Treatment of the Mycobacterium chelonae Infection after Fat Injection

For recent years, use of autologous fat injection has increased significantly in facial contouring surgery. Along with such increase in use, complications like atypical mycoplasma infection have been also on the increasing trend. The authors report two cases of Mycobacterium chelonae infection that occurred after autologous fat injection. Patients were treated as infection that resistant to common antibiotics and results were negative to routine culture and Gram staining. Acid-fast bacillus stain, polymerase chain reaction (PCR) test and mycobacterial cultures were conducted for diagnosis under suspicion of atypical mycoplasma infection. Then, combination antibiotics therapy, surgical treatment, and steroid injection were performed for treatment. Both patients were diagnosed with Mycobacterium chelonae in PCR test. They were positive to mycobacterial cultures. Combination antibiotics therapy was repeated to improvement of symptom. However, they could not be free from side effects such as deformation in facial contour, scar and pigmentation even after full recovery. When chronic wound infections after autologous fat injection, we must suspect atypical or mycobacterial infection and conduct examinations for a early diagnosis and proper antibiotic therapy that is effective to the nontuberculous mycobacteria.

Gender Reassignment Surgery in Human Immunodeficiency Virus-Positive Patients: A Report of Two Cases

It is believed that surgery on human immunodeficiency virus (HIV)-positive patients is dangerous and should be avoided due to the possibility of postoperative infection of the patients or HIV occupational transmission to the medical staff. We discuss here the preparations and measures needed to conduct surgery safely on HIV-positive patients, based on our experience. We performed sex reassignment surgery on two HIV-positive patients from January 2013 to January 2015. Both of them were receiving highly active antiretroviral therapy and were asymptomatic, with a normal CD4 count (>500 cells/microL). The HIV-RNA was undetectable within the bloodstream. All the staff wore protective clothing, glasses, and three pairs of protective gloves in the operating room because of the possibility of transmission. Prophylactic antibiotics were administered to the patients, and antiviral therapy was performed during their perioperative course. Neither of the patients had postoperative complications, and none of the medical staff experienced accidental exposure. Both patients had satisfactory surgery outcomes without complications. HIV-positive patients can undergo surgery safely without increased risk of postoperative complications or HIV transmission to the staff through the proper use of antibiotics, active antiretroviral therapy, and supplemental protective measures with post-exposure prophylaxis for the staff in case of HIV exposure.

Posterior Lumbar Interbody Fusion Using an Unilateral Cage: A Prospective Study of Clinical Outcome and Stability

OBJECTIVE: The purpose of this study was to evaluate the clinical and radiological results of instrumented posterior lumbar interbody fusion (PLIF) using an unilateral cage. METHODS: Seventeen patients with unilateral radiculopathy who underwent bilateral percutaneous screw fixation with a single fusion cage inserted on the symptomatic side for treatment of focal degenerative lumbar spine disease were prospectively enrolled in this study. Their clinical results, radiological parameters, and related complications were assessed 10 days, 3 months, and 12 months postoperatively. RESULTS: There was no pseudarthrosis, instrumented fusion failure, significant cage subsidence, or retropulsion in any patient. The surgery restored the disc space height and maintained it as of 12 months postoperatively and did not exacerbate the lumbar lordotic and scoliotic angles. All patients had excellent or good outcomes according to the modified MacNab's criteria. The mean pain score according to the visual analogue scale was 7.5 preoperatively but had improved to 2.5 when reassessed 3 months postoperatively. The improvement was maintained as of 12 months postoperatively. CONCLUSION: In cases of uncomplicated unilateral radiculopathy, PLIF using a single cage can be an effective and safe procedure with the advantage of preserving the posterior elements of the contralateral side. A shorter operative time and greater cost-effectiveness than for PLIF using bilateral cages can be expected.

Problems Associated with Alloplastic Materials in Rhinoplasty

PURPOSE: Augmentation rhinoplasty using alloplastic materials is a relatively common procedure among Asians. Silicon, expanded polytetrafluoroethylene (Gore-tex(R)), and porous high density polyethylene (Medpor(R)) are most frequently used materials. This study was conducted to analyze revisional rhinoplasty cases with alloplastic materials, and to investigate the usage of alloplastic materials and their complications. We also reviewed complications caused by various materials used in plastic surgery while operating rhinoplasty. MATERIALS AND METHODS: We report 581 cases of complications rhinoplasty with alloplastic implants and review of the literature available to offer plastic surgeons an overview on alloplastic implant-related complications. RESULTS: Among a total 581 revisional rhinoplasty cases reviewed, the alloplastic materials used were silicone implants in 376, Gore-tex(R) in 183, and Medpor(R) in 22 cases. Revision cases and complications differed according to each alloplastic implant. CONCLUSION: Optimal alloplastic implants should be used in nasal structure by taking into account the properties of the materials for the goal of minimizing their complications and revision rates. A thorough understanding of the mechanism involved in alloplastic material interaction and wound healing is the top priority in successfully overcoming alloplastic-related complications.

Clinical Experience of Sturdy Elevation of the Reconstructed Auricle

BACKGROUND: The ear is composed of elastic cartilage as its framework, and is covered with a thin layer of skin. Auricular reconstruction using autogenous cartilage in microtia patients requires delicacy. This paper reports clinical experiences related to elevation of reconstructed ear in the last 11 years. METHODS: This study was based on 68 congenital microtia patients who underwent auricular elevation in our hospital. Among these 68 patients, 47 patients were recruited. We compared the differences in the ear size, auriculocephalic angle, and conchal depth with those in the opposite ear, and the patients' satisfaction levels were investigated using a survey. RESULTS: The difference in the sizes of the two ears was less than or equal to 5 mm in 32 patients, 5 to 10 mm in 10 patients, and greater than or equal to 10 mm in 5 patients. The difference in the auriculocephalic angles of the two ears was less than or equal to 10 degrees in 14 patients, 10 to 20 degrees in 26 patients, and greater than or equal to 20 degrees in 7 patients. The difference in the conchal depths of the two ears was less than or equal to 5 mm in 24 patients, 5 to 10 mm in 19 patients, and greater than or equal to 10 mm in 4 patients. The average grade of 3.9 points out of 5 points was obtained by the patients with satisfactory surveys. CONCLUSION: We could make enough protrusion and maintain the three-dimensional shape for a long time to satisfy our patients.

Effectiveness of Repeated Radiofrequency Neurotomy for Facet joint Syndrome after Microscopic Discectomy

OBJECTIVE: Postoperative facet joint syndrome requiring radiofrequency neurotomy (RFN) is a relatively common problem following microscopic discectomy. However, the efficacy of repeated RFN after microscopic discectomy has not been clearly documented. The purpose of this study was to determine the success rate and symptom-free duration of repeated RFN for facet joint syndrome after microscopic discectomy. METHODS: Medical records from 56 patients, who had undergone successful initial RFN following microscopic discectomy, experienced recurrence of pain, and subsequently had repeated RFN, were reviewed and evaluated. Responses of repeated RFN were compared with initial radiofrequency neurotomy for success rates and duration of relief. The criterion for RFN to be successful was defined as greater than 50% relief from pain and sufficient satisfaction of patients with prior RFN to have repeated RFN. RESULTS: Fifty-six patients (41 women and 15 men; mean age=48 years) had repeated RFNs, which were successful in all except three patients. RFN denervated three bilateral segments (L3-L4, L4-L5, and L5-S1) in all patients. Mean duration of relief after initial RFN was 9.2 months (range 3-14). The mean duration of relief after secondary RFN in 53 patients was 9.0 months (range 4-14). The success rates and duration of relief remained consistent after subsequent RFNs. CONCLUSION: Repeated RFN for lumbar facet joint pain after microscopic discectomy is an effective palliative treatment. It provided a mean duration of relief of 9.0 months and >94% success rate.

An Introduction to the Septal Extension Graft

The septal extension graft is a very useful method of controlling nasal lengthening and tip projection, rotation, and shape by fixing a graft to the septum, which leads to a strong supporting structure. Enhancing graft stability is important for better long-term outcomes and minimizing complications or relapse, and even more efficient application of these methods is needed for East Asians who lack enough cartilage to be harvested in addition to possessing a weak cartilage framework. In this paper, the methods for overcoming the drawbacks of the septal extension graft, such as instability, a fixed tip, and insufficiency of cartilage, are presented, and the applications of each method for greater satisfaction with surgical outcomes are also discussed.

Craniosynostosis Occurring between Siblings

Craniosynostosis is a congenital anomaly in which cranial sutures close prematurely and restrict skull growth. In this paper, the case of two siblings, a male and a female, who were both diagnosed as craniosynostosis is reported. They underwent corrective osteotomy for cranial vault remodeling. A 22-month-old female infant who was brought to the department of plastic and reconstructive surgery of the authors' hospital was diagnosed with plagiocephaly. At the same time, her 7-month-old brother was diagnosed with brachycephaly. In the case of the female infant, corrective coronal osteotomy and supraorbital bar advancement were performed. Her brother underwent frontal advancement osteotomy using Tessier's tongue in the groove procedure. After the correction of the craniosynostosis, the two patients recovered in several days later, and the results were good in both cases cosmetically and functionally. They showed normal head circumference increasing curves and no symptom of functional disorder in their last follow-up. Isolated or nonsyndromic craniosynostosis is sporadic but mostly autosomal dominant. This paper presents a case of craniosynostosis with a genetic tendency; and although it occurred between siblings, the affected lesions differed. Thus, appropriate diagnosis and management in patients are needed.

Extraforaminal Lumbar Interbody Fusion for Cage Migration after Screw Removal: A Case Report

The use of titanium cages for posterior lumbar interbody fusion (PLIF) has gained popularity because it offers the advantages of anterior column support and stabilization. However, cage migration into the spinal canal may have severe or disastrous consequences. Here, the authors report an unexpected case of posterior migration of fusion cages after screw removal in a patient that underwent PLIF 12 months previously. Removal of the offending cages through revision extraforaminal lumbar interbody fusion (ELIF) with percutaneous screw fixation successfully managed this complication. As far as the authors' knowledge, this is the first case report to describe this sort of complication, and cautions that care must be taken to prevent cage migration.

Reliability of Reconstructed Breast Flap after Chemotherapy and Radiotherapy in Immediate Breast Reconstruction

BACKGROUND: Postmastectomy adjuvant therapy is used to prevent locoregional recurrence and improve overall breast cancer specific survival rates. However, it can adversely affect the cosmetic results of reconstruction. Therefore, the authors examined flap stability and patients' satisfaction with immediate breast reconstruction after adjuvant therapy. METHODS: We retrospectively reviewed the medical records of 204 patients from January 2006 to November 2011. For complication rates, the authors categorized the patients who underwent the immediate breast reconstruction into 4 groups: adjuvant chemotherapy and radiotherapy group, adjuvant chemotherapy only group, adjuvant radiotherapy only group, and the group that did not undergo adjuvant therapy. For comparison of patients' satisfaction, the study was performed with an additional 16 patients who had undergone delayed breast reconstruction. RESULTS: Regarding complication rates, the group that had undergone adjuvant therapy showed no significant difference compared to the group that did not undergo adjuvant therapy. In evaluating the patients' satisfaction, there was no significant difference. CONCLUSIONS: Even after adjuvant therapy, immediate breast reconstruction showed good results with respect to flap stability and patients' satisfaction. Immediate breast reconstruction and adjuvant therapy is a safe and useful option for breast cancer patients.

Considerations for the Management of Cryptotia Based on the Experience of 34 Patients

BACKGROUND: Cryptotia is a congenital ear deformity in which the upper pole appears buried beneath the mastoid skin. Cryptotia is a common auricular malformation among Asians. The aim of this paper is to examine the surgical techniques for and complications of 34 cryptotic patients. METHODS: Surgery was performed for 34 cryptotic deformities (January 2005 to January 2012). Twenty-two patients (64.7%) were classified as having type I cryptotia, and 12 patients (37.5%) type II cryptotia. Among the type I cryptotia patients, 8 patients had mild deformity and 14 severe deformity. Among the type II cryptotia patients, 10 patients had mild deformity and 2 severe deformity. RESULTS: The mild deformities were corrected via Z-plasty, V-Y plasty, full-thickness skin graft, and transposition flap, while the severe deformities were corrected via cartilage graft or Medporfor the spread of cartilage adhesion of antihelix. There were two cases of reinvagination in the autologous cartilage graft group. Implant exposure occurred with Medpor (two cases). There were two cases of hypertrophic scar on the previous surgical wound with Medpor. There were no complications in the 18 patients who had mild deformities. CONCLUSIONS: The type I cryptotia patients had more severe deformities than the type II cryptotia patients. As most of the type II cryptotia patients had only mild deformities, their deformities were corrected without using autologous conchal cartilage graft or Medpor, except for two patients. Through more case analyses, researchers should make an effort to identify methods for recurrence and prevention of complication.

The Etiology and Treatment of the Softened Phallus after the Radial Forearm Osteocutaneous Free Flap Phalloplasty

BACKGROUND: The radial forearm osteocutaneous free flap is considered to be the standard technique for penile construction. One year after their operation, most patients experience a softened phallus, so that they suffer from difficulties in sexual intercourse. In this report, we present our experience with phalloplasty by radial forearm osteocutaneous free flap, as well as an evaluation of the etiology and treatment of the softened phallus. METHODS: Between March 2005 and February 2010, 58 patients underwent phalloplasty by radial forearm osteocutaneous free flap. Most of their neophallus had been softened subjectively and among them, 12 patients who wanted correction were investigated. We performed repetitive fat injection, artificial dermis grafting, silicone rod insertion, and rib bone with cartilaginous tip graft. Physical examination, plain radiograph, computed tomography, bone scintigraphy, and satisfaction scores were investigated. RESULTS: Most of the participants' penises have been softened after phalloplasty, and the skin elasticity had been also decreased. On plain radiograph, the distal end of the bone was self-rounded; however, the bone shape of the neophallus had no significant interval changes or resorption. Computed tomography showed equivocal density of cortical bone. On bone scintigraphy, the bone metabolism was active at 3 months postoperatively, and remained active 9 years postoperatively. CONCLUSIONS: The use of a rib bone with cartilaginous tip graft could be an option for improvement of the softened phallus. Silicon rod insertion is also worth considering for rigidity of the softened phallus. Decreased rigidity due to soft tissue atrophy could be alleviated with repeated fat injection and artificial dermis grafting.

Limited Dissection Face Lift with PDS Quilting Suture

PURPOSE: Facial rejuvenating surgery has become a challenge to most plastic surgeons. Patients are demanding fewer complications, a prompt recovery, and more natural results. Current trend of the face lift surgery has been developed into less invasive procedures. Every aging patient in Asia wants to look younger without obvious evidence of surgical correction. METHODS: The authors performed the limited dissection face lift with PDS quilting suture on twenty five patients. These five quilting sutures consist of sutures at 1~2 cm posterior to the prominent point of zygoma to the periosteum of the zygomatic arch, at the lateral border of Bichat's fat pad area to the zygomatic arch, at the lateral border of the orbicularis oculi muscle to the deep temporal fascia, at the upper lateral border of the platysma to the periosteum of the mastoid, and at the anterior lower margin of the earlobe to the deep temporal fascia by quilting suture technique to achieve rejuvenation. RESULTS: These procedures could produce a balanced volumetric rejuvenation. This method gave considerable benefit of stable and satisfactory results. It provides reduced operative time, well corrected nasolabial fold and neck wrinkle, and swift recovery with minimal complications. CONCLUSION: Although it could not replace the classic facelift, this technique can be recommended as an option for patients who do not present with advanced facial aging or not want a more extensive procedure.

Removal of Silicon-associated Intraorbital Cyst with Gingival Sulcus Incision

PURPOSE: Alloplastic implants, such as Silastic(R) , Supramid(R) , Porous polyethylene, Teflon(R) have been used to prevent reherniation of orbital tissue and are known to be inert for many years, though complications are infrequently reported many years after their insertion. Complications associated with implants are infrequent, but infection, orbital hemorrhage, implant extrusion, motility restriction, migration of implant causing dacryocystitis, cystic formation have been described. The latter was known as a rare late complication of blow-out fracture repair. METHODS: We report the case of a discovery of a intraorbital hemorrhagic cyst which developed after silicon implant insertion. This patient developed diplopia, unilateral proptosis, exophthalmos, vertical dystopia, ectropion 10 years after repair of blow-out fracture. In this case, orbital CT scan revealed intraorbital cyst surrounding the orbital implant. At surgery, a fibrous capsule surrounded the silicon implant and was filled with mucin pools. RESULTS: Proptosis, diplopia, exophthalmos, ectropion, vertical dystopia were resolved after surgical removal of the cyst and implant. CONCLUSION: This case illustrate that it is important for us to be aware of the complication of cyst formation around the silicon implants.

A Study for the Biologic Changes and Viability of Adipose Tissue in Cryopreserved Fat Graft

PURPOSE: Adipose tissue injection as a free graft for the correction of soft-tissue deficiency or depression deformity is a widespread procedure in plastic surgery. This study is to analyze the changes and viability of cryopreserved adipose tissue and to find out efficient long-term storage period. METHODS: After centrifugation of aspirated abdominal tissues, 10mL of packed Adipose tissue were freezed at -20degrees C. For 2, 4, 6, 8 months, each frozen samples were taken and injected into scalp of SCID mice. After 15 weeks, injected Adipose tissue were sampled and analyzed at 2 months interval. We compared and analyzed each group about the weight of the injected fat, histologic impressions, activity of mitochondria, size of a fat cell and rate of survival. RESULTS: Significant weight changes were observed in cryopreservation for 2 months(p<0.05). Histologic changes were observed, independent of the freezing period with H-E stain. Among cryopreservations for 2, 4, 6 months, no significant change were observed. The reduction of mitochondrial enzymatic activity was observed independent of time interval but activity of mitochondrial dehydrogenase was reduced less than 50% in MTT assay. CONCLUSION: Freezing at -20degrees C for 6 months has no adverse effect to Adipose tissue, but fragile adipocytes, damaged cell membrane during harvesting procedure, were disrupted within 1-2 month and the maximum volume reduction were followed less than 2 months. These results demonstrate that tissue preparation cells without membrane damage have the greatest viability level and cryopreservation less than 2 months has great volume effect and cryopreservation for 6 months has stable volume effect.

The Useful Method on Temporary Fixation with Screw-wire Technique

PURPOSE: Until now, many kinds of treatment modalities for facial bone fractures have been proposed. Among them, the semi-rigid fixation using miniplates has become the most popular procedure due to its simplicity and good clinical results. However, achieving anatomic reduction of bone fragments with miniplates may be difficult because of inadequate instrumentation for fracture fragment stabilization. We examined the use of inter-maxillary fixation screws or titanium screws tied with stainless steel wire to assist in positioning of fractured segment. METHODS: We used this method for reduction in 50 cases of facial bone fractures. Inter-maxillary fixation screws or titanium screws tied with stainless steel wire were used to assist in aligning bony segment. Postoperative radiologic and clinical follow-ups were performed. RESULTS: Radiologic follow-up showed correct reduction and fixation in all cases. Nonnunion and malunion were not shown. Clinical follow-up showed an satisfactory results. CONCLUSION: By using Inter-maxillary fixation screws tied with stainless steel wire, it was shown that reducing the bony segment to their preinjury position is easy to perform and it enables us to make more accurate reduction, ensure wider visual field.

Infraorbital Nerve Function Following Tailoring of Medpor(R) in Reconstruction of Inferior Orbital Wall Fracture

PURPOSE: In the orbital floor fracture, sensory impairment due to the damage of the infraorbital nerve is one of the most common symptom and complication. In this report, we have the assumption that tailoring of medpor(R) for decompression may have correlations to the damage and regeneration of the nerve. METHODS: Among patients who had open reduction for pure orbital floor fracture in our hospital from March 2005 to March 2008, we selected 80 cases. In 40 cases, we inserted tailored medpor(R), and in other 40 cases, non-tailored medpor(R) was inserted. Patient's reports were obtained and analyzed, and the pin-prick test and the 2-point discrimination test on the infraorbital nerve regions were done for testing the sensory impairments. RESULTS: The results show that the patients who adopted sculpture of medpor(R) showed higher tendency of recovery of sensory impairments in the patient's subjective report, static touch sensation, static two point discrimination using. And in postoperative 3 months, there are statistically significant recovery of sensory symptoms, signs and the result of sensory tests. CONCLUSION: From these results, tailored medpor(R) in reconstruction of orbital wall fracture may improve recovery of sensory impairments for decreasing of compression of infraorbital nerve.

The Value of Routinely Culturing for Tuberculosis During Bronchoscopies in an Intermediate Tuberculosis-Burden Country

PURPOSE: Many medical centers routinely culture bronchoscopy samples for Mycobacterium tuberculosis, even when tuberculosis is not strongly suspected. The value of this practice, however, is controversial. We evaluated the role of that procedure in the diagnosis of pulmonary tuberculosis in an intermediate tuberculosis-burden country. PATIENTS AND METHODS: A prospective, observational study was conducted in a tertiary referral center and included 733 consecutive patients who underwent bronchoscopy examination. RESULTS: M. tuberculosis was isolated in 47 patients (6.4%). According to radiographic features, the rate of positive culture for M. tuberculosis was relatively high in patients with atelectasis (5/33, 15.2%) and those with pulmonary infiltrations of suspicious infections (26/183, 14.2%). M. tuberculosis was isolated even in patients with pulmonary masses (9/266, 3.4%) and those with pulmonary nodules (5/175, 2.9%). In 16/47 (34.0%) patients with positive cultures for M. tuberculosis, active pulmonary tuberculosis was not suspected at the time of bronchoscopy. CONCLUSION: These results suggest that routinely culturing for M. tuberculosis during bronchoscopy is still useful in the diagnosis of pulmonary tuberculosis in an intermediate tuberculosis-burden country.

Psychiatric Analysis about Transsexuals

PURPOSE: Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery(SRS). We evaluated psychologic status, health-related quality of life in female-to-male (FTM), male-to-female(MTF) transgender individuals. METHODS: We used the Minnesota Multiphasic Personality Inventory, Beck Anxiety Inventory, Beck Depression Inventory, Moudsley obsessive-compulsive Inventory, SCL-90-R, Short-Form 36-Question Health Survey version 2(SF-36v2). We enrolled 40 transsexual participants. RESULTS: Analysis of quality of life health concepts demonstrated statistically significant(p<0.01) diminished quality of life among the transsexual participants as compared to the Korea male and female population. FTM transgender participants reported more higher hostile, phobic than MTF transgenders. Overall, in all psychologic status examination, Transgender individuals are within normal population boundary. On all category, result is improved post-operatively. CONCLUSION: Transgender participants reported mental status within normal boundary. SRS improved their quality of life and mental stability.

Comparative Analysis in Social Development of Children with Cleft Lip Nasal Deformity According to Timing of Correction: School Age and Preschool Age

PURPOSE: Correction of cleft lip nasal deformity has been performed from March, 1995 to June, 2006 at Donga-A University. The goal of this study is to evaluate children's psychosocial development and to determine the optimal timing of repair. METHODS: This is the retrospective study of patients operated at pre-school and school age. The patients could be divided into two groups, corrected at pre-school age(n=30), and school age(n=30). To evaluate the social development, we used 4 parameters, Children individualism-collectivism scale, Pictorial scale perceived competence social acceptance for young children, Matson's children social adaptability scale, Academic performance rating scale. RESULTS: Operated group at pre-school age had better social adaptation, social acceptance, self-image, self- esteem and academic performance than operated group at school age. CONCLUSION: It is better that correction of secondary lip nasal deformity at pre-school age than at school age in social development.