Tofo gotoso en dorso nasal: reporte de caso / Nasal gouty tophus: case report

La gota es el trastorno del metabolismo de las purinas que se caracteriza por acumulación de ácido úrico por aumento de su producción o por disminución de su excreción. Con el paso del tiempo, el exceso de urato monosódico permite que se deposite en diferentes tejidos del organismo; siendo particularmente infrecuente la presentación de tofos a nivel facial. Paciente masculino adulto de 56 años, con antecedente de gota hace 38 años y presencia de tofos gotosos a nivel de miembros superiores e inferiores que acude por cuadro de 4 años de evolución de lesión indurada, levemente dolorosa a nivel de tercio medio de dorso nasal que ha ido aumentando de tamaño, que causa deformidad de pirámide nasal y leve sensación de obstrucción nasal bilateral por lo que se planifica resolución quirúrgica. El análisis histopatológico de las muestras enviadas bajo exéresis quirúrgica confirma que tejido enviado corresponde a tofo gotoso. Los tofos gotosos pueden aparecer en diferentes tejidos, como cartílagos, membranas y líquido sinovial, superficies articulares, siendo excepcionalmente raro, en el miocardio, válvulas mitral y aórtica, ojos, nariz y médula espinal. El lugar de presentación puede ser muy variable, al igual que su tamaño

Gout is a purine metabolism disorder characterized by accumulation of uric acid due to increased production or decreased excretion. Over time, excess monosodium urate allows it to be accumulated in different body tissues, although the occurrence in the facial area is particularly infrequent. A 56- year-old male patient with a gout antecedent from 38 years ago that presented gouty tophi at the level of the upper and lower limbs seek medical advice due to an indurated slightly painful lesion at the level of the middle third of the nasal dorsum that started 4 years before and has been increasing in size. The lesion was causing nasal pyramid deformity and a slight sensation of bilateral nasal obstruction, for which surgical resolution is planned. The histopathological analysis of the samples sent under surgical exeresis confirms that the tissue sample corresponds to gouty tophi. Gouty tophi can appear in different tissues, such as cartilage, membranes and synovial fluid, joint surfaces, being exceptionally rare in the myocardium, mitral and aortic valves, eyes, nose and spinal cord. The place of presentation can be very variable, as well as its size

Complications of the nasal dorsum reconstruction using autologous or alloplastic grafts: evidence from systematic review and meta-analysis / Complicações da reconstrução do dorso nasal com enxerto autólogo ou aloplástico: evidências de uma revisão sistemática e metanálise

Abstract Introduction Augmentation rhinoplasty depends mainly on intact stable bony and cartilaginous parts. Many trials have used different materials as a graft to perform the operation and support the nose. Debate exists whether alloplastic or autogenic grafts are more appropriate. Common available alloplastic grafts include silicone, medpor, and gore-tex. Autogenic grafts are usually derived from costal cartilages. Warping, infection, and hypertrophic scars are the main complications of the procedure. Yet no subgroup analysis has been performed to investigate the effect of different risk factors. Objective To investigate the effect of different types of grafts and the association of the income level of the country on surgery complications. Methods A comprehensive literature search of articles was conducted in PubMed, Cochrane Library, Web of Science, and SCOPUS databases through October 2019. We included articles that used autologous or alloplastic grafts in nasal dorsum reconstruction surgery. We performed subgroup analysis according to the type of graft used, region, and income level of the country. A meta-regression analysis model was carried out from the period of 1999-2018, to study the incidence of these complications over time. Results The overall complication rate was 7.1%, which was higher in the alloplastic group (7.8%) than the autogenic group (6.9%). The most common complications were secondary surgery for re-correction (4.1%), infection (2.1%), warping (1.6%), and hypertrophic scars (1.6%). All outcomes were homogeneous (I2 < 50%). Conclusion Patients with autogenic grafts are less liable to develop complications than their peers reconstructed with alloplastic grafts. Moreover, Asian patients are less susceptible to overall rhinoplasty complications. Attention should be noted for low-income countries in which surgical complications are more prone to occur.

Resumo Introdução A feitura de uma rinoplastia de aumento depende principalmente das partes ósseas e cartilaginosas intactas. Muitos estudos usaram enxertos de diferentes materiais para a feitura da cirurgia e como apoio da estrutura nasal. Ainda existem controvérsias em estudos prévios sobre quais tipos de enxertos, se materiais aloplásticos ou autogênicos, seriam os mais adequados. Os enxertos aloplásticos comuns incluem silicone, medpor e gore-tex. Os enxertos autogênicos são geralmente derivados de cartilagens costais. Deformações, infecção e cicatrizes hipertróficas são as principais complicações do procedimento. No entanto, nenhuma análise de subgrupo foi feita para investigar o efeito de diferentes fatores de risco. Objetivo Investigar o efeito de diferentes tipos de enxertos e o nível de renda do país nas complicações cirúrgicas Método Uma pesquisa abrangente de artigos na literatura foi feita nas bases de dados PubMed, Cochrane Library, Web of Science e SCOPUS até outubro de 2019. Foram incluídos artigos que usaram enxertos autólogos ou aloplásticos em cirurgias de reconstrução do dorso nasal. Foi feita uma análise de subgrupos de acordo com o tipo de enxerto usado, região e nível de renda do país. Um modelo de análise de metarregressão foi feito de 1999 a 2018, para estudar a incidência dessas complicações ao longo do tempo. Resultados A taxa global de complicações foi de 7,1%, a qual foi maior no grupo aloplástico (7,8%) do que no grupo autogênico (6,9%). As complicações mais comuns foram cirurgia secundária para recorreção (4,1%), infecção (2,1%), deformidade (1,6%) e cicatrizes hipertróficas (1,6%). Todos os resultados foram homogêneos (I2 < 50%). Conclusão Os pacientes com enxertos autogênicos são menos propensos a desenvolver complicações, em comparação com seus pares com enxertos aloplásticos. Além disso, pacientes asiáticos são menos suscetíveis a complicações gerais da rinoplastia. Merece atenção o fato de que em países de baixa renda as complicações cirúrgicas são mais propensas a ocorrer.

Nasal dorsum augmentation using autologous costal cartilage: accordion technique or multilayer oppositional suture technique / 中华医学美学美容杂志

Objective:To explore the effect of two different treatment methods of dorsum implants using autologous costal cartilage, accordion technique (AT) and multilayer oppositional suture technique (MOST), in preventing complications such as distortion and warping of the grafts.Methods:From January 2016 to December 2019, 119 patients underwent rhinoplasty with autologous costal cartilage as the dorsum implant. The dorsum implants were processed by two different techniuqes. Medical charts and operative records were reviewed to summary the complications, especially warping. Patients′ subjective satisfaction and doctors′ objective measurement of the postoperative nasal appearance were evaluated with a grading system.Results:The postoperative follow-up duration was 6 to 28 months. Graft exposure, mobility, or significant resorption, pneumothorax or significant donor-site pain were not observed. The warping rate was higher in the AT (7.8%, 6/77) than in the MOST (2.4%, 1/42) group, although not significantly. Overall, there were no differences in overall patient functional and aesthetic satisfaction between the two groups.Conclusions:Multilayered oppositional suture technique for the autologous costal cartilage grafting may minimize the complication of graft warping and might be an effective alternative for nasal dorsal augmentation, particularly in Asian patients.

Biometría de los músculos extensor corto de los dedos y extensor corto del hallux en individuos brasileños: análisis anatómico para su uso como colgajo muscular en cirugías reconstructivas / Biometry of the extensor digitorum brevis and extensor hallucis brevis muscles in Brazilian individuals: anatomical analysis for use as a muscle flap in reconstructive surgeries

RESUMEN: El músculo extensor corto de los dedos (ECD) se sitúa junto con el músculo extensor corto del hallux (ECH) en la región dorsal del pie y están encargados de colaborar con la acción agonista de los músculos extensor largo de los dedos (ELD) y extensor largo del hallux (ELH), en la extensión de los cuatro dedos mediales en las articulaciones metatarsofalángicas. Esta condición complementaria permite su transferencia quirúrgica hacia otras regiones receptoras sin afectar la funcionalidad extensora de los dedos del pie motivo por el cual durante las últimas décadas se ha convertido en un tejido importante para la reconstrucción de lesiones tisulares, sin embargo, son escasos los estudios biométricos que lo describan en detalle. El objetivo de esta investigación fue establecer la longitud, ancho y área de extensión de estos músculos acompañada de la determinación de las distancias de éstos respecto a la cuña medial y la base del quinto metatarsiano para su uso quirúrgico. Sumado a lo anterior y posterior a la descripción de las variantes musculares encontradas se determinó los puntos motores de inervación de estos dos músculos. Para ello se estudiaron 36 miembros inferiores formolizados de individuos adultos brasileños pertenecientes a la Universidad Federal de Alagoas (UFAL), Maceió, Brasil. Las mediciones se realizaron con un cáliper marca Mitutoyo de 0,01 mm de precisión obteniendo una longitud, ancho y área de 6,89 ± 1,64 cm, 3,81 ± 0,42 cm y 31,98 ± 7,60 cm2 en el lado derecho de 6,91 ± 1,64 cm, 3,68 ± 0,46 cm y 30,75 ± 7,61 cm2 en el izquierdo respectivamente. En el 17 % de los casos hay presencia de tendones accesorios para el músculo ECD. La distancia desde el margen medial del músculo ECH respecto a la cuña medial y del margen lateral del músculo ECD a la base del quinto metatarsiano fue de 1,97 ± 0,43 y 1,72 ± 0,41 al lado derecho y de 2,01 ± 0,62 y 1,87 ± 0,36 al lado izquierdo respectivamente. Los puntos motores (Pm) predominaron en un 64 % en el tercio medio del músculo ECH y en un 64 % en el tercio proximal del músculo ECD. Estos resultados son un aporte significativo, tanto para quienes realizan cirugía ortopédica como para el conocimiento detallado de la anatomía dorsal del pie.

SUMMARY: The extensor digitorum brevis muscle (EDB) is located along with the extensor hallucis brevis (EHD) in the dorsal region of the foot and are responsible for collaborating with the agonist action of the extensor digitorum longus muscles (EDL) and extensor hallucis longus (EHL) in the extension of the four medial fingers in the metatarsophalangeal joints. This complementary condition allows its surgical transfer to other receptor regions without affecting the extensor functionality of the toes, which is why during the last decades it has become an important tissue for the reconstruction of tissue injuries, however, there are few studies biometrics that describe it in detail. The objective of this investigation was to establish the length, width and area of extension of these muscles accompanied by the determination of their distances from the medial wedge and the base of the fifth metatarsal for surgical use. In addition to the above and after the description of the muscle variants found, the innervation motor points of these two muscles were determined. To do this, 36 formalized lower limbs of Brazilian adult individuals belonging to the Federal University of Alagoas (UFAL), Maceió, Brazil, were studied. Measurements were made with a 0.01 mm precision Mitutoyo caliper obtaining a length, width and area of 6.89 ± 1.64 cm, 3.81 ± 0.42 cm and 31.98 ± 7.60 cm2 on the right side of 6.91 ± 1.64 cm, 3.68 ± 0.46 cm and 30.75 ± 7.61 cm2 on the left, respectively. In 17 % of cases there is presence of accessory tendons for the EDB muscle. The distance from the medial margin of the EHB muscle with respect to the medial wedge and the lateral margin of the EDB muscle to the base of the fifth metatarsal was 1.97 ± 0.43 and 1.72 ± 0.41 on the right side and 2,01 ± 0.62 and 1.87 ± 0.36 on the left side respectively. Motor points (Pm) predominated in 64 % in the middle third of the EHB muscle and in 64 % in the proximal third of the EDB muscle. These results are a significant contribution both for those who perform orthopedic surgery and for detailed knowledge of the dorsal foot anatomy.

One stage repair of dorsum of hand and multiple fingers soft tissue defect with polyfoliate conjoined anterolateral thigh perforator flap / 中华显微外科杂志

Objective:To investigate the surgical method and clinical effect of one-stage repair of soft tissue defects of dorsum of hand and multiple fingers by using the polyfoliate conjoined anterolateral thigh perforator flap (ALTP) .Methods:From November, 2015 to September, 2019, 9 cases of soft tissue defects of dorsum of hand and multiple fingers were treated, including 8 males and 1 female. The average age was 32 years old. Causes of injury: 4 cases of thermal injury, 3 cases of strangulation injury, and 2 cases of traffic accident injury. Location of injury: 7 cases of right hand, 2 cases of left hand. Three cases of dorsum of hand with 1st-4th fingers, 3 cases with 2nd-5th fingers, 2 cases with 2nd-4th fingers, and 1 case with 3rd-5th fingers; All with bone, joint and tendon exposure. There were 6 cases with fracture or joint dislocation. All of them had no obvious defect of bone and joint. VSD was used to cover them after debridement. According to the shape and size of the wound, all flaps were designed to repair the soft tissue defect as the polyfoliate conjoined ALTP. The flap size was 7 cm×13 cm-12 cm×17 cm. Regular outpatient, telephone and Wechat follow-up were carried out to evaluate the flap survival, appearance, color elasticity, donor scar, sensory recovery, finger function recovery and patient satisfaction.Results:Nine cases of flap survived well. The average followed-up time was 12 (6-18) months. The postoperative followed-up revealed satisfactory shapes of the flaps, protective touch and recovery of functions. The donor site had good healing and no effect on function. In the last followed-up, according to the trial criteria for function evaluation of upper limbs by Chinese Society of Hand Surgery, 5 cases were excellent, 3 cases were good, and 1 case was fair. The hand function recovered well and returned to work and daily life on average 6 weeks after operation.Conclusion:The polyfoliate conjoined ALTP can repair the soft tissue defect of hand dorsum with multiple fingers at one stage, and the flap is in good shape. There is no need to divide the fingers. It is one of the ideal methods to repair the soft tissue defect of hand dorsum.

Rare Variations Of Extensor Tendons In The Dorsum Of Hand

Extensor digitorum muscle originates from the front of lateral epicondyle of humerus as common extensororigin, the adjacent intermuscular septa and the antebrachial fascia. It divides into four tendons in the distalthird of forearm for the medial four fingers. During routine dissection of back of forearm and dorsum of hand forundergraduate students, we discovered that extensor digitorum muscle was unusually giving a common slip tothe ring and little finger. Also, extensor digiti minimi(EDM) was found to be bifurcating into two separate slips forthe little digit.

Septum pyramidal adjustment and repositioning - a conservative and effective rhinoplasty technique / Ajuste e reposicionamento da pirâmide e septo nasal - uma técnica conservadora e eficaz em rinoplastia

Abstract Introduction: In rhinoplasty, the nasal dorsum has important relevance regarding the esthetic and functional aspects of the surgery. Its reduction should be performed with maximum accuracy and controlled resection to prevent or minimize potential complications. The septum pyramidal adjustment and repositioning consists of a conservative surgical technique of the nasal dorsum, which does not require the detachment of the upper lateral cartilages of the nasal septum, allowing the remodeling of the nasal dorsum while maintaining esthetic lines and nasal function, potentially reducing frequent complications in more traditional surgeries. Objective: To describe the septum pyramidal adjustment technique in detail, presenting its advantages and disadvantages in relation to the other surgical approaches, as well as to disclose results of this surgical procedure in patients submitted to primary rhinoplasty in a specific hospital. Methods: The medical records of all patients submitted to surgery from 2011 to 2015 through this surgical technique were evaluated by the same team. Of these cases, certain variables were analyzed such as gender, age, indication for reoperation and surgical complications. Results: 153 patients underwent rhinoplasty through septum pyramidal adjustment. Of these, 13 patients experienced an indication for a second surgery and four had some type of postoperative complication. Conclusion: The septum pyramidal adjustment surgical technique is a simple procedure, as it does not require the reconstruction of the nasal dorsum. It has a low number of complications and preserves the anatomical structures.

Resumo Introdução: Na rinoplastia, o dorso nasal tem importante relevância no quadro estético e funcional. A sua redução deve ser realizada com máxima precisão e ressecção controlada a fim de prevenir ou minimizar complicações potenciais. O termo septum pyramidal adjustment and repositioning consiste em uma técnica cirúrgica conservadora do dorso nasal, que não requer a desinserção das cartilagens laterais superiores do septo nasal, que permite remodelar o dorso nasal, manter as linhas estéticas e a função nasal, reduz potencialmente complicações frequentes nas cirurgias mais tradicionais. Objetivo: Descrever em detalhes o septum pyramidal adjustment, expor suas vantagens e desvantagens em relação às outras abordagens cirúrgicas, bem como apresentar resultados desse procedimento cirúrgico em pacientes submetidos à rinoplastia primária em um hospital específico. Método: Foram avaliados os registros médicos de todos os pacientes operados de 2011 a 2015 por essa técnica cirúrgica, pela mesma equipe. Desses casos, foram analisadas algumas variáveis, como: sexo, idade, indicação de reoperação e complicações cirúrgicas. Resultados: Foram submetidos 153 pacientes à rinoplastia por septum pyramidal adjustment. Desses, 13 tiveram segunda indicação cirúrgica e quatro apresentaram alguma complicação pós-operatória. Conclusão: A técnica cirúrgica septum pyramidal adjustment apresenta-se como um procedimento de fácil realização, pois não exige a reconstrução do dorso nasal. Apresenta baixo número de complicações e preserva as estruturas anatômicas.

Evaluation of postoperative patient satisfaction after covering the nasal dorsum with upper lateral cartilage: "upper lateral closing" / Avaliação da satisfação pós-operatória do paciente após cobertura do dorso nasal com a cartilagem lateral superior: "fechamento lateral superior"

Abstract Introduction: Following nasal hump removal during septorhinoplasty, the middle vault should be reconstructed to avoid functional and esthetic problems. Middle vault reconstruction, however, may result in widening of the middle vault and may need a camouflage graft to cover dorsal irregularities. Objective: To present the results of reconstructing the middle vault with a technique that covers the nasal dorsum with upper lateral cartilage, from the viewpoint of patient satisfaction. Methods: Retrospective study of patients who underwent septorhinoplasty that included nasal dorsum closure with upper lateral cartilage from December 1, 2014 to January 31, 2016. Those with postoperative follow-up of less than 3 months were excluded. The final study group included 39 patients. The same surgeon performed all septorhinoplasties. The dorsum was closed using an "upper lateral closing" technique that approximated upper lateral cartilages to each other over the septum. Postoperative patient satisfaction was determined using a visual analog scale and the rhinoplasty outcomes evaluation questionnaire. The questionnaire evaluates patient esthetic and functional satisfaction with the operated nose. High scores indicate improved esthetic results. Results: No dorsal irregularities were seen at postoperative follow-up evaluation of the patients. For esthetic nasal appearance, the median visual analogue scale scores was 86%, and the mean for the questionnaire was 77.03%. Conclusion: The natural dome-shaped anatomy of the nasal dorsum was achieved by approximating the upper lateral cartilages to each other. Closing the dorsum with this technique also covers any dorsal irregularities and results in a smooth dorsum. Patients expressed satisfaction with the esthetic and functional aspects of the smooth, attractive nasal dorsum.

Resumo Introdução: Após a remoção da giba nasal durante a rinosseptoplastia, a abóbada deve ser reconstruída para evitar problemas funcionais e estéticos. A reconstrução da abóboda entretanto, pode resultar em alargamento dorsal e pode necessitar de um enxerto para camuflar irregularidades dorsais. Objetivo: Avaliar a satisfação dos pacientes com os resultados da reconstrução da abóboda com uma técnica que utiliza a cartilagem lateral superior para recobrir o dorso nasal. Método: Estudo retrospectivo de pacientes submetidos a rinosseptoplastia, que incluiu fechamento do dorso nasal com cartilagem lateral superior, realizado de 1º de dezembro de 2014 a 31 de janeiro de 2016. Foram excluídos aqueles com acompanhamento pós-operatório de menos de 3 meses. O grupo final do estudo incluiu 39 pacientes. O mesmo cirurgião realizou todas as rinosseptoplastias. O dorso foi fechado com uma técnica de "fechamento lateral superior" que aproxima as cartilagens laterais superiores de cada lado sobre o septo. A satisfação pós-operatória dos pacientes foi determinada através de uma escala visual analógica e o questionário Rhinoplasty Outcomes Evaluation. O questionário avalia a satisfação estética e funcional do paciente com o nariz. Escores altos indicam percepção de melhoria estética. Resultados: Não foram observadas irregularidades dorsais na avaliação pós-operatória de seguimento dos pacientes. Em relação à aparência nasal estética, o escore médio da escala visual analógica foi 86% e o escore médio do questionário foi 77,03%. Conclusões: A anatomia natural em forma de domo do dorso nasal foi conseguida através da aproximação das cartilagens laterais superiores entre si. O fechamento do dorso com essa técnica também abrange todas as irregularidades dorsais e resulta em um dorso liso. Os pacientes expressaram satisfação com os aspectos estéticos e funcionais do dorso nasal liso e atraente.

Autologous costal cartilage for nasal tip surgery: report of 86 cases / 中华医学美学美容杂志

Objective To present our experience and techniques with the use of autologous costal cartilage grafts in Asian rhinoplasty,and to report the surgical results and complications in 86 consecutive rhinoplasty cases.Methods All operations were performed by the first author (Liu AT) with open approach,costal cartilages and perichondrium were used to reconstruct the nasal tip projection according to the tripod theory in rhinoplasty,after removing the previous injection material,L-shaped implant or hypertrophic scar tissue in the tip.Medical charts and operative records were reviewed retrospectively to summary the complications.Nasal dorsum augmentation was done by costal cartilage or I-shaped allograft,sometimes with anterior sheath of rectus abdominis.Patients' subjective satisfaction of the postoperative nasal appearance was self-evaluated with grading (1 worse,2 no change,3 improved,and 4 much improved).Results From September 2015 to March 2017,86 patients underwent rhinoplasty at our hospital.The postoperative follow-up duration was 6 to 20 months.Overall,functional and aesthetic outcome was satisfactory in most patients,and the mean score by the patients' self-evaluation was 3.3 ± 0.6.Graft exposure,mobility,or significant resorption,pneumothorax or significant donor-site pain were not observed.Conclusions Even with minimal complications and morbidities,autologous costal cartilage grafts in Asian rhinoplasty is a versatile and reliable graft material for nasal tip surgery in severe short or saddle nose,contracted nose due to previous L-shaped augmentation and revision rhinoplasty in which the septal cartilage has already been harvested.

Radiologic Measurement of the Nasal Length and Keystone Area in Relation to Nasal Bony and Septal Cartilaginous Dimensions in Korean Adults

Rinoseptoplastía: experiencia de 3 años en la Pontificia Universidad Católica de Chile / Rhinoseptoplasty: three-year experience at the Pontificia Universidad Católica de Chile

RESUMEN Introducción: La rinoseptoplastía es una cirugía compleja y desafiante. Permite resolver problemas estéticos y funcionales de la nariz. Objetivo: Describir la experiencia en rinoseptoplastías realizadas en el Comité de Nariz en nuestro centro. Material y método: Estudio descriptivo de pacientes sometidos a rinoseptoplastía entre 2013 y 2015. Resultados: Se operaron 265 pacientes en 3 años, 164 (61,8%) fueron mujeres y la edad promedio fue de 29 años (rango 13-73). Las cirugías fueron principalmente primarias (secundarias: 2,6%). El abordaje más utilizado fue abierto (92,5%). Se realizó trabajo de punta nasal en 253 (95,5%) pacientes; resección del dorso osteocartilaginoso en 252 (95,1%), y aumento de éste en sólo 5 (1,9%). Las osteotomías fueron frecuentes: paramedianas en 229 (86,4%), percutánea lateral bilateral en 217 (81,9%) y percutánea lateral unilateral en 17 (6,4%). El vástago columelar fue el injerto de punta más frecuentemente utilizado, en 241 (90,9%) pacientes, seguido del escudo en 69 (26,0%). En el dorso, se utilizaron autoespaciadores en 124 (46,7%) pacientes, y espaciadores en 109 (41,1%). Conclusiones: El abordaje abierto fue el más frecuente, demostrando ser favorable en nuestro centro por la exposición y aprendizaje de nuestros residentes. Se constató 2,6% de cirugías secundarias. Se destaca el uso de vástago columelar para otorgar soporte a la punta nasal dada la alta prevalencia de nariz hispana en nuestro centro.

ABSTRACT Introduction: Rhinoseptoplasty is a complex and challenging surgery. It addresses nasal aesthetics and functionality. Aim: To describe the experience in rhinoseptoplasty performed by the Nose Committee at our medical center. Material and method: Descriptive study, of the all rhinoseptoplasties performed by the Nose Committee between 2013 and 2015. Results: 265 patients underwent surgery in the 3-year period; 164 (61.8%) were women and the mean age was 29 years (range 13-73). Most were primary surgeries (secondary: 2.6%). An external approach was most commonly used (92.5%). Nasal tip surgery was performed in 253 (95.5%) patients; osteocartilaginous dorsum reduction in 252 (95,1%), and augmentation in only 5 (1,9%). Osteotomies were frequent: paramedian in 229 (86.4%), bilateral percutaneous lateral osteotomies in 217 (81.9%) and unilateral percutaneous lateral in 17 (6.4%). Regarding nasal tip grafts, columellar strut was most often used, in 241 (90,9%) patients, followed by the shield graft in 69 (26,0%). For the dorsum, autospreaders were used in 124 (46.7%), and spreader grafts in 109 (41.1%). Conclusions: Open rhinoseptoplasty was the most commonly used approach. This has shown favorable for residents due to better exposition of nasal anatomy. Only 2.6% were secondary rhinoseptoplasties. We emphasize the use of the columellar strut for nasal tip support as we frequently encounter hispanic noses at our center.

Repair of wound on dorsum of foot with thin anterolateral thigh perforator flap with sensory nerve / 中华整形外科杂志

Objective@#To investigate the treatment and clinical effect of thin anterolateral thigh perforator flap with sensory nerve in the repair of soft tissue defect of dorsal foot.@*Methods@#During January 2012 to February 2017, 14 cases of soft tissue defect of dorsalis pedis were treated. The flap was designed according to the three-dimensional structure of the defect in the recipient area, and the lateral femoral cutaneous nerve was carried. Free transplantation was performed for repair of soft tissue defect of dorsal foot after fine thinning under microscope. The selected size of the flap ranged from 6 cm×4 cm to 15 cm×9 cm, 10 cases of donor site width is less than or equal to 8 cm with direct suture, 4 cases of donor site wound greater than 8 cm, Free skin graft on the wound surface.@*Results@#After operation, all flaps survived. Meanwhile, superficial necrosis occurred in the distal part of the flap in 1 case due to local infection, and healed after dressing change. All patients were followed up for 6-24 months, the appearance of the flap was pleasant, the texture, color and elasticity of the flap were satisfactory. In addition, Partial skin flap two-point discrimination was 6-10 mm with S2, S3 sensory recovery. During the follow-up, patients were able to walk with normal shoes, no ulcer occurred in the flap, and healed well in donor site.@*Conclusions@#The application of thin anterolateral thigh perforator flap with sensory nerve is safe and reliable in the repair of soft tissue defect of dorsal foot. After the repair, the skin flap has a good appearance and can restore part of the sensation.

Unusual bilateral sensory innervation of the dorsum of hand by lateral antebrachial cutaneous nerve: a case report / 대한해부학회지

A 68-year-old male cadaver showed bilateral variation in the sensory innervation of the dorsum of hand. On the dorsum of right hand, first digit and lateral half of second digit were supplied by lateral antebrachial cutaneous nerve (LABCN); medial side of second digit and lateral side of third digit were supplied by superficial branch of radial nerve (SBRN) and medial side of third digit, the fourth and fifth digits were supplied by dorsal cutaneous branch of ulnar nerve (DBUN). On the dorsum of the left hand, lateral side of first digit was supplied by LABCN, medial side of first digit, the second and third digits as well as the lateral side of fourth digit were supplied by SBRN; medial side of fourth digit and fifth digit were supplied by DBUN. These variations would be helpful in understanding peripheral neuropathy, in interpretation of conduction velocity studies and in reconstructive surgery of hand.

A Case of Hepatocellular Carcinoma Metastasis to the Dorsal Tongue / 대한이비인후과학회지

Hepatocellular carcinoma (HCC) is a common neoplasm, and its metastasis to the head and neck area is rare. We herein describe a unique case of HCC metastasis to the dorsal tongue. A 54-year-old male who was already diagnosed with HCC visited our hospital complaining of dysphagia and a progressively enlarging dorsal tongue mass. We operated to excise on the mass using CO₂ laser including mucosal margin and deep margin. The diagnosis of HCC metastasis was confirmed immunohistochemically. After 2 weeks of follow-up, the patient did not exhibit any evidence of complication and could eat orally without any problem. Further treatment to the other metastatic lesion was rejected, and the patient was followed up for more than six months. We introduce this first case of metastatic HCC in the dorsal tongue. With the extended life expectancy of HCC patients, the incidence of rare metastasis is expected to increase.

Optimizing Outcomes in the Reconstruction of Postburn Scar Hand Deformities

PURPOSE: Reconstruction of severe postburn hand deformities with flexion or extension contractures with finger webbing deformities, large hypertrophic scars of dorsal hand are frequently encountered problems in burn hand surgery. To obtain the good results after correction of various type of postburn scar hand deformities, we have used the sophisticated reconstructive procedures such as scar contracture release, skin graft, and use of acellular dermal matrix (ADM). We report reliability and usefulness of these novel updated procedures according the type of postburn hand deformities, and reviewed the literatures. METHODS: We had 82 postburn hand deformities. Among them we selected 7 patients of severe postburn hand deformities, which had different affected sites involving over 1/3 of hand. To reconstruct the finger flexion contractures, the scar contracture release and full thickness skin graft was most frequently performed. For correction of finger webbing deformities, the 5 flap Z-plasty for 1(st) web, dorsal and volar interposition flap for 2, 3 and 4 web, FTSG were used. The diffuse hypertrophic scar of dorsum of hand was reconstructed with total excision of scars, skin coverage with one piece of medium thickness STSG, and postoperative clenched hand position. The postburn palmar contractures was reconstructed with extensive contracture release followed by resurfacing with ADM (AlloDerm™) and thin STSG. The severe postburn abduction contractures of wrist was treated by total excision of scars, ADM (CGDerm™), and thin STSG. RESULTS: After 1 month to 1.6 years follow up, relatively satisfactory results were obtained in all patients. As complications, 1 case of recurrent palmar contractures, which was reconstructed with ADM (AlloDerm™) with thin STSG, were noticed. CONCLUSION: The postburn finger flexion contractures could be managed by the scar contractures release and FTSG. This method is very safe and reliable. For reconstruction of postburn finger webbing deformities, it is mandatory to use 5-flap Z-plasty for 1(st) webbing deformities, and dorsal and volar interposition flap for 2, 3 and 4(th) webbing deformities concomitantly with resurfacing with FTSG. The diffuse hypertrophic scars of dorsum of hand was managed by total excision of scars, resurfacing with one large piece of over medium thickness STSG, and postoperative clenched hand position. After release of scar contractures of hand, acellular dermal matrix (ADM) with thin STSG can be used in case of deficient FTSG donor site.

Free peroneal perforator cutaneoadipofascial flap containing neurovascular axis for coverage of dorsal forefoot defects / 中华整形外科杂志

Objective@#To report operative techniques and clinical results of free sural cutaneoadipofascial flap containing the neurovascular axis based on a dominant peroneal perforating artery (DPPA, with a caliber≥0.8 mm) and its concomitant veins for reconstruction of dorsal forefoot soft tissue defects.@*Methods@#The flap was applied in 32 cases with middle to large soft tissue defects in the dorsal forefoot from Aug. 2009 to Dec. 2014. DPPAs arising from the posterolateral intermuscular septum was located and assessed preoperatively with color Doppler flow image and computed tomography angiography. According to the location, size, and shape of the defects, one of these DPPAs was chosen for flap planning. The flap was harvested from the posterolateral aspect of the leg. The neighboring neurovascular axis (one or more of that of the sural nerve, the medial cutaneous nerve, the lateral cutaneous nerve of calf and the sural communicating nerve) was included to ensure vascular supply. According to skin laxity of the donor site, the width of the full harvesting part which should be able to cover the region of the recipient site where pressure and friction force were prominent while wearing shores was decided; the rest was harvested as an adipofascial flap (without skin) to get enough size. After transfer to recipient site, the flap was revascularized by anastomosing the perforating artery and its venae comitantes with appropriate recipient vessels, and reinnervated (antegrade or retrograded methods). Skin grafting was performed on the adipofascial surface of the flap primarily or secondarily. The defects in donor site of the leg was closed directly.@*Results@#All flaps (ranged from 7.5 cm×5.0 cm to 23.0 cm×13.0 cm) were transplanted successfully, and no vascular or donor site problems occurred. All primary skin grafts (19 cases) was partially lost, but only 2 of them need a second grafting. Adipose necrosis occurred in 4 of 13 cases receiving secondary grafting but only needed wound care before surgery. Following up for 11-26 months showed both satisfactory functional and cosmetic results without problems of shoe wearing. Flap sensibility restored at least to the degree of S3.@*Conclusions@#The cutaneoadipofascial flap combines the advantages of perforator, neurocutaneous axis, free and adipofascial flaps leaving only suture scar in the donor leg, and is a satisfactory method for free-style and acute coverage of dorsal forefoot defects.

A morphological study of the dorsum sellae in human skull / Estudio morfológico del dorsum sellae en el cráneo humano

Anatomical variations in the shape and dimension of the dorsum sellae and posterior clinoid process are common. Most textbooks describe its shape as a median rectangular plate, a square plate, or a transverse ledge on a slope behind the sella turcica (hypophyseal fossa). This work aims to study the dorsum sellae of human skull. One hundred and twenty five dried adult human skulls, irrespective of age, were used for the study. Detailed features of the dorsum sellae were noted and classified into five types: crest like, thin plate, frail quadrilateral plate, heavy square plate, thick elongated plate. Fusion of the posterior and middle clinoid processes in one (unilateral) and all the clinoid processes (anterior, middle, and posterior) in three skulls (unilateral in one, bilateral in two) were also noticed. Findings are discussed in the light of the literature.

Son frecuentes las variaciones anatómicas de la forma y dimensión de dorsum sellae y de los procesos clinoides posteriores. La mayoría de los textos describen su forma como una placa rectangular mediana, una placa cuadrada, o un plano transversal en una pendiente detrás de la sella turcica (fosa hipofisaria). Este trabajo tiene como objetivo estudiar el dorsum sellae en cráneo humano. Para el estudio se utilizaron 125 cráneos humanos adultos secos, de diferentes edades. Se observaron características detalladas de dorsum sellae y se clasificaron en cinco tipos: cresta, al igual que la placa delgada, lámina cuadrilátera, placa cuadrada gruesa, placa alargada gruesa. En tres cráneos se observó fusión de la parte posterior y los procesos clinoides intermedios (unilateral) y los procesos clinoides (anterior, medio y posterior) (unilateral en uno de ellos, bilateral en dos). Los resultados se discuten en consideracion de la literatura.

Scleredema of Buschke associated with difficult-to-control type 2 diabetes mellitus / Escleredema de Buschke associado a diabetes mellitus tipo 2 de difícil controle

SUMMARY Scleredema of Buschke (SB) is a rare disorder of connective tissue characterized by diffuse non-pitting induration of the skin, mainly on the cervical, deltoid and dorsal regions. It is a cutaneous mucinosis of unknown etiology and is associated with bacterial or viral infections, hematological disorders and diabetes mellitus. Histopathological examination shows thickened dermis with wide collagen bundles separated by gaps that correspond to mucopolysaccharide deposits, visualized using special staining. Several treatments are reported in the literature without well-established results. We report a case of SB in a patient with type 2 diabetes mellitus.

RESUMO Escleredema de Buschke (EB) é doença rara do tecido conjuntivo caracterizada por endurecimento difuso e não depressível da pele, principalmente nas regiões cervical, deltoideanas e dorso. Enquadrado no grupo das mucinoses cutâneas, tem etiologia desconhecida e associação com: infecções bacterianas ou virais, alterações hematológicas e diabetes mellitus. O exame histopatológico evidencia derme espessada com fibras colágenas calibrosas separadas por fendas que correspondem a depósito de mucopolissacárides, observados por colorações especiais. Diversos tratamentos são relatados na literatura sem resultados bem definidos. Descrevemos caso de EB em paciente com diabetes mellitus tipo 2.

A Cadaveric Study of Incidence, Morphology, Phylogeny and Classification of Extensor Digitorum Brevis Manus.

Introduction: A rare type of variation of extensor muscles on the dorsum of hand is extensor digitorum brevis manus (EDBM).It is a small muscle rarely present on the dorsum of the hand which can be misinterpreted a pathological mass on the dorsum of the hand. Aim: Aim of the present cadaveric study is to observe the incidence, anatomical morphology of EDBM and to study its phylogenetic significance. Material and Methods: Present study was conducted on 32 adult human cadaveric hands of which 24 were of male and 8 were of female cadavers. Results: The EDBM was observed in one incidence (3.1%) of the specimens. EDBM was found to be between the tendons of extensor digitorum for index and middle fingers. It was of Anatomical variant type I. Conclusion: The knowledge of incidence and morphology of EDBM is of greater relevance in clinical practice to rule out any pathological mass on the dorsum of the hand.

Autoespaciador en rinoplastía por técnica abierta y cerrada / Autospreader in rhinoplasty by open and closed approach

Introducción: La dificultad en el adecuado manejo del dorso nasal radica en su pérdida de soporte, razón por la cual el injerto espaciador (spreader graft) ocupa un lugar destacado en rinoplastía, proveyendo amplitud al techo dorsal, a la vez que incrementa el ángulo de la válvula nasal interna, generando una optimización en los resultados estéticos y funcionales de la cirugía nasal. El autoespaciador mantiene estos mismos principios, utilizando el propio cartílago lateral superior. Objetivo: Describir la técnica del autoespaciador, beneficios y la experiencia de los autores en 80 casos de pacientes sometidos a rinoplastía por abordaje abierto y cerrado. Material y método: Trabajo retrospectivo descriptivo, de los pacientes intervenidos quirúrgicamente por autor principal utilizando la técnica señalada. Resultados: Casuística de 80 pacientes, de los cuales 70% sexo femenino, siendo el promedio de edad 30 años. Abordaje abierto en el 50%. No se reportaron complicaciones intraoperatorias, no existieron obstrucciones anatómicas ni funcionales a nivel de la válvula nasal interna, así como tampoco deformaciones estéticas en "V" invertida tras un seguimiento reportando entre 6 y 24 meses. Conclusión: El autoespaciador al igual que el injerto espaciador clásico, previene problemas funcionales manteniendo el ancho del dorso nasal y optimizando el adecuado funcionamiento de la válvula interna, al tiempo que incrementa el éxito estético de la cirugía, pareciendo a los autores, más simple y fisiológico respecto a su predecesor, el injerto espaciador clásico.

Introduction: The difficulty in the proper handling of the nasal dorsum is its loss of support, hence the spreader graft plays an important role in rhinoplasty, providing width to the dorsal ceiling, while increasing the angle of internal nasal valve, generating an optimization in the aesthetic and functional results of nasal surgery. The autospreader maintains these same principles, using the upper lateral cartilage itself. Aim: To describe the technique of autospreader, benefits and the experience of the authors in a series of patients undergoing open and closed rhinoplasty approach. Material and method: A retrospective descriptive study of patients operated on by primary author using the indicated technique. Results: Casuistry of 80 patients, of whom 70% female, average age being 30 years. Open approach 50%. No intraoperative complications were reported, there were no anatomical or functional obstruction at the level of internal nasal valve, neither aesthetic deformities like inverted "V" after a follow reporting between 6 and 24 months. Conclusions: The autospreader, like the classic spreader graft prevents functional problems maintaining the width of the nasal dorsum and optimizing the proper functioning of the internal valve, while increasing the aesthetic success of surgery, seeming to authors more simple and physiological over its predecessor, the spreader graft.