Deok Woo Kim

Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management

Skin necrosis following the inadvertent arterial injection of hyaluronic acid (HA) is a serious complication. It is not clear whether or not subcutaneous injections of hyaluronidase decrease skin necrosis in HA-induced vascular complications. We had four cases of HA-induced vascular complications, two of which were treated with hyaluronidase the next day. All of the patients had skin necrosis and scarring. We performed an animal study with rabbit ears in which HA filler was injected into the auricular arteries of both ears. Five rabbits each received a subcutaneous injection of 750 IU of hyaluronidase 4 and 24 h after the filler injection. The hyaluronidase-treated ears in the 4-h intervention group had significantly smaller necrotic areas (p<0.05), while the 24-h intervention group had no differences in the area of necrosis. Hyaluronidase reduced the vascular complications of HA fillers when used early, but there was no benefit to hyaluronidase injection after 24 h.

Effectiveness of mesotherapy on body contouring.

Background: Despite the increasing interest in mesotherapy as an alternative method for body contouring, there are few reports of its safety, efficacy, and mechanism of action. A clinical examination was performed to evaluate the efficacy of mesotherapy for body contouring. Methods: Twenty women were enrolled in this prospective, case-controlled study over a 12-week period. The authors injected a mixed solution (i.e., aminophylline, buflomedil, and lidocaine) into the superficial dermis of the medial aspect of one thigh weekly using a mechanical delivery gun. There was no treatment to the other thigh. The change in the fat level was evaluated by measuring the girth of the thighs and by computed tomographic scanning. The lipid profiles were checked to determine the effect of mesotherapy on lipid metabolism, and questionnaires were used to determine the satisfaction rate of the patients. Results: The loss of thigh girth on the treated side was not significantly different from that of the untreated side. The computed tomographic scans showed no statistically significant difference in the cross-sectional area or thickness of the fat layer between each group. There were no statistically significant changes in the lipid profiles except for the triglyceride level. A questionnaire asking about the effect of mesotherapy indicated poor patient satisfaction. Conclusion: Mesotherapy is not an effective alternative treatment modality for body contouring.

Facial Soft Tissue Augmentation using Autologous Fat Mixed with Stromal Vascular Fraction

Background Autologous fat grafting evolved over the twentieth century to become a quick, safe, and reliable method for restoring volume. However, autologous fat grafts have some problems including uncertain viability of the grafted fat and a low rate of graft survival. To overcome the problems associated with autologous fat grafts, we used uncultured adipose tissue-derived stromal cell (stromal vascular fraction, SVF) assisted autologous fat grafting. Thus, the purpose of this study was to evaluate the effect of SVF in a clinical trial. Methods SVF cells were freshly isolated from half of the aspirated fat and were used in combination with the other half of the aspirated fat during the procedure. Between March 2007 and February 2008, a total of 9 SVF-assisted fat grafts were performed in 9 patients. The patients were followed for 12 weeks after treatment. Data collected at each follow-up visit included clinical examination of the graft site(s), photographs for historical comparison, and information from a patient questionnaire that measured the outcomes from the patient perspective. The photographs were evaluated by medical professionals. Results Scores of the left facial area grafted with adipose tissue mixed with SVF cells were significantly higher compared with those of the right facial area grafted with adipose tissue without SVF cells. There was no significant adverse effect. Conclusions The subjective patient satisfaction survey and surgeon survey showed that SVF-assisted fat grafting was a surgical procedure with superior results.

Skin-tightening effect of fractional lasers: Comparison of non-ablative and ablative fractional lasers in animal models

This experimental study was performed to demonstrate the effects of non-ablative fractional laser (NAFL) and ablative fractional laser (AFL). Twenty male Sprague-Dawley rats were used for the study. Three 2×2-cm-sized squares were tattooed on the abdomen of the animals. Each tattooed square was used for NAFL, AFL and control experiments. The NAFL and AFL treatment were performed with the same total energy of 12,000 mJ cm(-2). The laser treatments consisted of four sessions, with an interval of 3 weeks between sessions. The areas of tattooed skin were serially measured, and skin samples were obtained for histologic examination after 4 months of treatment. NAFL did not cause immediate skin shrinkage, but the size of the NAFL-treated skin was reduced by 4.3% after 4 months. In contrast, AFL caused immediate skin shrinkage (11.5% reduction), and the size was maintained at 9% reduction after 4 months. In histologic examination, the dermal collagen was arranged flat and parallel to the skin surface in the upper dermis, and regenerated collagen fibres were clearly noticed in both NAFL-and AFL-treated skin samples. Immunohistochemical stains showed well-regenerated type I and III collagen fibres. Western blot analysis of skin samples showed that type I/III collagen ratio was not significantly changed after fractional laser treatment. Electron microscopic studies aimed to evaluate the long-term micro-architecture of the collagen fibrils. AFL treatment reduced D-band periodicity by 5.2% and fibril diameter by 14.8%, although there was no statistically significant difference (p>0.05). Fractional laser treatment shrinks the skin surface area and regenerates collagen. The AFL treatment showed more profound skin changes than NAFL.

Versatile use of extended transconjunctival approach for orbital reconstruction

When exposing the orbit, the transconjunctival approach is regarded to have limited surgical exposure. The aim of this study is to demonstrate the versatile usability of extended transconjunctival approach, which can be extended medially and laterally, in reconstruction of medial orbital wall, floor, and even the lateral rim in maxillo-malar complex fracture. We reviewed 122 cases of orbital fractures treated with extended transconjunctival approach. The operative results were assessed by postoperative CT scan and reviewing postoperative complications. The extended transconjunctival approach provided sufficient surgical exposures in all cases. There was no ectropion or scleral show during follow-up period. The cutaneous scars were almost invisible in most cases. The extensile character of this approach makes continuous exposure of the orbit from frontozygomatic suture laterally to the frontonasal suture medially, while minimizing scar and eyelid complications.

Neovascular potential of adipose‐derived stromal cells (ASCs) from diabetic patients

We explored the vascular biology of adipose‐derived stromal cells (ASCs) from diabetic patients and applied these cells to a murine ischemic flap model to assess the comparative angiogenic potentials between normal and diabetic human ASCs. ASCs were obtained from diabetic patients (n = 5) and controls (n = 5). Secretion and expression of angiogenic cytokines were measured under normoxic and hypoxic condition in vitro. Conditioned media harvested from ASC cultures were assessed for their ability to stimulate human umbilical vein endothelial cell proliferation and tubulization. The control and diabetic ASCs were injected into the murine ischemic flaps, and the surviving area was measured. Diabetic adipose‐derived stromal cells showed a lower level of vascular endothelial growth factor expression and cell proliferation rates than the control cells (p < 0.05). However, vascular endothelial growth factor, hepatocyte growth factor secretion, tubulogenesis, and cell proliferation in diabetic conditioned media were increased in response to hypoxic stimuli (p < 0.05), and it was similar to those of control cells. In an animal study, diabetic and normal ASCs significantly increased flap survival (p < 0.05); however, the functional difference was not found between the two groups. Diabetic ASCs were impaired in their ability to produce vascular endothelial growth factors and to induce cellular proliferation under hypoxic conditions. However, diabetic ASCs showed similar flap salvaging effect compared with controls. These findings may be important in the context of future study of autologous cell‐based therapy in diabetic patients.

Comparison of four different lasers for acne scars: Resurfacing and fractional lasers.

BACKGROUND Acne scars are common and cause cosmetic problems. There is a multitude of treatment options for acne scars, including dermabrasion, chemical peeling, and fillers, but the advent of laser technology has greatly improved the treatment of acne scars. Although several laser systems are available, studies comparing their efficacy are limited. This study compares the results of treatments using resurfacing (carbon dioxide, CO2; erbium-doped yttrium aluminum garnet, Er:YAG) versus fractional (nonablative fractional laser, NAFL; ablative fractional laser, AFL) lasers. METHODS A retrospective photographic analysis of 58 patients who underwent laser treatment for facial atrophic acne scars was performed. Clinical improvement was assessed by six blinded investigators with a scale graded from 0 to 10. Adverse events were also noted. RESULTS Mean improvement scores of the CO2, Er:YAG, NAFL, and AFL groups were 6.0, 5.8, 2.2, and 5.2, respectively. The NAFL group showed a significantly lower score than the other groups. The mean number of treatments was significantly greater in the fractional laser groups than in the resurfacing laser groups. The resurfacing laser groups had a prolonged recovery period and high risk of complications. The Er:YAG laser caused less erythema or pigmentation compared to the CO2 laser. CONCLUSIONS Although the CO2 laser, Er:YAG laser, and AFL improved the acne scars, the CO2 laser had a greater downtime. Three consecutive AFL treatments are as effective as a single treatment with resurfacing lasers, with shorter social downtime periods and less adverse effects.

Accelerated healing of pyoderma gangrenosum in Behçet patient treated with cyclosporine and split thickness skin graft.

Pyoderma gangrenosum is a dermatologic manifestation of systemic disease such as inflammatory bowel disease, monoclonal gammopathy, arthritis, malignancies, and Behçets disease. Pyoderma gangrenosum can be stabilized with oral cyclosporine administration. After stabilization, it can be managed with debridement and skin graft.

Fracture depth and delayed contour deformity in frontal sinus anterior wall fracture.

Objectives The choice to manage isolated frontal sinus anterior wall fractures without the involvement of nasofrontal outflow tract is mainly based on aesthetic concern and depends largely on surgeons’ preferences. Minimally depressed anterior wall fractures can be monitored by observation only with little risk of long-term morbidity and contour deformity. The purposes of this study were to evaluate the course of a nonoperated depressed frontal sinus anterior wall fracture and to identify the cutoff value of anterior wall displacement requiring surgical correction. Materials and Methods A retrospective chart review of 51 nonoperated isolated frontal sinus anterior wall fractures was performed. The depth and area of each fracture were measured by computed tomographic scans. Medical records were carefully reviewed to identify the delayed complications or contour changes. Results The mean fracture depth and size were 3.9 mm and 352 mm2, respectively. Patients who had a fracture depth of 4 mm or less did not develop late depressive contour changes of the skin. However, 7 patients who each had a fracture depth of more than 4 mm developed mild contour changes during the months of follow-up. The delayed contour change was associated with fracture depth (P < 0.01), but the fracture area was not considered as an independent factor for delayed contour deformity (P > 0.05). Conclusions The presence of depressive contour changes on the skin is an indication for surgical correction of the frontal sinus fracture. Mildly displaced isolated frontal sinus anterior wall fractures can be observed if the fracture depression is less than 4 mm.

An anatomic study and clinical application of medial pedis flap in Asians.

Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft tissue defects of the hand and digits. In a cadaveric study in 1997, Jayme and Hamilton described the anatomy of the medial branch of the deep division of the medial plantar artery, which is used in the medial pedis flap. However, they had only a few cases where this flap was used. There have been no such anatomic studies in Korea to date. We found the medial pedis flap to be a reliable option for reconstruction of soft tissue defects of the hand and digits, based on an anatomic study with 10 dissected fresh cadavers (20 cases) and analyzing the clinical outcomes in 17 patients. An anatomic study revealed that there were some racial differences in the diameter and length of the vessels. The diameter of vessels in the Korean population is larger than that in whites. Using a thin, flexible medial pedis flap, which has skin and subcutaneous tissue similar to that of the volar aspect of the hand and digits, we harvested and performed the reconstruction on 17 patients with soft tissue defects of the hands and digits. The vessels used for this flap were the medial branch of the deep division of the medial plantar artery and vena comitantes, or subcutaneous veins. The mean size of the flap was 2.82 cm × 4.15 cm. All flaps were successful without any significant complications. The medial pedis flap possesses several advantages: (1) it is very thin in comparison to other standard free flaps; (2) it has 2 draining venous pathways; (3) it provides a good color and texture match for the hand and fingers; (4) it has a satisfactory recovery of protective sensation.