the study. Five subcutaneous pockets were created on the back of the rabbit, and 20 × 20 mm sized square shaped Gore Bio-A sheets, each 1.5 mm, 3 mm, 4.5 mm, 6 mm, and 7.5 mm in thickness, were implanted into each pocket (1 layer to 5 layers). To analyze the morphologic and histologic changes, the implants were harvested 1, 3, and 6 months after implantation. Following the gross analysis, absorption rate was accelerated with increased implant duration and decreased thickness. Histological analysis of the implants demonstrated progressive neovascularization, fibroblast infiltration, and neocollagenation over time. Six months after implantation, Gore Bio-A was almost absorbed and degenerated, not maintaining its volume. Based on this study, Gore Bio-A was revealed as a biocompatible material; however, it is not suitable for soft tissue augmentation because it is absorbed in the process of changing into soft tissue without maintaining its own volume. Therefore, this material is incomplete and needs more study to overcome this limitation.

Clinical outcome in a series of 173 cases of foreign body granuloma: improved outcomes with a novel surgical technique.

BACKGROUND: Soft-tissue filler injections have become popular, and injections of even illegal materials are widespread. Complications such as foreign body granuloma often occur in such cases, and appropriate treatment is mandatory but no optimal treatment has been established. METHODS: We treated 173 patients who underwent surgical excision of foreign body granulomas via direct approach to the lesion (n = 121) or injection therapies (n = 52) at Kangbuk Samsung Hospital over a period of 7 years from April 2004 to February 2011. A retrospective chart review found that 104 patients had a history of treatment failure at other hospitals. Among these 104 patients, 83 had a history of prior injection therapy and 21 patients had a history of prior surgical therapy. Patient satisfaction was evaluated at our hospital on a scale of 1-5 using an in-house questionnaire. Comparisons between patients receiving injection therapy and patients receiving surgical therapy were made using the Mann-Whitney test. RESULTS: Patients who underwent surgical therapy via direct approach to the lesion reported statistically higher satisfaction scores 4(3-4) than those who underwent injection therapy 3(2-3) (p < 0.001). CONCLUSIONS: Our novel surgical technique results in better outcomes and patient satisfaction in cases of severe foreign body granuloma.

Solitary Langerhans cell histiocytosis arising from sternum: a case report.

Langerhans cell histiocytosis (LCH) is a rare idiopathic benign disease characterized by proliferation of Langerhans cells, most commonly in the skull. In extremely rare cases, the tumor can occur in the sternum. A 4-year-old girl presented to our institution with a firm, nontender mass in her anterior chest that had indolently enlarged to approximately 2 cm in diameter over the previous several months. Computed tomography, magnetic resonance imaging, and F18-flurodeoxy-glucose positron emission tomography computed tomography were performed for preoperative diagnosis, but the findings were inconclusive. Therefore, we performed surgical excision under general anesthesia, followed by microscopic and immunohistochemical analysis of the excised specimen. The mass was eventually diagnosed as a LCH arising from the sternum. No postoperative oncological treatment was given, and follow-up has continued for 1 year until the time of writing without any tumor recurrence. To our knowledge, only 10 cases of LCH arising from the sternum have been reported in the medical literature. Among them, surgical approaches including curettage and partial sternotomy were performed in only 6 cases. Without exception, all patients experienced excellent clinical outcomes. Therefore, additional clinical experiences are required. No standard treatment of choice for this disease currently exists. In our experience, curettage of the involved soft tissue mass and bone followed by appropriate reconstruction of the defect is considered a good option for the treatment of solitary LCH of the sternum. In addition, LCH should be considered in the differential diagnoses when a sharp delineated osteolytic mass is detected in the sternum.

Clinical experience with complications of hand rejuvenation.

PURPOSE: Prominent signs of ageing of the hands have recently been treated with permanent or longer-lasting injectable dermal fillers. However, few previous studies have described the long-term complications of such hand rejuvenation. The purpose of our report was to share our experience of 15 cases with long-term complications following hand rejuvenation using various medical fillers. PATIENTS AND METHODS: We performed a retrospective review of the management of 15 patients who presented with complications from the injection of synthetic fillers for hand rejuvenation at a tertiary medical centre over a period of 10 years from March 2002 to January 2011. RESULTS: Injected materials included polymethylmethacrylate (PMMA) microsphere filler, calcium hydroxyapatite filler, hyaluronic acid filler, poly-l-lactic acid (PLLA) filler and other medical fillers. Of the total study sample of 15 patients, nine underwent surgical excision, six patients with a history of PMMA or PLLA filler injection received intralesional steroid therapy and three patients with a history of hyaluronic acid filler injection received injection therapy using hyaluronidase. CONCLUSIONS: Hand rejuvenation complications can be successfully treated according to our proposed algorithm.

Clinical experience with hyaluronic acid-filler complications.

Hyaluronic acid (HA) fillers have become the material of choice for soft-tissue augmentation. HA fillers are longer lasting, less immunogenic and can be broken down by hyaluronidase. These advantages make HA fillers the most common of the temporary fillers on the market. However, early and delayed complications, ranging from minor to severe, can occur following HA-filler injection. We evaluated and treated 28 cases of HA-filler-related complications that were referred to our hospital over a period of 5 years from July 2004 to October 2009. Twenty-eight patients were included in our study; 82.1% of the patients were female and 17.9% were male. Complications were roughly classified as nodular masses, inflammation, tissue necrosis and dyspigmentation. Affected locations, in descending order of frequency, were the perioral area, forehead, including glabella, nose, nasolabial fold, mentum, including marionette wrinkles, cheek area and periocular wrinkles. The most disastrous complication was alar rim necrosis following injection of the nasolabial fold. We propose two 'danger zones' that are particularly vulnerable to tissue necrosis following filler injection: the glabella and nasal ala. Although there is no definite treatment modality for the correction of HA-filler complications, we have managed them with various available treatment modalities aimed at minimising patient morbidity.

Management of chest keloids.

Keloid formation is one of the most challenging clinical problems in wound healing. With increasing frequency of open heart surgery, chest keloid formations are not infrequent in the clinical practice. The numerous treatment methods including surgical excision, intralesional steroid injection, radiation therapy, laser therapy, silicone gel sheeting, and pressure therapy underscore how little is understood about keloids. Keloids have a tendency to recur after surgical excision as a single treatment. Stretching tension is clearly associated with keloid generation, as keloids tend to occur on high tension sites such as chest region. The authors treated 58 chest keloid patients with surgical excision followed by intraoperative and postoperative intralesional steroid injection. Even with minor complications and recurrences, our protocol results in excellent outcomes in cases of chest keloids.