Ultrasonographic Assessment of the Safe Zone for Carpal Tunnel Intervention: A Comparison Between Healthy Individuals and Patients With Carpal Tunnel Syndrome

Objective@#To compare transverse and longitudinal safe zones using ultrasonography between healthy individuals and patients with carpal tunnel syndrome (CTS). @*Methods@#This was a prospective observational case-control study. Forty wrists from 20 healthy individuals and 40 wrists from 24 patients with CTS were examined. Patients with CTS were classified into three groups (mild, moderate, and severe CTS) based on electrodiagnostic findings. Using ultrasonography, we measured the distance between the median nerve and ulnar vessels to identify the transverse safe zone, and between the distal flexor retinaculum and superficial palmar artery arch to identify the longitudinal safe zone. @*Results@#The transverse and longitudinal safe zones were significantly different between participants with CTS and those without CTS. The transverse safe zone significantly differed between the mild and severe CTS groups, while the longitudinal safe zone was not significantly different between the groups. The cross-sectional area of the median nerve negatively correlated with the transverse and longitudinal safe zones. @*Conclusion@#Transverse and longitudinal safe zones were narrower in patients with CTS than in the healthy group. A significant difference was observed between patients with mild CTS and those with severe CTS. Furthermore, the cross-sectional area of the median nerve was directly proportional to the degree of narrowing of the transverse and longitudinal safe zones.

Lambert-Eaton Myasthenic Syndrome Presenting as Cerebellar Symptoms

A 79-year-old man visited neurology clinic due to gait ataxia and vertigo for 10 months. Neurologic examination revealed saccadic pursuit, mild dysmetria, impaired tandem gait, and areflexia that recovers after exercise. The amplitude of compound muscle action potentials recorded on the abductor digiti minimi increased up to 6,639.4% during repetitive nerve stimulation at 50 Hz stimulation. This case demonstrates that clinicians should consider Lambert-Eaton myasthenic syndrome as a differential diagnosis when a patient complains of gait ataxia and vertigo.

Lambert-Eaton Myasthenic Syndrome Presenting as Cerebellar Symptoms

A 79-year-old man visited neurology clinic due to gait ataxia and vertigo for 10 months. Neurologic examination revealed saccadic pursuit, mild dysmetria, impaired tandem gait, and areflexia that recovers after exercise. The amplitude of compound muscle action potentials recorded on the abductor digiti minimi increased up to 6,639.4% during repetitive nerve stimulation at 50 Hz stimulation. This case demonstrates that clinicians should consider Lambert-Eaton myasthenic syndrome as a differential diagnosis when a patient complains of gait ataxia and vertigo.

Mechanism of Lipid Accumulation through PAR2 Signaling in Diabetic Male Mice

Background@#Protease-activated protein-2 (PAR2) has been reported to regulate hepatic insulin resistance condition in type 2 diabetes mice. However, the mechanism of lipid metabolism through PAR2 in obesity mice have not yet been examined. In liver, Forkhead box O1 (FoxO1) activity induces peroxisome proliferator-activated receptor γ (PPARγ), leading to accumulation of lipids and hyperlipidemia. Hyperlipidemia significantly influence hepatic steatoses, but the mechanisms underlying PAR2 signaling are complex and have not yet been elucidated. @*Methods@#To examine the modulatory action of FoxO1 and its altered interaction with PPARγ, we utilized db/db mice and PAR2-knockout (KO) mice administered with high-fat diet (HFD). @*Results@#Here, we demonstrated that PAR2 was overexpressed and regulated downstream gene expressions in db/db but not in db+ mice. The interaction between PAR2/β-arrestin and Akt was also greater in db/db mice. The Akt inhibition increased FoxO1 activity and subsequently PPARγ gene in the livers that led to hepatic lipid accumulation. Our data showed that FoxO1 was negatively controlled by Akt signaling and consequently, the activity of a major lipogenesis-associated transcription factors such as PPARγ increased, leading to hepatic lipid accumulation through the PAR2 pathway under hyperglycemic conditions in mice. Furthermore, the association between PPARγ and FoxO1 was increased in hepatic steatosis condition in db/db mice. However, HFD-fed PAR2-KO mice showed suppressed FoxO1-induced hepatic lipid accumulation compared with HFD-fed control groups. @*Conclusion@#Collectively, our results provide evidence that the interaction of FoxO1 with PPARγ promotes hepatic steatosis in mice. This might be due to defects in PAR2/β-arrestin-mediated Akt signaling in diabetic and HFD-fed mice.

Possibility of Injecting Adipose-Derived Stromal Vascular Fraction Cells to Accelerate Microcirculation in Ischemic Diabetic Feet: A Pilot Study

BACKGROUND AND OBJECTIVES: Beneficial effects of human adipose-derived stromal vascular fraction (SVF) cell injection on microcirculation have been recently reported in in vitro and in vivo studies. However, no clinical studies have reported its effect in diabetic patients who commonly experience compromised tissue perfusion, regardless of the status of intravascular blood flow. The present piloting study was designed to clinically examine the possibility of SVF cell injection to accelerate microcirculation, particularly in ischemic diabetic feet. METHODS: Ten diabetic feet were included to receive subcutaneous injection of SVF cells around wounds. Transcutaneous partial oxygen pressure (TcPO2) and cutaneous microvascular blood flow were measured before and every four weeks after cell injection until the 12th week visit. RESULTS: TcPO2 values increased from 31.3±7.4 before injection to 46.4±8.2 mmHg at 12 weeks after SVF injection (1.5-fold, p<0.05). Cutaneous microvascular blood flow levels increased from 34.0±21.1 before injection to 76.1±32.5 perfusion unit at 12 weeks after SVF injection (2.2-fold, p<0.05). There were no adverse events related to SVF cell injection. CONCLUSIONS: Results of this study demonstrate that adipose-derived SVF cell injection have the possibility to provide beneficial effects on microcirculation in ischemic diabetic feet.

Familiar Hyperekplexia, a Potential Cause of Cautious Gait: A New Korean Case and a Systematic Review of Phenotypes

Familial hyperekplexia, also called startle disease, is a rare neurological disorder characterized by excessive startle responses to noise or touch. It can be associated with serious injury from frequent falls, apnea spells, and aspiration pneumonia. Familial hyperekplexia has a heterogeneous genetic background with several identified causative genes; it demonstrates both dominant and recessive inheritance in the α1 subunit of the glycine receptor (GLRA1), the β subunit of the glycine receptor and the presynaptic sodium and chloride-dependent glycine transporter 2 genes. Clonazepam is an effective medical treatment for hyperekplexia. Here, we report genetically confirmed familial hyperekplexia patients presenting early adult cautious gait. Additionally, we review clinical features, mode of inheritance, ethnicity and the types and locations of mutations of previously reported hyperekplexia cases with a GLRA1 gene mutation.

Salivary Duct Carcinoma of the Deep Lobe of the Parotid Gland: A Rare Clinical Finding

No abstract available.

Surfer's Myelopathy

Surfer's myelopathy is a rare nontraumatic spinal cord disorder associated with surfing. This study reports three patients with surfer's myelopathy. All patients were young males who were previously healthy and first-time surfers at the onset of their symptoms. They developed the symptoms while surfing or shortly thereafter, presenting with lower back pain followed by an acute myelopathy. Spine magnetic resonance imaging showed T2 hyperintense cord lesion. Since the number of surfers is increasing in Korea, awareness of surfer's myelopathy is necessary for early recognition and proper management.

Footplate Incision in Rhinoplasty: an Update

BACKGROUND: In 2004, we reported on 110 consecutive Asian rhinoplasty patients who were treated with the addition of a footplate incision to obtain a greater aesthetic satisfaction. We continue to perform the reported technique with several modifications, and we still think that this method contributes to Asian rhinoplasty. METHODS: A footplate incision was made along the caudal border of the footplate of the medial crura onto the floor of the nasal vestibule. This incision can be made alone or in combination with either endonasal or open rhinoplasty. It enables surgeons to achieve a further tip projection since the pressure of the skin flap is reduced on the tip. In this study, we emphasize a couple of recent changes that we made to our procedure after publication of the prior article. First, we excised the dog-ear that appeared at the caudal end of the extended footplate incision. After making the new tip, a dog ear can be seen at the posterior end of the footplate incision. Second, an inferior columellar dissection was also extended to achieve an additional tip projection and to improve the columello-labial angle. RESULTS: This study included 85 consecutive patients who underwent an aesthetic rhinoplasty using footplate incision techniques between August of 2010 and May of 2013. A total of 43 patients had an adequate follow-up time of over 12 months. The majority of the patients (40/43 cases) were satisfied with the results. CONCLUSIONS: The authors believe that a footplate incision in aesthetic rhinoplasty is safe and can reliably achieve better results for Asian patients.

Revision of a Widened Scar Using Dermal Splinting Technique

BACKGROUND: Scar revision is a fundamental technique in the field of plastic and reconstructive surgery. Methods using local flaps, such as a Z-plasty, W-plasty, or geometric broken-line closure, have been used for scar revision. Widening of scars is a frustrating event that most plastic surgeons have encountered. Several therapeutic modalities have been proposed, but frequently, the result is disappointing. We describe our experience with the use of a dermal splinting technique for scar revision. METHODS: We propose a technique by which tension on the wound is applied by tough scar tissue instead of the suture line, thereby reducing the incidence of postoperative widening. This technique was used to treat 21 nonburn scars that had widened:5 scars were facial (3 patients), 8 were on the extremities (6 patients), and 8 were on the torso (5 patients). All scars were at least 4 months old. The operations were performed between January 2003 and December 2012; follow-up was 9 to 24 months. RESULTS: Only one scar widened during the follow-up period. Overall, satisfaction with scar appearance and surgery was assessed with a visual analog scale (VAS). Mean patient satisfaction was 8.1 +/- 0.5. CONCLUSIONS: We recommend this technique in dealing with widened scars in highly tensile areas during revision surgery.

Pilomatricoma Arising at an Influenza Vaccination Site

No abstract available.

Surgical Removal of Intraneural Perineurioma Arising in the Brachial Plexus Using an Interfascicular Dissection Technique

No abstract available.

Influence of Negative-Pressure Wound Therapy on Tissue Oxygenation of the Foot

BACKGROUND: Negative-pressure wound therapy (NPWT) is believed to accelerate wound healing by altering wound microvascular blood flow. Although many studies using laser Doppler have found that NPWT increases perfusion, recent work using other modalities has demonstrated that perfusion is reduced. The purpose of this study was to investigate the influence of NPWT on tissue oxygenation of the foot, which is the most sensitive region of the body to ischemia. METHODS: Transcutaneous partial pressure of oxygen (TcpO2) was used to determine perfusion beneath NPWT dressings of 10 healthy feet. The sensor was placed on the tarso-metatarsal area of the foot and the NPWT dressing was placed above the sensor. TcpO2 was measured until it reached a steady plateau state. The readings obtained at the suction-on period were compared with the initial baseline (pre-suction) readings. RESULTS: TcpO2 decreased significantly immediately after applying NPWT, but gradually increased over time until reaching a steady plateau state. The decrease in TcpO2 from baseline to the steady state was 2.9 to 13.9 mm Hg (mean, 9.3+/-3.6 mm Hg; 13.5+/-5.8%; P<0.01). All feet reached a plateau within 20 to 65 minutes after suction was applied. CONCLUSIONS: NPWT significantly decrease tissue oxygenation of the foot by 2.9 to 13.9 mm Hg. NPWT should be used with caution on feet that do not have adequate tissue oxygenation for wound healing.

Free Flap Coverage of the Finger Defect Caused by Digital Replantation Failure

PURPOSE: In case of the failed replantation, if the patients want to preserve the length of amputated stump, toe transfer is the ideal choice. However, reconstruction of these amputated stump with a free flap can be a useful method when the patients refuse sacrificing their toe. Our purpose of this study is to evaluate availability of functional results and patient satisfaction after this procedure. MATERIALS AND METHODS: From March 2008 to February 2012, we reconstructed the amputated stump with free flap by patients demand. Eleven patients were included, medial plantar artery perforator flap in seven cases and great toe pulp flap in five cases. Follow-up range 12 to 24 months and we evaluate patient satisfaction by using a visual analogue scale (VAS; 1=unsatisfied, 5=excellent) and functional recovery by measuring the range of motion of remaining joint at 12 months after operation. RESULTS: During follow-up period, all transferred free flaps survived and no major complications were noted. Range of motion of remaining joint appeared satisfactory result (15degrees to 100degrees). The VAS patient satisfaction score for aesthetic were five in six patients, four in four patients, and three in one patient. CONCLUSION: In case of the failed digital replantation, if patient refuse toe transfer, it could be useful method to reconstruction with the free flap to preserving maximal length of amputated stump.

An Analytical Study of Mammalian Bite Wounds Requiring Inpatient Management

BACKGROUND: Mammalian bite injuries create a public health problem because of their frequency, potential severity, and increasing number. Some researchers have performed fragmentary analyses of bite wounds caused by certain mammalian species. However, little practical information is available concerning serious mammalian bite wounds that require hospitalization and intensive wound management. Therefore, the purpose of this study was to perform a general review of serious mammalian bite wounds. METHODS: We performed a retrospective review of the medical charts of 68 patients who were referred to our plastic surgery department for the treatment of bite wounds between January 2003 and October 2012. The cases were analyzed according to the species, patient demographics, environmental factors, injury characteristics, and clinical course. RESULTS: Among the 68 cases of mammalian bite injury, 58 (85%) were caused by dogs, 8 by humans, and 2 by cats. Most of those bitten by a human and both of those bitten by cats were male. Only one-third of all the patients were children or adolescents. The most frequent site of injury was the face, with 40 cases, followed by the hand, with 16 cases. Of the 68 patients, 7 were treated with secondary intention healing. Sixty-one patients underwent delayed procedures, including delayed direct closure, skin graft, composite graft, and local flap. CONCLUSIONS: Based on overall findings from our review of the 68 cases of mammalian bites, we suggest practical guidelines for the management of mammalian bite injuries, which could be useful in the treatment of serious mammalian bite wounds.

Two-Year Follow-up on the Use of Absorbable Mesh Plates in the Treatment of Medial Orbital Wall Fractures

BACKGROUND: Absorbable materials offer many advantages in the reconstruction of orbital walls; however, the possibility of postoperative enophthalmos after complete absorption cannot be excluded. We evaluated the postoperative results of absorbable mesh plates used as onlay implanting on the medial orbital wall to determine whether they are suitable for medial orbital wall reconstruction. METHODS: The study included 20 patients with medial orbital wall fractures who were followed up for more than 2 years postoperatively. We used absorbable mesh plates in all of the patients. We measured the following: the changes in the expanded orbital volume by comparing the preoperative and postoperative computed tomography (CT) scans and the degree of clinical enophthalmos. RESULTS: There were no major complications associated with the use of absorbable materials such as infection, migration, or extrusion of mesh plates during the long-term follow-up. The orbital volumetric changes between the preoperative and postoperative CT scans were not statistically significant. However, the expanded orbital volume was not related to the degree of clinical enophthalmos. CONCLUSIONS: The reconstructed orbital wall may provide supportive scar tissue to the orbital contents even after the absorbable materials have dissolved completely. Absorbable mesh plates could be another option for the reconstruction of the medial orbital wall.

Rupture of Breast Implants after Augmentation Mammoplasty: A Case Report of Simultaneous Intra-extracapsular Rupture

This paper presents the case of a ruptured hydrogel breast implant, along with its clinical, radiologic, and pathologic findings. Breast asymmetry is typically the most common clinical feature of breast implant rupture. In case of a hydrogel breast implant rupture, hydrogel spreads out after implant leakage and the breast is enlarged with swelling and edema. Intracapsular ruptures showed no significant collapse of the implants despite a collection of fluid surrounding the implant inside the capsule. However, extracapsular ruptures showed implant collapse and extensive inflammation or fibrosis extension to the muscle and chest wall. In this case, a large amount of fluid collection with enlarged implants inside the capsule and extracapsular granulomas were showed simultaneously. Since the use of silicone breast implants has been restricted, hydrogel implants have been used for some time as an alternative option for breast implants. However, hydrogel implants have been restricted because of their unpredictability and unreliability. This case report draws attention to an unusual presentation of complications following the insertion of hydrogel breast implants for augmentation mammoplasty.

True Aneurysm of the Common Digital Artery: Case Report

PURPOSE: An aneurysm is defined as a permanent, localized dilation of an artery with a 50% increase in diameter over its expected normal diameter. Aneurysms can be classified by cause as traumatic and nontraumatic. Traumatic aneurysms can be divided into true and false aneurysms. Nontraumatic causes of peripheral artery aneurysms include mycotic, atherosclerotic, inflammatory, and idiopathic. In the hand, true aneurysms occurring at the common digital artery have been rarely reported. We present a rare case of a true aneurysm of the common digital artery that was resected and reconstructed using a reversed vein graft. METHODS: A 49-year-old male patient was refered to our institution with a 0.73x0.44x1.37cm sized pulsating mass between 2nd and 3rd flexor digitorum tendons on Lt. palm area. The mass had been present for 5 years and had increased in size over the previous year. No history of trauma was reported. After a physical examination and ultrasound sonography review, a diagnosis of aneurismal dilatation of common digital artery was made. Surgical treatment by excision of the aneurysm, and a reversed vein graft was performed. RESULTS: Histologic examination of the specimen(3.4x0.7cm) showed aneurismal dilatation, with elastin fibers present in the arterial wall. The lesions were healed without any complications and there were no evidence of recurrence. Doppler examination of the reconstruction showed good perfusion. CONCLUSION: Early excision is recommended to relieve symptoms and avoid neurologic damage. Also, artery reconstruction can be performed by primary end-to-end anastomosis or the placement of a reversed interposition vein graft. Micro surgical repair was the only possible treatment in this case. The authors believe that the vascular anatomy should always be restored as natural as possible.

Clinical Analysis of Zone 5 Wrist Lacerations

PURPOSE: We conduct a comprehensive review of demography, vector and cause of injury and results of zone 5 volar wrist lacerations. MATERIALS AND METHODS: From July 2001 and June 2010, a total of 170 patients with zone 5 wrist lacerations were reviewed retrospectively. Sex, age, vector and cause of injury, injured structures and results were investigated. The correlations between the wound length, vector, cause of injury and number of injured structures were analyzed statistically. RESULTS: The most common cause of injury is self-inflicted wrist injury followed by incidental accident, industrial accident, and the glass is the most common vector. Thirty six patients underwent primary repair only and 134 patients explored then underwent teno-neuro-arteriorraphy. Error rate between the preoperative and intraoperative evaluations was 30.6%, particularly greater than 50% in cases of flexor digitorum profundus and radial artery injuries. The most common injured structure was palmaris longus followed by flexor carpi radialis, flexor carpi ulnaris and median nerve. The cause and vector of injury did not correlate with the number of injured structures. Relationship between the mean length of wounds and the number of injured structures showed weak positive correlation. CONCLUSION: In zone 5 wrist lacerations, exploration should be performed if the laceration involved over dermis layer. In addition to the surgical treatment, psychological care of these injuries is necessary.

Treatment of Diabetic Ulcer using Autologous Fibroblast-Hyaluronic Acid Complex

PURPOSE: To evaluate clinical efficacy and safety of hyaluronic acid based autologous dermal fibroblasts (Hyalograft 3D) in the treatment of diabetic foot ulcers. METHODS: A total of 28 patients with diabetic ulcers were randomized to either the control group with nonadherent foam dressings(n=14) or the treatment group with autologous tissue-engineered grafts(n=14). Weekly assessment contained vital sign checks, ulcer size measurements, and wound photos. In the 12th week, percentages of complete wound healing and mean healing times were compared. Safety was also monitored by adverse events. RESULTS: Complete wound healing was achieved in 84.6% of the treatment group and 23.1% of the control group(p<0.005). The mean times of closures for the treatment versus control groups were 6.1 weeks and 10.9 weeks, respectively. No adverse events related to the study treatment occurred. CONCLUSION: The use of hyaluronic acid based autologous fibroblast grafts was found to be a safe and effective treatment for diabetic foot ulcers.