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Background: The superficial musculoaponeurotic system (SMAS) is an anatomical structure involved in facial aging. Objectives: This study focused on SMAS thickness and aimed to establish age-related changes in SMAS thickness. Methods: A total of 100 adult Japanese female participants (aged 20-79 years) were enrolled in the study. The participants were divided into 3 age groups: Y, M, and E, comprising 20 to 39, 40 to 59, and 60 to 79 years, respectively. Anatomical structures were used as landmarks to standardize the SMAS analysis sites. The SMAS in a fixed analysis area (FAA) was quantified using multi-detector computed tomography (MDCT), and the relationship between SMAS thickness and age, as well as BMI, was analyzed. Results: In 96 participants (four were excluded due to imaging artifacts), a moderate yet significant negative correlation was found between the average (A)-SMAS thickness within the FAA and age. The A-SMAS thickness in groups M and E was significantly lower than that of group Y, and the mean value of group E was significantly lower than that of group M. SMAS thickness was greater in the young population. The SMAS gradually became thinner with aging. A statistically significant correlation was not found between SMAS thickness and BMI. Conclusions: Using MDCT technology, age-related changes in SMAS were successfully analyzed. This highly objective analysis method corroborated the aesthetic surgical knowledge of the SMAS features related to facial aging. In clinical applications, our findings may help elucidate the mechanisms involved in facial aging.

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BACKGROUND: Age-related changes in the periocular areas are mainly caused by anatomic changes of the bony orbit and orbicularis oculi muscle (OOM). To achieve effective rejuvenation, it is necessary to understand the age-related aspects of these anatomic changes. OBJECTIVES: The aim of this study was to analyze the configuration of the bony orbit and OOM with computed tomography (CT) and to evaluate the effects of aging on these structures. METHODS: A total of 220 orbits and OOMs of 110 Japanese participants (55 males, 55 females) aged 20 to 87 years were enrolled. The long diameter of the orbits, orbital ellipticity, OOM thickness, and OOM attachment to the inferior orbital rim were analyzed. These variables were statistically evaluated for their relationship with age. RESULTS: The long diameter of the orbit was significantly longer in those over than in those under 60 years, with a moderate and significant positive correlation between orbital ellipticity and age. OOM thickness and age showed a strong negative correlation. The degree of OOM attachment to the inferior orbital rim decreased significantly with age. CONCLUSIONS: This study showed that age-related changes of the bony orbit in Japanese individuals tended to be the same as those in Caucasians, but there were differences in the degree of changes observed. As a new finding in the Japanese population, the OOM not only thins with aging, but also gradually loosens from the facial bone. In the elderly, only the nasal side of the OOM was attached to the bone. In clinical applications, this knowledge could contribute to the development of cosmetic surgeries.

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ABSTRACT: Modern medicine tends to provide comprehensive medical services based on disease or pathological features. As a result, the overlap between plastic surgery and other surgical departments greatly deepened. What was exclusively done by plastic surgeons are nowadays frequently practiced by other surgeons as well. Thus, generating confusion as to whether plastic surgery is an independent subject or a tool. Therefore, in this new era of modern medicine, it is necessary to reconsider the definition of plastic surgery.

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External levator advancement is commonly performed for involutional blepharoptosis repair; however, it is difficult to predict the postoperative upper eyelid position (UEP) accurately in blepharoptosis surgery. The purpose of this study was to determine the factors that influence postoperative UEP following surgery for involutional blepharoptosis. We retrospectively studied 40 Japanese women (80 eyelids) who underwent bilateral external levator advancement surgery. We used digital analysis software to measure the UEP and the eyebrow position from straight-gaze view photographs. Statistical analysis was performed to determine the correlation between postoperative UEP and related factors, including age, levator function, amount of levator advancement, anatomical fixed position, and preoperative and intraoperative UEP. We also compared UEP changes in mild, moderate, and severe ptosis groups. Levator function affected both preoperative and postoperative UEP. The amount of levator advancement and the anatomical fixation position on the aponeurosis did not affect the postoperative UEP. However, both preoperative (r = 0.49) and intraoperative (r = 0.55) UEPs affected the postoperative UEP. In cases of severe ptosis, there was significant re-drooping after surgery, while in cases with mild ptosis, the intraoperative eyelid position was maintained or slightly elevated. In involutional blepharoptosis, the degree of preoperative and intraoperative UEP contributed to the postoperative eyelid position. These data suggested that the levator muscle function is a major contributing factor in the pathogenesis of involutional blepharoptosis.

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Cleidocranial dysplasia is an autosomal skeletal disorder resulting from delayed or abnormal ossification of bony growth. Pectus excavatum independently presented in a 9-year-old boy with cleidocranial dysplasia and was corrected using the Nuss procedure. There were no perioperative complications, and the post-operative course was uneventful. Although there were concerns regarding extraordinary late consolidation or remodeling of the bony thorax, placement of a Nuss plate for 5 years and 6 months improved the patient's concave deformity without re-depression.

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Negative pressure wound therapy (NPWT) has been commonly used over the years for a wide range of chronic/refractory lesions. Alternatively, autologous micrografting technology is recently becoming a powerful modality for initiating wound healing. The case presented is of a patient with a lower leg ulcer that had responded poorly to NPWT alone for three weeks. Consequently, the patient was put on a combination therapy of NPWT and micrografting. After injection of a dermal tissue micrografts suspension into the entire wound bed, NPWT was performed successively for two weeks, resulting in fresh granulation tissue formation. Thereafter, the autologous skin graft was taken well. This case study indicates that for a chronic/refractory ulcer patient with poor NPWT outcome, combination therapy using micrografting treatment and NPWT could rapidly initiate and enhance granulation tissue formation, creating a favorable bedding for subsequent skin grafting.

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We report median cleft lip in an infant girl with lobar-typed holoprosencephaly who underwent presurgical naso-alveolar molding and subsequent cheiloplasty. At seven months postoperatively, we observed an upper lip with natural cupid-bow-shape formed with a nasal dome and two nostrils separated with reconstructed columella, which were maintained for eight years.

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BACKGROUND: We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap. METHODS: Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them. RESULTS: The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially. CONCLUSIONS: Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.

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A micrograft technique, which minces tissue into micro-fragments >50 µm, has been recently developed. However, its pathophysiological mechanisms in wound healing are unclear yet. We thus performed a wound healing study using normal mice. A humanized mouse model of a skin wound with a splint was used. After total skin excision, tissue micro-fragments obtained by the Rigenera protocol were infused onto the wounds. In the cell tracing study, GFP-expressing green mice and SCID mice were used. Collagen stains including Picrosirius red (PSR) and immunohistological stains for α-smooth muscle actin (αSMA), CD31, transforming growth factor-ß1 (TGF-ß1) and neutrophils were evaluated for granulation tissue development. GFP-positive cells remained in granulation tissue seven days after infusion, but vanished after 13 days. Following the infusion of the tissue micrograft solution onto the wound, TGF-ß1 expression was transiently upregulated in granulation tissue in the early phase. Subsequently, αSMA-expressing myofibroblasts increased in number in thickened granulation tissue with acceleration of neovascularization and collagen matrix maturation. On such granulation tissue, regenerative epithelial healing progressed, resulting in wound area reduction. Alternative alteration after the micrograft may have increased αSMA-expressing myofibroblasts in granulation tissue, which may act on collagen accumulation, neovascularization and wound contraction. All of these changes are favorable for epithelial regeneration on wound.

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A neck scar contracture can severely and negatively affect the function of mastication, phonic, or breathing and result in neck pain and issues with esthetics. The best way is of course to avoid such contracture by means of non-surgical treatment such as use of a growth factor. The basic fibroblastic growth factor is clinically well proven in decreasing scar formation and improving healing. There are numerous reconstructive methods for neck contracture, especially when the lesions are relatively limited in part of the neck. However, a very severe and full circumferential scar contracture requires extensive reconstruction. The thin groin flap is one of the answers and well matches with the tissue texture and maintains the flexibility. Even with extensive burns and delayed reconstructions due to resuscitation first, the groin area is well preserved and can be safely harvested by dual vasculature systems of the superficial circumflex iliac artery and superficial epigastric artery, which warrant more reliability compared to the perforator flaps in this area. More demanding and stringent forms of the neck burn scar contracture are the sequelae of radiation. A radiation burn or radiation injury can be progressing and hard to heal. Adipose-derived stem cells can reverse the scar contracture as the surrounding tissue is softened and can accelerate wound healing. In this review, different types of neck burn scar contracture and reconstructive methods are summarized, including innovative use of bFGF and ADSCs in the management of difficult wound healing and scar contracture.

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PURPOSE: Meticillin-resistant Staphylococcus aureus (MRSA) biofilm formation in humans is of serious clinical concern. Previous in vitro studies have been performed with biofilms grown only on inorganic substrates; therefore, we investigated the vancomycin (VCM) resistance of MRSA biofilms grown on skin tissue. METHODOLOGY: We established a novel tissue substrate model, namely MRSA grown on segments of mouse skin tissue (dermal chips, DCs), and compared its resistance capacity against VCM with that of MRSA biofilms grown on plastic chips (PCs).Results/Key findings. For one MRSA isolate, we found that the VCM MIC was identical (1.56 µg ml-1) for planktonic cultures and for biofilms-formed on PCs (PC-BF), although the minimum bactericidal concentration (MBC) increased to 6.25 µg ml-1 in PC-BF. On the contrary, the MIC and MBC for biofilms formed on DCs (DC-BF) significantly increased (25 and 50 µg ml-1, respectively). Furthermore, the minimum biofilm-eradicating concentration was higher for DC-BF (100 µg ml-1) than for PC-BF (25 µg ml-1). Using six MRSA strains, we found that in PC-BF, the c.f.u. number decreased with increasing VCM concentration, whereas in DC-BF, it greatly increased until the MIC was reached, accompanied by the formation of large colonies, thicker bacterial walls and the presence of many mitotic cells. CONCLUSION: Our results indicate that the VCM resistance of MRSA was greater in DC-BF. We conclude that DCs may provide a specific environment for MRSA that enhances bacterial growth under cytotoxic VCM concentrations, and might be useful for the study of skin wound infections and the effects of antimicrobial drugs.

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BACKGROUND: There have been few reports on the efficacy and safety of oral propranolol at 3 mg/kg/day for infantile hemangioma (IH) in Japanese patients. METHODS: A multicenter, open-label phase III study was conducted to evaluate the efficacy and safety of oral propranolol solution in Japanese infants aged 35-150 days with proliferating IH. Thirty-two patients were enrolled in the study, received propranolol solution for 24 weeks at 3 mg/kg/day, and completed the study. RESULTS: The success rate (complete or nearly complete resolution) at week 24 (primary endpoint) was 78% (95%CI: 60-91%). The improvement rate since the previous visit was 100% (32/32) after week 5. Overall, the IH surface area, maximum diameter, and color intensity all decreased over time. Consistency in assessment between the centralized and the investigator on-site assessments was observed in 26 patients. Of the 32 patients, 11 needed further treatment other than the study drug. The incidence of adverse events (AE) and drug-related AE was 97% and 31%, respectively. AE that occurred in ≥two patients were either typical of propranolol use (such as blood pressure decrease) or common events in infants. AE that resulted in dose reduction were observed in two patients, but no serious AE or AE that led to study drug discontinuation were observed. CONCLUSION: Oral propranolol solution at 3 mg/kg/day is effective and safe in Japanese IH patients.

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Although Staphylococcus aureus is part of the normal body flora, heavy usage of antibiotics has resulted in the emergence of methicillin-resistant strains (MRSA). MRSA can form biofilms and cause indwelling foreign body infections, bacteremia, soft tissue infections, endocarditis, and osteomyelitis. Using an in vitro assay, we screened 173 clinical blood isolates of MRSA and selected 20 high-biofilm formers (H-BF) and low-biofilm formers (L-BF). These were intravenously administered to mice and the general condition of mice, the distribution of bacteria, and biofilm in the liver, lung, spleen, and kidney were investigated. MRSA count was the highest in the liver, especially within Kupffer cells, which were positive for acid polysaccharides that are associated with intracellular biofilm. After 24 h, the general condition of the mice worsened significantly in the H-BF group. In the liver, bacterial deposition and aggregation and the biofilm-forming spot number were all significantly greater for H-BF group than for L-BF. CFU analysis revealed that bacteria in the H-BF group survived for long periods in the liver. These results indicate that the biofilm-forming ability of MRSA is a crucial factor for intracellular persistence, which could lead to chronic infections.

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Indwelling foreign-body infections are a critical medical problem, especially in immunocompromised patients. To examine the pathogenicity of biofilm-forming bacteria settling on foreign materials, mice implanted with plastic discs were infected with Staphylococcus aureus. After opening a wide subcutaneous pocket on the dorsal side of mice with or without temporal leukocytopenia, a plastic sheet was placed in the left subcutaneous space; subsequently, bacteria in a planktonic state were dispersed over the subcutaneous space. Bacterial numbers were examined 7 days after inoculation. In subcutaneous tissue on the right, S. aureus was found only in leukocytopenic mice. Meanwhile, bacteria were detected on the plastic and neighbouring tissue in both leukocytopenic and normal mice; however, colony-forming analysis indicated that leukocytopenic mice possessed significantly more bacteria. Tissue reaction against bacteria was pathologically examined. Invading S. aureus induced severe inflammation. In transient leukocytopenic mice, bacterial microcolonies formed on the plastic as well as in the developed necrotic tissue - both of which were shielded from inflammatory cell infiltration - result in bacteraemia. These results indicate that biofilm-forming S. aureus settling on indwelling foreign material are tolerant against host immunity and assault neighbouring tissue, which may lead to chronic wound infection.

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Patellar tumors represent an uncommon etiology of anterior knee pain and their diagnosis is often delayed. We present an unusual case of conventional osteosarcoma arising in the patella of a 47-year-old man. The patient presented with a 1-year history of increasing anterior knee pain and swelling. Plain radiographs revealed a multi-locular lytic lesion in the inferolateral side of the patella. Computed tomography scans demonstrated an intraosseous lytic lesion with cortical thinning/breakthrough anteriorly. On magnetic resonance imaging, the lesion exhibited low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images. Fluid-fluid levels were also observed on T2-weighted images. Contrast-enhanced fat-suppressed T1-weighted images demonstrated strong enhancement of the lesion. These imaging features were suggestive of a benign condition; however, the diagnosis of osteosarcoma was confirmed by histopathology. After neoadjuvant chemotherapy, a wide resection with a free anterolateral thigh flap was performed. The patient subsequently underwent adjuvant chemotherapy and had no evidence of local recurrence or distant metastasis six months after surgery. Our case highlights the difficulty in the diagnosis of patellar osteosarcoma and the importance of performing a biopsy before definitive treatment.

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PURPOSE: To accurately assess eyelid and eyebrow position, we have developed a new measurement method using a digital image analysis system. MATERIALS AND METHODS: (1) Plotting the corneal limbus by transferring to the software digital images of the patient's eyes in the primary gaze position; (2) determining the corneal ring, center, and longitudinal diameter; and (3) measuring the upper eyelid and eyebrow position. The method was tested on 24 patients with senile blepharoptosis and 45 young healthy eyelids without ptosis. RESULTS: The upper eyelid position of patients with blepharoptosis was significantly lower, and their eyebrow position is significantly higher than those of healthy subjects. The upper eyelid and eyebrow position of the patients with blepharoptosis corelated, but no correlation was observed in the healthy subjects. CONCLUSION: Our measuring system is a simpler, easier, and more accurate way of measuring both upper eyelid and eyebrow position than are currently used techniques.

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The extended latissimus dorsi (LD) flap, which includes adipofascial tissue around the posterior iliac crest, is a good option to reconstruct a large breast. However, poor vascularity in the extended part may cause partial fat necrosis. To minimise this problem, vascular augmentation of the extended adipofascial part was performed. When dissecting under the LD muscle, a single perforator from the 11th intercostal vessels was secured and traced upwards along the rib. After the flap was transferred to the chest, the intercostal vessels were anastomosed to the serratus branches of thoracodorsal vessels. This vascular supercharged extended LD flap technique was applied for selected patients. Intraoperative angiography showed that the contrast medium injected into the intercostal artery spread across the lumbar adipofascial part of the flap. This implies that vascular supercharge through the 11th intercostal vessel promotes the vascularity of the extended LD flap and may help to reduce the flap complication rate.

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INTRODUCTION: Although the Nuss procedure for pectus excavatum is widely employed, a variety of complications have been reported with relatively high frequency; those that involve cardiac and pericardial injuries can be life threatening. To reduce such dangers, we present here a newly developed sternal elevator. MATERIALS AND METHODS: The elevator is horseshoe shaped. Its elevator side has the same curvature as a Nuss introducer, so that interference between devices is minimal and no extra skin incision is needed for the elevator insertion. The elevator holds the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. RESULTS: The authors have used the elevator for 61 pectus excavatum cases between March 2004 and December 2009 without any major complications. The entire process of substernal tunneling was endoscopically observed, which eliminated any blunt and blind dissection, even in a significantly depressed funnel chest case. With the device, the sternum was effectively elevated again for the placement of the second plate in 30 cases. CONCLUSION: Our newly developed sternum elevator makes the Nuss procedure safer and more affordable without introducing any extra scarring.

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Myxoid liposarcoma occurs predominantly in the deep soft tissues of the extremities, and tends to metastasize to a wide range of soft tissue or bone locations. We report a case of myxoid liposarcoma arising in the ankle of a 19-year-old man. A diagnosis of myxoid liposarcoma was made by open biopsy, and a wide resection requiring plastic surgical reconstruction was performed. Cytogenetic analysis of the resected tumor exhibited a reciprocal translocation t(12;16)(q13;p11) as the sole anomaly, which is found in more than 90% of myxoid liposarcoma cases. The patient had no evidence of local recurrence or metastasis within 7 years of follow-up. Although myxoid liposarcoma is rare in the ankle, it should be considered in the differential diagnosis of a painless soft tissue mass in this region.

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PURPOSE: When using a free flap to reconstruct a facial deformity caused by Romberg's disease, it is important to prevent the flap from sagging after the operation. We report a new method of reconstructive surgery using a free subscapular adipofascial flap to prevent this problem. PATIENTS AND METHODS: Three female patients (ages 27, 28, and 34 years) with Parry-Romberg syndrome underwent microsurgical free scapular flap transfer for buccal defects. This operation requires making a gingivobuccal sulcus incision and forming a pocket for buccal fat reconstruction by dissecting over the periosteum of the maxillary bone. Preauricular and submandibular incisions are made to create a subcutaneous pocket for flap transfer. After the subscapular flap is elevated, we use its angiogram to observe its vascular pattern. The flap is separated to preserve the main blood vessels horizontal lower branches. The subcutaneous adipose tissue layer uses the horizontal branch, and the buccal fat pad layer the lower branch. METHODS: After the operations, the adipofascial flaps were in good condition and without postoperative complications. A half year after the first operation, revisional surgery was performed for one patient. No cases showed no sagging of the cheek, and in every case the overall appearance of the buccal region improved significantly. DISCUSSION AND CONCLUSION: Reconstruction of the buccal fat pad and subcutaneous adipose tissue using a free bilobed adipofascial flap nourished by the circumflex scapular artery, returned the adiposal tissue to its normal position, assuring more natural facial contours.

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