Versatility of n-butyl-2-Cyanoacrylate for the Reconstruction of Frontal Sinus Comminuted Fracture in Children

PURPOSE: In treatment of facial bone fracture, occurred in children, we generally use wires, miniplate, absorbable plate or their combination. These foreign bodies can be palpable, and sometimes may cause infections, and need reoperation for removing. When bone fragments are multiple, small or thin, they are hard to handle and make accurate reduction of all fragments. In these cases, a biodegradable tissue adhesive, Histoacryl(R) (n-butyl-2-cyanoacrylate), can be used as fixation technique for small, multiple, and thin fracture fragments. METHODS: 3 years old and 6 years old children, who has comminuted fracture on frontal sinus, we used Histoacryl(R) for fixation of multiple bone fragments. After approaching by coronal incision, we pulled out all bone fragments and reconstructed bone fragments by Histoacryl(R) and fixed those on frontal sinus by absorbable plates. RESULTS: Photographs and 3-dimensional CT obtained preoperatively and postoperatively. And we compared them each other in terms of accuracy of reconstructed bony contour. We could reconstruct almost all bone fragments easily along 3-dimensional structure and get excellent aesthetic results. There was no complication such as infection. CONCLUSION: In treatment of comminuted facial bone fracture, occurred in children, Histoacryl(R) is an excellent method for accurate reconstruction in small and thin bone fragments which cannot be fixed by wire, miniplate or absorbable plate without complication.

Reconstruction of Soft Tissue Defects after Snake Bites

PURPOSE: Substantial tissue necrosis after snake bites requiring coverage with flap surgery is extremely rare. In this article, we report 7 cases of soft tissue defects in the upper and the lower extremities caused by snake bites, which needed to be covered with flaps. Among the vast mass of publications on snake bites there has been no report that focuses on flap coverage of soft tissue defects due to snake bite sequelae. METHODS: Seven cases of soft tissue defects in tendon, ligament, or bone exposure after snake bites were included. All patients were males without comorbidities, the average age was 35 years. All of them required coverage with a flap. In 6 cases, the defects were localized on the upper extremity, in one case the lesion was on the lower extremity. Local flaps were used in 6 cases, one case was covered with a free flap. The surgical procedures included one kite flap, one cross finger flap and digital nerve reconstruction with a sural nerve graft, one reverse proximal phalanx island flap, one groin flap, one adipofascial flap, one neurovascular island flap, and one anterolateral thigh free flap. The average interval from injury to flap surgery was 23.7 days. RESULTS: All flaps survived without complication. All patients regained a good range of motion in the affected extremity. Donor site morbidities were not observed. The case with digital nerve reconstruction recovered a static two point discrimination of 7mm. The patient with foot reconstruction can wear normal shoes without a debulking procedure. CONCLUSION: The majority of soft tissue affection after snake bites can be treated conservatively. Some severe cases, however, may require the coverage with flap surgery after radical debridement, especially, if there is exposure of tendon, bone or neurovascular structures. There is no doubt that definite coverage should be performed as soon as possible. But we also want to point out that this principle must not lead to a premature coverage. If the surgeon is not certain that the wound is free of necrotic tissue or remnants of venom, it is better to take enough time to get a proper wound before flap surgery in order to obtain a good functional and cosmetic result.

Compression of the Ulnar Nerve in the Ulnar Tunnel Caused by an Anomalous Pulsatile S-shaped Ulnar Artery

PURPOSE: Compression of the ulnar nerve in the ulnar tunnel is a relatively uncommon condition. Many authors have described several etiologies of ulnar nerve compression. We experienced two cases of ulnar nerve compression in the ulnar tunnel due to an anomalous pulsatile S-shaped ulnar artery. METHODS: Case 1: A 51-year-old man was referred with numbness and paroxysmal tingling sensation along the volar side of the ring and little fingers of his right hand for 6 months. When exploration, the ulnar artery was pulsatile S-shaped and was impinging on the ulnar nerve. To decompress the ulnar nerve, the tortuous ulnar artery was mobilized and translocated radially onto the adjacent fibrous tissue. Case 2: A 41-year-old man was referred with tingling sensation on the 4th, 5th finger of the right hand for 4 months. Sensory nerve conduction velocities of the ulnar nerve was delayed. Preoperative 3D angio CT scan showed an anomalous S-shaped ulnar artery. Same operation was done. RESULTS: The postoperative course was uneventful. After decompression, paroxysmal tingling sensation decreased to less than 1 minute per episode, occurring 1 or 2 times a day. After 4 months, they had no more episodes of numbness and tingling sensation. Examination demonstrated good sensation to pinprick and touch on the ulnar aspect of the hand. CONCLUSION: We report two cases of ulnar nerve compressive neuropathy that was caused by an anomalous pulsatile S-shaped ulnar artery in the ulnar tunnel. Although this is an unusual cause of ulnar nerve compression, the symptoms will not spontaneously resolve. The prompt relief of compressive neuropathic symptoms following the translocation of the impinging ulnar artery from the affected ulnar nerve onto adjacent tissue proved that the ulnar nerve compression is due to the anomalous vessel.

Characteristics of Nasal Trauma in the Implanted Nasal Prosthesis

PURPOSE: Presently, silicone rubber is chosen most frequently for nasal augmentation. However, there is a possibility of extrusion with this material. Sometimes, noses are prone to be traumatized, and then silicone rubber has a possibility of deformity or deviation resulting in trauma. We experienced cases with complications and traumatic deformities after the augmentation rhinoplasty. METHODS: A retrospective review was performed to determine the characteristics of the implanted nasal silicone prosthesis after trauma. The patients' data such as deviation of implant, shape of fracture, age and sex of the patient, time of treatment, operative methods were reviewed. From March 2001 to March 2008, this study was performed in 30 patients. The patients were 25 females and 5 males, from 24 to 60 years of age, with an average of 42. All patients had previous augmentation rhinoplasty with silicone implant. RESULTS: All of the 30 patients were confirmed as deviation of silicone and nasal bone fractures in the facial bone CT scan. The most common cause of fracture was traffic accident. The classification of nasal trauma after augmentation was done by facial bone CT. Class I: Deviation of silicone without nasal bone fracture without extrusion(12 cases, 40%), Class II: Deviation of silicone without nasal bone fracture and with extrusion(4 cases, 13%), Class III: Deviation of silicone with nasal bone fracture and without extrusion(8 cases, 27%), Class IV: Deviation of silicone with nasal bone fracture and with extrusion(3 cases, 10%), Class V: Mild deviation of silicone with nasal bone fracture(3cases, 3%). Specially, the comminuted or trapezoid nasal fracture was confirmed in 11 cases(Class III, IV). CONCLUSION: The problems of silicone implant have generally been related to foreign body reactions, rigidity of the material, encapsulation, infections, and extrusion. We experienced 11 cases of comminuted or comminuted trapezoid shaped fracture below nasal implant. So, we think this phenomenon could be used in late problem of silicone implant.

A Case of Eccrine Porocarcinoma on Back

PURPOSE: Eccrine porocarcinoma is a very rare, potentially fatal tumor which arises from the intraepidermal portion of the eccrine sweat ductal apparatus. It does not have a characteristic clinical feature but does have a high incidence of metastasis. It may be developed de novo or in a preexisting benign eccrine poroma. It usually affects older people and is located most commonly on lower extremities. We report a rare case of eccrine porocarcinoma which developed on the back without metastasis. METHODS: The patient was a 94-year-old woman who showed a painful, ulcerated, dark brown colored polypoid 3.5x3.0cm sized mass on the back for 3 years. We totally excised the lesion including normal tissue. RESULTS: After wide excision of the lesion, pathologist reported an eccrine porocarcinoma. Histopathologic findings reveal that the classic type of eccrine gland carcinoma, eccrine porocarcinoma. Immunocytochemical studies showed a positive reactivity to anti-EMA antibody and anti-CEA antibody. CONCLUSION: Authors experienced a rare case of primary eccrine porocarcinoma on the back. Because of the propensity to develop local recurrence, wide excision of the primary tumor with histologic confirmation of negative margins represents the only curative treatment regimen for eccrine porocarcinoma.

Congenital Anonychia with Ectrodactyly of 5th Finger

PURPOSE: Despite a high frequency of acquired nail disease, congenital absence of the nail, also called as anonychia, is a rare anomaly. It may be seen as an isolated of phalangeal bone(ectrodactyly), nail-patella syndrome, birth trauma, impaired peripheral circulation, alopecia areata, and pemphigus, idiopathic atrophy of the nail, bullous drug eruptions, periodic shedding, lichen planus, Stenvens-Johnson syndrome and so forth. METHODS: We have experienced a rare case of 40-day-old neonate, suffering from intrauterine growth retardation, but without familial history, chromosomal anomalies or any other diseases. RESULTS: There was no nail on left 5th finger and distal phalangeal bone of same finger. So, We diagnosed as Congenital Anonychia with ectrodactyly of 5th Finger. CONCLUSION: We report this case as congenital anonychia of 5th finger which have developed from underlying distal phalangeal ectrodactyly. We also review other reported cased in the literatures.

Buccinator Myomucosal Flap for Wide Cleft Palate

PURPOSE: The goal of palatoplasty is focused on two points. One is to close the palatal defect completely, and the other to create a velopharyngeal system for normal speech. While established methods such as pushback palatoplasty or double opposing Z palatoplasty are used in wide cleft palate repair, sequelae such as maxillary hypoplasia or oronasal fistula may result. Therefore, when palatoplasty with buccinator myomucosal flap is used in the case of wide cleft palates, maxillary hypoplasia and oronasal fistula is reduced and optimal results are obtained. METHODS: From October 2005 to December 2006, four children with wide complete cleft palate underwent unilateral buccinator myomucosal flap and intravelar veloplaty. Mean age at cleft repair was 15 months, and mean cleft size was 2.15cm. The patients underwent intravelar veloplasty and palatoplasty was done using unilateral buccinator myomucosal flap. RESULTS: The patients, after mean 10 months of follow- up observation, showed no signs of oronasal fistula resulting from flap tension. The shape and color similar to normal oral mucosa was obtained, and velopharyngeal function was acquired. CONCLUSION: When intravelar veloplasty and palatoplasty with unilateral buccinator myomucosal flap is done on wide cleft palates, postoperative speech function is optimal, velopharyngeal incompetence is effectively corrected, and sequelae resulting from pushback palatoplasty and double opposing Z-plasty, such as maxillary hypoplasia and oronasal fistula, is reduced.

Versatility of Adipofascial Flap for the Reconstruction of Soft Tissue Defect on Hand or Foot

PURPOSE: Various types of flaps, with their own advantages and disadvantages, have been described for reconstruction of soft tissue defect with exposure of tendons, bones, or joints in the hand or foot. Local flaps with random vascularity have a limitation by their length. Free flaps are time-consuming procedure that may require the sacrifice of some major vessels. The ideal flap for covering soft tissue defects of the hand or foot must provide subcutaneous tissue that tendons can glide through which, supply enough subcutaneous tissue for cover of vital neural, bony, vascular and joint structures, and it has to be aesthetically pleasing. The adipofascial flap fulfills these criteria. It allows immediate or early closure of difficult wound of hand and foot in an easy way, and is especially indicated for small to medium-sized defects. METHODS: From October 2005 to December 2006, seven cases underwent this procedure to reconstruct soft tissue defect on hand or foot. RESULTS: All flaps survived completely, and no complications were observed. CONCLUSION: The adipofascial flap is a convenient flap for coverage of soft tissue with exposure of vital structure in the hand or foot, and provide several advantages, as following; easy and safe, short operating time, one stage procedure, thinness and good pliability of the flap, preservation of the major vascular pedicles, skin preservation at the donor site, thus preserve the shape of the limb and minimize donor site scar.

Late Vascular Complication after Mandibular Ramus Sagittal Split Osteotomy: A Case Report

PURPOSE: The mandibular ramus sagittal split osteotomy is a common procedure in cosmetic surgery. A late complication of this procedure, pseudoaneurysm rarely happens. The purpose of this case is to present our experience that is rare late vascular complication after mandibular ramus sagittal split osteotomy. METHODS: A 21-year-old male was operated by local plastic surgeon for treatment of mandibular prognathism. After 9 days, the man was transferred to our hospital with persistent bleeding and swelling on the mandibular area. We operated the man three times and failed to control hemorrhage. Therefore, we did angiography and found the pseudoaneurysm on the buccal and pterygoid branches of internal maxillary artery. Then we did selective embolization for removal of the pseudoaneurysm. RESULTS: The man was operated using the therapeutic embolization, and the pseudoaneurysm was removed. The results were successful, and we couldn't find any bleeding and the pseudoaneurysm during the follow-up of 12 months. CONCLUSION: The selective embolization is the good therapeutic method of late vascular complication after mandibular ramus sagittal split osteotomy.

Late Vascular Complication after Mandibular Ramus Sagittal Split Osteotomy: A Case Report

PURPOSE: The mandibular ramus sagittal split osteotomy is a common procedure in cosmetic surgery. A late complication of this procedure, pseudoaneurysm rarely happens. The purpose of this case is to present our experience that is rare late vascular complication after mandibular ramus sagittal split osteotomy. METHODS: A 21-year-old male was operated by local plastic surgeon for treatment of mandibular prognathism. After 9 days, the man was transferred to our hospital with persistent bleeding and swelling on the mandibular area. We operated the man three times and failed to control hemorrhage. Therefore, we did angiography and found the pseudoaneurysm on the buccal and pterygoid branches of internal maxillary artery. Then we did selective embolization for removal of the pseudoaneurysm. RESULTS: The man was operated using the therapeutic embolization, and the pseudoaneurysm was removed. The results were successful, and we couldn't find any bleeding and the pseudoaneurysm during the follow-up of 12 months. CONCLUSION: The selective embolization is the good therapeutic method of late vascular complication after mandibular ramus sagittal split osteotomy.

Seymour's Fracture of the Base of the Distal Phalanx in a Child

PURPOSE: Prior to closure of the epiphysis of the distal phalanx, fracture usually occurs through the growth plate, Salter-Harris type I or II, or through the juxtaepiphyseal region 1 to 2 mm distal to the growth plate. The terminal tendon of extensor inserts into the epiphysis only, while insertion site of the flexor digitorum profundus spans both the epiphysis and metaphysis. Because of the difference between these tendon insertions, this injury mimics a mallet deformity. But, this type of injury does not involve a tear or avulsion of the extensor, unlike mallet finger of adults. Seymour was the first to describe this type of injury in children and called after his name, Seymour's fracture. This fracture is prone to infection or remain the residual deformity unless adequate treatment. METHODS: We report a case of Seymour's fracture. A 9-year-old boy presented a laceration of the nail matrix, with the nail lies degloved from the nail fold on the right middle finger gotten from an impact against a door. An X-ray examination showed the fracture line lying 1 mm distal to the growth plate. The injury was treated with debridement and the fracture was reduced by applying hyperextension force. Under the C-arm, a single 0.7 mm K-wire was used to immobilize the distal interphalangeal joint. Intravenous antibiotics were applied for 5 days after surgery. RESULTS: The K-wire was removed in the 3rd week. No infection or significant deformity was found until follow-up of 12 months. CONCLUSION: Seymour's fracture may be at first classically mallet deformity by its appearance. But it is anatomically different and more problematic injury. If it isn't corrected at the time of injury, derangement of the extensor mechanism, and growth deformity of the distal phalanx may occur. The fracture site should be debrided, removed of any interposed soft tissue, and the patient should be given appropriate antibiotics. Reduction should be maintained by K-wire fixation. We experienced no infection or premature epiphyseal closure.

An Isolated Complete Rupture of Radial Collateral Ligament of the Fifth Metacarpophalangeal Joint: A Case Report

PURPOSE: Rupture of a collateral ligament of the metacarpophalangeal joint is rare except in the thumb. The injured digit became flexed and deviated toward ulna side by the hypothenar intrinsic musculature. Incomplete rupture of a collateral ligament of the metacarpophalangeal joint can be often managed by splinting the affected digit in flexion position, however, in the case of complete tears that distraction of the ends of the ruptured collateral ligament is too great to allow repositioning by splinting. Primary repair of the ruptured collateral ligament or reattachment to bone by a pull-out wire, or tendon graft technique appears to be adequate. METHODS: We report a case of instability of fifth metacarpophalangeal joint due to complete rupture of radial collateral ligament. This 18-year-old male presented pain in his right outstretched hand after trauma. The diagnosis was obtained by physical examination and simple radiography. Because of persistent instability after the initial conservative treatment, open reduction and repair surgical treatment was required. RESULTS: The fifth metacarpophalangeal joint became free of pain and stable under forced lateral deviation. Postoperative results showed good metacarpophalangeal joint function and stability during 8 months follow-up period. CONCLUSION: Because of the interposition of the sagittal band between the ruptured ends of radial collateral ligament such as Stener-like lesion of the thumb, surgical repair of metacarpophalangeal joint collateral ligament of the finger was justified in case of complete laxity in full flexion.

Total Tongue Reconstruction with Reinnervated Rectus Abdominis Musculocutaneous Flap

After total glossectomy, recovery of swallowing and speech function can greatly improve quality of life. The reconstructed tongue must be thick enough to contact with the hard palate for articulation. If the free flap is denervation, it may procede to have atrophy postoperatively. Therefor it is difficult to maintain the tongue volume for a long period of time. To resolve this problem, we have used a innervated rectus abdominis musculocutaneous flap and maintaining the volume through a neurorrhaphy. 7 patients underwent immediate reconstruction using a reinnervated rectus abdominis musculocutaneous free flap in which included intercostal nerve was anastomosed to the remaining hypoglossal nerve. The reinnervated rectus abdominis musculocutaneous free flap has provided good tongue contour with sufficient bulk and shown no obvious atrophy in all patients even though postoperative 9 months later. Considering swallowing and articulation, we concluded that reinnervated rectus abdominis musculocutaneous flap is a viable method after total glossectomy.

Reconstruction of Velopharyngeal Function after Resection of Lateral and Superior Oropharyngeal Cancer

PURPOSE: The reconstruction of oropharyngeal defect after cancer surgery is very difficult because of their complicated structure and the functional importance to prevent velopharyngeal incompetence. In this article we investigated affecting factors of velopharyngeal function after reconstruction and a fundamental rule of reconstruction for saving their functions such as swallowing, speeching and breathing. METHODS: We classified 18 patients into three group under Kimata's grouping. Type I defect(6 patients) was healed by primary closure or secondary intention. In Type II or III defect, two operation methods were used - the folded flap(8 patients) and modified Gehanno method(4 patients), which include a lateral-posterior pharyngeal rotation-advancement flap. We evaluated wound dehiscence between the flap and the soft palate, speech intelligibility using Hirose's method, regurgitation during oral feeding, and hypernasality. RESULTS: Most of type I or II defects patients recovered satisfactory velopharyngeal function. But, in patients with type III defects we found wound dehiscence, worse speech function, and common velopharyngeal incompetence. CONCLUSION: The large defect size and presence of wound dehiscence are major factors of postoperative velopharyngeal function. We conclude that folded flap or modified Gehanno method is a good reconstructive operation method for broad contact between the flap and defect site, preventing wound problem.

Endoscopically Assisted Breast Reconstruction of Female Poland Syndrome Through a Single Axillary Incision

Poland syndrome produces deformities of the breast and chest wall that can be highly disfiguring in young women. Incision from traditional surgical approaches can be unsightly, especially if a muscle harvest is used as part of the reconstruction. We report a case of a 19-year-old woman with Poland syndrome. In her case we used minimally invasive techniques to reconstruct her hypoplastic breast. A single midaxillary vertical incision was used to harvest and then transfer the latissimus muscle for breast reconstruction. Relatively, symmetric breast was achieved and the scar was well hidden by the arm. The aesthetic results were satisfactory.

Restoration of the Injured Fingertip with Eponychial Cutaneous Flap

The restoration of the fingernail is not simple in case of amputated distal fingertip which involved the pulp and nail. The nail should maintain a length of at least 2mm from the eponychium for an adequate grip and decent appearance. Various methods to reconstruct the fingernail bed are available. The nail bed graft from amputated finger or great toe, and free onychocutaneous flap are commonly used. The nail bed of the injured tip tends to be atrophied, deformed and failed as a graft. And the great toe is often turned down as a donor. We have restored satisfactorily the nail beds of three injured finger tips with eponychial cutaneous flaps. The pulps were reconstructed with either a reverse dorsal digital island flap or free pulp graft. Repeated again. A mean follow- up was six months. The nail grew up to the average of 3.7mm. All patients were satisfied with the length of the nail and met with good cosmetic results. An eponychial cutaneous flap is useful to restore the nail of the distal fingertip amputation. The procedure is relatively simple and morbidity is minimum.

Comparrison of End - to - side Loop Neurorrhaphy with Epineurium Versus without Epineurium

The high incidence of pain recurrence in traumatic neuromas continues to be a major problem in about 10% of patients. There are more than 100 techniques that have been proposed, but no single reliable method prevents painful neuroma formation. The end-to-side neurorrhaphy published by Viterbo1, and demonstrated encouraging results in prevention of neuroma with end-to-side loop neurorrhaphy. The aim of this study is to compare with the result that end-to-side loop neurorrhaphy with intact epineurium versus resected epineurium. Thirty Spraque-Dawley rats were divide in two group; control and experirnental group. In control group (n = 20), both sciatic nerve are transected and the ends were left unrepaired. In experimental group A (n = 20), the left sciatic nerve are transected and repaired with end-to-side loop neurorrhaphy with intact epineurium. In experimental group B (n = 20), the right sciatic nerve are transected and repaired after removal of epineurium. After 6 weeks, the cantrol and experimental group are sacrificed and examed grossly and histopathologically. In the control group, there were typical neuromas with irregular disorderly growth of axons, spreading out into the surrounding connective tissue. In experimental group A, there was no gross evidence of neuroma formation. In histology, there was some minirnal pattern of disorganized growth of the axons in the end-to-side surface, in only 1 case, but limited to the sutured area without typical spread out growth pattern. In experimental group B, the aspect were similar to the experimental group A. The end-to-side loop neurorrhaphy prevents disorganized axonal spouting seen in typical neuroma. And the interposing epineural sheath has no specific role in prevention of neuroma.

Reconstruction of the Leg with a Vertically-Based Deep Fascia Turnover Flap

The reconstruction of soft tissue defects on the leg remains a difficult challenge for plastic surgeons. If the defect is large and complicated by bone or joint defects, and excellent result can be obtained with free tissue transfer. In cases with no bony problem, no severe osteomyelitis and small medium-sized defects local flap is more acceptable than free tissue transfer because of its simple onestage and reliable operation. Fasciocutaneous turnover flaps revolve around the lack of criteria for safely designing these random pattern flaps as well as the risk of donorsite problems. Vertically-based deep fascia turnover flaps nourished by the subfascial plexus within deep fascia were used successfully for reconstruction of the leg in 5 patients. A vertically-based deep fascia turnover flap consists of deep fascia of the leg and its subfascial and epifascial plexus. As musculofascial, septofascial and periosteofascial branches these contribute to a richly anastomosing vascular network within deep fascia. Unlike adipofascial turnover flaps, the transversely-oriented deep fascia turnover flap keeps its subcutaneous layer with its intact vascular plexus so that the overlying skin is adequately perfused, even in patients with sizable flaps or extremely thin skin. Between March 1998 and February 1999, five cases underwent this procedure to reconstruct soft tissue defect on the leg. The advantages of this method are fast, safelyelevated preservation of the superficial vascular plexus, thus preserving the shape of the leg minimizing donor site scar and hypertrophy.