Lymphaticovenular anastomosis for Morbihan disease: a case report

Morbihan disease (MD) is a very rare condition characterized by rosaceous or erythematous lymphedema on the upper twothirds of the face. A definitive management strategy for MD is lacking, and treatment is challenging. Herein, we present a case of persistent bilateral eyelid edema treated by lymphaticovenular anastomosis (LVA) and lymph node-vein bypass surgery. The patient experienced persistent bilateral eyelid edema. Indocyanine green lymphography was performed, and the diagnosis of bilateral facial lymphedema was confirmed. On the right side, a preauricular lymphatic vessel was anastomosed to a vein. On the left side, lymphostomy on the preauricular lymph node was done, with anastomosis to the transected proximal end of the concomitant vein of the transverse facial artery. Furthermore, a preauricular lymphatic vessel was anastomosed to a vein. Eyelid edema decreased and progressively improved on both sides. The outcome of this case suggests that LVA and lymph node-vein bypass surgery are appropriate for treating persistent eyelid edema related to MD.

The relationship between lymphedema severity and awareness of lymphedema surgery

Background@#During the early stages of lymphedema, active physiologic surgical treatment can be applied. However, lymphedema patients often have limited knowledge and misconceptions regarding lymphedema and surgical treatment. We analyzed the correlations between lymphedema severity and surgical technique according to patients’ awareness of surgical treatment for secondary upper extremity lymphedema (UEL). @*Methods@#Patients with UEL diagnosed between December 2017 and December 2019 were retrospectively evaluated. At the time of their presentation to our hospital for the treatment of lymphedema, they were administered a questionnaire about lymphedema and lymphedema surgery. Based on the results, patients were classified as being aware or unaware of surgical treatment. Lymphedema severity was classified according to the arm dermal backflow (ADB) stage and the MD Anderson Cancer Center (MDACC) stage based on indocyanine green lymphography conducted at presentation. Surgical techniques were compared between the two groups. @*Results@#Patients who were aware of surgical treatment had significantly lower initial ADB and MDACC stages (P<0.05) and more frequently underwent physiologic procedures than excisional procedures (P=0.003). @*Conclusions@#If patients are actively educated regarding surgical treatment of lymphedema, physiologic procedures may be performed during the early stages of UEL.

Treatment of Morbihan disease

Morbihan disease (MD) is a rare condition that involves rosaceous lymphedema or erythematous lymphedema of the middle and upper thirds of the face. It typically affects the periorbital region, forehead, glabella, nose, and cheeks. The etiology of MD remains unclear, and its diagnosis is challenging. MD often tends to be unresponsive to therapies commonly used to treat rosacea, including corticosteroids, isotretinoin, and antibiotics. Surgical treatments have therefore been attempted, but most cases showed unsatisfactory responses. These problems could have resulted from an incorrect recognition and interpretation of the pathophysiology of MD and inaccurate planning of the operation, resulting in recurrence or exacerbation of edema.

The relationship between lymphedema severity and awareness of lymphedema surgery

Background@#During the early stages of lymphedema, active physiologic surgical treatment can be applied. However, lymphedema patients often have limited knowledge and misconceptions regarding lymphedema and surgical treatment. We analyzed the correlations between lymphedema severity and surgical technique according to patients’ awareness of surgical treatment for secondary upper extremity lymphedema (UEL). @*Methods@#Patients with UEL diagnosed between December 2017 and December 2019 were retrospectively evaluated. At the time of their presentation to our hospital for the treatment of lymphedema, they were administered a questionnaire about lymphedema and lymphedema surgery. Based on the results, patients were classified as being aware or unaware of surgical treatment. Lymphedema severity was classified according to the arm dermal backflow (ADB) stage and the MD Anderson Cancer Center (MDACC) stage based on indocyanine green lymphography conducted at presentation. Surgical techniques were compared between the two groups. @*Results@#Patients who were aware of surgical treatment had significantly lower initial ADB and MDACC stages (P<0.05) and more frequently underwent physiologic procedures than excisional procedures (P=0.003). @*Conclusions@#If patients are actively educated regarding surgical treatment of lymphedema, physiologic procedures may be performed during the early stages of UEL.

Treatment of Morbihan disease

Morbihan disease (MD) is a rare condition that involves rosaceous lymphedema or erythematous lymphedema of the middle and upper thirds of the face. It typically affects the periorbital region, forehead, glabella, nose, and cheeks. The etiology of MD remains unclear, and its diagnosis is challenging. MD often tends to be unresponsive to therapies commonly used to treat rosacea, including corticosteroids, isotretinoin, and antibiotics. Surgical treatments have therefore been attempted, but most cases showed unsatisfactory responses. These problems could have resulted from an incorrect recognition and interpretation of the pathophysiology of MD and inaccurate planning of the operation, resulting in recurrence or exacerbation of edema.

Nasal tip plasty using three-dimensional printed polycaprolactone (Smart Ball®) / 영남의대학술지

Background@#Rhinoplasty is one of the most commonly performed cosmetic surgery procedures. Most Asians desire elevation of their relatively flat nasal dorsum and tip to make them appear more prominent. This study introduces a simple method of nasal tip plasty using three-dimensional (3D)-printed polycaprolactone (PCL) (Smart Ball®), which provides the required length and volume for this purpose and enables the creation of a nasal tip of the desired shape in a safe and simple manner. @*Methods@#Between September 2014 and May 2017, 22 patients participated in a survey to assess postoperative satisfaction levels. Additionally, three plastic surgeons compared patients’ pre- and 1-year postoperative photographs to evaluate the results. All patients underwent 2- to 4-year postoperative follow-up. @*Results@#Levels of subjective satisfaction among patients were 3.59, 3.50, 3.82, 3.73, 3.55, and 3.82 for each of the 6 categories evaluated, with a mean of 3.67/4 points, indicating high satisfaction levels. The mean plastic surgeon-reported score for the 22 patients was 4.47/5 points, which also indicates highly successful outcomes. Postoperative nasal tip rotation and tip projection were ideal in most patients. @*Conclusion@#Our novel method using 3D-printed PCL (Smart Ball®) provides the optimal length and volume required for nasal tip plasty and enables the creation of a nasal tip of the desired shape, in a safe and simple manner. An advantage of our method is that it retains the original nasal structure in contrast to structural changes observed with the use of conventional methods.

Effect of lidocaine on pain caused by nasal pack removal after closed reduction of nasal bone fractures

Background@#Pain caused by nasal pack removal after closed reduction of nasal bone fractures is a common problem. This study investigated the effect of infiltrating lidocaine into nasal packs on the pain caused by pack removal after closed reduction of nasal bone fractures. @*Methods@#Seventy-five patients who underwent closed reduction of nasal bone fractures between March 2016 and March 2018 were enrolled in this prospective, randomized, single-blind study. Merocel (hydroxylated polyvinyl acetate) packs were applied bilaterally and retained for 5 days. Twenty minutes before removal, both packs were rehydrated with 6 mL of 2% lidocaine in 26 patients and with 6 mL of saline in 24 patients; the packs were not rehydrated in 25 patients. Visual analog scale (VAS) scores for pain on removal were recorded. @*Results@#The mean VAS score was 5.3±2.0 in all patients, 3.8±1.5 in the lidocaine group, 5.8±1.4 in the saline group, and 6.3±2.1 in the non-rehydrated group. There was a significant difference in the pain score between the lidocaine and saline groups (P<0.001) but not between the saline and non-rehydrated groups (P=0.186). @*Conclusions@#Infiltration of lidocaine into Merocel packs reduced the pain caused by pack removal after closed reduction of nasal bone fractures.

Early Stage Lymphedema in Breast Cancer Patient Detected by Indocyanine Green Lymphography but not by Lymphoscintigraphy: A Case Report

Secondary upper extremity lymphedema after lymph node dissection in breast cancer patients is a major complication affecting their quality of life. As lymphatic function is compromised before symptoms develop in most cases, early diagnosis and intervention before symptomatic manifestation is known to prevent severe progression of lymphedema. In this case report, we present a patient with secondary lymphedema, whose disease could be diagnosed at an early stage using indocyanine green (ICG) lymphography. The patient had mild edema of the left upper extremity that regressed with elevation, had normal lymph vessel distribution without dermal backflow pattern in lymphoscintigraphy. Her symptom improved after early prescription of complex decongestive physiotherapy. We conclude that ICG lymphography could be an effective diagnostic tool in addition to other imaging methods, for early diagnosis and intervention of lymphedema.

A novel technique for placing titanium mesh with porous polyethylene via the endoscopic transnasal approach into the orbit for medial orbital wall fractures

BACKGROUND: The endoscopic transnasal approach is widely used for reconstructing the medial orbital wall by filling it with a silicone sheet or Merocel, but this technique has the disadvantage of retaining the packing for a long time. To overcome this drawback, a method of positioning an absorbable plate in the orbit has been introduced, but there is a risk of defect recurrence after the plate is absorbed. Here, the authors report the results of a novel surgical technique of placing a nonabsorbable titanium mesh with porous polyethylene into the orbit through the endoscopic transnasal approach. METHODS: Fourteen patients underwent surgery using the endoscopic transnasal approach. Preoperative computed tomography (CT) was used to calculate the size of the bone defect due to the fracture, and the titanium mesh was designed to be shorter than the anteroposterior length of the defect and longer than its height. The titanium mesh was inserted into the orbit under an endoscopic view. The authors then confirmed that the titanium mesh supported the orbital contents by pressing the eyeball and finished the operation. Immediately after surgery, CT results were evaluated. RESULTS: Postoperative CT scans confirmed that the titanium mesh was well-inserted and in the correct position. All patients were discharged without any complications. CONCLUSIONS: We obtained satisfactory results by inserting a titanium mesh with porous polyethylene into the orbit via the transnasal approach endoscopically.

Usefulness of the orbicularis oculi myocutaneous flap in periorbital reconstruction

BACKGROUND: The esthetic and functional outcomes of periorbital defect reconstruction are very important because of the complex anatomy and specialized functions of this region. The orbicularis oculi myocutaneous (OOMC) flap is useful for the reconstruction of periorbital defects. But, according to the location and depth of the defects, the reconstruction using OMC flaps with various techniques is rare. The authors have used various kinds of OOMC flaps in various situations and we present an analysis of our experiences. METHODS: From November 2001 to July 2017, we used 36 OOMC flaps to reconstruct 30 periorbital defects in 25 patients. We analyzed the cause of the defect, its location, the type of concomitant surgery, the method of flap movement, and complications. RESULTS: Of the 30 defects, basal cell carcinoma was the most common cause, accounting for 20 cases. When the used OOMC flap was classified according to the location of the defects, the switch flap was used in nine cases among 15 defects of lower eyelid, and the V-Y advancement flap was mainly used for other parts. As surgical methods according to the depth of defect were classified, all cases involving the tarsal plate were reconstructed with a composite graft. In case of skin and muscles, they were reconstructed only with OOMC flap or with full-thickness skin graft. CONCLUSION: The OOMC flap provides good skin quality that is very similar to that of the defect tissue. Depending on the location and depth of the defect, the OOMC flap may be used properly in a variety of ways to achieve good results.

Expression of Glucagon-Like Peptide 1 Receptor during Osteogenic Differentiation of Adipose-Derived Stem Cells

BACKGROUND: Glucagon-like peptide 1 (GLP-1), an incretin hormone well known for its glucose-lowering effect, was recently reported to exert an anabolic effect on bone. Although the exact mechanism is not known, it likely involves the GLP-1 receptor (GLP-1R), which is expressed in some osteoblastic cell lines. Adipose-derived stem cells (ADSCs) have mesenchymal stem cell-specific characteristics, including osteoblastic differentiation potential. We evaluated the expression of GLP-1R during osteogenic differentiation of ADSCs. METHODS: ADSCs were isolated from subcutaneous adipose tissue obtained from three male donors during plastic surgery and were subjected to osteogenic induction. Mineralization was assessed by Alizarin Red staining on day 21. Expression of alkaline phosphatase (ALP), osteocalcin (OC), and GLP-1R was measured by real-time polymerase chain reaction in triplicate for each patient on days 0, 7, 14, and 21. Target mRNA expression levels were normalized to that of beta-actin. RESULTS: ADSCs were fibroblast-like in morphology, adhered to plastic, and had multipotent differentiation potential, as assessed using specific antigen markers. The osteogenic markers ALP and OC were notably upregulated at 21 days. Osteogenic differentiation resulted in a time-dependent increase in the expression of GLP-1R (P=0.013). CONCLUSION: We demonstrated upregulation of GLP-1R gene expression during osteogenic differentiation of ADSCs. This finding suggests that GLP-1 may induce osteogenic differentiation in bone tissue.

Lower Lip Reconstruction after Wide Excision of a Malignancy with Barrel-Shaped Excision or the Webster Modification of the Bernard Operation

BACKGROUND: Because there are numerous methods for reconstruction of the lower lip, it is not easy to choose the optimal method. In choosing the surgical method for lower lip reconstruction, we obtained acceptable outcomes based on our treatment strategy, which included either a barrel-shaped excision or the Webster modification of the Bernard operation. We report on the surgical outcomes based on our treatment strategy. METHODS: This study included 26 patients who underwent lower lip reconstructive surgery from September 1996 to September 2010. The operation was done using either a barrel-shaped excision or the Webster modification, considering the location of the defect, the size of the defect, and the amount of residual tissue on the lateral side of the vermilion after excision. RESULTS: In our series, 3 patients underwent a single barrel-shaped excision, and nine patients underwent a double barrel-shaped excision. In addition, the unilateral Webster modification was performed on in 6 patients, and there were eight cases of bilateral Webster modification. All of the patients except one were satisfied with the postoperative shape of the lip. In one case both recurrence and dehiscence occurred. One patient had a good postoperative lip shape, but had difficulty wearing a denture, and also underwent commissuroplasty. Furthermore, there were two patients who complained of drooling, and 4 with paresthesia. CONCLUSIONS: A soft tissue defect resulting from wide excision of a lower lip malignancy can be successfully reconstructed using only one of two surgical methods: the barrel-shaped excision or the Webster modification of the Bernard operation.

Immediate Debridement and Reconstruction with a Pectoralis Major Muscle Flap for Poststernotomy Mediastinitis

BACKGROUND: Poststernotomy mediastinitis is a rare, but life-threatening complication, thus early diagnosis and proper management is essential for poststernotomy mediastinitis. The main treatment for mediastinitis is aggressive debridement. Several options exist for reconstruction of defects after debridement. The efficacy of immediate debridement and reconstruction with a pectoralis major muscle flap designed for the defect immediately after the diagnosis of poststernotomy mediastinitis is demonstrated. METHODS: Between September 2009 and June 2011, 6 patients were referred to the Department of Plastic and Reconstructive Surgery and the Department of Thoracic and Cardiovascular Surgery of Ajou University Hospital for poststernotomy mediastinitis. All of the patients underwent extensive debridement and reconstruction with pectoralis major muscle flaps, advanced based on the pedicle of the thoracoacromial artery as soon as possible following diagnosis. A retrospective review of the 6 cases was performed to evaluate infection control, postoperative morbidity, and mortality. RESULTS: All patients had complete wound closures and reduced severity of infections based on the erythrocyte sedimentation rate and C-reactive protein levels and a reduction in poststernal fluid collection on computed tomography an average of 6 days postoperatively. A lack of growth of organisms in the wound culture was demonstrated after 3 weeks. There were no major wound morbidities, such as hematomas, but one minor complication required a skin graft caused by skin flap necrosis. No patient expired after definitive surgery. CONCLUSIONS: Immediate debridement and reconstruction using a pectoralis major muscle flap is a safe technique for managing infections associated with poststernotomy mediastinitis, and is associated with minimal morbidity and mortality.

Vein Wrapping Technique for Nerve Reconstruction in Patients with Thyroid Cancer Invading the Recurrent Laryngeal Nerve

Recurrent laryngeal nerve paralysis is the most common and serious complication after thyroid cancer surgery. The objective of this study was to report the advantages of the vein wrapping technique for nerve reconstruction in patients with thyroid cancer invading the recurrent laryngeal nerve and its effects on postoperative phonatory function. The subjects were three patients who underwent resection of the recurrent laryngeal nerve during surgical extirpation of papillary thyroid cancer. Free ansa cervicalis nerve graft or direct neurorrhaphy with a vein wrapping technique was used to facilitate nerve regeneration, protect the anastomosed nerve site mechanically, and prevent neuroma formation. One-year postoperative laryngoscopic examination revealed good vocal cord mobility. Maximum phonation time (19.5 +/- 0.3 sec) was longer than a previously-reported value in conventional reconstruction patients (18.8 +/- 6.6 sec). The present phonation efficiency index (7.88 +/- 0.78) was higher than that previously calculated in conventional reconstruction (7.59 +/- 2.82). The mean value of the Voice Handicap Index-10 was 6, which was within the normal range. This study demonstrates improvement in phonation indices measured 1 year after recurrent laryngeal nerve reconstruction. Our results confirm that the vein wrapping technique has theoretical advantages and could be favored over conventional reconstruction techniques for invenerate nerve injuries.

In vitro physical, chemical, and biological evaluation of commercially available metal orthodontic brackets / 대한치과교정학회지

OBJECTIVE: This in vitro study was undertaken to evaluate the physical, chemical, and biological properties of commercially available metal orthodontic brackets in South Korea, because national standards for these products are lacking. METHODS: Four bracket brands were tested for dimensional accuracy, (manufacturing errors in angulation and torque), cytotoxicity, composition, elution, and corrosion: Archist (Daeseung Medical), Victory (3M Unitek), Kosaka (Tomy), and Confidence (Shinye Odontology Materials). RESULTS: The tested rackets showed no significant differences in manufacturing errors in angulation, but Confidence brackets showed a significant difference in manufacturing errors in torque. None of the brackets were cytotoxic to mouse fibroblasts. The metal ion components did not show a regular increasing or decreasing trend of elution over time, but the volume of the total eluted metal ions increased: Archist brackets had the maximal Cr elution and Confidence brackets appeared to have the largest volume of total eluted metal ions because of excessive Ni elution. Confidence brackets showed the lowest corrosion resistance during potentiodynamic polarization. CONCLUSIONS: The results of this study could potentially be applied in establishing national standards for metal orthodontic brackets and in evaluating commercially available products.

A case of vincristine-induced polyneuropathy in an patient with acute leukemia / 대한내과학회지

When neurological symptoms occur during the treatment of acute lymphoblastic leukemia, the differential diagnosis includes a leukemic infiltration of the nervous system, drug toxicity, infection, and other neurological disorders. We describe a 16-year-old girl with acute lymphoblastic leukemia that appeared to be complicated by vincristine-induced peripheral and cranial polyneuropathy after induction chemotherapy. She presented with right ptosis six weeks after the first dose of vincristine, and her neurological symptoms progressed to peripheral polyneuropathy. She recovered from these neurological symptoms over the next three months. Leukemic involvement of the nervous system and other neurological disorders could be excluded as potential causes of the neurological symptoms. This report shows that vincristine-induced neurotoxicity should be considered as a cause of cranial neuropathy that develops during the treatment of acute lymphoblastic leukemia.

A Case of Klebsiella pneumoniae Liver Abscess Which Progressed to Pyomyositis and Infected Aneurysm of Aorta

Klebsiella pneumoniae causes pyogenic infections in various sites, with the risk of which increases in patients with diabetes mellitus. Recently, K. pneumoniae has emerged as a leading cause of pyogenic liver abscess. Primary liver abscess caused by K. pneumoniae in the absence of underlying hepatobiliary disease is commonly associated with metastatic infections such as endophthalmitis, meningitis, brain abscess and infection in other sites. We experienced a case of K. pneumoniae liver abscess associated with septic metastatic lesions including pyomyositis and infected aneurysm of aorta. Despite the aggressive management with antibiotics, surgical pus drainage and aortic bypass graft, patient died of ventilator associated pneumonia and multiorgan failure. Our experience suggests that clinicians should be alert to septic metastatic infections when they treat a patient with K. pneumoniae liver abscess.

A Case of Klebsiella pneumoniae Liver Abscess Which Progressed to Pyomyositis and Infected Aneurysm of Aorta

Klebsiella pneumoniae causes pyogenic infections in various sites, with the risk of which increases in patients with diabetes mellitus. Recently, K. pneumoniae has emerged as a leading cause of pyogenic liver abscess. Primary liver abscess caused by K. pneumoniae in the absence of underlying hepatobiliary disease is commonly associated with metastatic infections such as endophthalmitis, meningitis, brain abscess and infection in other sites. We experienced a case of K. pneumoniae liver abscess associated with septic metastatic lesions including pyomyositis and infected aneurysm of aorta. Despite the aggressive management with antibiotics, surgical pus drainage and aortic bypass graft, patient died of ventilator associated pneumonia and multiorgan failure. Our experience suggests that clinicians should be alert to septic metastatic infections when they treat a patient with K. pneumoniae liver abscess.

A Case of Synchronous Intestinal Tuberculosis Involving the Stomach and Colon / 대한소화기학회지

Intestinal tuberculosis is a common disease of extrapulmonary tuberculosis and should be differentiated from the inflammatory bowel diseases and malignancy such as Crohn's disease, ulcerative colitis, amebic colitis, and colon cancer. Most frequently involved sites (75% of cases) are the terminal ileum and cecum. Other sites of involvement, in order of frequency, are ascending colon, jejunum, appendix, duodenum, stomach, esophagus, sigmoid colon, and rectum. Intestinal tuberculosis simultaneously involving the stomach and colon has been very rarely reported. Recently, we experienced a case of synchronous gastric and colonic ulcers with granulomatous inflammation. Although we did not find acid fast bacilli and the culture test was negative, empirical anti-tuberculosis therapy resulted in dramatic clinical and endoscopic improvement. We report a rare case of multifocal gastrointestinal tuberculosis with a review of literature.

The Use of Vacuum-Assisted-Closure Theraphy for the Treatment of Methicillin-Resistant-Staphylococcus aureus Infected Wounds

PURPOSE: Methicillin-Resistant-Staphylococcus aureus (MRSA) has been increasingly recognized as a cause of nosocomial infection. MRSA is hardly-controllable organism among the pathogen of nosocomial infection, because it is resistant to most antibiotics except vancomycin, and local treatment with most antiseptics are not effective to eradicate MRSA from the infection. The effectiveness of Vacuum-Assisted-Closure(VAC) was reported widely. we tried to modify original VAC. We tried VAC dressing on MRSA infected wound to evaluate whether or not the VAC is effective to eradicate MRSA which existed in the open wound. METHODS: From September 2003 to December 2003, 24 patients admitted to the plastic and reconstructive surgery and orthopedic surgery, were studied. All patients were found to be positive in previous wound. Using clinical randomized study, 24 patients were divided into two groups: VAC dressing group and the Betadine(R) dressing group(control). During treatment, wound culture was done twice a week for evaluation of MRSA infection elimination. RESULTS: The mean period that MRSA become not detected in all case was 17.1 days in VAC dressing group, and 25.8 days in control group, respectively. The p value was 0.013. The result reveals that the VAC dressing group is more effective to MRSA infection control. As a result, the VAC dressing was more effective in MRSA infected wound than conventional dressing. CONCLUSION: Through this study, we found objective result of VAC dressing. We hope that VAC dressing is more widely applied to fresh and infected wound.