Application of Artificial Dermis Combined With a Medial Flap From the Second Toe to Repair Degloving Injury of the Fingertip.

There is no standard technique for repairing degloving injuries of the fingertip. Nail bed flap transplantation is a common surgical technique to address this injury, but this procedure inevitably damages the donor site in the toe. This article describes a surgical technique that can restore the appearance of the injured fingernail and preserve the length and function of the injured finger without damaging the toenail.

Application of Autogenous Dermis Combined With Local Flap Transplantation in Repair of Titanium Mesh Exposure After Cranioplasty.

OBJECTIVES: To investigate the clinical outcome of autogenous dermis combined with local flap transplantation in the treatment of titanium mesh exposure after cranioplasty. METHODS: We studied a total of 8 patients with titanium mesh exposure after cranioplasty. After debridement of the head wound, the autogenous dermal tissue from the lateral thigh was transplanted to the surface of titanium mesh, and the local skin flap was then applied after suturing and fixation to repair the wound on the surface of the dermis. To repair the lateral thigh dermal tissue area, a local skin flap was obtained, and a blade thick skin graft was used. RESULTS: Both dermal tissue and local skin flap survived. In the meanwhile, the donor skin area of the lateral thigh healed well, with only slight scar hyperplasia, and the titanium mesh was preserved. There was no recurrence after 6 months of follow-up. CONCLUSIONS: The application of autogenous dermis combined with local skin flap to repair titanium mesh exposure can effectively avoid skin flap necrosis, potential re-exposure of titanium mesh, sub-flap effusion, infection, and other problems. This method has an ideal effect, has easy access to materials, and reduces patients' economic burden. It is worth popularizing.

Primary Dermal Melanoma: A Case Report.

ABSTRACT: Primary dermal melanoma (PDM) is defined as a primary melanoma tumor confined to the dermis, subcutis, or both, without epidermal involvement. The significant overlap of histopathological features in PDM and cutaneous metastatic melanoma makes diagnostic accuracy of PDM challenging. We present a case of a 48-year-old man with a nontender 1.5 × 1.5 cm subcutaneous nodule on the left leg, which had been present for years. Biopsy revealed a dermal tumor with melanocytic differentiation noted to be positive for SOX-10. Additional pathology findings included a high Ki-67 proliferation index and a loss of p16 expression. Pathology reports were consistent with primary tumor stage 4a, and the patient was referred to surgical oncology where examination and workup demonstrated no evidence of the residual lesion representing a metastasis from a primary site. As PDM is histologically indistinguishable from melanoma metastasis to the skin, clues including a history of an evolving subepidermal nodule and exclusion of previous or concurrent melanomas can assist in its accurate diagnosis. Currently, a consensus on the criteria, staging, and management of PDM does not exist. Poorly defined diagnostic criteria and general lack of awareness of PDM result in high rates of incorrect and late-stage diagnoses. This case report highlights the importance of physician familiarity with PDM to ensure accurate recognition, evidence-based management, and improved patient outcomes.

Infraeyebrow Blepharoplasty Using Dynamic Suspension Technique Between Dermis-Fascia Flap and Frontalis in Upper Eyelid Lifting and Eyebrow Augmentation.

OBJECTIVE: Upper eyelid laxity affects facial aesthetics and the eyebrow arch in the East Asian population is generally low. The authors developed infraeyebrow blepharoplasty using a dynamic suspension technique between the dermis-fascia flap and frontalis for upper eyelid lifting and eyebrow augmentation. METHODS: A retrospective study was performed on 43 female patients with upper eyelid laxity from August 2015 to October 2019. The epidermis and superficial dermis of the infraeyebrow was removed from the surgical marking area with the deep dermis and fascia preserved. The eyebrow skin flap was separated from the frontalis surface which fully exposed the area around eyebrow arch. The preserved dermis-fascia flap was folded and suspended to frontalis in the superior margin of eyebrow arch. RESULTS: Forty-three patients (median age 54 years [range, 38-70]) underwent this operation. Mean follow-up was 25 months (range, 8-42) was assessed. All incisions healed well and were almost invisible. The eyebrow area improved with upper eyelid skin lift and eyebrow augmentation; 40 cases were "very satisfied" with their appearance. Three cases were "not very satisfied," including 1 case with numbness in surgical area. 2 cases had slight bilateral asymmetry of the upper eyelids. CONCLUSIONS: The dynamic suspension technique is worthy of clinical application because it can correct upper eyelid laxity, augment the low eyebrow arch, and obtain an invisible scar by reducing the incision tension.

Double-Eyelid Blepharoplasty: Dermis-Outer Orbicularis Fascia-Orbicularis-Levator Fixation Technique with Preorbicular Venous Network Preservation.

BACKGROUND: This article presents a new method using a dermis-outer orbicularis fascia-orbicularis-levator (DOOL) fixation technique for double-eyelid blepharoplasty. METHODS: Our surgical technique preserves the preorbicular venous network (POVN) and uses mattress sutures to fix the dermis, outer fascia of the orbicularis oculi muscle, and orbicularis oculi muscle with pretarsal levator aponeurosis (DOOL). Between January 2016 and July 2018, 335 patients were treated with this POVN-preserving DOOL technique (321 women and 14 men; mean age, 29.6 y). The patients were followed up for 6-30 months. The complications were documented, and the overall outcomes of the upper eyelid folds were evaluated by both surgeons and patients as good, fair, or poor. RESULTS: Among 335 patients, 307 (91.6%) had good results, 17 (5.1%) had fair results, and 11 (3.3%) had poor results. Postoperative complications included partial (n=4) or complete (n=3) loss of the double-eyelid line and asymmetric folds (n=4). Hypertrophic/depressed scars did not occur. CONCLUSIONS: With less invasiveness and secure internal fixation, the DOOL fixation technique with POVN preservation can achieve a stable and natural double-eyelid appearance. 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 .

Anatomic Characteristics and Treatment of the Midcheek Groove by Deep Filling.

BACKGROUND: Because the anatomic mechanisms underlying the formation of the midcheek groove are unclear, treatments to date have resulted in unsatisfactory outcomes. OBJECTIVE: This study investigated the anatomical foundation of the midcheek groove and evaluated appropriate treatment methods. MATERIALS AND METHODS: Six cadaver hemifacial specimens were subjected to gross anatomic dissection and 6 to P45 sheet plastination. Based on the anatomic results, the area under the orbicularis oculi muscle (OOM) was selected for deep filling. Patients were evaluated by measuring 3D depth, regrading, and self-assessment. RESULTS: The medial band was observed to be an important structure of the OOM, with the facial projection overlapping the midcheek groove trace. Two of the 6 P45 specimens were found to have compact fibroelastic bundles (CFBs) between the medial band and the dermis. Deep filling of the area under the OOM significantly reduced the depth of each section in all 34 patients (p < .001). Grades 3 and 4 midcheek grooves were downgraded distinctively. Most subjects expressed satisfaction with outcomes. CONCLUSION: Formation of the midcheek groove is associated with the passage of CFBs. Deep filling of the area under the OOM effectively improves the midcheek grooves.

Negative Pressure Wound Therapy in Conjunction With Artificial Dermis for Burned Hand Reconstruction.

INTRODUCTION: Proper wound care along with the use of skin grafts over deep burn wounds has been the standard treatment. However, the goal in burn wound care has shifted from achieving a satisfactory survival rate to improving long-term form and function of the healed wound, which is sometimes hindered by scar contracture. This has prompted surgeons to find alternative ways to treat burn wounds without compromising function. Among burn cases, hand injuries are the most problematic when it comes to delicate function recovery. METHODS: This study presents the results of conjunctive use of a bilayer artificial dermis, negative pressure wound therapy, and split-thickness skin grafts for grafting over acute burn wounds and scar-releasing defects after severe hand burns. RESULTS: Three months after the operation, the scar was soft and pliable, the aesthetic outcome was good, and the patients gained much improvement in hand function and quality oflife. CONCLUSIONS: The combined technique achieved a good scar quality and aesthetic effect on burned hands as well as excellent functional outcome, which resulted in major improvements and an independent life for the patient.

Dynamic Histological Events and Molecular Changes in Excisional Wound Healing of Diabetic DB/DB Mice.

BACKGROUND: Wound contraction and re-epithelialization over the entire healing process had never been histologically examined daily in diabetic mouse wounds. Correlating morphological characters with molecular changes may be essential to understand the potential mechanism of impeded diabetic wound healing. MATERIALS AND METHODS: In 99 db/db and 63 db/m mice, dorsal-paired 8 mm-diameter wounds were created. Wound contraction and re-epithelialization were histologically analyzed daily-six wounds per group each day. A novel three-dimensional collagen gel model was used to study diabetic dermal fibroblast contractility. Fibroblast-to-myofibroblasts differentiation and TGFß-SMAD signaling pathway through the diabetic db/db wound healing process were studied by immunohistochemistry. RESULTS: Db/db wounds presented delayed closure with impaired wound contraction. Re-epithelialization was not slow but showed thinner epithelial formation and irregular keratinocyte arrangement. Diabetic dermal fibroblasts had significantly lower contractile ability than nondiabetic fibroblasts. In db/db wounds, α-SMA, the marker of myofibroblasts, showed constantly low through the healing, which represented reduced fibroblast-to-myofibroblasts differentiation. Remarkably weak staining of TGFßRI and low accumulation of Smad3 in nuclei were observed. CONCLUSIONS: We demonstrated and precisely located downregulated TGFß signaling pathway in db/db wounds by showing low expression of TGFßRI and failure of Smad3 translocation from cytoplasm to nuclei, which was not reported previously. The downregulated TGFß signaling pathway may contribute to the attenuated fibroblast-to-myofibroblast differentiation. Deficient re-epithelialization and defective wound contraction contribute principally to delayed healing of diabetic db/db wounds.

A Systematic Review of the Treatment of Superficial Leiomyosarcoma With Mohs Micrographic Surgery.

BACKGROUND: Wide local excision (WLE) with 2 to 5 cm margins has been conventionally used for the treatment of superficial leiomyosarcoma (LMS). Because margin control is the strongest predictor of clinical recurrence, many dermatologic surgeons have recently recommended Mohs micrographic surgery (MMS) over wide local excision (WLE) as the primary treatment modality. OBJECTIVE: To determine the aggregate rate of local recurrence after treatment of superficial LMS with MMS among the few reports in the literature. METHODS: A systematic literature search using the PubMed/MEDLINE database and the Cochrane Library was performed from inception to June 2017. One case report from our institution was included. RESULTS: A meta-analysis of 14 reports of 48 cases of superficial LMS treated with MMS showed a mean recurrence rate of 2.08% to 6.25% with a mean follow-up period of 1570.9 days, compared to reported recurrence rates of 30% to 50% for WLE. Among these cases there were no reports of distant metastases. CONCLUSION: Treatment of superficial leiomyosarcoma with MMS shows markedly lower rates of recurrence compared to reported rates of recurrence after WLE. Further prospective trials with larger sample sizes are needed to compare both modalities.

Cutaneous Nodular Amyloidosis: A Disfiguring Aspect of the Face.

Primary localized cutaneous nodular amyloidosis is a rare plasma cell dyscrasia in which an amorphous material consisting of light chain amyloid is produced and deposited in the dermis, with varied clinical presentation. We describe the case with unusual and tumor lush clinical presentation in the face with no progression to systemic disease and no evidence of extracutaneous commitment.

Efficacy and Safety of a Novel Method of Insulated Intralesional Radiofrequency Ablation for Deep Dermal and Subcutaneous Lesions: A 3-Year Institutional Experience.

BACKGROUND: Although insulated intralesional radiofrequency ablation (IL-RFA) is being increasingly used in other specialties, not much information on its safety and efficacy in dermatology is available. OBJECTIVE: To describe our experience with insulated IL-RFA for various dermatological conditions. METHODS: This is a retrospective review of the patients who underwent IL-RFA in the past 3 years. Our technique involved creating a small window in the proximal end of plastic sheath of an intravenous cannula using a surgical blade, and then touching the RF probe to the cannula through the window to deliver the electric current. Information regarding diagnosis, number of sessions, adverse effects, and follow-up was recorded. Clinical improvement was assessed on a visual analog scale by the patient and 2 independent observers. RESULTS: Data on 19 patients with lymphangioma circumscriptum (n = 9), venous or capillary-venous malformation (n = 4), angiolymphoid hyperplasia with eosinophilia (n = 3), arteriovenous malformation, hidradenitis suppurativa, and hypertrophic scar (n = 1 each) was available. The mean number of IL-RFA sessions was 2.26 ± 1.61. The mean patient and physician global assessment scores were 7.6 ± 2.22 and 7.3 ± 2.42, respectively. Adverse effects were seen in 9 (47.4%) patients. All patients, except 1, had sustained improvement in the mean follow-up period of 11.4 ± 11.6 months. CONCLUSION: Insulated IL-RFA seems to be safe and effective in selectively targeting deep-seated cutaneous lesions.

Biocompatibility and Immunotoxicology of the Preclinical Implantation of a Collagen-based Artificial Dermal Regeneration Matrix.

OBJECTIVE: Graft rejection, with the possibility of a violent immune response, may be severe and life threatening. Our aim was to thoroughly investigate the biocompatibility and immunotoxicology of collagen-based dermal matrix (DM) before assessment in clinical trials. METHODS: DM was subcutaneously implanted in BALB/c mice in two doses to induce a potential immune response. The spleen and lymph nodes were assessed for shape, cell number, cell phenotype via flow cytometry, cell activation via CCK8 kit, Annexin V kit, and Ki67 immunostaining. Serum samples were used to measure antibody concentration by enzyme-linked immunosorbent assay. Local inflammation was analyzed by histology and immunohistochemistry staining. Data analysis was performed by one-way ANOVA and non-parametric tests. RESULTS: Our data illustrate that the spleen and lymph node sizes were similar between the negative control mice and mice implanted with DM. However, in the high-dose DM (DM-H) group, the total cell populations in the spleen and lymph nodes, T cells and B cells in the spleen had slight increases in prophase, and the low-dose DM (DM-L) group did not display gross abnormities. Moreover, DM-H initiated moderate cell activation and proliferation in the early phase post-immunization, whereas DM-L did not. Neither DM-H nor DM-L implantation noticeably increased IgM and IgG serum concentrations. Examination of the local cellular response revealed only benign cell infiltration and TNF-α expression in slides of DM in the early phase. CONCLUSION: Overall, DM-H may have induced a benign temporary acute immune response post-implantation, whereas DM-L had quite low immunogenicity. Thus, this DM can be regarded as a safe product.

Dermal Regenerative Template as a Cost-Effective Alternative for Complex Scalp Reconstruction.

BACKGROUND: Use of dermal regeneration template (DRT) is well documented in the literature for complex wounds ranging from the scalp, trunk, and lower extremity. METHODS: A retrospective cohort study was performed of the use of dermal regeneration template and skin grafting. A literature review was performed of all studies where DRT was used for scalp reconstruction. RESULTS: Patients in the DRT cohort had an average age of 70, with wounds averaging 108 cm in size. These patients also had a relatively low rate of complications (0.4), a short hospital stay (average 2 days), and a relatively short operating room time (114 minutes). CONCLUSION: This study demonstrates dermal regeneration template to be an effective and reliable option for soft tissue reconstruction with minimal morbidity and complications in patients with extensive medical comorbidities. Emerging applications include radiation exposure and hypercoaguable states.

Novel method for facial rejuvenation using Er:YAG laser equipped with a spatially modulated ablation module: An open prospective uncontrolled cohort study.

Facial aging is a complex biological process that affects the skin and superficial musculoaponeurotic system (SMAS). A new technology (RecoSMA) for skin rejuvenation based on acoustic-interference method using Er:YAG laser (2936 nm) equipped with a special module SMA that targets both the dermis and SMAS was evaluated in an open-label prospective cohort study of 100 female patients treated for facial rejuvenation. Measure of clinical improvement included investigator-rated clinical photography using the Modified Fitzpatrick Wrinkle Scale, and ultrasound measurements in the dermis a week, 30 days and six months post treatment. All patients completed the study and no complications were noted. Improvements in skin tone and texture were noted in all participants and significant decrease in wrinkle depth was demonstrated at the six-month follow-up that was confirmed by ultrasound skin measurements. Data presented herein confirm the safety and efficacy of RecoSMA treatment for facial rejuvenation.

Treatment of facial photodamage and rhytides using a novel 1,565 nm non-ablative fractional erbium-doped fiber laser.

BACKGROUND AND OBJECTIVE: Non-ablative fractional lasers (NAFL) generate microscopic non-contiguous columns of thermal injury in the dermis, resulting in collagen remodeling. This manuscript details our experience with a novel 1,565 nm scanned, erbium-doped fiber NAFL for the treatment of facial photodamage. STUDY DESIGN/MATERIALS AND METHODS: A prospective, open-label clinical trial was conducted at two clinical sites in the United States on 16 female subjects with a mean age of 49.6 years, Fitzpatrick skin types II to IV, and a baseline Fitzpatrick-Goldman Wrinkle and Elastosis Score (FGWES) of 3-6. Each subject received three treatments at 4-5 week intervals with follow-up assessments at 1, 3, and 6 months after the last treatment. RESULTS: The mean FGWES demonstrated a statistically significant decrease from baseline both at 3 months (-0.58 ± 0.23, P = 0.02) and 6 months (-0.66 ± 0.22, P = 0.008) after the last treatment. Fifty percent (95%CI [24.21%, 68.49%]) of subjects showed a significant (at least 1 grade) improvement in FGWES from baseline at 3-month follow-up. At least 72% of subjects perceived the results as "moderate" to "very good" at 3 months post-treatment, with comparable satisfaction rates. Treatments were not associated with a high level of pain or discomfort and typical downtime was less than 2 days. No unexpected adverse events or serious adverse events were reported. CONCLUSION: The 1,565 nm erbium-doped scanned NAFL is an effective treatment for facial wrinkles with a favorable recovery and side effect profile.

Spatiotemporal closure of fractional laser-ablated channels imaged by optical coherence tomography and reflectance confocal microscopy.

BACKGROUND AND OBJECTIVE: Optical coherence tomography (OCT) and reflectance confocal microscopy (RCM) offer high-resolution optical imaging of the skin, which may provide benefit in the context of laser-assisted drug delivery. We aimed to characterize postoperative healing of ablative fractional laser (AFXL)-induced channels and dynamics in their spatiotemporal closure using in vivo OCT and RCM techniques. STUDY DESIGN/MATERIALS AND METHODS: The inner forearm of healthy subjects (n = 6) was exposed to 10,600 nm fractional CO2 laser using 5 and 25% densities, 120 µm beam diameter, 5, 15, and 25 mJ/microbeam. Treatment sites were scanned with OCT to evaluate closure of AFXL-channels and RCM to evaluate subsequent re-epithelialization. RESULTS: OCT and RCM identified laser channels in epidermis and upper dermis as black, ablated tissue defects surrounded by characteristic hyper-and hyporeflective zones. OCT imaged individual laser channels of the entire laser grid, and RCM imaged epidermal cellular and structural changes around a single laser channel to the depth of the dermoepidermal junction (DEJ) and upper papillary dermis. OCT images visualized a heterogeneous material in the lower part of open laser channels, indicating tissue fluid. By OCT the median percentage of open channels was evaluated at several time points within the first 24 hours and laser channels were found to gradually close, depending on the used energy level. Thus, at 5 mJ/microbeam, 87% (range 73-100%) of channels were open one hour after laser exposure, which declined to 27% (range 20-100%) and 20% (range 7-93%) at 12 and 24 hours after laser exposure, respectively. At 25 mJ/microbeam, 100% (range 100-100%) of channels were open 1 hour after laser exposure while 53% (range 33-100%) and 40% (range 0-100%) remained open at 12 and 24 hours after exposure. Median depth and width of open channels decreased over time depending of applied energy. RCM verified initial re-epithelialization from day 2 for all energy levels used. Morphology of ablation defects by OCT and RCM corresponded to histological assessments. CONCLUSIONS: OCT and RCM enabled imaging of AFXL-channels and their spatiotemporal closure. Laser channels remained open up to 24 hours post laser, which may be important for the time perspective to deliver topical substances through AFXL channels.

Understanding the logic of common suturing techniques in dermatologic surgery.

Although most trainees in dermatology learn that different suturing techniques are designated for a specific purpose (i.e., certain functional and cosmetic outcomes), students often have a difficult time visualizing how a given suture functions in its designated capacity. In this article, we address the logic behind the most common suturing techniques in dermatologic surgery, including the direction and magnitude of their pulling force with respect to the wound edges and the ensuing displacement of dermal and epidermal structures. To aid better understanding, we diagram the vectors of suture force with each of the techniques discussed.

Autologous dermal grafts as posterior lamellar spacers in the management of lower eyelid retraction.

PURPOSE: To determine the safety and efficacy of autologous postauricular dermal grafts as posterior lamellar spacing material in patients with lower eyelid retraction. METHODS: At a tertiary care institution, 10 eyelids of 10 patients (7 men, 3 women; mean 56 years, range 24-78) who underwent repair of lower eyelid retraction using a postauricular dermal graft between July 2008 and December 2010 were retrospectively assessed. Data collected included patient demographics, etiology of retraction, and surgical history. Outcome measures included preoperative and postoperative eyelid position and surgery-related complications. RESULTS: Postoperative results were favorable: mean preoperative inferior scleral show was 3.3 ± 2.6 mm compared with 0.3 ± 1.2 mm postoperatively, p = 0.004 (paired t test). Mean follow up was 39.2 weeks (range 12-94). Complications included keratinization of the graft with vellus hair growth (n = 1) and ectropion (n = 1), both corrected with minor surgical interventions. One patient achieved overcorrection but declined further treatment. No donor site complications were encountered. CONCLUSIONS: These data suggest postauricular dermal grafts are effective posterior lamellar spacers in the correction of eyelid retraction. They have adequate rigidity whilst maintaining sufficient pliability to mold to the globe. Resorption, common to acellular dermis matrix allografts and xenografts, was not encountered. Donor site complications were not encountered. Complications shared with other material include overcorrection and ectropion. Complications unique to autologous dermis include keratinization and hair growth.