Choong Hyun Chang

Earlobe Keloids: Classification According to Gross Morphology Determines Proper Surgical Approach

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

Impact of Large-Volume Liposuction on Serum Lipids in Orientals: A Pilot Study

Recent advances in liposuction techniques now make it possible to remove considerable amounts of subcutaneous adipose tissue. However, the metabolic consequences of this procedure are not well documented. The aim of this study was to identify the effects from the surgical removal of subcutaneous fat on the body weights and serum lipids of patients who have undergone large-volume liposuction. In this study, eleven consecutive patients with a minimum aspirate volume of 5,000 ml were evaluated, and their serum lipids were measured at a postoperative 2-month follow-up assessment. Tumescent fluid was infiltrated using the superwet technique. The liposuction device used was a Liposlim® power-assisted liposuction system. The amount of solution infiltrated and the volume of aspirate were measured. Pre- and postoperative serum lipids, body weights, and body mass indices were compared. Statistical analysis was performed on lipid profile changes and aspirate volumes using Spearman’s correlations. The average volumes of infiltrate and aspirate were 7,241 and 6,790 ml, respectively. Mean body weight decreased from 64.5 ± 18.8 to 59.9 s ± 17.8 kg (p < 0.01). The change in body weight per 1 l of aspirate volume was 0.67 ± 0.10 kg/l. The mean body mass index dropped from 23.8 ± 4.4 to 22.0 ± 4.2 kg/m2 (p < 0.01), and the mean total serum cholesterol levels from 168.2 ± 23.6 to 162.9 ± 26.5 mg/dl, an average of 3.2%. The mean low-density lipoprotein (LDL) decreased from 94.3 ± 20.5 to 89.5 ± 19.0 mg/dl, a 5.1% drop, and the mean high-density lipoprotein (HDL) decreased from 55.8 ± 9.5 to 53.7 ± 10.7 mg/dl, a 3,8% drop. The mean HDL/LDL proportion increased from 62.6 ± 20.9% to 63.5 ± 22.4%, averaging 1.4%. However, no significant correlation was found between the aspirated volume of fat and lipid profile change. In conclusion, over a 2-month period, large-volume liposuction reduced weight and total cholesterol level and increased the HDL/LDL ratio. The authors hope to discover whether the therapeutic impact of liposuction is long-lasting, and to determine whether it reduces the morbidity and mortality associated with obesity.

Clinical experience with complications of hand rejuvenation

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

Clinical experience with polymethylmethacrylate microsphere filler complications.

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

Keloid Recurrence in Pregnancy

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

Methylene Blue Dye-Induced Skin Necrosis in Immediate Breast Reconstruction: Evaluation and Management

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

Histologic Changes of Implanted Gore Bio-A in an Experimental Animal Model

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

Suggestion of End Points of Complete Keloid Excision

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

Three-Dimensional Circumferential Liposuction of the Overweight or Obese Upper Arm

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

Botulinum Toxin A Upregulates Rac1, Cdc42, and RhoA Gene Expression in a Dose-Dependent Manner: In Vivo and in Vitro Study.

AbstractAngiogenesis is the development of new capillaries from existing blood vessels and is a prerequisite for the wound-healing process. Many lines of scientific evidences have shown that complicated roles of small guanosine triphosphatases (GTPases) (ras-related C3 botulinum toxin substrate 1 [Rac1], cell division control protein 42 [Cdc42], and ras homolog gene family, member A [RhoA]) in regulation of signal transduction pathways exist to transmit distinct cellular effects on the modulation of actin cytoskeleton remodeling such as cell cycle progression, cell survival, and cell motility. In addition, these small GTPases activate mitogen-activated protein kinase kinase kinases (MAP3Ks) leading to activated mitogen-activated protein kinase kinases (MAPKK), mitogen-activated protein kinase (MAPK), and various transcription factors such as vascular endothelial growth factor with involvement of MAPK signaling pathways.In this study, the authors hypothesized that botulinum toxin A increases angiogenesis via the expression of small GTPases in vivo and in vitro studies.In vivo experiment, 24 Sprague–Dawley rats were randomly divided into 2 groups: a control group and a botulinum toxin A group. Five days prior to superiorly based transverse rectus abdominis myocutaneous flap elevation, the botulinum toxin A (BoTA) group was pretreated with BoTA, while the control group was pretreated with normal saline. quantitative real-time polymerase chain reaction was performed to evaluate the expression of Rac1, RhoA, and Cdc42.The angiogenic effects of botulinum toxin A on human dermal fibroblasts were measured in vitro experiment. To understand the mechanism of botulinum toxin A on small GTPases production of fibroblasts, Rac1, Cdc42, and RhoA were measured using qRT-PCR.The relative messenger ribonucleic acid expression of Rac1, RhoA, and Cdc42 was significantly higher in the BoTA group than in the control group, in every zone and pedicle muscle, on postoperative days 1, 3, and 5. Levels of these molecules increased significantly in human dermal fibroblasts grown in the presence of BoTA compared with control group over 5 IU.Our in vivo and in vitro studies suggest that administration of BoTA upregulates the expression of RhoA, Rac1, and Cdc42 in a dose-dependent manner. MAPK signaling pathway might be involved in BoTA-induced angiogenesis mechanism.Level of Evidence: N/A