Earlobe Reconstruction Using Two Opposed Periauricular Dermal Pedicled Flap.

There are several flap techniques of earlobe reconstruction. The ideal method should be a 1-stage procedure that is simple, has fewer complications, and has excellent esthetic outcomes with a proper earlobe texture and volume. We report a case of a 45-year-old man presented with skin and soft tissue defect of right ear lobule. He underwent composite graft using 2×1 cm sized stump. Two weeks later, total necrosis of graft site was observed. After that, he underwent 2 opposed periauricular dermal pedicled flap. Each flap caudally based periauricular flaps were elevated and consisted of redundant fat tissue. These flaps were sutured like sandwich and the donor sites were closured by primary repair. There was no complication as flap congestion or hematoma. After 6 months, the patient was satisfied esthetically and there was no need of additional surgical procedure. We introduce new technique of earlobe reconstruction named 2 opposed periauricular flap. This method affords reconstruction of large sized and full-thickness earlobe defect in a simple, easy manner. It provides proper texture and volume as normal earlobe. Also, it is 1-stage method not requiring skin graft or debulking procedure. Therefore, if plastic surgeon reconstructs a large defect of earlobe, our technique can be thought of as one good option.

Prediction of diabetic foot amputation using newly revised DIRECT coding system: Comparison of accuracy with that of five existing classification systems.

Diabetes mellitus (DM) causes various complications over time, one such complication is diabetic foot ulcers (DFU), which are challenging to treat and can lead to amputation. Additionally, a system for accurate prediction of amputation has yet to be developed. In total, 131 patients were included in the study after retrospectively collecting data from 2016 to 2020 about DFU. The collected data were used for comparison of the accuracy between five existing classification systems and the newly revised DIRECT coding system, and investigation of risk factors for lower extremity amputation (LEA). The existing five classification systems and DIRECT system can effectively predict LEA. The DIRECT3 system has three elements, C-reactive protein (CRP), ulcer history (UH), and hypertension (HTN) in addition to those of the DIRECT system. It had a high predictive value and accuracy similar to that of Wagner and University of Texas (UT) on depth among the five classification systems. Among the statistically significant risk factors, duration of DM and HTN, haemoglobin (Hb), CRP, and UH showed an association with LEA. The DIRECT coding system is effective for predicting LEA and explaining appropriate treatment methods for DFU, and is widely applicable because of its user accessibility and convenience.

A long-term follow-up study of diabetic foot ulcer using micronized acellular dermal matrix.

Treating a diabetic foot ulcer (DFU) extending to the tendon or bone can be a challenge for physicians. Recent studies have shown positive results of micronized acellular dermal matrix (ADM) treatment for treating DFU. However, studies on such ADM with a long-term follow-up are rare. Thus, the objective of this study was to retrospectively analyse patients treated with micronized ADM with a long-term follow-up to assess the effectiveness of the treatment and determine the recurrence rate. The rate of success of complete healing was 62.96% and the time of complete healing was 86.96 days in this study. The recurrence rate of DFUs was 41.17% in the overall group. However, it was only 23.52% in the micronized ADM group. The average duration of recurrence was 720.50 ± 505.12 days. The recurrence rate was 50% in weight bearing areas such as the plantar and heel. It was 12.5% in toes and non-weight bearing areas. In conclusion, micronized ADM can be used to effectively treat DFUs that have invaded ligaments or bones. A close follow-up of weight bearing area wounds will allow us to identify and treat recurrence early.

The correlation between transcutaneous oxygen pressure (TcPO2 ) and forward-looking infrared (FLIR) thermography in the evaluation of lower extremity perfusion according to angiosome.

The increased peripheral arterial disease (PAD) incidence associated with aging and increased incidence of cardiovascular conditions underscores the significance of assessing lower limb perfusion. This study aims to report on the correlation and utility of two novel non-invasive instruments: transcutaneous oxygen pressure (TcPO2 ) and forward-looking infrared (FLIR) thermography. A total of 68 patients diagnosed with diabetic foot ulcer and PAD who underwent vascular studies at a single institution between March 2022 and March 2023 were included. Cases with revascularization indications were treated by a cardiologist. Following the procedure, ambient TcPO2 and FLIR thermography were recorded on postoperative days 1, 7, 14, 21 and 28. In impaired limbs, TcPO2 was 12.3 ± 2 mmHg and FLIR thermography was 28.7 ± 0.9°C. TcPO2 (p = 0.002), FLIR thermography (p = 0.015) and ankle-brachial index (p = 0.047) values significantly reduced with greater vascular obstruction severity. Revascularization (n = 39) significantly improved TcPO2 (12.5 ± 1.7 to 19.1 ± 2.2 mmHg, p = 0.011) and FLIR (28.8 ± 1.8 to 32.6 ± 1.6°C; p = 0.018), especially in severe impaired angiosomes. TcPO2 significantly increased immediately post-procedure, then gradually, whereas the FLIR thermography values plateaued from day 1 to 28 post-procedure. In conclusion, FLIR thermography is a viable non-invasive tool for evaluating lower limb perfusion based on angiosomes, comparable with TcPO2 .

Improvement in linear depressed atrophic scar using 755-nm picosecond alexandrite laser vs. ablative fractional carbon dioxide laser.

ABBREVIATIONS: AFL = ablative fractional laser, CO2= carbon dioxide, LiOB = laser-induced optical breakdown, PIH = postinflammatory hyperpigmentation, mVSS = Modified Vancouver scar scale.

Pathophysiologic Review of Blow-Out Fracture and Blow-Out Fracture Extended to Subarachnoid Space Due to Air Gun Injury.

ABSTRACT: Blow-out fracture is usually caused by direct traumatic events in the periorbital area. But in this case, the authors introduce a case in which the medial orbital wall was fractured directly through the medial rectus muscle by high pressure air gun.A 38-year-old man was injured in his right periorbital area after being hit by high pressure air gun. He had mild ecchymosis and subconjunctival hemorrhage. He had a normal light reflex and intraocular pressure of 14 mm Hg. A facial computed tomography scan confirmed a blow-out fracture of the medial orbital floor with multiple extensive subcutaneous emphysema in the right hemifacial area. Free air was also seen near the basal cistern and Sylvian fissure, indicating a pneumocephalus. The operation was performed after swelling and emphysema were subsided. Intraoperative, medial rectus muscle was damaged. After the operation, no abnormal findings were observed in the ophthalmic examination. Also, the free air findings, which were observed in preoperative x-ray, have disappeared.This case is a rare case in which an orbital wall has been fractured directly through the medial rectus muscle due to an air gun injury. Therefore, we should always kept in mind that blow-out fractures can occur even with unusual mechanisms.

Early diagnosis of craniofacial necrotising fasciitis: Analysis of clinical risk factors.

Necrotising fasciitis (NF) is a rapidly progressing fatal disease. Craniofacial necrotising fasciitis (CNF) is limited to the region above the mandibular margin, and early diagnosis is particularly difficult in the absence of related studies. Ten-year data of patients with craniofacial infection were collected from four separate hospitals. Based on the diagnostic criteria, patients were classified into abscess and CNF. The risk factors for early diagnosis were analysed by comparing the two groups. Simple abscess was found in 176 patients, and CNF was detected in 25 patients. The risk factors associated with CNF include old age, presence of odontogenic infection, elevated white blood cell count (WBC), increased C-reactive protein (CRP), high levels of creatinine (Cr) and glucose (Glu) and low levels of haemoglobin (Hb) and albumin (Alb). In addition, fever above 38°C and sinusitis at the time of admission and progressive sepsis after admission were also risk factors. Among the statistically significant risk factors, low Alb level showed the greatest association with CNF progression. Appropriate management of CNF via early diagnosis and extensive surgical intervention based on identified risk factors can reduce the mortality rate, complications and unnecessary medical expenses. Clinical question/level of evidence: Diagnostic, III.

Hidden Preauricular Sinus as a Cause of Persistent Infection After Facelift.

The facelift is one of the most popular cosmetic surgery methods of antiaging. There are many complications in facelift, but infections rarely occur relatively. The authors would like to introduce a patient who developed infection after a facelift procedure. The cause of the infection was preauricular sinus, one of the congenital anomalies. The patient was treated with complete excision of sinus tract and the patient was treated without any further complications. Based on this clinical report, surgeons performing cosmetic surgery need to be interested in rare congenital lesions such as preauricular sinus.

Complicated calcified alloplastic implants in the nasal dorsum: A clinical analysis.

BACKGROUND: In rhinoplasty, calcification around silicone implants is frequently observed in the tip dorsum (TD) area. Additionally, based on a review of various literature, it is presumed that calcification in silicone implants occurs due to both inflammatory chemical reactions and physical friction against the tissue. The calcification of nasal silicone implants not only results in the functional loss of the implants, but also leads to material deformation. However, there is a lack of research on calcification of nasal silicone implants in the current literature. AIM: To elucidate various clinical characteristics of calcification around nasal silicone implants, using histological and radiological analysis. METHODS: This study analyzed data from 16 patients of calcified nasal implants, who underwent revision rhinoplasty for various reasons after undergoing augmentation rhinoplasty with silicone implants. The collected data included information on implant duration, implant types, location of calcification, presence of inflammatory reactions, and computed tomography (CT) scans. RESULTS: The most common location of calcification, as visually analyzed, was in the TD area, accounting for 56%. Additionally, the analysis of CT scans revealed a trend of increasing Hounsfield Unit values for calcification with the duration of implantation, although this trend was not statistically significant (P = 0.139). CONCLUSION: Our study shows that reducing the frequency of calcification may be achievable by using softer silicone implants and by minimizing the damage to perioperative tissues.

Tongue-in-Groove: A Novel Implant Design for a Blow-Out Fracture.

Background: During blow-out fracture surgery, restoration of the orbital volume and rigid implant fixation are essential. The migration of an implant is a concern of most surgeons. The purpose of this study was to introduce a simple idea of molding and fixing an orbital implant. Methods: In the tongue-in-groove method, an incision of about 2 mm was made on the edge of the implant and it was bent to form a slot. A hole was made in the center of the implant for fitting a bone hook, and the implant was firmly fit into the remaining intact bone. Before and after surgery, computed tomography (CT) was used to evaluate changes in the orbital volume and the location of the implant. Statistically significant restoration of the orbital volume was confirmed on postoperative CT. Results: Compared with the unaffected orbital volume, the affected orbital volume was increased from 87.06 ± 7.92% before surgery to 96.14 ± 6.11% after surgery (p < 0.001). There was one case of implant migration during follow-up. However, the degree of movement was not severe, and there were no events during the follow-up period. Conclusions: The tongue-in-groove technique offers advantages, such as easy fixation of the implant, with minimal trauma to the surrounding tissues. In addition, the method offers advantages, such as being easy to learn, requiring little time for trimming the implant, and being relatively low cost. Therefore, it can be one of the options for implant fixation.

An Experimental and Clinical Study of Flap Monitoring with an Analysis of the Clinical Course of the Flap Using an Infrared Thermal Camera.

Flap surgery is a common method used to cover defects following tumor ablation, trauma, or infection. However, insufficient vascularity in the transferred flap can lead to flap necrosis and failure. Proper postoperative monitoring is essential to prevent these complications. Recently, research has explored the use of infrared thermal imaging in plastic surgery, leading to its clinical application. This study comprises two separate parts: an in vivo experimental study and a clinical study. In this study, 28 rats underwent reverse McFarlane flap surgery, and their flaps were analyzed using a FLIR thermal imaging camera seven days post-surgery. Additionally, thermal images of flaps were taken on postoperative days 0, 1, 2, 3, and 7 in 22 patients. This study focused on temperature differences between normal skin and the perforator compared to the average flap temperature. Results showed that the temperature difference was higher in the necrosis group and increased over time in cases of total necrosis. A lower perforator temperature compared to the flap's average indicated vascular compromise, potentially leading to flap failure. The FLIR camera, being contact-free and convenient, shows promise for understanding and inferring the clinical progression of flaps in postoperative monitoring.

A CARE-compliant article: A case report of unusual eschar and extensive soft tissue necrosis in Tsutsugamushi disease.

RATIONALE: Tsutsugamushi disease is a common infectious disease in the Northern Hemisphere. A patient infected with tsutsugamushi disease will show a characteristic clinical course with eschar formation, which is mostly small and self-limited in nature without causing major problems. We report a rare case of unusually extensive necrosis started from a small eschar. PATIENT CONCERNS: In this report, a 65-year-old female patient with a history of diabetes mellitus present an 8 × 6 cm-sized huge eschar and extensive soft tissue necrosis aggravated from a small eschar. Also, there were 3 other small eschars in the scalp and left flank area. In early July, she was farming in a field in Hongseong-gun, South Korea. She had been treated at another hospital for 2 weeks. However, the eschar became bigger and worse. DIAGNOSES: After admission, escharectomy was performed and extensive soft tissue necrosis was identified. Orientia tsutsugamushi antibody tests were positive from blood test. Providencia rettgeri and Enterococcus faecalis were detected in a tissue bacterial culture test. INTERVENTION: While using oral azithromycin and intravenous imipenem/cilastatin, the necrosis of the thigh was excised and covered by lateral femoral circumflex artery based myocutaneous Keystone flap. OUTCOMES: The remaining small eschars recovered spontaneously, the large eschars that had caused necrosis were successfully treated, and all other clinical symptoms improved without complications. LESSONS: For unusual eschar of an unknown cause, especially in patients with uncontrolled diabetes or immunocompromised, the possibility of Tsutsugamushi should be considered. Careful physical examination and proper management should be performed as soon as possible.

Does the advantage of transcutaneous oximetry measurements in diabetic foot ulcer apply equally to free flap reconstruction?

BACKGROUND: Transcutaneous oxygen pressure (TcpO2) is a precise method for determining oxygen perfusion in wounded tissues. The device uses either electrochemical or optical sensors. AIM: To evaluate the usefulness of TcpO2 measurements on free flaps (FFs) in diabetic foot ulcers (DFUs). METHODS: TcpO2 was measured in 17 patients with DFUs who underwent anterolateral thigh (ALT)-FF surgery and compared with 30 patients with DFU without FF surgery. RESULTS: Significant differences were observed in the ankle-brachial index; duration of diabetes; and haemoglobin, creatinine, and C-reactive protein levels between the two groups. TcpO2 values were similar between two groups except on postoperative days 30 and 60 when the values in the ALT-FF group remained < 30 mmHg and did not increase > 50 mmHg. CONCLUSION: Even if the flap is clinically stable, sympathectomy due to adventitia stripping during anastomosis and arteriovenous shunt progression due to diabetic polyneuropathy could lead to low TcpO2 values in the ALT-FF owing to its thick fat tissues, which is supported by the slow recovery of the sympathetic tone following FF. Therefore, TcpO2 measurements in patients with DFU who underwent FF reconstruction may be less accurate than in those who did not.

Successful reconstruction using a buccal fat pad flap in misdiagnosed buccinators intramuscular synovial sarcoma: A case report.

INTRODUCTION: Synovial sarcoma (SS) is a subtype of soft tissue sarcoma that primarily usually occurs in the lower extremities but rarely arises in the head and neck areas, including the oral cavity. Due to its variable presentation and similarity to benign masses in terms of age at onset, growth rate, and favorable outcomes, SS is often misdiagnosed as a benign tumor. However, it is a malignant tumor. PATIENT CONCERNS: We report the case of intramuscular SS in the oral cavity. Initially, the lesion was clinically suspected as a benign mass but was ultimately confirmed as malignant SS. DIAGNOSIS: Although histopathological examination is the first step in diagnosing SS, molecular testing to confirm the presence of SYT-SSX fusion can provide a definitive diagnosis when the histopathology is inconclusive. In this patient as well, the postoperative pathological report confirmed the diagnosis of biphasic SS, and molecular testing revealed positive SYT/SSX fusion. THERAPEUTICS INTERVENTIONS: Following the recommendation of multidisciplinary care system, a wide excision was performed including the buccinators muscle, and reconstruction was performed using a buccal fat pad flap to prevent cheek depression. OUTCOMES: On the final pathologic report, SS was removed margin-free, and there were no metastatic lymph nodes. No evidence of cheek dimpling was observed, and follow-up neck CT showed no significant changes in the lymph nodes. As a result of observation up to several months after surgery, there were no functional and aesthetic complications. CONCLUSIONS: We report a successful case of intramuscular SS resection, initially misdiagnosed as a benign mass, using a buccal fat pad flap. We also highlight the importance of correctly diagnosing SS, especially in the craniofacial region where it can be mistaken for benign masses.

Breast filler granuloma mistaken for implant rupture: A case report.

RATIONALE: Breast augmentation is usually performed by inserting implants into the breasts. However, injectable fillers are sometimes used for the convenience of both patients and surgeons. If foreign substances, such as biomaterials, are injected into the body, complications such as inflammation, granuloma, and tissue necrosis can occur owing to foreign body reactions. PATIENT CONCERNS: A 39-year-old female patient visited our hospital complaining of tenderness, redness, and swelling in both breasts. The patient had undergone bilateral breast augmentation using implants 4 years prior to current consult. DIAGNOSES: On magnetic resonance imaging (MRI), cystic lesions and fluid collections were observed, with findings suggesting implant rupture; hence, surgery was planned to remove both implants. INTERVENTIONS: Intraoperatively, the implant was malpositioned in the upper lateral portion without rupture. Capsular contracture findings were also not prominent. A large amount of inflammatory granuloma was observed and removed in the prepectoral plane, and the implants were immediately inserted into a new subpectoral plane. OUTCOMES: The volume of the new implant was 175 mL, which was smaller than the previous one, as per the patient preference. Cytology of the fluid from the previous implant pocket showed no evidence of malignancy, and the granuloma was identified as inflammatory tissue caused by a foreign body reaction on biopsy. The excessive protrusion of both breasts was corrected after surgery, and the patient was satisfied with the aesthetic outcomes without any complications up to 3 months after surgery. LESSONS: The use of injectable fillers for breast augmentation carries the risk of misdiagnosis, and, therefore, surgeons should always exercise caution.

Secondary craniofacial necrotizing fasciitis from a distant septic emboli: A case report.

BACKGROUND: Craniofacial necrotizing fasciitis (CNF) is an uncommon but fatal infection that can spread rapidly through the subfascial planes in the head and neck region. Symptoms usually progress rapidly, and early management is necessary to optimize outcomes. CASE SUMMARY: A 43-year-old man visited our hospital with left hemifacial swelling involving the buccal and submandibular areas. The patient had fever for approximately 10 d before visiting the hospital, but did not report any other systemic symptoms. Computed tomography scan demonstrated an abscess with gas formation. After surgical drainage of the facial abscess, the patient's systemic condition worsened and progressed to septic shock. Further examination revealed pulmonary and renal abscesses. Renal percutaneous catheter drainage was performed at the renal abscess site, which caused improvement of symptoms. The patient showed no evidence of systemic complications during the 4-mo post-operative follow-up period. CONCLUSION: As the patient did not improve with conventional CNF treatment and symptoms only resolved after controlling the infection, the final diagnosis was secondary CNF with septic emboli. Aggressive surgical decompression is important for CNF management. However, if symptoms worsen despite early diagnosis and management, such as pus drainage and surgical intervention, clinicians should consider the possibility of a secondary abscess from internal organs.

Clinical significance of early venous enhancement on CT angiography of the ischemic lower limbs.

The authors observed good clinical courses in patients with lower limb ulcers and extensive skin inflammation who showed early venous enhancement at contrast-enhanced lower extremity computed tomographic angiography. The author hypothesized that these early venous enhancements tend to occur in conditions of healthier vascular status. A total of 145 patients who met the inclusion criteria were classified based on the degree of arterial occlusion and early venous enhancement according to lower extremity angiography. Early venous enhancement correlated with age over 65 (t-score = 0.001), absence of ulcer history (t-score = 0.003), absence of amputation history (t-score = 0.004), and low ankle-brachial index (P value = .001). We confirmed that the factors related with early venous enhancement differ from the factor inducing arterial occlusion. Prior to this study, early enhancement of veins in the lower limb was thought to be an artifact. However, in this study, veins that show early enhancement are suspected of being healthier and more responsive to inflammation than those that do not show early enhancement. These findings may help to predict the clinical course and to determine therapeutic planning without additional studies. Also, it can be easily reproduced in other facilities.

Reduction of comminuted fractures of the anterior wall of the frontal sinus using threaded Kirschner wires and a small eyebrow incision.

BACKGROUND: Frontal sinus fractures are relatively rare. Their surgical management significantly differs depending on whether the posterior wall is invaded and the clinical features vary. A bicoronal incision or endoscopic approach can be used. However, the minimally invasive approach has been attracting attention, leading us to introduce a simple and effective surgical method using multiple-threaded Kirschner wires. METHODS: All patients had isolated anterior wall fractures without nasofrontal duct impairment. The depth from the skin to the posterior wall was measured using computed tomography to prevent injury. The edge of the bone segment on the skin was marked, a threaded Kirschner wire was inserted into the center of the bone segment, and multiple Kirschner wires were gently reduced simultaneously. RESULTS: Surgery was performed on 11 patients. Among them, seven patients required additional support for appropriate fracture reduction. Therefore, a periosteal elevator was used as an adjunct through a small sub-brow incision because the reduction was incomplete with the Kirschner wire alone. The reduction results were confirmed using facial bone computed tomography 1 to 3 days postoperatively. The follow-up period was 3 to 12 months. CONCLUSION: The patients had no complications and were satisfied with the surgical results. Here we demonstrated an easy and successful procedure to reduce a pure anterior wall frontal sinus fracture via non-invasive threaded Kirschner wire reduction.

Humulus japonicus attenuates LPS-and scopolamine-induced cognitive impairment in mice.

BACKGROUND: Neuroinflammation plays an important role in cognitive decline and memory impairment in neurodegenerative disorders. Previously, we demonstrated that Humulus japonicus (HJ) has anti-inflammatory effects in rodent models of Alzheimer's disease and Parkinson's disease. The present study aimed to examine the protective potential of HJ extracts against lipopolysaccharide (LPS)-induced cognitive impairment and scopolamine-induced amnesia in mouse models. Cognitive improvement of mice was investigated by novel object recognition test. For analyzing effects on neuroinflammation, immunohistochemistry and quantitative real-time polymerase chain reaction (qRT-PCR) assays were performed. RESULTS: We found that the oral administration of HJ significantly improved cognitive dysfunction induced by LPS in a novel object recognition test. The LPS-induced activation of microglia was notably decreased by HJ treatment in the cortex and hippocampus. HJ administration with LPS also significantly increased the mRNA expression of interleukin (IL)-10 and decreased the mRNA expression of IL-12 in the parietal cortex of mice. The increased expression of LPS-induced complement C1q B chain (C1bq) and triggering receptor expressed on myeloid cells 2 (Trem2) genes was significantly suppressed by HJ treatment. In addition, HJ administration significantly improved novel object recognition in a scopolamine-induced amnesia mouse model. CONCLUSIONS: These findings revealed that HJ has a beneficial effect on cognitive impairment and neuroinflammation induced by systemic inflammation and on amnesia induced by scopolamine in mice.

Agathobaculum butyriciproducens Shows Neuroprotective Effects in a 6-OHDA-Induced Mouse Model of Parkinson's Disease.

Parkinson's disease (PD) is the second-most prevalent neurodegenerative disease and is characterized by dopaminergic neuronal death in the midbrain. Recently, the association between alterations in PD pathology and the gut microbiota has been explored. Microbiota-targeted interventions have been suggested as a novel therapeutic approach for PD. Agathobaculum butyriciproducens SR79T (SR79) is an anaerobic bacterium. Previously, we showed that SR79 treatment induced cognitive improvement and reduced Alzheimer's disease pathologies in a mouse model. In this study, we hypothesized that SR79 treatment may have beneficial effects on PD pathology. To investigate the therapeutic effects of SR79 on PD, 6-hydroxydopamine (6-OHDA)-induced mouse models were used. D-Amphetamine sulfate (d-AMPH)-induced behavioral rotations and dopaminergic cell death were analyzed in unilateral 6-OHDA-lesioned mice. Treatment with SR79 significantly decreased ipsilateral rotations induced by d-AMPH. Moreover, SR79 treatment markedly activated the AKT/GSK3ß signaling pathway in the striatum. In addition, SR79 treatment affected the Nrf2/ARE signaling pathway and its downstream target genes in the striatum of 6-OHDA-lesioned mice. Our findings suggest a protective role of SR79 in 6-OHDA-induced toxicity by regulating the AKT/Nrf2/ARE signaling pathway and astrocyte activation. Thus, SR79 may be a potential microbe-based intervention and therapeutic strategy for PD.