Hook Sun

Regulation of ADAM10 and ADAM17 by Sorafenib Inhibits Epithelial-to-Mesenchymal Transition in Epstein-Barr Virus-Infected Retinal Pigment Epithelial Cells.

PURPOSE The a-disintegrin-and-metalloprotease (ADAM) family proteins are widely expressed in the different layers of the retina throughout development. The effect of ADAM proteins on the epithelial-to-mesenchymal transition (EMT) in proliferative vitreoretinopathy (PVR) or AMD is yet to be elucidated. In this study we used Epstein-Barr virus (EBV)-transformed adult retinal pigment epithelial (ARPE) cells to investigate how sorafenib, a multikinase inhibitor, modulates ADAM proteins to control EMT. METHODS Epithelial to mesenchymal transition and related mechanisms in EBV-infected ARPE cells were determined by RT-PCR, Western blot, invasion assay, ELISA assay, and gene silencing with siRNA. RESULTS Mesenchymal-like ARPE/EBV cells exhibited considerably increased cellular migration and invasion compared with ARPE cells and produced EMT-related cytokines. Sorafenib significantly inhibited production of TGF-β1, VEGF, IL-6, IL-8, MCP-1, and TNF-α and blocked the activation of migration-related signaling molecules, such as HIF-1α, p-STAT3, MMP2, and Ang-1. The expression of mature ADAM10, ADAM17, and cleaved Notch 1 proteins in ARPE/EBV cells was downregulated after treatment with sorafenib through the regulatory activity of nardilysin (NRD-1). Gene silencing of NRD-1 in ARPE/EBV cells attenuated secretion of EMT-related cytokines and expression of ADAM10 and 17 and upregulated epithelial markers. CONCLUSIONS Sorafenib controls the mesenchymal characteristics of EBV-infected ARPE cells. Nardilysin and ADAM family proteins might be new targets for the prevention or control of EMT in retinal diseases.

Surgical management of recurrent squamoid eccrine ductal carcinoma of the scalp.

Squamoid eccrine ductal carcinoma (SEDC) is an exceedingly rare tumor that shows both squamous differentiation and adnexal ductal differentiation. As our review of the literature revealed, only a total of 7 cases were reported to date. We report an additional case of SEDC occurring on the scalp of a 53-year-old man. Despite complete excision by conventional technique with clear margin, the lesion recurred within a 3-month period, with regional lymph node metastasis. The tumor was completely removed, and the large scalp defect was reconstructed by using scalp rotation flap. We present a case of recurrent SEDC on the scalp, and we surgically resected this tumor. In addition, the large scalp defect was reconstructed successfully with scalp flap, and no recurrence has been observed in the patients postoperative follow-ups.

Congenital Midline Cervical Cleft

The occurrence of congenital midline cervical cleft (CMCC) is very rare all over the world and has never been reported in Korea. The typical characteristic of CMCC is a longitudinal skin defect on the midline of the anterior neck that has a nipple-like skin tag at the cranial end, a fistula or sinus tract at the caudal end, and atrophic skin in between. It appears anywhere between the mandibular symphysis and the manubrium [1,2]. Surgical removal in early infancy is the choice of treatment in order to prevent neck extension disabilities caused by cicatricial neck contracture that may occur while aging. Complete excision of abnormal tissue and closure with single or multiple Z-plasty is usually required for functional and aesthetic purposes [1,2,3]. This report is about a 13-month-old female with the typical characteristics of CMCC, for whom we performed complete excision, platysmaplasty with Z-plasty, and skin closure with single Z-plasty. The patient was a 13-month-old girl born by a full-term vaginal delivery and whose initial crying and other activities were normal. No other abnormal finding except a vertical skin defect in the anterior neck region was reported at birth or during growth. At our hospital, we clinically examined the skin lesion on the midline of the anterior neck, noting that it had a nipple-like skin tag at the cranial end, a fistula-like skin lesion at the caudal end, and atrophic skin in between them. Further, it showed a cervical tethering cord formed by the skin lesion (Fig. 1). Fig. 1 Preoperative photograph shows typical characteristics of congenital midline cervical cleft. Neck magnetic resonance imaging and neck sonography showed a hypoechoic lesion in the subcutaneous layer of the midline of the anterior neck at the suprahyoid level with no definite evidence of a thyroglossal duct cyst or a fistula tract. The patient clinically diagnosed with CMCC was placed on the operating table in a supine position under general anesthesia. A fistula opening at the caudal end was checked under the 0.5-cm-long blind end by testing with probe insertion. The cleft and the underlying band-like subcutaneous tissue were completely excised. The cranial end was loosely adhered to the mentalis muscle, and the caudal end was extended with band-like tissue near the manubrium (Fig. 2). After complete excision, platysma flap with Z-plasty and skin closure with single Z-plasty were performed (Figs. 3, ​,44). Fig. 2 Subcutaneous band-like tissue at the caudal end; it reached nearby the manubrium. Fig. 3 Platysma flap with Z-plasty was performed for a functionally and aesthetically better prognosis. Fig. 4 Postoperative photograph. Skin closure with single Z-plasty was performed. The excised tissue was a 4.0 cm×1.1-cm tube-like tissue with a relatively smooth inner surface. Microscopically, the inner surface was covered with squamous epithelium with irregular thickness and parakeratosis. The subepithelial portion revealed a paucity of skin adnexal tissue and had haphazardly arranged skeletal muscle bundles mixed with fat tissue and seromucinous glandular tissue. Minimal scarring was expected two months after the surgery (Fig. 5). No limitation of neck extension was expected upon long-term follow-up. Fig. 5 Postoperative 2-month photograph. Minimal scarring was predicted. CMCC is very rare, and less than 100 cases of this condition have been reported worldwide. It is reported to occur sporadically, and girls have as high as twice the incidence rate as compared to boys [2,3]. The mechanism of CMCC has not yet been ascertained; however, embryologically defective fusion of the first and the second branchial arches is the most accepted hypothesis [1,2]. It is regarded as a variant of the Tessier median mandibular facial cleft and the type-30 craniofacial cleft [3]. Genetic studies are currently in progress; these studies focus on the mutation in the SIX5 gene and the deletion of the pregnancy-associated plasma protein A (PAPPA) as potential candidates, but an accurate mechanism is still unknown [4]. CMCC has three typical characteristics: 1) a nipple-like skin tag in the cranial portion, 2) a sinus tract or fistula in the caudal portion, and 3) a midline cleft resembling a skin defect in between. Subcutaneous band-like fibrosis usually appears above the platysma plane [1,2,3]. Other head and neck anomalies such as lower lip cleft, cleft tongue, cleft mandible, or hypoplasia of midline neck structures are known to be associated [1,2]. In this case, there are three typical characteristics of CMCC without any other anomalies. The characteristic pathologic findings are reported as parakeratosis in the skin, the absence of skin appendages, the presence of striated muscle tissues under the skin, and the presence of respiratory epithelium or seromucinous glands [2,3,4]. In this case, the abovementioned histologic findings were conspicuous, but skin adnexal tissues were absent or very focally dispersed. In the previously reported articles, complete excision of the cleft including the subcutaneous band and skin closure with Z-plasty (single or multiple) have been performed to prevent cicatricial neck contracture and the resulting limitation of neck motion [1,2,3]. In this report, in addition to the above treatment, we performed platysma flap with Z-plasty to prevent midline platysma banding and continuation of scar adhesion. This is expected to produce a functionally and aesthetically better prognosis [5].

Platysma Flap with Z-Plasty for Correction of Post-Thyroidectomy Swallowing Deformity

Background Recently, the number of thyroid surgery cases has been increasing; consequently, the number of patients who visit plastic surgery departments with a chief complaint of swallowing deformity has also increased. We performed a scar correction technique on post-thyroidectomy swallowing deformity via platysma flap with Z-plasty and obtained satisfactory aesthetic and functional outcomes. Methods The authors performed operations upon 18 patients who presented a definitive retraction on the swallowing mechanism as an objective sign of swallowing deformity, or throat or neck discomfort on swallowing mechanism such as sensation of throat traction as a subjective sign after thyoridectomy from January 2009 till June 2012. The scar tissue that adhered to the subcutaneous tissue layer was completely excised. A platysma flap as mobile interference was applied to remove the continuity of the scar adhesion, and additionally, Z-plasty for prevention of midline platysma banding was performed. Results The follow-up results of the 18 patients indicated that the definitive retraction on the swallowing mechanism was completely removed. Throat or neck discomfort on the swallowing mechanism such as sensation of throat traction also was alleviated in all 18 patients. When preoperative and postoperative Vancouver scar scales were compared to each other, the scale had decreased significantly after surgery (P<0.05). Conclusions Our simple surgical method involved the formation of a platysma flap with Z-plasty as mobile interference for the correction of post-thyroidectomy swallowing deformity. This method resulted in aesthetically and functionally satisfying outcomes.

Reconstruction of Abdominal Wall of a Chronically Infected Postoperative Wound with a Rectus Abdominis Myofascial Splitting Flap

Background If a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patients hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect. Methods From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpas fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction. Results Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery. Conclusions Using a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle.

New nasal fracture classification for patients with silicone implants.

Abstract Aesthetic nasal augmentation has increased in popularity among Asian populations, and nasal bone fracture is the most common type of facial bone fracture. In Asia, the frequency of nasal bone fractures is also increasing among patients who have undergone silicone augmentation rhinoplasty. The increasing prevalence of this injury presents a challenge to the surgeon. Thirty-six patients who had previously undergone augmentation rhinoplasty with silicone implant presented with nasal bone fracture from June 2007 through December 2011. The patients were grouped into three categories: patients with fractures in the high level (type I), patients with fractures in the low level (type II), and patients with fractures throughout the entire nasal bone, from base to top (type III). The largest group comprised patients with type I fractures (n = 24, 67%), followed by type II (n = 4, 11%), and Type III (n = 8, 22%) fractures. Symptoms and surgical outcomes for nasal bone fractures may be different in patients with silicone implants. A novel classification system for nasal bone fractures is required, as is a new approach to diagnosis and treatment.

Clinical extension of corrective malarplasty with tripod osteotomy.

Purpose Facial asymmetry can be produced by congenital or acquired factors, and surgical correction is one of the very important and difficult fields in plastic surgery. Zygoma plays a key role to keep facial symmetry, and diverse methods have been tried to correct asymmetric face. We used the malarplasty with tripod osteotomy to correct nontraumatic asymmetric face. Method From December 2008 to February 2010, 3 patients presenting with facial asymmetry and enophthalmia were selected, and their average age was 18 years. One of the patients has undergone surgeries 4 times without improvement for rare facial cleft no. 4 from other hospitals. The other 2 cases had hypoplastic zygoma complex caused by early enucleation and radiation therapies because of retinoblastoma in their childhood. Through a bicoronal approach, malarplasty and calvarial bone graft were done after tripod osteotomy including the zygomaticofrontal suture, zygomatic arch, and zygoma body. Results The surgery results were evaluated by radiographic inspection and the photographs of the patients. Differences in preoperative heights of both normal and hypoplastic zygoma-orbit complex in Waters and zygomatic view were estimated. After corrective operation, the height of the zygoma complex was almost close to normal height, and orbital volume was increased, and ectropion was corrected at the same time in patients. Conclusions Using corrective malarplasty with tripod osteotomy, we achieved satisfactory results of zygoma expansion and improvement in orbital area. Therefore, malarplasty via tripod osteotomy cannot be applied only on the patients with traumatic zygoma deformation, but also on the patients with nontraumatic facial asymmetry.

Skin Necrosis with Oculomotor Nerve Palsy Due to a Hyaluronic Acid Filler Injection

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient’s clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.

Late Complication of a Silicone Implant Thirty Years after Orbital Fracture Reconstruction

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Cephalometric Angular Measurements of the Mandible Using Three-Dimensional Computed Tomography Scans in Koreans

Background We conducted this study to analyze the values of the key cephalometric angular measurements of the mandible using 3-dimensional (3D) computed tomography scans. Methods In the 106 enrolled patients, a 3D cephalometric analysis was performed to measure the angular variables of the mandible. These values were compared between the two sides and between the two sexes. Results The frontal measurements revealed that the mandibular body curve angle was larger on the left (Lt) side (right [Rt], 141.24±7.54; Lt, 142.68±6.94; P=0.002) and the gonial angle was larger on the right side (Rt, 134.37±8.44; Lt, 131.54±7.14; P<0.001). The sagittal measurements showed that the gonial angle was larger on the right side (Rt, 134.37±8.44; Lt, 131.54±7.14; P>0.05). Further, the transverse measurements revealed that the mandibular body curve angle was larger on the right side (Rt, 140.28±7.05; Lt, 137.56±6.23; P<0.001). Conclusions These results provide an average of the mandibular angular measurements for the Korean population, establishing a standard for determining surgical patient groups and outcome evaluations in the field of mandible contour surgery.