Volumetric change of the latissimus dorsi muscle after postoperative radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap

Background@#This study aimed to determine the magnitude of volume reduction of the latissimus dorsi (LD) muscle after treatment using only postoperative radiotherapy (PORTx) in patients who underwent immediate breast reconstruction using an extended LD musculocutaneous (eLDMC) flap after partial mastectomy. @*Methods@#We retrospectively reviewed 28 patients who underwent partial mastectomy and an eLDMC flap, received only PORTx, and underwent chest computed tomography (CT) 7 to 10 days after surgery and 18±4 months after the end of radiotherapy, from March 2011 to June 2016. The motor nerve to the LD was resected in all patients. One plastic surgeon performed the procedures, and the follow-up period was at least 36 months (mean, 46.6 months). The author obtained LD measurements from axial CT views, and the measurements were verified by an experienced radiologist. The threshold for statistical significance was set at P<0.05. @*Results@#A statistically significant decrease in the LD volume was found after the end of PORTx (range, 61.19%–80.82%; mean, 69.04%) in comparison to the measurements obtained 7 to 10 days postoperatively (P<0.05). All cases were observed clinically for over 3 years. @*Conclusions@#The size of an eLDMC flap should be determined considering an average LD reduction of 69% after PORTx. Particular care should be taken in determining the size of an eLDMC flap if the LD is thick or if it occupies a large portion of the flap.

Attachment distribution of pectoral muscle origins identified in dual-plane breast implant insertion

Background@#Implant-based dual-plane augmentation mammoplasty requires accurate separation of the pectoralis major muscle (PMM) at its origins. The authors identified the PMM origins during breast reconstruction surgery with the goal of providing additional information on subpectoral implant insertion for reconstructive or aesthetic purposes. @*Methods@#This study was conducted on 67 patients who underwent breast reconstruction surgery at the breast center of our hospital between November 2016 and June 2018. In total, 34 left and 39 right hemithoraces were examined. The left and right hemithoraces were each divided into 15 zones to determine the percentage of PMM attachments in each zone. The distribution of PMM origins in each zone was examined to identify any statistically significant differences. @*Results@#There were no statistically significant differences in the origins of the PMM between the right and left hemithoraces. The percentage of attachments increased moving from the fourth to the sixth rib and from the lateral to the medial aspect. @*Conclusions@#The anatomical findings of this study could be used as a reference for accurate dissection of the origins of the PMM for the preparation of the subpectoral pocket for subpectoral implant placement.

Dermoid cysts: Epidemiology and diagnostic approach based on clinical experiences

BACKGROUND: Dermoid cysts are congenital tumors that are benign. Dermoid cysts with intracranial extension can cause serious neurological complications. It is important, therefore, to determine whether a patient has a dermoid cyst when their chief concern at a doctor’s visit is a mass in the head or neck area. In this study, we present a literature review of dermoid cysts and an analysis of the authors’ experiences, with the goal of providing guidance useful for the diagnosis and treatment of dermoid cysts. METHODS: This study retrospectively analyzed the medical records of 62 patients who visited the two medical clinics with which the authors are affiliated. The patients were enrolled between October 2003 and January 2017. RESULTS: Of the 62 patients analyzed in this study, 32 were 0 to 5 years of age (52%) and 23 were 17 years of age or older (37%). Forty-seven patients underwent 1 or more imaging study during the process of diagnosis. Thirty-two patients were suspected to have a dermoid cyst. Forty-nine patients were analyzed to determine the depth of the cyst. Bone was seen in 43 patients through imaging tests or during actual surgery, and nine of the 43 had bony problems (21%). CONCLUSIONS: This study found that dermoid cysts were present in many adults, and that a high rate of deep lesions was observed, as well as many cases in which even the bone was affected. These results suggest, therefore, that dermoid cysts should be considered, and medical professionals should actively conduct imaging studies.

Evaluation of the donor site after the median forehead flap

BACKGROUND: Forehead flaps are useful for facial reconstruction. Studies of these flaps have mostly focused on the results of the reconstruction. However, due to the scarring and changes on the forehead caused by the median forehead flap (MFF), surgeons may be reluctant to perform this flap. Research into the donor site is needed for practical purposes. METHODS: We examined 42 patients who underwent an MFF at Pusan National University Hospital from 1996 to 2016. Based on a retrospective chart review, we examined the occurrence of complications. We also evaluated scars on the forehead using the Vancouver Scar Scale (VSS) and assessed changes in the eyebrow position of 22 patients. RESULTS: No complications occurred in the 42 patients. The mean VSS score of the 22 patients was 2.8±0.79. The ratio of the height of the eyebrow on each side to the distance between the medial canthi increased postoperatively, meaning that both the left and right brows were elevated slightly (P=0.026 and P=0.014). However, the symmetry between the left and right sides did not change (P=0.979). The ratio of the interbrow distance to the distance between the medial canthi decreased slightly, meaning that the interbrow distance narrowed mildly (P < 0.001). Moreover, there were no noticeable changes in the brow position as seen in a photo overlay. CONCLUSIONS: There were no notable complications in the forehead. Forehead scarring was acceptable. No change in brow symmetry was observed via photographic measurements and a photo overlay. Therefore, we propose that the MFF is a useful choice for minimizing scarring or deformation of the donor site.

A rare case of isolated schwannoma in infraorbital nerve

A schwannoma is a benign tumor that develops from Schwann cells. It is known to occur more frequently in women than men, and about one third of schwannoma cases occur in the head and neck area. It is also known to originate mainly in the auditory nerve. However, it is rarely associated with the trigeminal nerve, and especially, schwannomas related to the infraorbital nerve are very rare. we report a rare case of a schwannoma involving the infraorbital branch of the trigeminal nerve in a 45-year old male adult. The patient underwent physical examination and magnetic resonance imaging. The mass was approached through subciliary approach that is familiar to the plastic surgeon and completely resected. Histopathological findings showed pointed to a benign schwannoma. Infraorbital nerve schwannoma is difficult to distinguish from other diseases by means of clinical symptoms, physical findings, or imaging. In spite of its rarity, infraorbital nerve schwannoma may be considered a possible diagnosis in the case of mass on cheek. Assessment by computed tomography or magnetic resonance imaging is necessary for proper diagnosis. About the surgical approach, excision through the subciliary approach should be considered rather than the direct transfacial approach in view of stability, cosmetic effects, and familiarity.

Intraosseous hemangioma of the orbit

Intraosseous hemangioma is an extremely rare tumor that accounts for 1% or fewer of all osseous tumors. The most common sites of its occurrence are the vertebral column and calvaria. Occurrence in a facial bone is very rare. The authors aim to report a case of the surgical treatment of intraosseous hemangioma occurring in the periorbital region, which is a very rare site of occurrence and to introduce our own experiences with the diagnosis and treatment of this condition along with a literature review. A 73-year-old male patient visited our hospital with the chief complaint of a mass touching the left orbital rim. A biopsy was performed by applying a direct incision after local anesthesia. Eventually, intraosseous hemangioma was diagnosed histologically. To fully resect the mass, the orbital floor and zygoma were exposed through a subciliary incision under general anesthesia, and then the tumor was completely eliminated. Bony defect was reconstructed by performing a seventh rib bone graft. Follow-up observation has so far been conducted for 10 months after surgery without recurrence or symptoms.

Reconstruction of Large Facial Defects via Excision of Skin Cancer Using Two or More Regional Flaps

BACKGROUND: Free-flap surgery and skin grafting can be used to reconstruct large facial defects that may result after skin cancer removal by Mohs micrographic surgery (MMS). However, these two methods may produce low postsurgical patient satisfaction with aesthetics, and free-flap surgery may produce an undue burden for the majority of skin cancer patients, who are of advanced age. Hence, the authors examined outcomes of large facial defect reconstruction using multiple flaps. METHODS: Among patients undergoing MMS for skin cancer at Pusan National University Hospital between January 2013 and December 2015, we evaluated 7 patients (2 males, 5 females; average age, 73.14 years) treated for large facial defects from basal cell carcinoma. Based on operative and follow-up records, we investigated the number and type of flaps used, postsurgical complications, and patients' post-surgical satisfaction. RESULTS: Two and 3 types of flaps were used for 5 and 2 patients, respectively. Most frequently used were nasolabial flaps (7 times in 6 patients) and forehead flaps (once in each of 4 patients). The average follow-up period was 14 months, with no complications—including necrosis, hematoma, or wound dehiscence—observed. Post-surgical satisfaction averaged 4.4 out of a maximum of 5 points. CONCLUSIONS: Reconstruction using two or more flaps for large facial defects after skin cancer removal using MMS produced satisfactory outcomes while preventing aesthetic problems. Practitioners should consider using multiple flaps when choosing a reconstruction method for large facial defects following skin cancer removal.