A technique for auricular keloid core excision using a skin biopsy punch.

BACKGROUND: Keloids of the auricular region, resulting from ear piercing or external injury, are a common cosmetic problem. Surgical treatment followed by conservative management often is needed. The "hollowing out method for keloids of the auricle" retains the skin over the keloid lesion to minimize tension on the wound. This is considered to be the appropriate surgical treatment method, but skill is required to remove the keloid and retain the skin with a uniform thickness and appropriate form. MATERIAL AND METHODS: Four patients with auricle keloids were included in this study. All the patients were females between the ages of 18 and 29 years (average age, 24.8 years). Keloid core excision using a skin biopsy punch with the patient under local anesthesia was performed for all the patients. RESULTS: Use of a skin biopsy punch resulted in a shorter operating time without causing ear deformity. CONCLUSION: The authors report a technique for keloid core excision using a skin biopsy punch and believe it is a useful method LEVEL OF EVIDENCE V: 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 www.springer.com/00266.

Dye laser photodynamic therapy for Bowen's disease in a patient with epidermodysplasia verruciformis.

Epidermodysplasia verruciformis (EV) is a rare heritable skin disease that results in unusual susceptibility to infection with specific types of human papillomavirus (HPV). Here we report a 53-year-old man with EV who developed Bowen's disease on his lower eyelid and the chest. Mutation analysis of EVER1 gene revealed homozygous splice acceptor site mutation (IVS8-2, A > T). In this patient, HPV3, HPV14, and HPV38 had been identified from the skin lesions. The Bowen's skin lesion on the left lower eye-lid was treated by photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) and pulsed dye laser (PDL). After two rounds of the PDT treatment, the skin lesion disappeared and a skin biopsy confirmed the efficacy of the treatment. This method was simple, less invasive than other treatments, and achieved a satisfactory cosmetic result.

Establishment of a core outcome set for burn care research: development and international consensus.

Objective: To develop a core outcome set for international burn research. Design: Development and international consensus, from April 2017 to November 2019. Methods: Candidate outcomes were identified from systematic reviews and stakeholder interviews. Through a Delphi survey, international clinicians, researchers, and UK patients prioritised outcomes. Anonymised feedback aimed to achieve consensus. Pre-defined criteria for retaining outcomes were agreed. A consensus meeting with voting was held to finalise the core outcome set. Results: Data source examination identified 1021 unique outcomes grouped into 88 candidate outcomes. Stakeholders in round 1 of the survey, included 668 health professionals from 77 countries (18% from low or low middle income countries) and 126 UK patients or carers. After round 1, one outcome was discarded, and 13 new outcomes added. After round 2, 69 items were discarded, leaving 31 outcomes for the consensus meeting. Outcome merging and voting, in two rounds, with prespecified thresholds agreed seven core outcomes: death, specified complications, ability to do daily tasks, wound healing, neuropathic pain and itch, psychological wellbeing, and return to school or work. Conclusions: This core outcome set caters for global burn research, and future trials are recommended to include measures of these outcomes.

Bilateral nevus of Ota: a rare manifestation congenital type in a boy.

BACKGROUND: The nevus of Ota is usually characterized by small, flat, unilateral, blue-black or gray-brown spots occurring on skin innervated by the first or second branch of the trigeminal nerve. It comprises dermal melanocytes, presumably arising due to the dermal arrest of cells migrating from the neural crest. Nevus of Ota is 3-5 times more common in women than men, and is classified into congenital type, appearing soon after birth, and acquired type, appearing during or after puberty. METHODS: We report on a six-year-old Japanese boy with the bilateral nevus of Ota. He was referred to our hospital because of bilateral hyperpigmentation of the face, present since birth. Our treatment consisted of Q-switched ruby laser irradiation under general anesthesia. The Q-switched ruby laser (Model IB101; Niic Co. Ltd., Tokyo, Japan), had a wavelength of 694.3 nm, a spot size of 5 mm, a 1 Hz repetition rate, a pulse duration of 20 nsec and fluence ranged from 3.0 J/cm2 to 6.0 J/cm2. RESULTS: Q-switched ruby laser irradiation improved his pigmentation, and will therefore be repeated several times. CONCLUSIONS: This case of congenital bilateral nevus of Ota in a young male patient was very rare. And Q-switched ruby laser irradiation was effective as same as another nevus of Ota.

Comparison of regional efficacy and complications in the treatment of aberrant Mongolian spots with the Q-switched ruby laser.

BACKGROUND AND OBJECTIVE: Aberrant Mongolian spots (AMS) distal from the lumbosacral region are said to be more apt to persist than the typical sacral AMS, so the Q-switched ruby laser (QSRL) has been the treatment of choice for AMS. However, so far as we could determine, there is no statistical analysis of the treatment of AMS. This paper shows statistical comparisons of the efficacy and complications in the treatment of AMS with QSRL. METHODS: Fifty-three patients (16 males and 37 females) with 57 AMS regions were treated with the QSRL from March 1999 to April 2007, and we divided the diseased areas into exposed regions that could not be concealed by clothing and non-exposed regions that could be concealed by clothing, and performed a statistical analysis. RESULTS: The results indicated that QSRL treatment of AMS in the exposed regions showed significantly improved coloration and caused less pigmentation when compared with the non-exposed regions. CONCLUSION: We concluded that QSRL treatment of AMS in the exposed regions is more effective than that of AMS in the non-exposed regions.

Sentinel lymph node biopsy in conjunctival malignant melanoma at the lacrimal caruncle: a case report.

BACKGROUND: Conjunctival malignant melanoma (CMM) is so rare that there are no certain guidelines for its treatment. Factors influencing its prognosis include region of onset, tumor thickness, lymph node metastasis, and distant metastasis. Whether regional lymph node metastasis is present or not is one of the most powerful factors for predicting recurrence in and survival of patients with CMM. METHODS: A 72-year-old man with conjunctival malignant melanoma at the lacrimal caruncle was underwent sentinel lymph node (SLN) biopsy by preoperative lymphoscintigraphy and intraoperative vital blue mapping. RESULTS: A blue-dyed node could be identified in the superficial lobe of the parotid gland. A split half of the cropped SLN was immediately submitted to rapid pathological examination. After confirming no metastasis, it was decided not to perform lymph node dissection. The final diagnosis was pT3N0M0. Neither recurrence nor distant metastasis has been observed for 7 years after the operation. CONCLUSIONS: We were able to evaluate N (lymph node metastasis) in the TNM classification accurately. SLN may facilitate N classification and decisions regarding employment of appropriate lymph node dissection as well as combined therapy after operation.

Survival analysis of malignant melanoma in Japan--multivariate analysis of prognostic factors.

BACKGROUND: The prognostic factors of cutaneous melanoma reported in Japan were different from those in US and Europe in evaluating the prognostic values of the biopsy types, sex, anatomic location and so on. The aim of this study was to identify the prognostic factors for survival in cutaneous melanoma in Japan by performing univariate and multivariate analyses. METHODS: We studied a total of 103 patients with cutaneous melanoma, treated in Osaka City University Hospital during the period 1991-2003. Eleven factors were evaluated by uni- and multivariate analyses. Kaplan-Meier analyses were performed to estimate and compare five-year survival rates. After checking for independence, prognostic factors were then evaluated applying a Cox proportional hazards model in localized melanoma patients and in all invasive melanoma patients. RESULTS: On univariate analysis, anatomic location, ulceration, tumor thickness, Clark's level, lymph node metastasis, distant metastasis and TNM staging were significantly related to five-year survival rates. Clark's level and TNM staging were excluded after checking for independence. Multivariate analysis revealed that significant prognostic factors were tumor thickness and anatomic location in localized melanoma patients, and distant metastasis, tumor thickness, sex and anatomic location in all invasive melanoma patients. CONCLUSIONS: Thinner tumors, female gender and location on the extremity are favorable prognostic features in malignant melanoma. Tumor thickness whose best cut-off point is 4 or 5 mm is the most important prognostic factor in predicting survival in the melanoma patient. These results were similar to those in U.S. and Europe.

Giant epidermal cyst extending from sole to dorsum of the foot by penetrating the interosseous muscles.

We present a 65-year-old man with a giant epidermal cyst extending from sole to dorsum of the foot by penetrating the interosseous muscles. This epidermal cyst extending from the sole to the dorsum of the foot was big and an extremely rare lesion.

Experimental pseudocyst model resembling human ganglion.

There is no animal model of ganglion. We describe a simple and reproducible animal model of pseudocystic diseases. First, we experimented to establish a pseudocystic model. We used cylindrical glass implants (6 mm diameter, 30 mm long) to create fibrous capsules in rats. The implants were inserted in the subcutaneous tissue in the dorsum of rats. Sixty implants were carried out (two implants per rat). Twelve weeks after implantation, the glass implants were removed and 0.5 mL sodium hyaluronate solution was injected into each cavity. Next, we tested the model by histological examination after OK-432 administration. Microscopic examination revealed that the wall was composed of a layer of collagenous fibers similar to those noted in ganglia; the lumen was retained for 3 weeks. Histopathological changes after OK-432 administration showed nonspecific inflammatory response induced by OK-432, resulting in in vivo activation of many inflammatory cells and then fast and reliable closure of cavities. No harmful reactions to OK-432 were observed histopathologically. These data suggest that our experimental cyst is a suitable model for studying pseudocystic diseases. This model can be used for research evaluating safe drug doses, conducting therapeutic comparison of several agents, and histopathological time course studies of the affected tissues. OK-432 administration on this model showed the potential of one of the ideal agents to treat pseudocystic lesions like ganglion.

Dermatofibrosarcoma protuberans with atrophic appearance at early stage of the tumor.

We report a case of dermatofibrosarcoma protuberans (DFSP) which had looked like an atrophic plaque on the face for 20 years and been diagnosed as morphea. At the late stage after subsequent development of a nodule, histopathological examinations including immunohistochemical stainings revealed the final diagnosis of DFSP. While DFSP is given typical "protuberant" morphology, our case indicates that DFSP sometimes appears as a non-protuberant lesion. Some reported variants of non-protuberant DFSP are suspected to be preceding features at the early stage of DFSP before the protuberant feature occurs. We should take this preprotuberant stage of DFSP into consideration of different diagnoses with non-protuberant lesions. Histopathological examination and immunohistochemical stainings are necessary for an accurate and early diagnosis of DFSP.

Accumulation of glucose in keloids with FDG-PET.

OBJECTIVE: Glucose metabolism has not been investigated in human (in vivo) keloids. In the present study, we performed positron emission tomography (PET) with fluorine-18-fluorodeoxyglucose (FDG) to examine glucose metabolism in keloids. MATERIALS AND METHODS: Five patients (2 men and 3 women) with typical keloids having a thickness of more than 5 mm were studied. HEADTOME-IV SET-1400W-10 (Shimadzu, Tokyo, Japan) was employed for PET studies. Transmission scanning was performed on each patient. After fasting for more than 4 hours, the patients were injected intravenously with FDG 185-370 (MBq) following each transmission scan. Emission scans were performed 40-55 min after injection. For quantitative evaluation, the regions of interest (Circles ROIs: 6 mm in diameter) were placed on all the keloid lesions and surrounding tissues, and then their standardized uptake value (SUV = the tissue concentration/the activity injected per body weight) was calculated. RESULTS: FDG was defined as showing the accumulation in keloids when its uptake was relatively higher in the keloid than that in the surrounding tissue. The SUV of the keloids ranged from 1.0 to 2.74, with a mean of 1.79. CONCLUSION: FDG-PET was performed in 5 patients with keloids and low-grade accumulation of FDG was observed in all lesions. This indicated that glucose metabolism was accelerated in keloids.

Aggressive conservative therapy for refractory ulcer with diabetes and/or arteriosclerosis.

A foot ulcer due to diabetes and/or arteriosclerosis obliterans (ASO) frequently results in an intractable condition that resists treatment. To cope with this condition, we have developed a combination therapy that includes conventional conservative therapy plus surgical therapy. This aggressive conservative therapy using aggressive debridement, trafermin (Fiblast Spray, Kaken, Japan) treatment and vacuum-assisted closure (VAC) therapy was adopted to treat seven patients suffering from diabetes and ASO-related refractory foot ulcer accompanied by bone exposure. With the exception of one patient who died during the treatment, the remaining six patients obtained limb salvage. The mean time to cure was 8.3 months. This approach should be considered before amputation. Some patients may refuse amputation or cannot tolerate highly invasive surgical treatment including tissue transplantation. In such cases, this aggressive conservative therapy can be employed as a highly useful and reproducible technique requiring simple techniques.

Improvement of the radial forearm donor site by compression with hydrocolloid dressing and adhesive sponge.

CONCLUSIONS: With our method, general improvement is obtained as compared with traditional split-thickness skin grafting of the radial forearm flap donor site. As our method is simple and easy, the same results can be obtained wherever and by whomever it is performed. OBJECTIVE: The radial forearm flap is associated with complications of graft take and a poor aesthetic appearance despite its usefulness in reconstructing the oral cavity and oropharynx. We describe a simple technique for improvement of the radial forearm donor site. PATIENTS AND METHODS: We studied 12 patients who underwent reconstruction with radial forearm free flaps following resection of oral or oropharyngeal tumors. We covered the donor site defect using traditional split-thickness skin grafts and performed aftercare with a hydrocolloid dressing and an adhesive sponge to retain moisture and apply compression. After the treatment series, color matching, texture matching, depressive deformity, and hypertrophic scar were evaluated. RESULTS: The results of comprehensive evaluation of the two patients with premature discontinuation of compression were good. One patient was assigned only 1 point for hypertrophic scar, and another only 1 point for color match. The evaluation of the other 10 patients was excellent.

Arthroplasty of the interphalangeal joint of the great toe using costal osteochondral grafting.

Although many reports have been published on the usefulness of costal cartilage grafting in the reconstruction of interphalangeal joints of fingers, there are only a few published reports on the reconstruction of interphalangeal joints of toes. We describe a 21-year-old woman with a tissue defect of the dorsum pedis and a partial defect of the interphalangeal joint of the great toe caused by a motor-vehicle accident. We attempted arthroplasty using a free latissimus dorsi myocutaneous flap and a costal osteochondral graft. The grafted rib and cartilage survived, allowing the patient to resume functional ambulation for day-to-day activities. Arthroplasty using costal osteochondral grafts seems to be an effective means of reconstructing the interphalangeal joints of toes.

Aggressive basal cell carcinoma in the nasal region.

It is extremely rare for basal cell carcinoma (BCC) to metastasize, so it is often only simply excised. However, BCC may cause severe local tissue destruction, which often extends to surrounding muscle, cartilage, and bone; it is then termed "aggressive" BCC. We evaluated the safety margin and the reconstruction method in four cases of nasal BCC that were diagnosed as aggressive BCC histopathologically or by imaging, including magnetic resonance imaging (MRI) and computerized tomography (CT) and then treated by excision. The results showed that the larger the aggressive BCC was, the smaller the histopathological safety margins became. The lateral nasal region was classified into three regions, and individual reconstruction was performed according to anatomical unit, resulting in favorable outcomes. Nasal BCC should be closely examinated, it requires a careful treatment strategy similar to that for other malignant skin tumors.

Clinical results of OK-432 injection therapy for ganglions.

We performed a study of intralesional OK-432 injection therapy for the non-surgical treatment of ganglions. OK-432 is an agent made from penicillin-killed and lyophilized preparations of a low-virulence strain of group A streptococcus pyogenes, which has been developed as an immune-augmentation agent for cancer therapy. Derived from an extract of bacterial culture it, induces an immunological response and causes local inflammation and subsequent tissue shrinkage following intralesional injection. After skin anesthesia and aspiration of the ganglion contents, OK-432 was injected into the ganglion cavity. When the ganglion recurred, this procedure was repeated usually up to a total of three times. Clinical evaluations six months after the last injection were: 56.6% complete cure, 35.3% incomplete cure with size reduced, 7.5% no change. Complications were as follows. There were no cases of shock. High fever was seen in five patients (9.4%); two patients suffered a high fever up to 39.0 degrees C for one day, and the others had fevers from 1 to 3 days. Thirty-two patients (60.4%) complained of local swelling that persisted for 1 to 7 days, and 11 (20.8%) complained of continuous pain for 1 to 3 days. Intralesional OK-432 injection therapy is thought to be a safe and convenient alternative to surgical treatment.

A case of ileoileal intussusception caused by metastatic pedunculated tumor of cutaneous angiosarcoma.

Cutaneous angiosarcoma is a rare aggressive vascular tumor that occurs in elderly patients and is usually located on the head and face. Metastases often develop in the cervical lymph nodes, lungs, bone, liver and spleen. There have been no reports of ileoileal intussusception due to metastatic tumor from cutaneous angiosarcoma. We reported a case of cutaneous angiosarcoma in a 67-year-old Japanese male accompanied with ileoileal intussusception due to metastatic angiosarcoma. We assume that the metastatic tumor in the small intestine was metastasized hematogeneously from cutaneous angiosarcoma, resulting in the formation of nodules and the rapid growth of a pedunculated tumor as a forerunner of the ileoileal intessusception.

Superiority of water application to water sealing in burn wound healing.

BACKGROUND: Recently there have appeared on the market many external dressings for wound management. They all use water-sealing materials to maintain wounds in a moist state. However, in our daily clinical observations, a water-sealing material sometimes results in poor wound healing. Although a water-sealing material does in fact keep the wound moist, the quality of the water is far from that of the optimum extracellular fluid. METHODS: A second-degree burn wound was made in the rat by contact with a metal stick. Experiment 1 was to evaluate the influence of delayed primary wound treatment on burn-wound depth progression. We used a time lag procedure. Each group was treated with a water-sealing application (hydrocolloid sheet). Experiment 2 was to investigate the progression-preventing effect of normal saline on a burn allowed to dry for 3 hours, we compared a group that received a water sealing (non-moistening and incomplete moisture) dressing with one that received a water-supplying (moistening) dressing with using chi-square test. RESULTS: In the Experiment 1 (time lag and water sealing test), the early group showed quite normal wound healing at 7 days after onset. The slough was thin (about 10-20% of full dermal thickness). The delayed groups showed the poor healing characteristic. The slough was relatively thick (about 30-60% of full dermal thickness). Three hours' delay seemed to bring about poor healing. In the Experiment 2 (water application test), the moistening (water application) group showed relatively good healing after seven days. The slough was as thin as in the early group in the Experiment 1. The non-moistening group showed a poor healing process like the delayed group in the Experiment 1. For the moistening group, the healing percentage of 77.8% was significantly greater than the 41.3% observed in the non-moistening group (chi-square test, p < 0.05). CONCLUSIONS: All the materials in wound dressing are water-sealing. When the component water under the sheet is far from the extracellular fluid, these applications bring about poor healing. Delayed application and incomplete moisture should be corrected by external water-application.

Reconstruction of the inner site of the auricle with two local skin flaps.

The external auditory canal and the auricular concha were reconstructed with two local skin flaps after resection of a primary adenoid cystic carcinoma of the external auditory canal. The upper part of the inner site of the auricle was covered with a superiorly-based posterior skin flap and the lower part of it with an inferiorly-based anterior one. Both were cutaneous flaps with a random pattern of blood supply. At the same time the surgical field after the flaps had been raised made additional excision easy, including partial mastoidectomy and parotidectomy. After 10 years of the operation auricular disfigurements and recurrence of the tumour are not observed.