Clinical characteristics of and therapeutic approach to complications due to the injection of foreign material in the face: a retrospective study

Background@#Soft tissue fillers are increasingly used to rejuvenate and beautify the body and face. Unknown foreign materials that have not always been proven to be safe for human use have been used for injections in the past. Various commercial injectable materials have since been developed and are used; however, the number of complications has increased as soft tissue fillers have increased in use. @*Methods@#A retrospective study of 39 patients with facial foreign body complications who underwent surgical treatment between March 2012 and February 2021 was conducted. Patient information was analyzed, and patient satisfaction was evaluated using a questionnaire after surgical treatment. A comparative statistical analysis was undertaken. @*Results@#Patients who underwent procedures performed by unlicensed practitioners tended to be older at the time of presenting to the hospital (P=0.004). The degree of satisfaction after surgical repair was significantly lower following the direct approach than after the indirect approach using a bypass incision (P=0.044). The degree of satisfaction significantly decreased (P=0.001) as the number of operations the patient received increased. @*Conclusions@#When treating complications caused by foreign material injections, surgical removal is a more reliable method than treatment with medication or further injections; however, treatment decisions should be made thoughtfully, and many factors must be considered. Patient satisfaction can be improved by reducing the number of operations and making the appropriate corresponding incisions or excisions to treat the full range of symptoms caused by foreign substances and by indirectly using bypass incisions to mitigate post-surgery scars.

Long-term postoperative satisfaction and complications in nasal bone fracture patients according to fracture type, site, and severity

Background@#It is difficult to completely fix nasal bone fractures with closed reduction, as it is often accompanied by septal cartilage damage, and this often results in postoperative secondary deformities. Thus, patients are often reluctant to undergo closed reduction surgery. The present study aimed to evaluate aesthetic and functional satisfaction, as well as satisfaction with and complications of closed reduction, according to nasal bone fracture type. @*Methods@#The subjects were patients who underwent closed reduction under general anesthesia from January 2017 to December 2018. Based on the modified Murray classification, patients were classified into five groups according to the fracture site, septal fracture, and deviation. A total of 211 patients were sent a web-based survey on postoperative satisfaction and complications, as well as intention for revision and cosmetic surgery. Sixty-one patients (28.9%) responded. @*Results@#There were no significant differences in aesthetic and functional satisfaction or satisfaction with closed reduction according to the fracture type, site, or severity. Postoperative functional complications developed in 14 of 61 patients (22.95%). With 10 out of 24 (41.67%) patients (p = 0.044), the bilateral fracture with septal fracture or prominent septal deviation type had a higher incidence of complications than the other types. @*Conclusion@#The incidence of complications is higher for bilateral fracture with septal fracture or prominent septal deviation compared to the other nasal bone fracture types. Therefore, long-term follow-up after closed reduction surgery for this fracture type can aid in establishing additional postoperative treatment plans and improving patient satisfaction.

The efficacy of dermofat grafts from the groin forcorrection of acquired facial deformities

Background@#Posttraumatic acquired facial deformities require surgical treatment, with optionsincluding scar revision, fat grafts, implant insertion, and flap coverage. However, each techniquehas specific advantages and disadvantages. @*Methods@#From 2016 to 2018, 13 patients (eight with scar contracture and five with a depressedscar) were treated using dermofat grafts from the groin. The harvested dermofat was then insertedinto the undermined dead space after the contracture was released, and a bolster suture wasdone for fixation considering the patient’s contour and asymmetry. A modified version of the VancouverScar Scale and satisfaction survey were used to compare deformity improvements beforeand after surgery. @*Results@#In most cases, effective volume correction and an aesthetically satisfactory contourwere maintained well after dermofat grafting, without any major complications. In some cases,however, lipolysis proceeded rapidly when inflammation and infection were not completely eliminated.A significant difference was found in the modified Vancouver Scar Scale before and aftersurgery, with a p-value of 0.001. The average score on the satisfaction survey was 17.07 out of 20points. @*Conclusion@#A dermofat graft with the groin as the donor site can be considered as an effectivesurgical option that is the simplest and most cost-effective method for the treatment of acquiredfacial deformities with scar contracture.

Clinical usefulness of fixation of absorbable implants with cyanoacrylate in comminuted fractures of the maxilla

BACKGROUND: The open reduction of craniofacial bone fractures requires internal fixation using metal plates and screws, which have been considered the gold standard. However, metal implants pose a risk of palpation, protrusion, and foreign body reaction, and they may require an additional operation for removal. Recently, good results have been reported for absorbable implants which complement the disadvantages of metal implants. This study presents the results of using absorbable mesh, plates, and screws with cyanoacrylate for more accurate and firmer fixation of comminuted fractures of the maxilla. METHODS: In total, 235 patients underwent operations for comminuted fractures of the maxilla. From January 2012 to December 2014, absorbable mesh and screws were used in 114 patients, while from January 2015 to December 2017, absorbable mesh, plates, and screws with cyanoacrylate were used in 121 patients. Open reduction of the bone fragments was performed, after which absorbable implants were accurately molded and fixed by screws. RESULTS: All patients underwent postoperative computed tomography scans, which showed highly accurate reduction and firm fixation in the patients who underwent procedures using absorbable implants, screws, and cyanoacrylate. There were no postoperative complications or cases of abnormal facial contour. CONCLUSION: When absorbable implants and screws are used for maxillary fractures, no additional surgery to remove the metal plate is required. In addition, the use of cyanoacrylate enables accurate and firm fixation of the tiny bone fragments that cannot be fixed with screws.

The efficacy of mobile application use on recall of surgical risks in nasal bone fracture reduction surgery

BACKGROUND: The number of surgical risks recalled by a patient after surgery can be used as a parameter for assessing how well the patient has understood the informed consent process. No study has investigated the usefulness of a self-developed mobile application in the traditional informed consent process in patients with a nasal bone fracture. This study aimed to investigate whether delivery of information, such as surgical risks, through a mobile application is more effective than delivery of information through only verbal means and a paper. METHODS: This prospective, randomized study included 60 patients with a nasal bone fracture. The experimental group (n=30) received preoperative explanation with the traditional informed consent process in addition to a mobile application, while the control group (n=30) received preoperative explanation with only the traditional informed consent process. Four weeks after surgery, the number of recalled surgical risks was compared for analysis. The following six surgical risks were explained: pain, bleeding, nasal deformity, numbness, nasal obstruction, and nasal cartilage necrosis. RESULTS: The mean number of recalled surgical risks among all patients was 1.58±0.56. The most frequently recalled surgical risk was nasal deformity in both groups. The mean number of recalled surgical risks was 1.72±0.52 in the experimental group and 1.49±0.57 in the control group. There was a significant association between mobile application use and the mean number of recalled surgical risks (p=0.047). Age, sex, and the level of education were not significantly associated with the mean number of recalled surgical risks. CONCLUSION: This study found that a mobile application could contribute to the efficient delivery of information during the informed consent process. With further improvement, it could be used in other plastic surgeries and other surgeries, and such an application can potentially be used for explaining risks as well as delivering other types of information.

Evaluation of Triamcinolone Injection and Subcision as a First-Line Non-Surgical Treatment of Post-Traumatic Acute Trap-Door Deformity

BACKGROUND: Trap-door deformity is a biophysical phenomenon in which U-, C-, or V-shaped linear scars tend to become depressed and the tissue circumscribed by them tends to bulge. The aim of the present study was to demonstrate the efficacy of triamcinolone acetonide (TCA) injection and subcision as a first-line treatment for post-traumatic acute trap-door deformity. METHODS: In trap-door deformity patients, a subcision was made by cutting the fibrotic band along the scar line in the depression using a 22-gauge needle. TCA was administered. An intralesional injection was made along areas of scarring that were difficult to penetrate with the needle. Scar quality parameters were assessed at each follow-up by a single observer and the patient, using the patient and observer scar assessment scale (POSAS) with an additional question about bulging. RESULTS: The average POSAS score per question on the observer scale improved from 6.6±1.31 to 3.6±1.08, and the average POSAS score per question on the patient scale improved from 5.5±1.57 to 2.5±1.26. The average bulging score on the observer scale decreased from 6.0±0.98 to 3.0±0.83, and that on the patient scale decreased from 5.0±1.67 to 2.0±1.30. The average general opinion score on the observer scale decreased from 5.5±1.12 to 3.5±0.91, and that on the patient scale decreased from 6.0±1.84 to 2.0±0.79. CONCLUSIONS: Better outcomes can be obtained by using both TCA and subcision as the first-line therapy for post-traumatic acute trap-door deformity.

Usefulness of the Versajet Hydrosurgery System for the Removal of Foreign Body Granuloma

No abstract available.

Late-Onset Methicillin-Resistant Staphylococcus aureus Infection after Facial Poly-L-Lactic Acid Injection

No abstract available.

Use of Triamcinolone Acetonide to Treat Lower Eyelid Malposition after the Subciliary Approach

BACKGROUND: The subciliary approach is commonly used for reconstruction of orbital wall or zygomaticomaxillary fractures. However, this approach is associated with postoperative complications, especially lower eyelid malposition. We report the experience of managing postoperative lower eyelid malposition with triamcinolone acetonide. METHODS: A retrospective review was performed for all traumatic facial fractures requiring surgery via the subciliary approach at Chosun University Hospital in 2014. For each patient meeting inclusion criteria, the medical chart was reviewed for demographic information and postoperative course, including the presence of postoperative eyelid malposition or scleral show. RESULTS: The review identified 189 cases in which the subciliary approach was used, and postoperative lower eyelid malposition was found in 7 cases (3.7%). For these 7 patients, the mean therapeutic period (interval to correction of the malposition) was 10.5 weeks (range, 8 to 14 weeks). On average, patients received 3 injections of triamcinolone. In all cases, degrees of the malposition were improved, and none of the patients required an operative intervention to correct the malposition. CONCLUSION: Triamcinolone injection is an appropriate treatment modality for lower eyelid malposition after subciliary approach. Treatment duration is relatively short, requiring fewer than 4 outpatient clinic visits, with relatively earlier recovery compared to conservative "wait-and-see" management.

Clinical Efficacy of Gluteal Artery Perforator Flaps for Various Lumbosacral Defects

PURPOSE: Soft tissue defects in the lumbosacral area can be challenging to treat, and various methods to accomplish this have been proposed, including the use of perforator flaps. Herein, we present our experience with superior gluteal artery perforator (SGAP) and inferior gluteal artery perforator (IGAP) flaps for the reconstruction of lumbosacral defects. MATERIALS AND METHODS: From March 2013 to July 2016, 28 cases (27 patients) of lumbosacral defects were treated by reconstruction with SGAP or IGAP flaps. The defects were caused by pressure sores (21 cases), burns (3 cases), tumor resection (2 cases), scars (1 case), or foreign body infection (1 case). Reliable perforators around the defect were found using Doppler ultrasound. The perforator flaps were elevated with a pulsatile perforator and rotated to cover the defects. RESULTS: Twenty-three SGAP and 5 IGAP flap reconstructions were performed. The mean flap size was 9.2×6.1 cm² (range, 5×3 cm² to 16×10 cm²). Donor sites were closed by primary closure. Partial flap necrosis occurred in two cases, and minor complications of wound dehiscence occurred in 3 cases, which were healed by primary closure. The mean follow-up period was 4.4 months (range, 1~24 months). CONCLUSION: Gluteal-based perforator flaps can be safely harvested due to pliability and reliable vascularity in the gluteal area, reducing donor site morbidity without sacrificing the underlying muscles. Thus, these flaps are useful options for the reconstruction of lumbosacral defects.

A Patient with Multiple Unfavorable Reconstruction Options: What Is the Best Choice?

The method of lower limb reconstruction surgery is selected based on a patient's underlying conditions, general conditions, and wound status, and it usually varies from direct closure to skin graft and flap coverage. Herein, we describe a patient with Duchenne muscular dystrophy who developed critical limb ischemia after femoral cannulation for extracorporeal membrane oxygenation was used during knee disarticulation, which was followed by reconstruction of the defect around the knee using a pedicled anterolateral thigh flap and skin graft.

Transient Exotropia after Open Reduction of a Naso-Ethmoidal-Orbital Fracture

No abstract available.

Direct Open Venous Drainage: An Alternative Choice for Flap Congestion Salvage

In this report, we present a scalp defect reconstruction with lateral arm free flap. We highlight the difficulty in obtaining a recipient vein and the venous drainage managed through an open end of the donor vein. A 52-year-old woman presented with a pressure sore on the left scalp. A lateral arm free flap was transferred to cover this 8x6 cm defect. The arterial anastomosis was successful, but no recipient vein could be identified within the wound bed. Instead, we used a donor venous end for the direct open venous drainage. In order to keep this exposed venous end patent, we applied heparin-soaked gauze dressing to the wound. Also, the vein end was mechanically dilated and irrigated with heparin solution at two hour intervals. Along with fluid management and blood transfusion, this management was continued for the five days after the operation. The flap survived well without any complication. Through this case, we were able to demonstrate that venous congestion can be avoided by drainage of the venous blood through an open vessel without the use of leeches.

Complex Correction of Complete Cleft Lip with Severe Prominent Premaxilla using Lip Adhesion and Nasoalveolar Molding Device

Nasoalveolar molding (NAM) device is an effective treatment for protruding maxilla in infants with cleft palate. However, only a few studies have investigated the effect of NAM devices on the treatment of protruding maxilla in infants with cleft lip only. We have designed a combination treatment using NAM devices prior to cheiloplasy for cleft lip-only patients with severe anterior protrusion of the premaxilla. Three cleft lip-only infants with 1-cm or more of premaxilla protrusion were included. Definitive cheiloplasty was performed at 6 months of age without any preoperative correction in infant 1. Cheiloplasty was performed in conjunction with the use of NAM device and lip adhesion in infants 2 and 3. Postoperative columella length and anterior-posterior dimension of the protruding premaxilla were compared amongst the infants. We were able to obtain satisfactory postoperative columella length and general nasal appearance.

Using the Dorsal Metacarpal Artery Perforator Flap for Reconstruction of Rheumatoid Ulcers

Rheumatoid arthritis is a long lasting autoimmune disorder that primarily affects joints, and patients with rheumatoid arthritis are predisposed to development of chronic skin ulcers. In addition, skin ulcers with rheumatoid arthritis tend to persist despite treatment because of sustained inflammation and poor healing capacity. Treatment of skin ulcers involves medications, wound coating agents, and surgical procedures including skin grafting, however, wound dressing or skin grafts are generally excluded because of excessive cost and time and poor intake rate. The dorsal metacarpal artery perforator (DMAP) flap, a vascular island flap for coverage of soft tissue defects on the fingers, provides promising results including matched quality and color. We experienced a case of DMAP flap for reconstruction of a rheumatoid ulcer, and a DMAP flap may be considered as a good faithful option for treatment of patients with rheumatoid ulcer.

A Case Report of Bilateral Retrobulbar Hemorrhage after Lower Blepharoplasty

Retrobulbar hemorrhage is a rare but serious complication after blepharoplasty, mid-face injury, and treatment of facial bone fractures. The incidence of postoperative retrobulbar hemorrhage is 0.055% with an incidence of associated permanent blindness of 0.005%. A 69-year-old male came to the emergency room with pain on both orbital areas and uncontrolled bleeding after cosmetic lower blepharoplasty performed at a private clinic. He had not been evaluated preoperatively by the private clinic, but we found that he had undergone percutaneous transluminal coronary angioplasty and taken anticoagulants for 10 years. We performed an emergency operation to evacuate the hematoma. However, after surgery, he persistently complained of orbital pain, pressure and diminished visual acuity. Intraocular pressure was increased, and computed tomography demonstrated a retrobulbar hemorrhage with globe displacement. Emergent lateral canthotomy and cantholysis were performed. Intraocular pressure was decreased to 48/30 mm Hg immediately after the operation, falling within the normal range the next day. We recommend three points to minimize loss of vision by retrobulbar hematoma. Firstly, careful preoperative evaluation must be conducted including current medications, underlying diseases and previous history of surgeries. Secondly, cautious postoperative observation is important for the early diagnosis of retrobulbar hematoma. Lastly, immediate treatment is crucial to prevent permanent blindness.

The Development of a Critical Pathway for Facial Bone Fractures and the Effect of its Clinical Implementation

BACKGROUND: If patients have a better understanding about their problem and treatment, compliance and satisfaction with treatment will increase. For this purpose, simple repeated explanations regarding a patients' problem and treatment are essential. Critical pathway (CP) has a very wide range in medicine with the exception of the plastic surgery field. The authors developed a CP for facial bone fractures and implemented it clinically. The aim of this study was to evaluate the effectiveness of the CP on the degree of recognition of the problem along with patient satisfaction with the treatment process. METHODS: From May 2011 to October 2011, a total of 82 patients suffering from facial bone fractures were studied. The CP for facial bone fractures was developed by plastic surgeons, residents and nurses. Subsequently, the authors investigated the degree of recognition of the disease and patient satisfaction with the treatment through the use of a questionnaire. The authors compared the score of the questionnaires before and after implementation of the clinical pathway. RESULTS: The degree of the recognition of the problem changed from 3.1 to 4.2 (p<0.001). Further, the degree of satisfaction with the treatment process changed from 3.6 to 4.3 (p<0.05). Overall, there was a two point increase in improvement. CONCLUSION: Implementation of the CP for facial bone fractures was effective in improving the degree of recognition and satisfaction. The authors expect that hereafter, the CP for facial bone fractures will be implemented actively in the plastic surgery field.

Retrobulbar Hematoma in Blow-Out Fracture after Open Reduction

Retrobulbar hemorrhage, especially when associated with visual loss, is a rare but significant complication after facial bone reconstruction. In this article, two cases of retrobulbar hematoma after surgical repair of blow-out fracture are reported. In one patient, permanent loss of vision was involved, but with the other patient, we were able to prevent this by performing immediate decompression after definite diagnosis. We present our clinical experience with regard to the treatment process and method for prevention of retrobulbar hematoma using a scalp vein set tube and a negative pressure drainage system.

Clinical Follow-up on Sagittal Fracture at the Temporal Root of the Zygomatic Arch: Does It Need Open Reduction?

BACKGROUND: The zygoma is a major portion of the midfacial contour. When deformity occurs in this area, a reduction should be conducted to correct it. If a sagittal fracture at the temporal root of the zygomatic arch occurs, this also requires reduction, but it is difficult to approach due to its anatomical location, and the possibility of fixation is also limited. Thus, the authors attempted the reduction of sagittal fracture by two- or three-point fixation and the Gillies approach without direct manipulation. The preoperative and postoperative results of the patients were evaluated. Follow-up was performed to establish a treatment guideline. METHODS: A retrospective study was done with 40 patients who had sagittal fractures at the temporal root of the zygomatic arch from March 2009 to June 2012. Only two- or three-point fixation was performed for the accompanying zygomatic-orbital-maxillary fracture. The Gillies approach was used for complex fractures of the zygomatic arch, while the temporal root of the zygomatic arch was only observed without reduction. Preoperative and postoperative computed tomography and X-ray scans were performed to examine the results. RESULTS: The result of the paired t-test on preoperative and postoperative bone gap differences, the depression level, and the degree of temporal protrusion showed a marked decrease in the mean difference at a 95% confidence interval. The results were acceptable. CONCLUSIONS: In the treatment of sagittal fractures at the temporal root of the zygomatic arch, it is acceptable to use indirect reduction and non-fixation methods. This leads to a satisfactory aesthetic and functional outcome.

The Correction of Inverted Nipple Using Modified Purse-String Sutures

Inverted nipples have shortened lactiferous ducts and less fibrous and collagenous muscular tissue and less connective tissue present, thus giving less bulk and less tissue for nipple projection. Until now, many authors suggested various methods of correction of inverted nipple, but it shows that perfect method does not exist. From July 2008 to December 2010, 41 nipples in 21 patients were treated. 20 patients had bilateral inverted nipples. Under the local anesthesia with sedation, the nipple was everted. A small incision was made on both lateral side at the nipple-areola junction. After nipple traction, the lactiferous ducts and surrounding connective tissues were divided by sharp dissection only through vertical direction. Upper and lower purse-string sutures using Nylon 4-0 were performed for the maintenance of corrected nipple. The small incision was closed by the simple suture. The operation time averaged 15minutes for each nipple. The mean follow-up period was 6 months. There were no complications associated with surgery, such as recurrence, infection, hematoma, nipple necrosis and sensory loss. We applied modified purse-string sutures to mild and moderate inverted nipple patients, and acquired good results. So we report our experience with a review of literature.