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Background Vulvovaginal laxity, atrophic vaginitis, and orgasmic dysfunction are not only aesthetic but also sexual problems. Autologous fat grafting (AFG) facilitates tissue rejuvenation through the effects of adipose-derived stem cells; the fat grafts serve as soft-tissue filler. However, few studies have reported the clinical outcomes of patients undergoing vulvovaginal AFG. Objectives The aim of this study was to describe a new technique, micro-autologous fat transplantation (MAFT), for AFG in the vulvovaginal area. Posttreatment histologic changes in the vaginal canal that imply improved sexual function were assessed. Methods This retrospective study enrolled females who underwent vulvovaginal AFG performed through MAFT between June 2017 and 2020. Assessments were based on the Female Sexual Function Index (FSFI) questionnaire and on histologic and immunohistochemical staining. Results In total, 20 female patients (mean age, 38.1 years) were included. On average, 21.9 mL of fat was injected into the vagina and 20.8 mL in the vulva and mons pubis area. Six months afterwards, the patients’ mean total FSFI score (68.6) was significantly higher than that at baseline (43.8; P < .001). Histologic and immunohistochemical staining of vaginal tissues revealed substantially increased levels of neocollagenesis, neoangiogenesis, and estrogen receptors. By contrast, the level of protein gene product 9.5, which is associated with neuropathic pain, was considerably lower after AFG. Conclusions AFG performed through MAFT in the vulvovaginal area may help manage sexual function–related problems in females. In addition, this technique improves aesthetics, restores tissue volume, alleviates dyspareunia with lubrication, and reduces scar tissue pain. Level of Evidence: 4

BACKGROUND The rates of aesthetic breast augmentation have risen substantially in Asia. Outcomes of various breast augmentation approaches in Asia have not been comprehensively studied. In the past, the inframammary approach to breast augmentation was not popular because of conspicuous scarring. In this article, the authors review academic articles related to the use of an inframammary incision for breast augmentation in Asian women and present our recommendations for the available techniques. METHODS A literature search was performed for articles published after 2015 on Asian women with augmentation mammoplasty describing techniques, incision sites, outcomes, and complications. The search was performed using the MEDLINE, Embase, and Cochrane databases. We also included our own technique to demonstrate the outcome of augmentation mammoplasty through inframammary incision. RESULTS Eight articles satisfied our inclusion criteria. Evidence indicates that with proper preoperative design and surgical techniques, scarring resulting from the inframammary approach is not inferior to that resulting from the transaxillary approach in Asian patients. Long-term satisfaction with the inframammary approach to breast augmentation is high in Asian patients.Eight articles reported the outcomes of 1168 women receiving breast augmentation. Inframammary incisions were used in 45.29% of patients (529 patients). After the 2015 publication of Zelken's review paper on Asian breast augmentation, the rate of inframammary incisions increased from 3.1% to 45.29%. CONCLUSIONS With precise design of the new inframammary fold, accurate wound suture fixation, and postoperative scar care, the inframammary approach to breast augmentation offers optimal operative visualization, reduced pain, fewer complications, and desirable esthetic outcomes even in Asian patients. This study demonstrates that the percentage of inframammary fold approach of Asian esthetic mammoplasty grows rapidly after 2015.

The most challenging complication associated with lower blepharoplasty is ectropion, and the traditional lateral canthopexy or canthoplasty procedure may carry the risk of eyelid malposition or subsequent chemosis. We propose lateral tarsoplasty with a detailed description of the techniques to treat and even prevent ectropion by not involving the medial or lateral canthal ligament so as to avoid complications.Lower eyelid laxity was analyzed with the snap-back test and distraction test before surgery. Approximately 5 mm medial to the lateral canthus, lateral tarsoplasty is performed through a full-thickness pentagonal tarsal-conjunctival resection according to the "overlapping test" for an accurate measurement of the amount of the tarsus to be resected. Seventy-two eyelids that received either ectropion correction or prevention with lateral tarsoplasty over an 8-year period at a single institution were collected and analyzed for this retrospective review.Lateral tarsoplasty was performed in 39 patients with a mean age of 63.8 years. Thirteen patients with 20 eyelids presented for ectropion correction, in whom 5 to 10 mm of tarsus was resected, 6.0 mm in average. The other 26 patients with 52 eyelids presented for ectropion prevention, in whom 3 to 7 mm of tarsus was resected, 4.1 mm in average. Apart from temporary mild chemosis, all patients experienced highly satisfactory results without any ectropion or malposition of the involved lower eyelids after a follow-up of 8.1 months in average.For patients with moderate and severe laxity of lower eyelids, lateral tarsoplasty without involvement of the lateral canthal ligament proves to be an effective way to treat and prevent lower eyelid ectropion.

Diabetic wound care is a major health care concern. The major cause of non-healing of wounds in patients with diabetes mellitus (DM) patients mainly involves poor glycemic control, which hinders the migration of progenitor cells including mesenchymal stem cells to the wound site. In this study, we introduced adipose-derived stromal cells (ADSCs) into wound sites and demonstrated that the local transplantation of ADSCs accelerated DM-related wound healing. Furthermore, the migration ability of ADSCs, which diminishes in a high-glucose environment, was partially restored by the exogenous replenishment of the cutaneous T-cell attracting chemokine (CTACK/CCL27). Our findings suggest that CTACK is a potential novel therapeutic target in DM-related wound healing. Keywords: ADSC, CTACK/CCL27, Diabetes mellitus, Wound

Purpose Treatment of blepharoptosis caused by ocular myasthenia gravis (OMG) is challenging in patients with serious side effects or failed response to medical therapy. Only a few surgical reports have been published for refractory myathenic blepharoptosis. This study is aimed at the evaluation of the surgical outcome of blepharoptosis correction in intractable OMG patients. Methods Twelve OMG patients who accepted frontalis sling with frontalis orbicularis oculi muscle (FOOM) flap for blepharoptosis correction were reviewed. Patients' demographies, perioperative changes of the interpalpebral fissure height (IPFH), margin reflex distance 1 (MRD1), levator function (LF), and quality of life (QOL) score were evaluated. Results The duration of OMG ranged from 3 to 31 years. LF was normal in 6 patients, good in 5, and poor in 1. There is no significant change of LF before and after surgery. MRD1 improved significantly from -1.8 mm (range, 0 to -5 mm) preoperatively to 2.9 mm (range, 2-4 mm) postoperatively. IPFH improved significantly from 3.8 mm (range, 2-6 mm) preoperatively to 7.8 mm (range, 6-9 mm) postoperatively. Upper eyelid margin was above the pupil in all patients. QOL score improved significantly from 18.2 (range, 14-23) preoperatively to 5.8 (range, 0-10) postoperatively. Conclusions Our report reveals that surgical correction of the blepharoptosis is effective for patients with intractable OMG and that frontalis suspension with FOOM flap is a valuable option because of its ready availability and pliability. All patients are satisfied with the results, especially the improvement of QOL.

The aim of this literature review is to examine Hering's law, a well-documented phenomenon in blepharoptosis patients, with 10% to 20% noted in cases of unilateral ptosis. Predominantly presenting as contralateral eyelid drop postoperatively, it poses a challenge for eyelid surgeons in the pursuit of symmetry and appropriate eyelid height. Proper preoperative evaluation is of utmost importance, consisting of one of either lifting test, covering test, or phenylephrine test. A deeper understanding of Hering's law further provides adequate information for optimal management of ptosis. In regard to ptosis etiology, congenital ptosis does not appear to have a distinct relation to positive Hering's law, commonly associated with a low incidence, when compared with acquired ptosis. Ptosis in the dominant eye seems to be related to a higher incidence of the phenomenon than ptosis in the nondominant eye, with statistical significance in studies ranging from P < 0.001 to P = 0.09. This can be explained as an innate response for increased innervation to regain the field of vision. Both ptosis severity and levator function appear to be of lesser importance than ptosis etiology, with minimal incidence of Hering's law in congenital ptosis regardless of these factors. It is, however, noted that ptosis severity has direct association with contralateral eyelid position in acquired ptosis, whereas there is a lack of studies for levator function. In the event of preoperative contralateral eyelid drop, surgeons should consider simultaneous surgery instead of delayed surgery for bilateral ptosis (P = 0.002). For unilateral ptosis, although reoperation is done per patient request, it may be more appropriate to first wait for roughly 2 weeks and reassess for self-regulation to a normal eyelid position.

Objective Under physiological stress, the membranes of organelles undergo conformational change to tubulo-reticular structures (TRS) for gaining survival advantage. We aim to explore whether TRS formation in the peripheral blood mononuclear cells (PBMCs) of patients with systemic lupus erythematosus (SLE) correlates with more active disease where physiological stress prevails. Methods To mimic the intracellular impact of interferon-alpha (IFN-α) on lymphocytes, human B-lymphocyte cell line was stimulated by recombinant IFN-α in concentrations of 100, 1000 and 10 000 IU/mL for 72 h. TRS within the lymphocytes was then quantified by transmission electron microscopy (TEM). Upon confirming TRS formation under IFN-α influence, PBMCs of lupus patients were isolated, fixed and quantified for TRS under TEM. The frequency of TRS in lupus PBMCs was compared with that of healthy controls and correlated with the clinical SLE disease activity index (SLEDAI). Results After 72 h, an increase in TRS frequency was observed in a dose-response fashion when the human B-lymphocyte cell line was stimulated by increasing concentrations of IFN-α. In lupus patients, their PBMCs had a significantly higher TRS frequency than healthy controls (P = 0.037). The frequency of TRS was positively associated with the SLEDAI (Spearman ρ = 0.632, P = 0.012), which remained statistically significant after adjustment for daily prednisolone dose (Pearson r = 0.747, P = 0.002). Conclusions While the clinical significance of TRS formation in lupus PBMCs deserves further investigation, these preliminary findings suggest a significant relationship between the disease severity of SLE and intracellular physiological stress. These results underscore the potential of TRS in PBMCs as an ultra-structural disease activity biomarker of SLE.

Non-replantable fingertip amputation is still a clinical challenge. We performed modified composite grafting with pulp adipofascial advancement flap for Hirase IIA fingertip amputations. Results from a series of patients are presented and achieved better outcome than traditional composite grafting.From September 2012 to April 2014, fourteen patients with sixteen digits were included in our study. Mean age of patients was 43.9 years (20-71 years). All of our patients underwent this procedure under digital block anesthesia. We performed pulp adipofascial advancement flap for better soft tissue coverage of bone exposure stump first. The amputated parts were defatted, trimming, and reattached as composite graft. Age and gender of patients, injured finger, Hirase classification, mechanism of trauma, overall graft survival area, two-point discrimination (2PD) (mm) at six-month, length of shortening of digit, The average disabilities of the arm, shoulder, and hand (DASH) score and subjective self-evaluation questionnaire at 6 month were recorded.Average graft survival area was 89% (75-100%). Average length of shortening was 2.2 mm (1.8-3.5 mm). 2PD at six-month after surgery was 6.3 mm in average (5-8 mm). Average DASH score at 6 month was 1.45 (0.83-2.5). The self-evaluated aesthetic results showed twelve patients (85.7%) were very satisfied, and no patient was completely unsatisfied.In Hirase zone IIA traumatic fingertip amputation where replantation is difficult, our modified technique of composite grafting with pulp adipofascial advancement flap provided an alternative choice with high successful rate, acceptable functional and aesthetic outcomes. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016. © 2015 Wiley Periodicals, Inc. Microsurgery 36:651-657, 2016.

Background Muscle infarction is a rare complication of spontaneous ischemic necrosis occurring in skeletal muscle. It is particularly common in patients with diabetes who have impaired sugar regulation. However, muscle infarction is frequently misdiagnosed due to varied clinical manifestations. Methods We presented 3 cases of muscle infarction reported during April 2009 to April 2014. After a comprehensive literature review, we selected 147 muscle infarction cases from the literature, first investigating the relationships between type of muscle blood supply and infarcted muscle. Results The result indicated that muscle infarction 25.85% belonged to type I vascular supply and 61.21% belonged to type II vascular supply, according to the definition by Mathes and Nahai. Conclusions Poor glucose regulation, intense exercise without adequate hydration, vascular disease, and type I and II muscular blood supply were critical predisposing factors. For preventing muscle infarction, we recommend strict glucose regulation and a gradual increase in exercise with adequate hydration.

On the basis of the close anatomical interdigitation between the longitudinal-oriented frontalis muscle and the horizontal-oriented orbicularis oculi muscle (OOM), frontalis OOM (FOOM) flap was developed to treat blepharoptosis. Retrospective study during an 11-year period, 66 patients with 81 poor levator function ptotic eyelids accepted FOOM flap shortening (65 lids; 80.2%) or double-breasted FOOM flap advancement (16 lids; 19.8%) to correct blepharoptosis. There were 51 (77.3%) patients with unilateral ptosis and 15 (22.7%) patients with bilateral ptosis. Severity of blepharoptosis included severe type in 72 (88.9%) lids, moderate type in 5 (6.2%) lids, and mild type in 4 (4.9%) lids. The underlying etiology included congenital origin in 43 (65.1%) patients, involutional change in 19 (28.8%) patients, and neurologic origin in 4 (6.1%) patients. Marginal reflex distance 1 and lid slit distance improved from -1.6 (2.0) to 3.3 (1.2) and 3.2 (2.0) to 7.2 (1.4) mm, respectively, after operation. The postoperative outcome includes good results in 54 (81.8%) patients, fair results in 10 (15.2%) patients, and poor results in 2 (3.0%) patients. The undercorrection or recurrence rate is 14.8%, and secondary revision rate is 11.1%. Positive Hering law is 17.6% among patients with unilateral ptosis. Overall patients' satisfaction rate is 95.1%. Both FOOM flap shortening and double-breasted FOOM flap advancement are effective to treat poor levator function blepharoptosis. Double-breasted FOOM flap advancement is highly recommended because of the more natural contour and minimal lagophthalmos postoperatively, because of the maximal preservation of OOM.

There is a painting that looks like a representation of a simple surgical procedure. However, it holds a warm story of the love surrounding the first skin graft made by Dr. David Landsborough III for a Taiwanese child in 1928. He harvested the donor skin from his wife, Marjorie Landsborough, to save a poor boy. Although the grafted skin could not grow onto the wound, the graft of love was permanently imprinted on Taiwanese People's hearts. The first Taiwanese recipient of MD, PhD degree, Dr. Tsung-Ming Tu invited an artist to recreate and draw the surgical procedure to immortalize the unforgettable love and memory of Dr. Landsborough III. The painting hanging on the hospital wall portrays an important professional role model for every student and health care provider. The life story of this medical missionary in Formosa from 1895 to 1936 contributed greatly to the development of medical care in Taiwan. It is hoped that this story, outlining great love and selflessness, can be glorified and remembered for the world to appreciate for generations to come.

Summary Introduction Double eyelidplasty is one of the most common cosmetic surgeries in Asia. Subjective enlargement of the ocular surface area (OSA) after double eyelidplasty was appreciated by patients. Objective measurement of the OSA provides a more scientific result. We introduce a relatively precise method, using iris as a scale combined with the digital photography and software calculation, to measure the OSA before and after double eyelidplasty. Materials and methods One hundred and nineteen patients (108 females and 11 males) were enrolled in this study. Ninety-two patients received minimally invasive double eyelidplasty without other procedures and 27 patients received medial epicanthoplasty with modified Z-plasty besides double eyelidplasty. Digital photographs of the operative eyes in all patients were obtained preoperatively and postoperatively. The image processing software we used was ImageJ (v1.43, National Institutes of Health, United States). Preoperative and postoperative OSAs were measured. The percentage of difference of the OSA between two eyes in same patient before and after the operation was calculated and compared. Results The average increase of the OSA among 238 operative eyes was 12.5 ± 8.2%. Preoperative and postoperative OSA differences between two eyes in same patients were significantly decreased after surgery. Conclusion Digital photography using iris as a scale combined with software calculation is an easy and convenient method to measure the OSA; it provides quantitative information for both preoperative and postoperative evaluation. Our study revealed that double eyelidplasty not only increased OSA but also improved ocular asymmetry after surgery.

Summary Cystic hygroma (CH) is an uncommon congenital anomaly of the lymphatic channels that occurs mainly in children. CH is usually found in the cervical, axillary, inguinal, retroperitoneal, or thoracic region. CH is rare in adults, and to the best of our knowledge, there are only three adult case reports in the English literature (searched via PubMed) that discuss the development of CH in the axilla during adulthood. The lesion in our case presented as a soft, painless, mobile, and transilluminable mass on physical examination. Surgical removal was performed, CH was diagnosed, and the patient recovered uneventfully.