New proposal for skin grafts on tendon-exposed wounds

Performing a skin graft is not feasible for tendon-exposed defect reconstruction because tendons are fibrous connective tissues with relatively poor blood supply. This study proposes a method to effectively perform skin graft surgery in tendon-exposed wounds. A 48-year-old male patient with diabetes mellitus had a very large left dorsal foot defect (8×8 cm). The wound bed had healthy granular tissue, with tendon exposure. The tendons were turned over so that the posterior side would behave as the anterior side. The edge of the paratenon was then fixed together to the surrounding granulation tissue or dense remnant fascia using absorbable sutures, and the close granulation tissue was approximated and buried. A split-thickness skin graft was performed after 1 week. The graft site was stably taken on postoperative day 3. A small disruption was then observed at the graft site within 1 week postoperatively, but conservative treatment was continued for 1 month, after which the defect site was completely restored. This technique can increase the success rate of skin grafts for defects with tendon exposure.

A Case of Mucinous Cystadenocarcinoma in Labial Mucosa of Upper Lip / 대한두경부종양학회지

Mucinous cystadenocarcinoma (MCA) is a malignant tumor that mainly occurs in the breast or ovary, but MCA is internationally rarely reported in head and neck region. Especially MCA in minor salivary gland of oral cavity is even more rare. It is characterized by cystic spaces lining of epithelial cells containing intracytoplasmic mucin. We report a case of MCA in the labial mucosa of upper lip considered to develop from minor salivary gland with a review of literatures.

A Case of Tumor of Follicular Infundibulum in Parietal Scalp / 대한두경부종양학회지

Tumor of follicular infundibulum (TFI) is a rare benign cutaneous appendage tumor that does not have characteristic clinical features. It is mainly present in the head, neck, and trunk as a solitary lesion. In particular, TFI typically manifests as a plate-like proliferation with multiple thin epidermal connections comprise of monomorphic cells. TFI do not represent cutaneous characteristics, but have clinical significance because TFI is associated with basal cell carcinoma and Cowden's syndrome. We report a case of TFI in parietal scalp with a review of literatures.

A Case of Mucinous Cystadenocarcinoma in Labial Mucosa of Upper Lip / 대한두경부종양학회지

Mucinous cystadenocarcinoma (MCA) is a malignant tumor that mainly occurs in the breast or ovary, but MCA is internationally rarely reported in head and neck region. Especially MCA in minor salivary gland of oral cavity is even more rare. It is characterized by cystic spaces lining of epithelial cells containing intracytoplasmic mucin. We report a case of MCA in the labial mucosa of upper lip considered to develop from minor salivary gland with a review of literatures.

Staged excision of basal cell carcinoma arising from a tattooed eyebrow

Side effects of tattoos can occur due to unexpected body responses. Concerns about the side effects of tattoos are growing concomitantly with the increasing number of tattooed individuals. We report a rare case of basal cell carcinoma (BCC) on a tattooed eyebrow. A 48-year-old woman with no family history or occupational risk of skin cancer had her eyebrows tattooed 6 years prior, and she noticed a black mass on her right eyebrow 1 year before presentation. Staged excision was planned due to the patient’s reluctance regarding the possibility of a wide scar. After the first surgical procedure, a histopathological examination confirmed BCC. Wide excision and primary closure were performed for remnant BCC, and no recurrence was observed. The mechanism of skin neoplasms involving tattoos has not been clearly identified. Unapproved tattoo inks contain carcinogenic substances, and previous case reports indicate that skin neoplasms may differ depending on the tattoo color. Therefore, the carcinogenic effects of these unknown components of tattoo ink might cause skin neoplasms. Accurate component analysis and systematic management of tattoo ink is necessary, and medical practitioners must also pay attention to this possibility because it is easy to overlook tattoos as a causal factor contributing to cancer.

Multiple nonmelanocytic skin cancers in multiple regions

The most common forms of nonmelanocytic skin cancer (NMSC) are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The growing incidence of skin cancer in the Republic of Korea has sparked increasing scientific interest in these types of tumors. In the case described herein, multiple NMSCs occurred asynchronously in various areas of the body in a single patient. A 67-year-old man presented with an ulcerative lesion on the right retro-auricle and multiple keratinized masses on the back and face. The right retro-auricular lesion was diagnosed as BCC, and the keratinized masses on the patient’s back and face were diagnosed as SCC. He subsequently presented with numerous pigmented skin lesions on the forehead, temple, pre-auricle, neck, right forearm, right hand, and both thighs. One lesion on the neck was diagnosed as BCC, and five lesions on the right hand and forearm were diagnosed as SCC. The patient was also diagnosed with supraglottic SCC and external auditory canal SCC. An otolaryngologist performed radical excision of the primary SCC. Suspected skin cancer lesions observed on the face and both ears were diagnosed as SCC. Patients with multiple NMSCs are at an elevated risk for additional skin cancers, making periodic follow-up important; furthermore, all suspicious lesions should be biopsied.

Diabetic Foot and Soft Tissue Necrosis Caused by Moxibustion Burn Injury

A 72-year-old man with diabetes, who underwent moxibustion, developed a foot wound but did not receive proper treatment.Examination showed a soft tissue defect (6×6 cm) on the dorsal aspect of the right foot with involvement of the first and second toes along with some phalangeal bone loss. The wound was treated with a skin graft and healed without complications.The right calf showed a raw surface (4×3 cm), which underwent epithelialization after conservative treatment. We observed four focal necrotic lesions (1.5×1.5 cm) on the right lower leg and anterior chest, which served as indicators of moxibustion, and debridement and primary closure were performed. Moxibustion is increasingly used as a therapeutic option; however, statistical data describing its adverse effects are limited. Moxibustion significantly increases skin temperature and can cause burn injuries. It is important to prevent moxibustion-induced adverse effects and avoid severe complications, particularly in patients with diabetes.

Dichloromethane-Induced Chemical Burn of the Hand: A Report of Two Cases

Myxoma arising from the parotid gland

Myxomas can be divided into two groups: those derived from the facial skeleton, and those derived from external skeletal soft tissue. Soft tissue myxomas of the head and neck are uncommon, with fewer than 50 cases reported. In any form and location, myxoma of parotid gland is rare. We report a case of myxoma arising from the left superficial lobe of the parotid gland with good long-term follow-up after superficial parotidectomy with tumor excision. A 49-year-old man was referred to our department of plastic and reconstructive surgery with a painless palpable mass that had persisted in the left mandible angle region for 2 years. Excision of the facial mass and superficial parotidectomy with facial nerve preservation were performed. The biopsy result was myxoma. Long-term follow-up for 22 months showed favorable results without evidence of recurrence but with temporary facial nerve weakness right after the surgery. Myxoma should be considered as a differential diagnosis when benign tumor of the parotid gland is being considered.

A useful additional medial subbrow approach for the treatment of medial orbital wall fracture with subciliary technique

BACKGROUND: To date, a variety of surgical approaches have been used to reconstruct the medial orbital wall fracture. Still however, there is still a controversy as to their applicability because of postoperative scars, injury of anatomical structures and limited visual fields. The purpose of this study was to introduce a useful additional medial subbrow approach for better reduction and securement more accurate implant pocket of medial orbital wall fracture with the subciliary technique. METHODS: We had performed our technique for a total of 14 patients with medial orbital wall fracture at our medical institution between January 2016 and July 2017. All fractures were operated through subciliary technique combined with the additional medial subbrow approach. They underwent subciliary approach accompanied by medial wall dissection using a Louisville elevator through the slit incision of the medial subbrow procedure. This facilitated visualization of the medial wall fracture site and helped to ensure a more accurate pocket for implant insertion. RESULTS: Postoperative outcomes showed sufficient coverage without displacement. Twelve cases of preoperative diplopia improved to two cases of postoperative diplopia. More than 2 mm enophthalmos was 14 cases preoperatively, improving to 0 case postoperatively. Without damage such as major vessels or extraocular muscles, enophthalmos was corrected and there was no restriction of eyeball motion. CONCLUSION: Our ancillary procedure was useful in dissecting the medial wall, and it was a safe method as to cause no significant complications in our clinical series. Also, there is an only nonvisible postoperative scar. Therefore, it is a recommendable surgical modality for medial orbital wall fracture.

A novel cannula for uniform mixing of liquid substances

Uniform mixing of liquid substances is difficult to attain. Recently, mixtures of fat and platelet-rich plasma (PRP) have been used extensively in autologous fat transfer. Although various methods have been utilized to mix the fat and PRP involved in this procedure, these methods still carry disadvantages in the time taken and the potential for cell damage, and it is questionable whether effective mixing can occur using these techniques. To facilitate mixing that is as uniform as possible, the authors of this study invented a special cannula. Use of the conventional luer-lock-to-luer-lock connector method has been found to cause cell damage and makes it difficult to achieve uniform mixing, while random injection-type mixing has been shown to have limited accuracy and effectiveness. We expect that the newly designed cannula will solve the problem detailed above.

Adverse Hemodynamic Effects of Nefopam in Patients Undergoing Plastic and Aesthetic Surgery: A Single-Center Retrospective Study

BACKGROUND: Nefopam is used to improve postoperative hypothermia in the field of plastic and aesthetic surgery. However, there is a paucity of data about its adverse hemodynamic effects and safety. We therefore assessed its adverse hemodynamic effects in patients undergoing plastic and aesthetic surgery. METHODS: We conducted a single-center retrospective study of 148 patients, in whom we measured hemodynamic parameters using sphygmomanometry (systolic blood pressure [SBP], diastolic blood pressure [DBP], arterial blood pressure [ABP], and heart rate [HR]). Moreover, we also assessed myocardial oxygen demand using the rate pressure product (RPP). RESULTS: The patients included 96 men and 52 women, with a mean age of 34.7±8.5 years. There were no significant differences in SBP, DBP, ABP, HR, or RPP before and after nefopam administration (P>0.05). However, a significant difference was found in the number of the patients with an HR of >100 beats per minute or with an RPP of >12 U before and after nefopam administration (P=0.001). CONCLUSIONS: Surgeons should consider the possibility of tachycardia and increased blood pressure in the management of postoperative hypothermia in patients with cardiac arrhythmia, ischemic heart disease, or essential hypertension. Nonetheless, further prospective, large-scale, multi-center, randomized, controlled studies are warranted to confirm our results.

Usefulness of Microscopic Procedures in Composite Grafts for Fingertip Injuries

PURPOSE: Fingertip amputations are the most common type of upper limb amputations. Composite grafting is a simple and cost-effective technique. Although many factors have investigated the success of composite grafting, the success rate is not high. Therefore, this study was conducted to investigate whether the microscopic procedure process during composite grafts improves the success rate. MATERIALS AND METHODS: Thirteen cases of unreplantable fingertip amputation underwent a microscopic resection procedure for composite graft in the operating room. The principle of the procedure was to remove the least devitalized tissue, maximize the clean tissue preservation and exact trimming of the acral vessel and to remove as many foreign bodies as possible. RESULTS: All fingertips in the thirteen patients survived completely without additional procedures. CONCLUSION: Composite grafting allows for the preservation of length while avoiding the donor site morbidity of locoregional flaps. Most composite grafts are performed as quickly as possible in a gross environment. However, we take noticed the microscopic resection. This process is thought to increase the survival rate for the following reasons. First, the minimal resection will maximize the junction surface area and increase serum imbibition. Second, sophisticated trimming of injured distal vessels will increase the likelihood of inosculation. Third, accurate foreign body removal will reduce the probability of infection and make it possible to increase the concentration and efficiency in a microscopic environment. Although there is a need for more research into the mechanisms, we recommend using a composite graft under the microscopic environment.

A Case of Malignant Peripheral Nerve Sheath Tumor with Neurofibromatosis Type 1

The malignant peripheral nerve sheath tumor (MPNST) originates from neurofibromatosis type 1 (NF1). Because NF1 patients have many accompaniments with growth of additional masses, they usually overlook potential malignant changes in their masses. Our patient had two growing mass near the left elbow for several months; however, she ignored these masses until 7 days prior to writing this article, at which time they began bleeding. Traditionally, sarcoma including MPNST treatment consisted of amputation of the involved extremity. However, treatment now consists of surgical resection with adjuvant therapy. Therefore, we conducted resection of the mass and subsequent coverage with a local advancement flap. We believe that the most effective treatment for MPNST is early diagnosis and fast surgery, coupled with notification that there is always potential for malignant change in NF1 patient's masses.

Factors Associated with a Prolonged Length of Hospital Stay in Patients with Diabetic Foot: A Single-Center Retrospective Study

BACKGROUND: We conducted this study to identify factors that may prolong the length of the hospital stay (LHS) in patients with diabetic foot (DF) in a single-institution setting. METHODS: In this single-center retrospective study, we evaluated a total of 164 patients with DF, and conducted an intergroup comparison of their baseline demographic and clinical characteristics, including sex, age, duration of diabetes, smoking status, body mass index, underlying comorbidities (e.g., hypertension or diabetic nephropathy), wound characteristics, type of surgery, the total medical cost, white blood cell (WBC) count, C-reactive protein (CRP) levels, erythrocyte sedimentation rate, and albumin, protein, glycated hemoglobin, and 7-day mean blood glucose (BG) levels. RESULTS: Pearson correlation analysis showed that an LHS of >5 weeks had a significant positive correlation with the severity of the wound (r=0.647), WBC count (r=0.571), CRP levels (r=0.390), DN (r=0.020), and 7-day mean BG levels (r=0.120) (P 5 weeks had a significant positive correlation with the severity of the wound (odds ratio [OR]=3.297; 95% confidence interval [CI], 1.324–10.483; P=0.020), WBC count (OR=1.423; 95% CI, 0.046–0.356; P=0.000), CRP levels (OR=1.079; 95% CI, 1.015–1.147; P=0.014), albumin levels (OR=0.263; 95% CI, 0.113–3.673; P=0.007), and 7-day mean BG levels (OR=1.018; 95% CI, 1.001–1.035; P=0.020). CONCLUSIONS: Surgeons should consider the factors associated with a prolonged LHS in the early management of patients with DF. Moreover, this should also be accompanied by a multidisciplinary approach to reducing the LHS.

Anisakiasis Involving the Oral Mucosa

Anisakis is a parasite with life cycles involving fish and marine mammals. Human infection, anisakiasis, occurs with the ingestion of raw infected seafood and usually presents with acute or chronic gastrointestinal symptoms from esophageal or gastric invasion. We report a rare caseinvolving the oral cavity. A 39-year-old male presented with oral and sub-sternal pain of one day duration after eating raw cuttlefish. Physical examination revealed areas of erythema and edema with a central white foreign particle on the labial and buccal mucosa. With microscopic field we could remove the foreign material from the lesions. The foreign material was confirmed to be Anisakis. Anisakis was also removed from the esophagus by esophagogastroduodenoscopy. The patient was discharged the following day without complication. Anisakiasis is frequently reported in Korea and Japan, countries where raw seafood ingestion is popular. The symptoms of acute anisakiasis include pain, nausea, and vomiting and usually begin 2–12 hours after ingestion. The differential diagnosis includes food poisoning, acute gastritis, and acute pancreatitis. A history of raw seafood ingestion is important to the diagnosis of anisakiasis. Treatment is complete removal of the Anisakis to relieve acute symptoms and prevent chronic granulomatous inflammation.

Fibroareolar Tissue Wrap-Around Flap for Tip Plasty in Rhinoplasty in Asians

BACKGROUND: Asians tend to have bulbous, wide, and thick-skinned noses, leading to limitations in tip augmentation. Therefore, following various tip plasty procedures, the use of a dermal graft or a fat graft may be considered for additional augmentation. For definition of the Asian nasal tip, thick fibroareolar and subcutaneous tissues are resected. However, these previously discarded tissues may be a useful material for tip augmentation. Hence, we would like to propose the fibroareolar tissue wrap-around flap as an adjuvant augmentation procedure. METHODS: Tip plasty procedures, including various suture techniques and cartilage grafts, were performed. Near the scroll area, the fibroareolar tissues above both lower lateral cartilages were dissected in the supraperichondrial plane. Caudally based fibroareolar tissue flaps were elevated around the nasal tip. The tip portion of the alar cartilage framework was covered with the flaps. The flaps were fixed to the middle or medial crura of the lower lateral cartilages. RESULTS: A total of 13 patients underwent the fibroareolar tissue wrap-around flap procedure for nasal tip plasty. No complaints were reported at follow-up by 12 patients. No cases of major infection, hematoma, or vascular compromise occurred. CONCLUSIONS: The fibroareolar tissue wrap-around flap offers several advantages for tip plasty in Asians, including additional tip projection, soft tissue volume reduction, redraping, and a naturally soft nasal tip, and likely aids in preserving the volume of other cartilage grafts. Therefore, this fibroareolar tissue wrap-around flap is worth considering as a useful adjuvant option for tip plasty in rhinoplasty in Asian patients.

Nipple Reconstruction Using a Scar-Based Modified C-V Flap

BACKGROUND: Numerous techniques have emerged for nipple-areolar complex (NAC) over the years. Scar-based modified C-V flap technique is a new method for creating NAC, surgeons can accomplish nipple reconstruction and scar revision simultaneously. This article described the modified C-V flap technique for nipple reconstruction. This modified method is simple and reliable with good outcome. METHODS: To evaluate the effectiveness of our technique, we reviewed 21 patients who underwent nipple reconstruction using the scar-based modified C-V flap technique. For scar-based modified C-V flap, a C flap was designed to match the contralateral nipple in width while a V flap including scar after mastectomy was designed. The flap pedicle was centrally located. The V flap was then fixed surrounding the central part with a proper shape and volume considering the distal part of the flap that had poor vascularization. RESULTS: The average age of the 21 patients was 48.4 years. The average length of follow up was 7.4 months. Complication rate was 19.0% including projection loss in 2 cases, tip necrosis in 1 case, postoperative infection in 1 case, and wound dehiscence in 1 case. Re-operations were performed for 2 cases of projection loss, 1 case of partial flap necrosis, and 1 case of wound dehiscence. CONCLUSIONS: The scar-based modified C-V flap technique is a simple and reliable method for nipple reconstruction with aesthetic outcome. Patients who have undergone this surgical technique tend to have great satisfaction with the results.

The Efficacy of Bioabsorbable Mesh in Craniofacial Trauma Surgery

BACKGROUND: The ultimate goal of craniofacial reconstructive surgery is to achieve the most complete restoration of facial functions. A bioabsorbable fixation system which does not need secondary operation for implant removal has been developed in the last decade. The purpose of this study is to share the experience of authors and to demonstrate the efficacy of bioabsorbable mesh in a variety of craniofacial trauma operations. METHODS: Between October 2008 and February 2015, bioabsorbable meshes were used to reconstruct various types of craniofacial bone fractures in 611 patients. Any displaced bone fragments were detached from the fracture site and fixed to the mesh. The resulting bone-mesh complex was designed and molded into an appropriate shape by the immersion in warm saline. The mesh was molded once again under simultaneous warm saline irrigation and suction. RESULTS: In all patients, contour deformities were restored completely, and bone segments were fixed properly. The authors found that the bioabsorbable mesh provided rigid fixation without any evidence of integrity loss on postoperative computed tomography scans. CONCLUSION: Because bioabsorbable meshes are more flexible than bioabsorbable plates, they can be molded and could easily reconstruct the facial bone in three dimensions. Additionally, it is easy to attach bone fragments to the mesh. Bioabsorbable mesh and screws is effective and can be easily applied for fixation in various craniofacial trauma reconstructive scenarios.

Characteristics of Inpatients with Distal Phalangeal Injuries: Predictors of Long Term Hospitalization

PURPOSE: Distal phalangeal injury is one of the most common hand injuries. Distal phalanx is very small area, but in the patients who injure in this area, hospiltalization is often necessary. Some of the patients need the long hospital stay for three or more weeks. Assessment of trends of the injuries may help in enhancing patient education and designing the management plan. We analyzed the characteristics of inpatients with distal phalangeal injuries and the predictors of long-term hospitalization. METHODS: A retrospective review of inpatients with distal phalangeal injuries was performed consecutively from June 2008 to July 2015. Patient demographics and outcomes were compared with chi-squared analysis and Student's t-test. Using multivariate regression analysis, predictors of long-term hospitalization were identified. RESULTS: Five hundred and twelve patients were investigated. The rate of long-term hospitalization was 21.9%. Multivariate logistic regression model revealed that diabetes mellitus, operation time of three or more hours, amputation injury, injury sustained at an industrial place, complication, distant flaps, and replantation were significant risk factors of long-term hospitalization. CONCLUSION: This analysis will help evaluate the possibility of long-term hospitalization and manage patients with distal phalangeal injuries.