Two Cases of Reversible Neutropenia Associated with Olanzapine-Valproate Combination Treatment / 신경정신의학

The novel antipsychotic, olanzapine, has structural and pharmacological properties similar to clozaine. Antipsychotic drugs, as well as mood stabilizers, can cause neutropenia, which can progress to life-threatening agranulocytosis if the medication is not discontinued. We report two cases of reversible neutropenia associated with a olanzapine-valproate combination treatment. This report suggests that patients treated with the combination of olanzapine and valproate should be monitored for the occurrence of leukopenia and neutropenia.

A Case Report: Surgical Treatment of Pachydermodactyly

Pachydermodactyly is a rare distinct form of fibromatosis characterized by acquired, asymptomatic dense fibrosis and fibroblastic proliferation around one or more proximal interphalangeal joints. Intralesional triamcinolone injection may be helpful in improving the clinical appearance. A 20-year-old unemployed female patient gave a four years history of progressive swelling of the fingers affecting predominantly the proximal interphalangeal joints of index fingers of left hand and index, middle fingers of right hand. There was no pain and tenderness. Physical examination, complete blood count, antinuclear antibody, rheumatoid factor were unremarkable and radiograph of both hands showed soft tissue swelling only without bony abnormality. We excised the redundant soft tissue from the both sides of proximal interphalangeal joint with longitudinal elliptical fashion. After operation, the fingers of the patient showed marked improvement cosmetically. There were no motor or sensory changes. Pachydermodactyly was first reported in 1996 in Korea. Histologic features include an increased dermal accumulation of collagen and occasionally an increased number of fibroblast. We report for one patient with pachydermodactyly treated with longitudinal elliptical excision and obtained an improvement of clinical appearance.

Effects of Maternal Hyperthermia on the Palatal Mesenchyme Development of Hsp70 Knock-out Mice Fetuses / 체질인류학회지

To investigate the effects of maternal hyperthermia on the development of the palate, pregnant Hsp70 knock-out mice at gestational day (GD) 8.5 were immersed in 43degrees C water bath until their body core temperature reached at 43degrees C. Thereafter, pregnant mice were given more 5 minutes hyperthermic exposure. Heat-untreated Hsp70 WT mice fetuses were used as the control group. Fetuses were collected at embryonic day 13.5, 14.5 and 15.5 (E13.5, E14, 5 and E15.5). Heads followed by removal of the mandible and the tongue were obtained and photographed for palatal development. Developing palates were processed for histological and immunohistochemical studies. Tissue sections were immunostained for TGF-beta2, FGF-8 and fibronectin, and observed with light microscope. The obtained results were as follows: Cleft palate was formed in heat-treated Hsp70 KO fetuses at E14.5 and E15.5. Immunohistochemical findings indicated that TGF-beta2 expression of the experimental fetuses were more delayed than that of the control fetuses. Mesenchyme under the medial edge epithelium (MEE) and cells of MEE showed continuously strong positive TGF-beta2 reactivity at E15.5. FGF-8 was revealed in both of the mesenchyme and the epithelium at the same time. FGF-8 immunoreactivity in the mesenchyme and the epithelium of the heat-treated fetuses showed strong reactivity at E15.5. In the experimental fetuses fibronectin was revealed the mesenchyma and basal lamina at E15.5. Taken together, it is suggested that maternal hyperthermia induces continuous expression of TGF-beta2 and FGF-8 in the mesenchyme and delayed expression of fibronectin. These should affect the normal palatogenesis and result in cleft palate.

Application of ThermalCAMTM P40-Infrared Thermographic Imaging in the Monitoring of Survival of Lower Abdominal Random Flap in the Rabbit

The monitoring of viability of the flap is important in improvement of the flap survival. The flap survival depends on the vascularity of the flap, and the skin temperature is up to the vascularity. The authors applied ThermalCAMTM P40 infrared thermographic imaging system for the monitoring of the vascular supply of the flap. The various sized flaps are designed on the lower abdomen of rabbit, having expected risk rate of flap necrosis respectively. The surface temperatures on designed flap were checked with ThermalCAMTM P40 before flap elevation and after respectively. The flaps with high risk of necrosis, 1:4(width/length) designed flaps and some 1:3 flaps, showed remarkable color change in distal portion according to difference of surface temperatures. After 1 week, the flaps of lower abdomen showed different viability of flap, and the flap with remarkable color change showed partial necrosis distally. The Necrotic areas were identical with the color change area checked with ThermalCAMTM P40. This study shows that ThermalCAMTM P40 infrared thermographic imaging system has the utility in prediction on flap survival through detection of the vascularity with ease, quickness and safety for patient and flap.

Intraoral Reconstruction with Buccinator Myomucosal Flap

Since the buccinator myomucosal flap was first described, it has been modified, with the study of anatomical model. Therefore, buccinator myomucosal flap can be elevated in various direction according to defect with its sufficient arc of rotation. With the buccinator myomucosal flap, intraoral reconstruction was performed in 3 patients. Two adult patients were suffered from complete cleft palete. Partial tongue reconstruction was performed in another patient following partial glossectomy due to tongue cancer. Satisfied results were obtained in all three patients. In these cases, the author designed flaps in island patterns. It would be more helpful to close donor site primarily and obtaining free rotation arc. The pedicle was located in retromolar trigone, flap detachment was not needed. Considering the disadvantages of other reconstruction methods, such as contracture, hair growth and poor oral hygiene caused by skin graft or conventional free flap, the buccinator myomucosal flap would be another good option for intraoral reconstruction with "like tissue".

Treatment of Brachycephaly: Traditional Cranioplasty vs. Distraction Osteogenesis

Craniosynostosis refers to the premature fusion of single or multiple sutures of the cranial base or vault. It causes restriction of cranium and brain growth and variable morphologic deformity. Inadequate intracranial volume for rapid brain growth brings about increased intracranial pressure and functional impairment. To solve this problem, the key is the surgical decompression and insurance of adequate intracranial volume. Traditional surgical approach is frontal advancement with cranial vault remodeling, but has drawbacks such as invasiveness, long operation time, large amount of hemorrhage, difficult postoperative care, and frequent complications. Recently, distraction osteogenesis is used for the treatment of craniosynostosis. So, we compared cranial distraction osteogenesis with traditional cranioplasty about merits and drawbacks and present the effectiveness of cranial distraction osteogenesis. In a comparative study of cranioplasty and distraction osteogenesis, clinical documents and pre/ postoperative X-ray and CT scans of 12 brachycephaly patients were reviewed. From April, 1994 to October, 2001, 8 patients were treated with traditional cranioplasty and 4 patients were treated with distraction osteogenesis. We achieved not only an increase in intracranial volume but also merits such as a reduction in operation time and bleeding, easy postoperative care and low complication rate with distraction osteogenesis.

Correction of Syndactyly with Modified M Flap and Minimal Skin Graft

The principles of syndactyly correction are well established at the present time, such as the creation of dorsal and/or palmar rectangular flaps designed to reconstruct the web space, the utilization of zigzag incisions along the full length of the syndactyly to avoid contraction that might follow a straight line closure, and skin grafts to cover raw surfaces. Although numerous operative techniques based on the above principles have been introduced, most of them required skin graft inevitably because the separated fingers have a greater surface area than the syndactylized digits. The grafted hyperpigmented skin makes the finger and toe noticeable and the multiple small pieces of skin graft themselves are time-consuming procedure, and the grafted skin near the base of fingers could cause future recurrence or contracture. So we tried to develop a modified technique which could minimize the case of skin grafts by using regional skin as much as possible. A new method that we present here is a combination of first, a diverging M flap from syndactilized digital skin for commissure, second, an island flap from ventral or dorsal surface of the hand and foot to cover the raw surface at the base of divided digit, and third, the removal of fat tissue around the neurovascular bundles of the fingers for primary closure with flaps without tension at least in one digit. 11 patients composed of 5 hands and 16 feet syndactylies were operated for their correction with newly modified technique for 4 years. A long term follow-up indicates that gratifying functional and aesthetic results could be achieved without recurrences or disabling contractures of the interdigital space. This easy and rapid technique can be recommended for the correction of syndactyly because of its advantage of minimizing the problems appeared in cases by previous methods.

Foot Salvage using Free Flap in the Extensive Soft Tissue Defects

Sensation, durability, and aesthetic contour should be considered in reconstructive surgery of the foot. Extensive soft tissue defects in the foot can be successfully reconstructed by proper flap selection. Fifty-one patients underwent 54 cases of free flap reconstruction for extensive soft tissue defects of the foot from March, 1986 to August, 2002. The causes of soft tissue defects in the foot included trauma, burn injury, peripheral vascular disease, and tumor. The used free flaps were lateral arm, radial forearm, scapular, latissimus dorsi, rectus abdominis, and other free flaps. Secondary free flap operations were performed in 3 patients due to flap necrosis by vascular thrombosis. Free flaps were selected with consideration of anatomic, functional, and aesthetic aspects. Thick, durable, and innervated flaps were selected for weight bearing regions, thick flaps for non-weight bearing regions, and thin fasciocutaneous or cutaneous flaps for the dorsum of foot. If the transferred muscle flap was too bulky to allow the patient to wear the shoes, a debulking procedure was performed for functional and aesthetic demands. The end-to-side vascular anastomosis was performed to preserve blood supply to the distal part of the foot. Free flap surgery could obviously provide one stage reconstruction even in the case of complex foot defect including those with bone and tendon damage. We selected the free flaps according to the recipient's specific requirements, and then it provided ambulation, durable foot preservation, and a better quality of life in patients undergoing the reconstruction of extensive soft tissue defects of the foot.

Nasal Reconstruction for Nasal Deformity or Defects: Based on Aesthetical Nasal Subunits

The nose, salient part in the face, is more vulnerable to injury and its minor defect or deformity is highly perceptible. It is thus essential to establish the certain rules for reconstruction. Gonzalles Ulloa mentioned 5 aesthetic nasal subunits, which are nasal dorsum, nasal tip, lateral portion, alar portion and soft triangle. However, the authors insist on the importance of the columella and nasal floor as well as other nasal subunits, considering the nasal reconstruction in structural and functional aspects. Authors' study was based on the aesthetical nasal subunits considering the in-depth knowledge of anatomical and functional aspects of each unit as an individual. Reconstruction of the proximal 2/3 portion of the nose having thin, soft and mobile skin over the osteochondral framework with sparse distribution of the sebaceous glands can be done with skin graft, nasolabial flap, and median forehead flap and lateral wall defect can be repaired by nasolabial flap or glabellar flap. Reconstruction of the distal 1/3 portion of the nose is rather difficult due to its thick, sebaceous skin that is characterized by firm and dense cartilaginous attachment, which makes it more harder to handle especially when it comes to the alar portion. Therefore, composite graft for the small defect and nasolabial flap or median forehead flap for on the larger defect can be used. However, when defect is located on the nasal tip, it results in tremendous spoiling of the whole facial harmony even with a tiny defect so that replantation, composite graft or median forehead flap has been used for the reconstruction. Reconstruction of the columellar defect is considered more complicated and V - Y advancement flap, bilateral nasolabial flap, and composite graft have been utilized.Nasal deformity or defect was reconstructed based on 7 aesthetical nasal subunits; by further dividing the nasal units, in terms of adding 2 more subunits, columella and nasal base, aesthetically and functionally acceptable and advantageous results were deduced with less contractures and scars. Current trends of nasal reconstruction are based on the concepts of aesthetic nasal subnunits or units in which modification was added in some extent. The most important factors that contribute to the later results are evaluation of the depth and color of the deformed or defected area according to the aesthetic nasal subunits whether it is congenital or acquired. Various reconstruction methods of the nose can be utilized based on the size, depth and location of the defects where it can be reconstructed as a unit. Columella and nasal base were newly added in concepts of subdivision from the previously established nasal subunits to produce more detailed, precise and favorable result. Also, nasal reconstruction should be carefully carried out considering the importance of the psychological, social and functional influences of the nasal deformity.

A Clinical Analysis and Appropriate Management of Pediatric Facial Bone Fractures: 6 Years Survey

As significant increase in the pediatric accidents becomes socially and morally concerned, reviewing over the statistical analysis of the pediatric accidents was needed especially in their facial bone traumas, in order to deduce a preventive and so to speak, protocols of treatments. This retrospective study comprise 73 pediatric patients who sustained facial bone fractures through various accidents and treated in the department of Plastic and Reconstructive Surgery, Seoul Hospital, Hanyang Medical Center during past 6 years from January 1993 to December 1998. The medical records of these 73 patients (91 fractures) were reviewed and analyzed retrospectively in order to obtain the clinical pattern and understand the therapeutic modalities. The statistical items were the prevalent time, age, sex and cause distribution, fracture sites, accompanying injuries, intervals among accident, arrival and operation, treatment methods with fixation materials, and complications were reviewed as following results. An increment of 5.1% per year of pediatric facial bone fractures was noted where 5.4% reduction of the population during the same periods. The mean age of patients was 10.5 years and the range of age was 3 to 15 years with males predominating over females in 3.1:1 ratio as in 3.5:1 in adults. Traffic accidents(43.9%) were responsible for the majority of facial bone fractures followed by violence(26.4%), fall(18.7%) and 91 facial fractures in 73 patients were classified where most common sites were nasal bone (56.1%) followed by blow-out fracture excluding other orbital fractures(17.6%), mandible(15.4%), zygoma(5.5%), orbital rim(2.2%), maxilla (2.2%) and frontal sinus(1.1%). Associated soft tissue injuries were combined in 52 patients(71.2%) and fractures other than facial bone were developed in 12 patients (16.4%) and treatment for facial bone fracture consisted of open reduction(40.6%), closed reduction(54.9%) and conservative treatment(5.5%). The complication rate was 9.4% and the most common complication was local infection followed by ophthalmologic problems and facial asymmetry. All data were analyzed based on the charts, medical records, and X-ray findings and presentation of the goals and optimal course of the entire management was made.