Reconstruction of microstomia considering their functional status

Background@#Microstomia is defined as a condition with a small sized-mouth that results in functional impairment such as difficulty with food intake, pronunciation, and poor oral hygiene and cosmetic problems. Several treatment methods for microstomia have been proposed. None of them are universally applicable. This study aims at analyzing the cases treated at our institution critically reviewing the pertinent literature. @*Methods@#The medical records of all microstomia patients treated in our hospital from November 2015 to April 2018 were reviewed retrospectively. Of these, all patients who received surgical treatment for microstomia were included in the study and analyzed for etiology, chief complaint, surgical method, and outcomes. The functional outcomes of mouth opening and intercommissure distance before and after the surgery were evaluated. The cosmetic results were assessed according to the patients’ satisfaction. @*Results@#Five patients with microstomia were corrected. Two cases were due to scar contracture after chemical burn, two cases derived from repeated excision of skin cancer, and one patient suffered sequela of Stevens-Johnson syndrome. The following surgical methods were applied: one full-thickness skin graft on the buccal mucosa, three buccal mucosal advancement flaps after triangular excision of the mouth corner, and one local buccal mucosal flap. Mouth opening was increased by 6.0 mm, and the intercommissure distance improved by 7.2 mm on average. Follow-up was 9.6 months (range, 5–14 months). Cosmetic assessment was as follows: two patients found the results excellent, three judged it as good. @*Conclusion@#Microstomia has several causes. In order to achieve optimal functional recovery and aesthetic improvement it is important to precisely evaluate the etiologic factors and the severity of the impairment and to carefully choose the appropriate surgical method.

Early surgical correction of microstomia followingStevens-Johnson syndrome

Stevens-Johnson syndrome (SJS) is a rare disease in which extensive toxic epidermolysis occursafter medication. Skin and mucous membranes are involved in about 90% of SJS cases, and webbingof mouth corners (microstomia) may occur when they are affected. Few reports have been issuedon microstomia in SJS, and no consensus has been reached regarding treatment methods,timings, or results. We encountered a case of microstomia following SJS after ofloxacin medicationin a 22-year-old woman treated by commissuroplasty using a lozenge-shaped excision. Wepresent an appropriate correction method and surgical timing for microstomia following SJS.

Unplanned change from double free flap to a chimeric anterolateral thigh flap in recurrent laryngeal cancer

Reconstruction method choice in recurrent head and neck cancer depends on surgical history, radiation therapy dosage, conditions of recipient vessels, and general patient condition. Furthermore, when defects are multiple or three dimensional in nature, reconstruction and flap choice aimed at rebuilding the functional structure of the head and neck are difficult. We experienced successful reconstruction of recurrent laryngeal cancer requiring reconstruction of esophageal and tracheostomy stroma defects using a chimeric two-skin anterolateral thigh flap with a single pedicle.

Early Intervention for Low-Temperature Burns: Comparison between Early and Late Hospital Visit Patients

BACKGROUND: Various focal heating devices are popular in Korea under the cultural influence of the traditional ondol under-floor method of home heating. These devices can cause severe burn-like injuries resulting from device malfunction or extended with low heat contact. In addition to injuries under these high heat contact, burns can be occurred by low heat exposure with prolonged periods despite the devices are properly functioning. In order to develop strategies to reduce the duration of periods of illness due to low-temperature burns, we analyzed and compared treatment methods and therapeutic periods for this type of injury. METHODS: This retrospective study included 43 patients burned under low heat conditions. Patients were divided into an operative group and a conservative group. The patients in the operative group underwent at least one surgical excision, and were further subdivided into early and late visit groups. The conservative group was treated only with dressings. We compared the treatment periods between the operative group and the conservative group, and also compared the preparation periods and treatment periods between the two operative groups. RESULTS: The average treatment period was significantly shorter in the operative group (P=0.02). In the early visit operative group, both wound preparation and treatment were briefer than in the late visit group. CONCLUSIONS: We recommend that early proper burn care and early surgical intervention, including appropriate excision, are feasible ways to reduce the treatment period of low-temperature burn patients.

Two-Step Incision for Periarterial Sympathectomy of the Hand

BACKGROUND: Surgical scars on the palmar surface of the hand may lead to functional and also aesthetic and psychological consequences. The objective of this study was to introduce a new incision technique for periarterial sympathectomy of the hand and to compare the results of the new two-step incision technique with those of a Koman incision by using an objective questionnaire. METHODS: A total of 40 patients (17 men and 23 women) with intractable Raynaud's disease or syndrome underwent surgery in our hospital, conducted by a single surgeon, between January 2008 and January 2013. Patients who had undergone extended sympathectomy or vessel graft were excluded. Clinical evaluation of postoperative scars was performed in both groups one year after surgery using the patient and observer scar assessment scale (POSAS) and the Wake Forest University rating scale. RESULTS: The total patient score was 8.59 (range, 6-15) in the two-step incision group and 9.62 (range, 7-18) in the Koman incision group. A significant difference was found between the groups in the total PS score (P-value=0.034) but not in the total observer score. Our analysis found no significant difference in preoperative and postoperative Wake Forest University rating scale scores between the two-step and Koman incision groups. The time required for recovery prior to returning to work after surgery was shorter in the two-step incision group, with a mean of 29.48 days in the two-step incision group and 34.15 days in the Koman incision group (P=0.03). CONCLUSIONS: Compared to the Koman incision, the new two-step incision technique provides better aesthetic results, similar symptom improvement, and a reduction in the recovery time required before returning to work. Furthermore, this incision allows the surgeon to access a wide surgical field and a sufficient exposure of anatomical structures.

Wire or Hook Traction for Reducing Zygomatic Fracture

BACKGROUND: Variable methods have been introduced for reduction of the zygomatic fractures. The Dingman elevator is used widely to reduce these fractures but is inappropriate in certain types of fractures which require atypical traction vectors. We introduce and examine an alternate method of reducing zygomatic fractures using wire and hook traction. METHODS: A retrospective study was performed for all zygomatic fracture patients admitted between 2008 and 2014. Medially rotated fractures were reduced by using a wire looped through an intermaxillary screw secured on the medial side of the zygoma. Laterally rotated fractures were reduced using a hook introduced through an infrazygomatic skin incision. RESULTS: No accidental bleeding or incomplete reduction was observed in any of the cases. Postoperative imaging demonstrated proper reduction immediately after the operation. Follow-up computed tomography study at 1 month after operation also demonstrated proper reduction and healthy union across the previous site of fracture. CONCLUSION: The hook and wire method allowed precise application of traction forces across zygomatic fractures. The fractured bone fragment could be pulled in the direction precisely opposite to the vector of impact at the time of trauma. Soft tissue damage due to dissection was minimized. In particular, this method was effective in reducing rotated bone fragments and can be an alternative option to using the zygoma elevator.

Scalp Reconstruction after Resection of a Large Recurred Proliferating Trichilemmal Tumor Using an Anterolateral Thigh Free Flap

No abstract available.

Risk Factors of Treatment Failure in Diabetic Foot Ulcer Patients

BACKGROUND: Some diabetic feet heal without complication, but others undergo amputation due to progressive wounds. This study investigates the risk factors for amputation of diabetic feet. METHODS: A total of 55 patients who visited our institution from 2008 to 2012 were included in the study. The patients with abnormal fasting blood sugar levels, lower leg vascularity, and poor nutrition were excluded from the study group, and the wound states were unified. The patients were categorized into a treatment success group (n=47) and a treatment failure group (n=8), and their hemoglobin A1C (HgA1C), C-reactive protein (CRP), white blood cell count (WBC), and serum creatinine levels were analyzed. RESULTS: The initial CRP, WBC, and serum creatinine levels in the treatment failure group were significantly higher than that of the treatment success group, and the initial HgA1C level was significantly higher in the treatment success group. The CRP and WBC levels of both groups changed significantly as time passed, but their serum creatinine levels did not. CONCLUSIONS: The initial CRP, WBC, and serum creatinine levels were considered to be risk factors for amputation. Among them, the serum creatinine level was found to be the most important predictive risk factor. Because serum creatinine represents the renal function, thorough care is needed for the feet of diabetic patients with renal impairment.

Delayed Soft Tissue Coverage after Negative Pressure Wound Therapy in Open Fractures of Lower Extremities / 대한정형외과학회잡지

PURPOSE: To evaluate the delayed soft tissue coverage after previous negative wound therapy in treating wounds associated with open lower extremity fracture. MATERIALS AND METHODS: Between June 2007 and February 2011, delayed soft tissue coverage of open lower extremity fractures after previous use of a negative pressure vacuum device, were performed in 15 consecutive patients. Patients included 13 male and 2 female, and their mean age was 39.0 (7-65) years old. Information on the time from injury to definitive wound coverage, type of coverage, functional result, bone union, and complications such as infection were collected. RESULTS: The vacuum-assisted closure devices was applied for an average of 29.3 (9-50) days, and the mean time from injury to definitive wound was 36.1 (21-60) days. Skin graft coverage was performed in 5 cases, free flap in 8 cases, and local flap in 3 cases. The mean time to radiographic union was 5.2 (3-8) months and delayed union occurred in 2 cases. CONCLUSION: Delayed soft tissue coverage after previous negative wound therapy was considered an alternative treatment method in open lower extremity fractures associated with severe concomitant injury.

Donor Site Morbidity after Sural Nerve Harvesting for Peripheral Nerve Reconstruction

PURPOSE: Although the sural nerve is the most commonly used donor for autologous nerve graft, its morbidity after harvesting is sparsely investigated. The sural nerve being a sensory nerve, complications such as sensory changes in its area and neuroma can be expected. This study was designed to evaluate the donor site morbidity after sural nerve harvesting. METHODS: Among the 13 cases, who underwent sural nerve harvesting between January 2004 and August 2009, 11 patients with proper follow up were included in the study. The collected data included harvested graft length, actual length of the grafted nerve, anesthetic and paresthetic area, presence of Tinel sign and symptomatic neuroma, and scar quality. RESULTS: In 7 patients, no anesthetic area could be detected. Of the patients with a follow up period of more than 2 years, all the patients showed no anesthetic area except two cases who had a very small area of sensory deficit (225 mm2) on the lateral heel area, and large deficit (4,500 mm2) on the lateral foot aspect. The patients with a short follow up period (1~2 m) demonstrated a large anesthetic skin area (6.760 mm2, 12,500 mm2). Only one patient had a Tinel sign. This patient also showed a subcutaneous neuroma, which was visible, but did not complain of discomfort during daily activities. One patient had a hypertrophic scar in the retromalleolar area, whereas the two other scars on the calf were invisible. CONCLUSION: After a period of 2 years the size of anesthetic skin in the lateral retromalleolar area is nearly zero. It is hypothesized that the size of sensory skin deficit may be large immediately after the operation. This area decreases over time so that after 2 years the patient does not feel any discomfort from nerve harvesting.

Analysis of the embrasure dimensions between maxillary central incisors in relation to the topography of the interdental papilla

PURPOSE: To analyze the dimensions of the embrasure space between the maxillary central incisors as potential factors influencing interdental papilla fill and height. METHODS: The embrasure dimensions between the maxillary central incisors of 100 subjects (40 females/60 males) were assessed with clinical, study model, and radiographic examinations. Variables of the complete and deficient papilla fill groups were compared. Multiple regression analyses were performed to investigate potential influence of the distance between the contact point and bone crest (CP_BC), horizontal interdental distance (HID), and facio-lingual thickness (FLT) at the papilla base on complete/deficient papilla fill and papilla height (PH). RESULTS: CP_BC was the only variable that showed a significant difference between the complete and deficient papilla groups (P<0.05). When the CP_BC was less than 5 mm, the embrasure spaces between the maxillary central incisors were completely filled with interdental papilla. Multiple regression analyses revealed that a significant predictor for complete/deficient papilla fill was CP_BC, and significant predictors for PH were CP_BC and HID (P<0.05). CONCLUSIONS: The chances of complete papilla fill increased as CP_BC decreased, while PH increased as CP_BC and HID increased. However, the FLT of the papilla base did not appear to affect papilla fill or PH. From an esthetic perspective, CP_BC as well as HID should be considered as factors influencing the topography of interdental papilla.

Ulnar Artery Obstruction in Guyon Canal Compression Syndrome

PURPOSE: There are many articles describing about Guyon canal compression syndrome. Until recently, most of these articles have been presented about the symptoms of ulnar nerve compression, but there have been no reports about ulnar artery compression. In this article, besides the nerve compression symptoms in the Guyon's canal, we represented the symptoms and treatments based on the ulnar artery obstruction. METHODS: Guyon canal is composed of the hamate and pisiform, and the ligaments which connect them. The course of the ulnar nerve and artery, which passes through this narrow canal, is affected by the anatomical structure of the base of the canal. Out of 14 patients (21 cases) were retrospectively reviewed in this study from 2006 to 2009. Of 14 patients, there were 5 men and 9 women with ages between 21 to 61 years old. The symptoms had volar sensory loss of ulnar sided digits, with muscular atrophy of hypothenar muscles. Prior to surgery, most of these patients had vascular disorders which was diagnosed definitively by angiography and electromyogram. RESULTS: The release of Guyon canal and interposition graft of the obstructed arteries was carried out to 11 patients (15 cases) who had artery (vascular) occlusive disorder, and. 12 cases had sympathectomy and interposition graft after resection of obstructed ulnar artery. Six cases had release of carpal tunnel performed simultaneously. There were no major complications after surgery. The circulation of the ulnar artery was improved along with the patients' symptoms. CONCLUSION: The pre-existing articles about Guyon canal compression syndrome were mainly focused on ulnar nerve compression. This study, which was carried out by our department, showed that most of these patients had ulnar artery obstruction or stenosis simultaneously with ulnar nerve compression. The vascular disorder was corrected by interposition graft after the resection of the site of ulnar artery occlusion. And to conclude, When we resolve the ulnar nerve compression, the proper diagnosis & treatment of impaired ulnar artery circulation should be carried out concomitantly.

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.

Morphometric Study on the Arterial Palmar Arch of the Hand

PURPOSE: Deviations of arterial palmar arches in the hand can be explained on the embryological basis. The purpose of this study is to provide new information about palmar arches through cadaver's dissection. The values of the location and diameter in these vessels were analyzed in order to support anatomical research and clinical correlation in the hand. METHODS: The present report is based on an analysis of dissections of fifty-three hands carried out in the laboratory of gross anatomy. A reference line was established on the distal wrist crease to serve as the X coordinate and a perpendicular line drawn through the midpoint between middle and ring fingers, which served as the Y coordinate. The coordinates of the x and y values were measured by a digimatic caliper, and statistically analyzed with Student's test. RESULTS: Complete superficial palmar archs were seen in 96.2 % of specimens. In the most common type of males, the superficial arch was formed only by the ulnar artery. In the most common type of females, the superficial arch was formed anastomosis between the radial artery and the ulnar artery. The average length of the superficial and deep palmar arch is 110.3 +/- 33.0 mm and 67.9 +/- 14.0 mm respectively. Regarding the superficial palmar arch, ulnar artery starts -16.1 +/- 5.1 mm on X-line, and 2.5 +/- 24.5 mm on Y-line. Radial artery appears on palmar side 7.7 +/- 3.2 mm on X-line, and 20.9 +/- 10.9 mm on Y-line. But radial artery starts on 6.3 +/- 3.6 mm on X-line, and 3.4 +/- 5.1 mm on Y-line. Digital arteries of superficial palmar arch starts on 6.1 +/- 3.7 mm, 33.9 +/- 8.8 mm on index finger, 1.8 +/- 3.4 mm, 40.1 +/- 7.3 mm on middle finger, -3.2 +/- 4.9 mm, 42.6 +/- 7.0 mm on ring finger, and -8.9 +/- 5.1 mm, 42.5 +/- 80 mm on little finger in respective X and Y coordinates. Radial artery of deep palmar arches measured at the palmar side perforating from the dorsum of hand. It's coordinates were 9.7 +/- 4.8 mm on X-line, 21.7 +/- 10.2 mm on Y-line. Ulnar artery was measured at hypothenar area, and it's coordinates were -20.4 +/- 6.3 mm on X-line, and 30.6 +/- 7.4 mm on Y-line. CONCLUSIONS: Anatomically superficial palmar arch can be divided into a complete and an incomplete type. Each of them can be subdivided into 4 types. The deep palmar arch is less variable than the superficial palmar arch. We believe these values of the study will be used for the vascular surgery of the hand using the endoscope and robot in the future.

Secondary Breast Reconstruction

PURPOSE: Secondary breast reconstruction is defined as a whole reconstructive procedure to correct complications and to improve the aesthetics when a patient is dissatisfied with her initial reconstruction. We would like to present these particular procedures on previously failed breast reconstruction with analysis of unsatisfactory results. METHODS: From June 2002 to August 2008, we performed secondary breast reconstructions for 10 patients with failed breasts. Six patients with implant failure underwent secondary breast reconstructions using free TRAM flaps after the removal of implants. Two patients with partial loss of pedicled TRAM flaps underwent secondary breast reconstruction using Latissimus Dorsi flaps. Two patients with 1 total loss of free TRAM flap and 1 extensive fat necrosis underwent secondary breast reconstruction using implants. RESULTS: The average age of the patients were 36.4 years (26 - 47 years). All flaps survived completely and had relatively good aesthetic results in free TRAM cases. There was breast asymmetry in one patient using cohesive gell implants in total loss of previously free TRAM patient, which was corrected by exchanging the implants and placing dermofat grafts. CONCLUSION: Secondary breast reconstruction differs from primary procedures in several aspects; there are changes in the anatomy and tissue environment of the breasts, and various limitations in choosing reconstruction methods. In addition, the patients may be uncomfortable with previous complication. It is important to consider various factors before deciding to undergo a secondary breast reconstruction carefully with informed consent.

Correction of Cup Ear Using the Mattress Suture

PURPOSE: Constricted ear, which is named by Tanzer includes lop ear, cup ear, and sort of prominent ear. It has been classified into three groups by Tanzer. Especially the group I and IIA have been corrected by banner flap, Musgrave's technique, tumbling concha-cartilage flap, reversed banner flap and others. However, these techniques were too invasive for correcting mild degree of deformity. Therefore, we corrected the ear with mattress suture which is simple and less invasive. Method: The operations were done for 5 patients from March 2005 to April 2008. All the cases were unilateral ears with constriction including helix and scaphoid fossa without differences in length between both ears. Though a posterior auricular skin incision, the folded cartilage is exposed and two parallel incisions on superior crus were made. After mattress suturing in cartilage, the superior crus of antihelix was formed and its force enables the folded portion to be in a normal anatomic position. Result: All the 5 patients got satisfactory results. There were no complications like hematoma or skin necrosis, and no recurrence during follow-up period(the average period was 11 months). And we couldn't recognize the difference between height of both auricles. CONCLUSION: Mattress suture is simple, less invasive, and suitable in correcting mild deformity of constricted ear with better result, so here we suggest the method.

Selection of Recipient Vessels in Delayed Breast Reconstruction with Free TRAM Flap

PURPOSE: The selection of the recipient vessels in breast reconstruction has a great influence on the surgical result and the shape of the reconstructed breast. We would like to introduce the criteria for the selection of recipient vessels in delayed reconstruction of the breast. METHODS: We studied 56 patients with delayed breast reconstruction using free TRAM flaps from April 1994 to December 2006. The thoracodorsal and the ipsilateral internal mammary vessels were used as recipients in 25 patients each, the opposite internal mammary vessels in 3 patients, the thoracoacromial vessels in 2 patients, and the transverse cervical artery with the cephalic vein in 1 patient. The survival rate of the flaps, the vessel diameter, the length of the pedicles, and the convenience of vessel dissection were studied. RESULTS: The diameter of the recipient vessel did not influence the anastomosis. The operation time, the survival rate of flap, the postoperative complications showed no significant difference according to the recipient vessel. Dissection of the thoracodorsal vessels was tedious due to scar formation from the prior operation. Dissection of the internal mammary vessels proved to be relatively easy, and the required length of the pedicle was shorter than any other site, but the need for removal of rib cartilage makes this procedure inconvenient. CONCLUSION: The first choice of the recipient vessel in immediate breast reconstruction is the thoracodorsal vessels, but in cases of delayed reconstruction the internal mammary vessels are favored as the first choice, because the thoracodorsal vessels have a high unusability rate. If the ipsilateral internal mammary vessels prove to be useless, the contralateral vessels can be used. The thoracoacromial vessels are useful, when the mastectomy scar is located in the upper portion. The transverse cervical artery and the cephalic vein can serve as the last resort, if all other vessels are unreliable.

Long Term Follow Up of Maxilla Reconstruction Following the Ablative Cancer Surgery

PURPOSE: The objective of this study was to evaluate the outcomes of using the free flap in the reconstruction of maxillary defects. METHODS: 27 consecutive cases of maxillary reconstruction with free flap were reviewed. All clinical data were analyzed, including ideal selection of flap, time of reconstruction, recurrence of cancer, postoperative complications, flap design, and follow-up results. The main operative functional items, including speech, oral diet, mastication, eye globe position and function, respiration, and aesthetic results were evaluated. RESULTS: Among the 24 patients who underwent maxillary reconstruction with the free flap, 14 patients underwent immediate reconstruction after maxillary cancer ablation, and 10 patients underwent delayed reconstruction. There occurred 1 flap loss. Recurrences of the cancer after the reconstruction happened in 2 cases. Postoperative complications were 3 cases of gravitational ptosis of the flap, 2 cases of the nasal obstruction, and 1 case of fistula formation. Out of 27 free flaps, there were 15 latissimus dorsi myocutaneous flaps, 5 radial forearm, 4 rectus abdominis myocutaneous flaps, 1 scapular flap, 2 fibula osteocutaneous flap, respectively. Flaps were designed such as 1 lobe in 9 cases, 2 lobes in 9 cases, and 3 lobes in 5 cases. Among the 14 patients who had intraoral defect or who had palatal resection surgery, 2 patients complained the inaccuracy of the pronunciation due to the ptosis of the flap. It was corrected by the reconstruction of the maxillary buttress and hung the sling to the upper direction. All of the 14 patients were able to take unrestricted diets. In 6 patients who had reconstruction of inferior orbital wall with rib bone graft, they preserved normal vision. Aesthetically, most of the patients were satisfied with the result. CONCLUSION: LD free flap is suggested in uni-maxilla defect as the 1st choice, and fibular osteocutaneous flap and calvarial bone graft to cover the larger defect in bi-maxilla defect.

Aesthetic Surgery for a Posttraumatically Split Medial Head of the Clavicle

PURPOSE: We experienced a patient with posttraumatic duplication of the sternoclavicular joint causing a protruding deformity, whose major complaint was aesthetic. The patients history, radiologic findings, and surgical treatment are reported. METHODS: A 41-year-old bus driver complained a bony prominence at the left medial clavicle, which had developed after a fracture. The patient was annoyed by the protrusion, which was even visible, when he was wearing a pullover. A three dimensional CT scan showed that the medial head was split into two portions, of which the anterior portion was protruding. In general anesthesia the anterior portion of the medial head was excised. RESULTS: The bony prominence was corrected successfully. Follow up three dimensional CT scans showed that the anterior cortex of the clavicle had regenerated completely at the resection line one year after the operation. CONCLUSION: Surgical interventions for complications after clavicular fracture are usually carried out, only if there is a limitation of function or if it is painful. We report of a patient with posttraumatic bifurcation of the medial clavicular head, most probably caused by malunion. Upon the patient's request, the deformity causing protrusion of the medial clavicular area was successfully resected for cosmetic reasons.

Huge Lipoma of the Face: A Case Report

PURPOSE: Lipomas of the skin are one of the most frequently encountered tumors in plastic surgical practice. Huge lipomas of all areas of the body have been described. Large lipomas of the face, however, are not so common. We report on the treatment of a huge lipoma of the forehead causing distortion of the eyebrows. METHODS: A 55 year old man was referred to our department by the neurosurgeons. He was primarily admitted for removal of a meningioma of the left frontal lobe of his brain. More striking was a huge protruding mass of 75x60x30mm covering almost the whole left half of his face's upper third and displacing his left eyebrow downward by almost 1cm. MRI showed a large lipoma, which caused 3cm anterior protrusion of the overlying skin. A meningioma of the left frontal lobe was also seen. The lipoma was removed via an external approach. Before closure of the skin a 3.5 cm wide strip of muscle and skin was resected. The multilobulated specimen was covered by a thin capsule and weighed 95g. The pathologist diagnosed it as benign lipoma. RESULTS: The postoperative course was uneventful. At 11 months after the operation the resulting scar was inconspicuous, the position of the eyebrows was almost symmetric and a symmetric brow elevation was observed. CONCLUSION: We describe the largest facial lipoma reported in the recent literature. By using an open approach, skin excision and redraping, we achieved an aesthetically satisfactory outcome.