Tae Hwan Park

Reconstructive challenge of dermatofibrosarcoma protuberans in the female breast

Dermatofibrosarcoma protuberans is an uncommon locally aggressive malignant neoplasm that most frequently appears in the trunk, followed by the extremities, head, and neck. But occurrence in the breast is extremely rare. We present a case of a 28-year-old woman, who had a history of trauma 5 years previously and excision 1 year before presentation at our clinic. We performed wide excision, together with microscopic and immunohistochemical analysis. No postoperative oncologic treatment was used and she remains disease-free 1 year after the surgery without any tumor recurrence. Here, we report a case of dermatofibrosarcoma protuberans in the female breast and present a detailed discussion of the diagnosis and treatment with reference to available literatures.

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.

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.

The effects of botulinum toxin A on survival of rat TRAM flap with vertical midline scar.

AbstractThe transverse rectus abdominis musculocutaneous (TRAM) flap has been widely used in various reconstructive surgeries. Recently, there have been reports regarding the positive effect of botulinum toxin A (BoTA) on flap survival. We hypothesized that pretreatment with BoTA could augment the survival of pedicled TRAM flaps with a vertical midline scar.Twenty-four Sprague-Dawley rats were randomly divided into 2 groups, namely, control group and BoTA group. Five days after a vertical midline incision, the BoTA group was pretreated with BoTA, whereas the control group was pretreated with normal saline. Ten days after the initial incision, the TRAM flap was harvested.We evaluated the gross flap survival and analyzed the overall histologic change, lumen area of pedicle, and microvessel density with immunohistochemistry. Reverse transcription polymerase chain reaction was performed for the evaluation of angiogenesis-related factors.In the BoTA group, the gross flap survival rate was significantly higher than that in the control group on both ipsilateral and contralateral sides (P < 0.001). In the BoTA group, a significant increase in pedicle lumen area was observed (P < 0.001). In the control group, mild to moderate epidermal necrosis was seen; microvessels were relatively small compared with those of the BoTA group. According to immunohistochemistry, the number of CD31 positively stained vessels was significantly higher on the contralateral side in the control group compared to that in the BoTA group (P < 0.001).The relative messenger RNA (mRNA) expression of CD31 was significantly lower in the BoTA group than that in the control group on both ipsilateral and contralateral sides (P < 0.001). Meanwhile, the relative mRNA expression of VEGF was significantly higher in the BoTA group than in the control group on both ipsilateral and contralateral sides (P < 0.001).We believe that preoperative BoTA therapy is a feasible method to improve circulation of the rat TRAM flap with a vertical midline incision scar.

Management of chest keloids

Keloid formation is one of the most challenging clinical problems in wound healing. With increasing frequency of open heart surgery, chest keloid formations are not infrequent in the clinical practice. The numerous treatment methods including surgical excision, intralesional steroid injection, radiation therapy, laser therapy, silicone gel sheeting, and pressure therapy underscore how little is understood about keloids. Keloids have a tendency to recur after surgical excision as a single treatment. Stretching tension is clearly associated with keloid generation, as keloids tend to occur on high tension sites such as chest region. The authors treated 58 chest keloid patients with surgical excision followed by intraoperative and postoperative intralesional steroid injection. Even with minor complications and recurrences, our protocol results in excellent outcomes in cases of chest keloids.

The effects of botulinum toxin A on mast cell activity: Preliminary results

I read with great interest the article by Akhtar et al. entitled ‘‘The use of botulinum toxin in the management of burns itching: Preliminary results.’’ and I congratulate the authors on their interesting preliminary study [1]. Various endogenous neurotransmitters are considered to be associated with itching sensation. Among them, histamine, known as inflammatory cascade trigger and pruritus inducer, is used in experimental models of pruritus in humans and in animals. A mast cell is well-known as containing many granules rich in histamine. Gazerani et al. reported that botulinum toxin type A reduces histamine-induced itch and vasomotor responses in human skin [2]. I conducted preliminary experiments to clarify the effects of botulinum toxin A on activity of mast cells, which was approved by the Institutional Animal Care and Use b u r n s 3 9 ( 2 0 1 3 ) 8 1 6 – 8 3 1

Presurgical Botulinum Toxin A Treatment Increases Angiogenesis by Hypoxia-Inducible Factor-1α/Vascular Endothelial Growth Factor and Subsequent Superiorly Based Transverse Rectus Abdominis Myocutaneous Flap Survival in a Rat Model.

AbstractTo date, there have been several experimental studies to assess tissue viability of transverse rectus abdominis myocutaneous (TRAM) flaps. Botulinum toxin A (BoTA) has gained popularity in many clinical fields, for a variety of therapeutic and aesthetic purposes. In addition, there have been reports regarding the positive effect of BoTA on flap survival by various mechanisms. In this study, we hypothesized that pretreatment with BoTA could augment the survival of TRAM flaps via increased hypoxia-inducible factor (HIF)1&agr;/vascular endothelial growth factor (VEGF)–dependent angiogenesis.Twenty-four Sprague-Dawley rats were randomly divided into 2 groups: a control group and a BoTA group. Five days before superiorly based TRAM flap elevation, the BoTA group was pretreated with BoTA, whereas the control group was pretreated with normal saline. Gross flap survival rates were assessed, and quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) and Western blotting were performed for the evaluation of angiogenesis-related factors (CD34, HIF-1&agr;, and VEGF).In the BoTA group, the gross flap survival rate was significantly higher than that in the control group on both ipsilateral (92.78.3 ± 5.05% vs 86.8 ± 3.88%, P = 0.009) and contralateral (91.57 ± 5.79% vs 74.28 ± 11.83%, P < 0.001) sides.The relative mRNA expression of CD34 and VEGF was significantly higher in the BoTA group than that in the control group in every zone, whereas the relative mRNA expression of HIF-1&agr; was significantly higher in the BoTA group than that in the control group on contralateral sides. The relative protein expression of CD34, VEGF, and HIF-1&agr; was significantly higher in the BoTA group than that in the control group in every zone.In conclusion, we demonstrate that presurgical BoTA treatment might increase angiogenesis by HIF-1&agr;/VEGF, subsequently increase superiorly based TRAM flap survival in a rat model.

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.

Aesthetic reconstruction of retroauricular keloid: Creating a keystone flap from the mastoid-helix area

Advances in aesthetic rhinoplasty using conchal cartilage grafts have led to a high occurrence of retroauricular keloids. The purpose of this study is to introduce our surgical experiences using a keystone flap in retroauricular keloids following conchal cartilage grafts. The present study is a retrospective review of patients with pathologically confirmed retroauricular keloids following conchal cartilage grafts. These cases were surgically excised and we covered the defect with a keystone flap followed by one‐time steroid injection at postoperative day 14 and silicone gel sheeting application for 3 months. Treatment outcome was recorded as recurrence or non‐recurrence. In all patients, a follow‐up period of minimum 12 months was required. Of these patients, 90.0% had successful treatment of their auricular keloids, whereas 10.0% had recurrences. The postoperative course was uneventful. In conclusion, our aesthetic reconstruction using a keystone flap created from the mastoid‐helix area is a useful treatment strategy in terms of retroauricular keloids following conchal cartilage grafts.

Clinical implications of single- versus multiple-site keloid disorder: a retrospective study in an Asian population.

BackgroundThere is strong evidence of genetic susceptibility in individuals with keloid disorder. The purpose of this cross-sectional study was to determine the clinical relevance of our proposed variables on the multiplicity of keloids by further investigating the presence of other keloids and a family history. MethodsThis was a retrospective review, using institutional review board–approved questionnaires, of patients with keloids who were seen at Kangbuk Samsung Hospital between December 2002 and February 2010. Eight hundred sixty-eight patients were included in our study. Comparisons between the 2 groups were made using Mann-Whitney tests for continuous variables and &khgr;2 tests for categorical variables. ResultsIn our patient group, younger age of onset and the presence of family history were significantly associated with the occurrence of keloids at multiple sites. The locations of extra-auricular keloids, in order of frequency, included the shoulder; anterior chest, including the breasts; deltoid; trunk and pubic area; upper extremities; lower extremities; and other sites. As compared to secondary keloids, primary keloids were significantly associated with both a lower degree of recurrence and the presence of other keloids. The presence or absence of family history was significantly associated with the presence or absence of other keloids and primary or secondary keloids. ConclusionsKeloid disorder is one of the most frustrating problems in wound healing and advances in our understanding of the differences of occurrence at a single site versus multiple sites might help in understanding pathogenesis and improving treatment.