Division of a single free flap in multiple digit reconstruction

Background@#Single free flaps are a commonly used reconstructive method for multiple soft tissue defects in digits. We analyzed the flap size, division timing, and degree of necrosis in cases with various types of flap division. @*Methods@#We conducted a retrospective review of the medical charts of patients who had undergone single free flap reconstruction for multiple soft tissue defects across their digits from 2011 to 2020. The flap types included were the lateral arm free flap, venous forearm free flap, thenar free flap, hypothenar free flap, anterolateral thigh free flap, medial plantar free flap, and second toe pulp free flap. Flap size, anastomosed vessels, division timing, and occurrence of flap necrosis were retrospectively investigated and then analyzed using the t-test. @*Results@#In total, 75 patients were included in the analysis. The success rate of the free flaps was 97.3%. All flaps were successfully divided after at least 17 days, with a mean of 47.17 days (range, 17–243 days) for large flaps and 42.81 days (range, 20–130 days) for the medium and small flaps (P=0.596). The mean area of flap necrosis was 2.38% in the large flaps and 2.58% in the medium and small flaps (P=0.935). Severe necrosis of the divided flap developed in two patients who had undergone flap division at week 6 and week 34. @*Conclusions@#In cases where blood flow to the flap has been stable for more than 3 weeks, flap division can be safely attempted regardless of the flap size.

Fingertip reconstruction with a subcutaneous flap and composite graft composed of nail bed and volar pulp skin

Background@#Fingertip injuries are very common; however, the reconstruction of volar pulp defects with nail bed defects is challenging in the absence of the amputated segment. We reconstructed fingertip amputations with nail bed defects using a new surgical approach: a subcutaneous flap and composite graft. @*Methods@#We treated 10 fingertip amputation patients without an amputated segment, with exposed distal phalangeal bone and full-thickness nail bed defects between February 2018 and December 2020. All patients underwent two-stage surgery: in the first stage, a subcutaneous flap was performed to cover the exposed distal phalanx, and in the second stage, a composite graft, consisting of nail bed, hyponychium, and volar pulp skin, was applied over the subcutaneous flap. @*Results@#All flaps survived and all composite grafts were successful. The wounds healed without any significant complications, including the donor site. The average follow-up duration was 11.2 months (range, 3–27 months). The new nail and the shape of the volar pulp were evaluated during follow-up. All patients were satisfied with their natural fingertip shapes and the new nails did not have any serious deformities. @*Conclusions@#A subcutaneous flap in combination with a composite graft fitting the shape of the defect could be another option for fingertip injuries without amputated segments.

Arterial or venous free flaps for volar tissue defects of the proximal interphalangeal joint: A comparison of surgical outcomes

Background@#For volar soft tissue defects of the proximal interphalangeal (PIP) joint, free flaps are technically challenging, but have more esthetic and functional advantages than local or distant flaps. In this study, we compared the long-term surgical outcomes of arterial (hypothenar, thenar, or second toe plantar) and venous free flaps for volar defects of the PIP joint. @*Methods@#This was a single-center retrospective review of free flap coverage of volar defects between the distal interphalangeal and metacarpophalangeal joint from July 2010 to August 2019. Patients with severe crush injuries (degloving, tendon or bone defects, or comminuted/intra-articular fractures), thumb injuries, multiple-joint and finger injuries, dorsal soft tissue defects, and defects >6 cm in length were excluded from the study, as were those lost to follow-up within 6 months. Thirteen patients received arterial (hypothenar, thenar, or second toe plantar) free flaps and 12 received venous free flaps. Patients’ age, follow-up period, PIP joint active range of motion (ROM), extension lag, grip-strength ratio of the injured to the uninjured hand, and Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score were compared between the groups. @*Results@#Arterial free flaps showed significantly higher PIP joint active ROM (P=0.043) and lower extension lag (P=0.035) than venous free flaps. The differences in flexion, grip strength, and QuickDASH scores were not statistically significant. @*Conclusions@#The surgical outcomes of arterial free flaps were superior to those of venous free flaps for volar defects of the PIP joint.

Partial second toe pulp free flaps in early childhood

Background@#The introduction of the partial second toe pulp free flap has enabled superior aesthetic and functional results for fingertip reconstruction in adults. Children undergoing fingertip amputation for various reasons have limited options for reconstruction. Conventional treatment could shorten the finger, leading to poor cosmesis and function. We report 18 years of our experiences with fingertip reconstruction using partial second toe pulp free flaps in patients in early childhood. @*Methods@#Medical charts of children who had undergone fingertip reconstruction using partial second toe pulp free flaps from 2001 to 2018 were retrospectively reviewed. The surgical procedures were identical to those for adults, except for the usage of 11-0 nylon sutures. Patients’ demographic data, vessel size, flap dimensions, length of the distal phalanx, and functional outcomes over the course of long-term follow-up were documented. The statistical analysis was performed with the Student t-test, the Mann-Whitney U test, and Pearson correlation analysis. @*Results@#Eighteen toe pulp flaps in 17 patients (mean age, 3.0 years) were identified. All the flaps survived without any major complications. In long-term follow-up, the flap-covered distal phalanges showed growth in line with regular development. There was no donor-site morbidity, and all children adapted to daily life without any problems. In two-point discrimination tests, the fingertip sensation recovered to almost the same level as that in the contralateral finger. @*Conclusions@#Partial second toe pulp free flaps are an excellent option for fingertip reconstruction in young children, as well as in adults.

Long-term outcomes of nail bed reconstruction

BACKGROUND@#There are various reconstructive options for nail bed defects. However, it is challenging not to leave a deformity. In this study, we investigated differences in outcomes depending on the reconstruction method, attempted to determine which method was better, and analyzed other factors that may affect outcomes.@*METHODS@#The long-term outcomes of nail bed reconstruction were reviewed retrospectively. We performed three types of reconstruction depending on the defect type: composite grafts of severed segments, nail bed grafts from the big toe, and two-stage surgery (flap coverage first, followed by a nail bed graft). Subsequent nail growth was evaluated during follow-up, and each outcome was graded based on Zook’s criteria. The reconstruction methods were statistically analyzed. Other factors that could contribute to the outcomes, including age, the timing of surgery, germinal matrix involvement, defect size, and the presence of bone injuries, were also compared.@*RESULTS@#Twenty-one patients (22 digits) who underwent nail bed reconstruction were evaluated. The type of reconstruction method did not show a significant relationship with the outcomes. However, patients who sustained injuries in the germinal matrix and patients with a defect larger than half the size of the nail bed had significantly worse outcomes than the comparison groups.@*CONCLUSIONS@#The results suggest that no operative method was superior to another in terms of the outcomes of nail bed reconstruction. Nevertheless, involvement of the germinal matrix and defect size affected the outcomes.

Tardy Ulnar Nerve Palsy by Neurofibroma

Tardy ulnar nerve palsy is ulnar neuropathy at or around elbow and commonly evaluated in the electromyography laboratory. However, ulnar neuropathy at the elbow due to neurofibroma is rare. Neurofibromas are tumors that arise within nerve fasciculi and anywhere along a nerve from dorsal root ganglion to the terminal nerve branch. We report one case of ulnar neuropathy at the elbow due to neurofibroma. Patient had paresthesia on the left 5th finger and there had been left hypothenar atrophy since 2 months ago. Tinel's sign was positive at left elbow. As a result of electromyography, there were suggestive of right ulnar neuropathy at or around elbow, referred to as tardy ulnar nerve palsy. Ultrasonography showed a diffuse tortuous thickening with multiple neurofibromas arising from individual fascicles of the ulnar nerve in cubital tunnel area. Surgery was then performed to release cubital tunnel of left elbow, then the patient's symptoms improved.

Flexor Carpi Radialis Tendon Rupture due to Repetitive Golf Swing

Flexor carpi radialis (FCR) muscle is located in the forearm anteriorly that runs through a synovial fibro-osseous tunnel in the forearm. We described a case of FCR tendon rupture due to repetitive overuse injury. A 55-year-old man, right-hand dominant, presented with right forearm pain and swelling which started 3 days ago while playing amateur golf. Focal tenderness and bruising over volo-ulnar region of the right forearm were examined. Plain radiographs showed soft tissue edema around lesion area and no detectable fracture. Ultrasonography showed multiple hypoechoic lesions suspected as hematoma of the flexor muscle group. After done magnetic resonance imaging, he was diagnosed with rupture of FCR tendon at proximal origin and strain of flexor digitorum superficialis and palmaris longus muscle. He received compressive dressing and restriction of wrist range of motion for three weeks. Two months later, remaining traces of lesions were observed at the follow-up ultrasonography and the pain disappeared.

Acellular Dermal Matrix and Split-Thickness Skin Graft Stabilized by Negative Pressure Wound Therapy for Postburn Scar Contracture: A Case Report

Postburn scar contracture for ankle is commonly treated with contracture release procedure and skin graft but contracture recurrence rate is high. Contracture in grafted skin is inversely related to the graft thickness but full-thickness skin graft is limited in large defect coverage. Using ADM for ankle joint defect which was following ankle postburn scar contracture release procedure with grafting split-thickness skin may be an alternative reconstructive option. We present a 63-year-old man with postburn scar contracture and Marjolin ulcer on his left ankle. He originally had limited ankle movement function but surgical resection of skin malignancy and surrounding scar tissue released the ankle. Coverage using ADM and STSG was performed and NPWT was used for graft fixation. Ankle range of motion was satisfactory at postoperative follow-up. The ADM and STSG with NPWT could be considered an alternative reconstruction option after contracture release for ankle.

Retained large glass fragments for over 40 years in the maxillofacial region

Foreign body (FB) impaction in the maxillofacial area could be caused by knives, glass fragments, and vegetative materials. We present the rare case of a 62-year-old man with a large glass FB in the left cheek retained for over 40 years. He had traffic accident over 40 years ago and glass fragments impacted on his left cheek. Glass fragments were retained around the zygomatic arch with dimpled scar and unclear serous discharge, but other facial motor or sensory dysfunction was not observed. We confirmed three glass fragments with radiologic examination including plain radiograph and computed tomographic image. Under general anesthesia, impacted glass fragments were removed through the direct incision on the dimpled scar and the additional incision on the left lateral canthal area. Remnant FBs were not seen on an intraoperative C-arm radiograph. After 2 days of irrigation for inflammation control, the dimpled wound was sutured. The wound was healed without major complication and the original dimpled scar was much improved.

Sinus Tract Formation with Chronic Inflammatory Cystic Mass after Beta Tricalcium Phosphate Insertion

Beta tricalcium phosphate (β-TCP) is one of allogenic bone substitute which is known to have interconnected pores that draws cell and nutrients for bone generation. It has been resulted in good outcomes for bone defect coverage or augmentation. However, several studies have also reported negative outcomes and associated complications including unexpected formation of cystic mass, continuous pain and secretion. We present the case of a 36-year-old man with a right cheek cystic mass who had a history of right zygomaticomaxillary (ZM) complex fracture and surgical correction with β-TCP powder insertion to ZM bone defect. Excisional biopsy under local anesthesia revealed calcified mass in a sinus tract which was found to be connected to the ZM bone defect site in postoperative computed tomography image. Further excision under general anesthesia was performed to remove the sinus tract and fine granules which filled the original defect site. Pathologic report revealed bony spicules and calcification materials with chronic foreign body reaction. Postoperative complications and recurrence were not reported.

Sinus Tract Formation with Chronic Inflammatory Cystic Mass after Beta Tricalcium Phosphate Insertion

Beta tricalcium phosphate (β-TCP) is one of allogenic bone substitute which is known to have interconnected pores that draws cell and nutrients for bone generation. It has been resulted in good outcomes for bone defect coverage or augmentation. However, several studies have also reported negative outcomes and associated complications including unexpected formation of cystic mass, continuous pain and secretion. We present the case of a 36-year-old man with a right cheek cystic mass who had a history of right zygomaticomaxillary (ZM) complex fracture and surgical correction with β-TCP powder insertion to ZM bone defect. Excisional biopsy under local anesthesia revealed calcified mass in a sinus tract which was found to be connected to the ZM bone defect site in postoperative computed tomography image. Further excision under general anesthesia was performed to remove the sinus tract and fine granules which filled the original defect site. Pathologic report revealed bony spicules and calcification materials with chronic foreign body reaction. Postoperative complications and recurrence were not reported.

Bilateral Dermoid Cysts on the Lateral Ends of Eyebrows

No abstract available.

Cutaneous Rosai-Dorfman Disease Confused with Vascular Mass

Rosai-Dorfman disease is a rare histiocytic disorder, clinically characterized by massive, bilateral painless cervical lymphadenopathy with potential for extranodal manifestations. We report a 45-year-old male patient who presented with a slowly growing erythematous nodule of the left chin. The mass appeared non-vascular on computed tomography study, but ultrasonogram was suggestive of a vascular lesion. The lesion was excised with presumptive diagnosis of a hemangioma. However, histopathologic examination of the surgical biopsy revealed histiocytic infiltration with emperipolesis, which was pathognomic for Rosai-Dorfman disease. Additional imaging studies did not reveal lymph node enlargement or other extranodal manifestation. The patient was diagnosed with cutaneous form of the Rosai-Dorfman disease and was discharged home. He remains free of local recurrence at 8 months.

Multiple Epidermal Cysts in the Volar Skin of the Thumb

No abstract available.

Microcystic Adnexal Carcinoma Misdiagnosed as Desmoplastic Trichoepithelioma on Preoperative Biopsy

Microcystic adnexal carcinoma is a rare type of tumor, with about 300 cases reported globally. Due to its similar histology with other tumors, it is occasionally misdiagnosed as desmoplastic trichoepithelioma, basal cell carcinoma, syringoma, and so on. We present a patient with a mass on the perioral area who was preoperatively diagnosed with trichoepithelioma. Microcystic adnexal carcinoma was diagnosed after excisional biopsy and a wide excision. Defects were reconstructed with a mucosal advancement flap. There was no recurrence and there were no significant complications during the 18-month follow-up period. Because superficial punch biopsy has limitations in width and depth, surgeons should always consider the possibility of malignancy of a mass even if a biopsy shows a benign result.

Management of Foreign Object Migration and Surgical Removal with C-Arm Fluoroscopy

No abstract available.

Combined Rotation and Advancement Flap Reconstruction for a Defect of the Upper Lip: 2 Cases

Many types of upper lip reconstruction have been introduced to treat defects after a tumor excision or trauma. The authors treated two cases of upper lip defects. A 35-year-old woman presented with a squamous cell carcinoma of the left upper lip that had invaded the corner of the mouth. After resecting the tumor, the defect was 3.7x3.5 cm in size. A 52-year-old woman presented with a dog bite of the right upper lip. The defect measured 4.0x2.2 cm in size. The two cases were reconstructed by combined rotation and advancement of a cheek flap. This technique produced a good functional outcome that allowed for oral competence and created an opening of adequate size. A combination of rotation and an advancement flap can be used to treat upper lip defects in a single-stage procedure. This approach produces a good functional and cosmetic outcome.

Surgical Treatment of Dermatomal Capillary Malformations in the Adult Face

BACKGROUND: Facial capillary malformations (CMs) rarely recede; they often become darker and raised in proportion to their growth. These malformations may hypertrophy in adulthood, resulting in increased disfigurement and dysfunction. Laser treatment is considered a first-line therapy for focal CMs, but thick wide lesions, which are accompanied by hypertrophy and have a well-circumscribed nodularity, may be treated with surgical excision and reconstruction. METHODS: We retrospectively reviewed the records of 25 consecutive patients who had undergone complete or partial excisions of facial capillary malformations in our unit. After the excisions, the defects that encompassed their facial aesthetic units were subsequently covered by various methods, including primary closures, local flaps, expanded flaps, split-thickness skin grafts, and full thickness skin grafts. RESULTS: The data demonstrated satisfactory results and reliability. Our patients were treated without significant complications, and all of the patients were moderately or fully satisfied with the outcome of their surgeries. CONCLUSIONS: Among the many reconstructive options for adult patients with facial capillary malformations, thick split-thickness skin grafts can be a good choice for the coverage of widely excised wounds.

Vascular Endothelial Growth Factor Effect on Notch 1 Expression and Proliferation of Fibroblast

PURPOSE: Vascular endothelial growth factor (VEGF) is known as a growth factor of endothelium and fibroblast. The purpose is to know the VEGF effects on fibroblast proliferation and fibroblast's notch receptor expression. METHODS: CCD-986sk fibroblast was purchased from the Korean Cell Bank and was used in XTT assay for proliferation and wound healing assay for migration. Immunofluorescent (IF) staining and western blotting were used in testing notch expression of fibroblast. Semiquantitative RT-PCR was used in checking notch 1 mRNA production by fibroblast. Student-t test was used for analyzing results. RESULTS: Cell proliferation assay using XTT showed significant higher proliferation in VEGF treated fibroblast, 2.324 +/- 0.0026 vs. 2.463 +/- 0.017 (p=0.002). Wound healing assay showed longer migration in VEGF treated fibroblast (p=0.062). The fluorescence was brighter in VEGF treated cells of notch 1 IF staining. Notch 1 expressions and mRNA productions increased more in VEGF treated cells. CONCLUSION: VEGF stimulates fibroblast to proliferate, migrate and to express Notch 1 simultaneously. Notch receptor could be related to VEGF mediated wound healing.

Foot Reconstruction by Reverse Island Medial Plantar Flap Based on the Lateral Plantar Vessel

PURPOSE: Tumor ablation and traumatic intractable ulceration of the plantar surface of the foot results in skin and soft tissue defects of the weight-bearing sole. Simple skin grafting is not sufficient for reconstruction of the weight-bearing areas. Instead, the island medial plantar flap(instep flap) and distally-based island medial plantar flap was used for proper reconstruction of the weight bearing area. However, there are some disadvantages. In particular, an island medial plantar flap has a short pedicle limiting the mobility of the flap and the distally-based island medial plantar flap is based on a very small vessel. We investigated whether good results could be obtained using a reverse island medial plantar flap based on the lateral plantar vessel as a solution to the above limitations. METHODS: Three patients with malignant melanoma were cared for in our tertiary hospital. The tumors involved the lateral forefoot, the postero-lateral heel, and the medial forefoot area. We designed and harvested the flap from the medial plantar area, dissected the lateral and medial plantar artery and vena comitans, and clamped and cut the vessel 1cm proximal to the branch from the posterior tibial artery and vena comitans. The medial plantar nerve fascicles of these flaps anastomosed to the sural nerve, the 5th interdigital nerve, and the 1st interdigital nerve of each lesion. The donor sites were covered with skin grafting. RESULTS: The mean age of the 3 subjects was 64.7 years(range, 57-70 years). Histologically, all cases were lentiginous malignant melanomas. The average size of the lesion was 5.3cm2. The average size of the flap was 33.1cm2. The flap color and circulation were intact during the early postoperative period. There was no evidence of flap necrosis, hematomas or infection. All patients had a normal gait after the surgery. Sensory return progressively improved. CONCLUSION: Use of an island medial plantar flap based on the lateral plantar vessel to the variable weight-bearing sole is a simple but useful procedure for the reconstruction of any difficult lesion of the weight-bearing sole.