Sukwha Kim

Update on scar management: guidelines for treating Asian patients.

Background: Following injury, Asian skin has a tendency towards hyper-pigmentation and scar formation, and therefore the prevention of scarring is particularly important in Asian patients. Since publication of an International Clinical Recommendation on Scar Management in 2002, there have been numerous publications in the field of scar management. Advances in understanding scar formation have also led to the introduction of new treatments as well as a better understanding of established therapeutic options. Methods: A literature search for abstracts, clinical trials and meta-analyses evaluating scar prevention and treatment was performed using PubMed and the Cochrane Database of Systematic Reviews. Based on this data a panel of experts formulated treatment recommendations for Asian patients. Results: Following surgery, scar prevention should be initiated in all Asian patients due to the high risk of poor scars. There is strong evidence for the efficacy of silicone based products, and due to their ease of use, they can be considered first-line therapy. Silicone gel (versus silicone gel sheets) products have demonstrated efficacy. For patients who fail to respond to first-line therapy, intralesional steroid injections, radiation therapy, and intralesional 5-flourouracil injections have achieved widespread acceptance. Laser treatments have been increasingly used, although the evidence remains largely anecdotal without a clear consensus on optimal wavelength, or amount of energy. Surgical approaches have increased in sophistication with recognition of the impact that tension has on scar formation. Conclusion: Updated scar management recommendations will benefit practitioners making decisions regarding optimal, evidence-based treatment strategies for their patients.

Regeneration of peripheral nerves by transplanted sphere of human mesenchymal stem cells derived from embryonic stem cells

In cell therapy, the most important factor for therapeutic efficacy is the stable supply of cells with best engraftment efficiency. To meet this requirement, we have developed a culture strategy such as three-dimensional sphere of human embryonic stem cell-derived mesenchymal stem cells (hESC-MSCs) in serum-free medium. To investigate the in vivo therapeutic efficacy of hESC-MSC spheres in nerve injury model, we transected the sciatic nerve in athymic nude mice and created a 2-mm gap. Transplantation of hESC-MSC as sphere repaired the injured nerve significantly better than transplantation of hESC-MSC as suspended single cells in regard to 1) nerve conduction (sphere; 28.81 ± 3.55 vs. single cells; 18.04 ± 2.10, p < 0.05) and 2) susceptibility of nerve stimulation at low voltage (sphere; 0.38 ± 0.08 vs. single cells; 0.66 ± 0.11, p < 0.05) at 8 weeks. Recovery after sphere transplantation was near-complete when compared with the data of normal control (sphere 28.81 ± 3.55 vs normal 32.62 ± 2.85 in nerve conduction : sphere 0.38 ± 0.08 vs normal 0.36 ± 0.67 in susceptibility of nerve stimulation, no significant difference, respectively). Recovery in function of the injured nerve was well corroborated by the histologic evidence of regenerated nerve. In the mechanistic analysis, the supernatant of sphere-forming hESC-MSC contains hepatocyte growth factor and insulin-like growth factor-binding protein-1 significantly more than the supernatant of the single cells of hESC-MSC has, which might be the key factors for the improved engraftment efficiency and greater regeneration of injured peripheral nerve.

Change in grafted secondary alveolar bone in patients with UCLP and UCLA. A three-dimensional computed tomography study.

OBJECTIVE To evaluate changes in the grafted bone after secondary alveolar bone graft (ABG) with iliac bone using 3-dimensional computed tomography (3D-CT). MATERIALS AND METHODS The sample consisted of 10 patients with unilateral cleft lip and palate (UCLP) and 5 patients with unilateral cleft lip and alveolus (UCLA) (mean age = 10 years). 3D-CT data (Sensation 10, Siemens, Munchen, Germany), which was obtained 1 month before (T0), 3 months after (T1), and 12 months (T2) after ABG, were used to measure the height, labiolingual thickness (LLT), and volume of the grafted bone using V-Works 4.0 program (Cybermed Inc, Seoul, Korea). All of the UCLA patients showed the lingual process in the cleft area at T0, but the UCLP did not. RESULTS During T1-T2, there was a significant decrease in height of the upper part of the grafted bone; however, volumes of both the upper and lower parts were decreased. Unilateral cleft type and presence of ULI in the cleft area did not affect the change in height and volume of the grafted bone. The resorption amount (RA) was significantly larger in the lower part than in the upper part, while the resorption rate (RR) exhibited an opposite result. In addition, there was significantly more RA in the labial side in UCLA than UCLP (P < .05). There was no correlation between the initial cleft width and changes in height, LLT, and volume of the grafted bone. CONCLUSION Overpacking and/or excessive condensation of the grafted bone is not necessary in UCLA with the lingual process because of the greater chance of resorption on the labial side of the grafted bone.

Protective effects of EGCG on UVB-induced damage in living skin equivalents.

In this study, we evaluate the effects of (−)-epigallocatechin-3-gallate (EGCG) on ultraviolet B (UVB)-irradiated living skin equivalents (LSEs). Histologically, UVB irradiation induced thinning of the LSE epidermis, whereas EGCG treatment led to thickening of the epidermis. Moreover, EGCG treatment protected LSEs against damage and breakdown caused by UVB exposure. Immunohistochemically, UVB-exposed LSEs expressed p53, Fas, and 8-hydroxy-deoxyguanosine (8-OHdG), all of which are associated with apoptosis. However, EGCG treatment reduced the levels of UVB-induced apoptotic markers in the LSEs. In order to determine the signaling pathways induced by UVB, Western blot analysis was performed for both c-Jun NH2-terminal kinase (JNK) and p38 mitogen-activated protein kinase (MAPK), which are associated with UVB-induced oxidative stress. UVB activated JNK in the epidermis and dermis of the LSEs, and EGCG treatment reduced the UVB-induced phosphorylation of JNK. In addition, p38 MAPK was also found to have increased in the UVB-exposed LSEs. Also, EGCG reduced levels of the phosphorylation of UVB-induced p38 MAPK. In conclusion, pretreatment with EGCG protects against UVB irradiationvia the suppression of JNK and p38 MAPK activation. Our results suggest that EGCG may be useful in the prevention of UVB-induced human skin damage, and LSEs may constitute a potential substitute for animal and human studies.

Postoperative pain management using intravenous patient-controlled analgesia for pediatric patients.

Pain control is an important consideration after any surgical procedures. Especially in children, more attention and care are needed during the period of postoperative pain control, which must be both sufficiently safe and effective. In this respect, intravenous patient-controlled analgesia provides improved titration of analgesic drugs, thereby maintaining optimal analgesic status with few side effects. Thirty pediatric patients were randomly divided into two groups: the intravenous patient-controlled analgesia group (with nalbuphine HCl and ketorolac tromethamine) and the conventional pethidine HCl intramuscular group. The degree of analgesia was assessed every 4 hours until the second postoperative day. The intravenous patient-controlled analgesia group had significantly lower pain scores and took less time until they were able to walk to the bathroom, but as many side effects as the control group. We concluded that intravenous patient-controlled analgesia is safe and effective for pediatric patients who have moderate to severe pain after operations such as rib cartilage graft, iliac bone graft, and large flap surgeries.

The determinants of successful distraction osteogenesis of the mandible in hemifacial microsomia from longitudinal results.

The purpose of this study was to investigate sagittal, vertical, asymmetric skeletal characteristics that could determine successful distraction osteogenesis (DO) of the mandible in patients with hemifacial microsomia using longitudinal follow-up data. Lateral and posteroanterior cephalometric radiographs before DO (T0), after DO (T1), and after retention (T2) were analyzed to investigate initial skeletal characteristics, DO effect, and retention. From the measurements at T2, patients were classified into group 1 (good retention results, N = 10) and group 2 (poor results, N = 9). Sagittal, vertical, dental, and asymmetric variables were measured. The differences at each stage and during T0-T1 and T1-T2 between two groups were compared by Mann-Whitney u test, Wilcoxon signed rank test and ANOVA test. Pruzansky type significantly influenced the success or failure of DO. At T0, group 2 showed more retrognathic mandible, smaller ramus height, larger gonial angle, more inward ramus inclination of the affected side, and more chin point deviation to the affected side than did group 1. The major effects of DO on group 1 were lengthening of the ramus height, forward positioning of the mandible, increase of gonial angle, counterclockwise rotation caused by a decrease of the articular angle, increase of ramus inclination of the affected side, and improvement of occlusal canting and chin point deviation. However, by DO, group 2 showed clockwise rotation of the mandible, and less increase of the ramus height than did group 1. After retention, group 2 showed counterclockwise rotation of the mandible and little growth of the ramus height. Group 1 showed reverse tendency. These factors could contribute to the difference in long-term results between two groups.

Assessment of the relationships among posture, maxillomandibular denture complex, and soft-tissue profile of aesthetic adult Korean women.

The objective of this study was to assess the relationships among the posture, the maxillomandibular denture complex, and the soft-tissue profile of aesthetic adult Korean women. From an initial group of 346 women, the authors examined 28 beautiful adult Korean women who had normal vertical and sagittal skeletal relationships and normal occlusion. There were no differences in the inclinations of the incisors to the occlusal planes in the maxilla and the mandible in the data for Korean women vs. Arnetts data for white women. However, the overbite and overjet in Korean women were slightly smaller than in white women. AB to maxillary occlusal plane angle (MxOP) represented the anteroposterior denture base discrepancy to the occlusal plane. Angulation of the maxillary occlusal plane to the Frankfurt (FH) plane and the true vertical line at submasale (TVL) (Sn) was a little steeper in Korean women than in white women. The FH plane was almost parallel to the true horizontal line in Korean women who had normal vertical and sagittal skeletal relationships and normal occlusion. With regard to soft-tissue variables, the upper lip length (Sn-Stms), interlabial gap, upper incisor exposure, nasolabial angle, lip and nose tip projection value, and TVL (Sn)-to-upper lip line (UL) angle showed interracial differences. The results of this study can assist in the diagnosis and treatment planning of orthognathic surgery.

ANTI-INFLAMMATORY EFFECTS OF ANTHOCYANINS FROM BLACK SOYBEAN SEED COAT ON THE KERATINOCYTES AND ISCHEMIA-REPERFUSION INJURY IN RAT SKIN FLAPS

Ischemia‐reperfusion injury is a phenomenon that occurs when tissues are subjected to ischemia for a variable period of time, and then reperfused. Inflammatory reaction has been implicated as one of the most important mechanism of ischemia‐reperfusion injury. The purpose of this study was to evaluate the anti‐inflammatory effects of anthocyanins from black soybean seed coat on keratinocytes in vitro and ischemia‐reperfusion injury in vivo. We investigated the inhibition, by anthocyanins, of the expression of various inflammatory genes associated with ischemia‐reperfusion injury in the tumor necrosis factor‐alpha‐treated (TNF‐α) immortalized epidermal keratinocyte cell line (HaCaT). We also investigated the effects of anthocyanins on the survival of skin flaps after ischemia‐reperfusion injury in the rats. According to Western blot analysis and a luciferase activity assay, anthocyanins inhibited TNF‐α‐induced intercellular adhesion molecule‐1 and cyclooxygenase‐2 (COX‐2) levels through the NF‐κB‐dependent pathway. Administration of anthocyanins (50 and 100 mg/kg) significantly improved the flap area survival in the 10‐hour ischemic model from 62% to 74.5% and 83%, respectively (P = 0.001). The related cytokines in skin flap also changed as the same pattern as in vitro. Our results indicate that anthocyanins from black soybean seed coat had anti‐inflammatory effects on the HaCaT cell line and increase the survival of skin flaps through anti‐inflammatory properties against ischemia‐reperfusion injury.

Bioabsorbable bone plates enabled with local, sustained delivery of alendronate for bone regeneration.

We prepared a bone plate enabled with the local, sustained release of alendronate, which is a drug known to inhibit osteoclast-mediated bone resorption and also expedite the bone-remodeling activity of osteoblasts. For this, we coated a bone plate already in clinical use (PLT-1031, Inion, Finland) with a blend of alendronate and a biocompatible polymer, azidobenzoic acid-modified chitosan (i.e., Az-CH) photo-crosslinked by UV irradiation. As we performed the in vitro drug release study, the drug was released from the coating at an average rate of 4.03μg/day for 63days in a sustained manner. To examine the effect on bone regeneration, the plate was fixed on an 8mm cranial critical size defect in living rats and the newly formed bone volume was quantitatively evaluated by micro-computed tomography (micro-CT) at scheduled times over 8weeks. At week 8, the group implanted with the plate enabled with sustained delivery of alendronate showed a significantly higher volume of newly formed bone (52.78±6.84%) than the groups implanted with the plates without drug (23.6±3.81%) (p<0.05). The plate enabled with alendronate delivery also exhibited good biocompatibility on H&E staining, which was comparable to the Inion plate already in clinical use. Therefore, we suggest that a bone plate enabled with local, sustained delivery of alendronate can be a promising system with the combined functionality of bone fixation and its expedited repair.

Successful re-plantation of an amputated nasal segment by supermicrosurgery: a case report and review of the literature.

The nose is a critical aesthetic subunit of the face, but because of the difficulties in anastomosis of the small-sized arteries and veins, several cases of nasal replantation have been reported. Using supermicrosurgical techniques, we successfully replanted a patients nasal segment which had been amputated by a falling sharp metal pipe. The result was excellent both aesthetically and functionally, and the patient was very satisfied. The nose is located at the centre of face and is thus important aesthetically. The nose also has functions in olfaction, respiration, humidification, filtration, temperature regulation and phonation. However, the nose protrudes from the face and is readily injured by trauma, and in injured cases, reconstruction of the nose is essential. Recently, with the development of microsurgery, microsurgical replantation of the amputated nose has been reported.(1-11) We performed successful replantation of the nasal alar and tip that were completely amputated and smaller in size than previous reports, using a supermicrosurgical technique.