Reconstruction of a temporal scalp defect without ipsilateral donor vessel possibilities using a local transposition flap and a latissimus dorsi free flap anastomosed to the contralateral side: a case report

Scalp defects necessitate diverse approaches for successful reconstruction, taking into account factors such as defect size, surrounding tissue, and recipient vessel quality. This case report presents a challenging scenario involving a temporal scalp defect where ipsilateral recipient vessels were unavailable. The defect was effectively reconstructed utilizing a transposition flap and a latissimus dorsi free flap, which was anastomosed to the contralateral recipient vessels. Our report underscores the successful reconstruction of a scalp defect in the absence of ipsilateral recipient vessels, emphasizing the importance of employing appropriate surgical interventions without necessitating vessel grafts.

Introduction of Multidisciplinary Team Approach for Head and Neck Cancer: Patient Satisfaction / 대한이비인후과학회지

Background and Objectives@#The head and neck multidisciplinary team (MDT) approach plays a crucial role in bringing together the ideas of various medical professionals. This study aimed to evaluate the early characteristics of the MDT approach for head and neck cancer and analyzed patients’ satisfaction.Subjects and Method We analyzed 450 head and neck cancer patients who received MDT care from August 2014 to June 2022. Patient satisfaction with MDT care was evaluated by selfadministered questionnaires consisting of 9 questions. @*Results@#Of 450, 298 (66.2%) were male and 152 (33.8%) were female. The mean age was 60.8±14.7 year. The most common primary site was the larynx (17.3%), followed by the oral cavity and oropharynx. A total of 726 cases of the MDT approach were performed in 266 MDT sessions, and the mean number of patients per MDT session was 2.74. The number of medical professionals participating in MDT ranged from a minimum of 3 to a maximum of 9, with a mean of 5.11. The mean running time of MDT meetings per case was 19.51 minutes. The time of the 2nd MDT was significantly shorter than that of the 1st or 3rd MDT. The mean score was close to very satisfactory in each of the 9 patient satisfaction questions. @*Conclusion@#We believe that the MDT approach is feasible and recommend its introduction for the treatment of head and neck cancer as most patients have shown very high satisfaction. Further studies on the role and efficacy of MDT care for head and neck cancer are necessary.

Resurfacing the donor sites of reverse sural artery flaps using thoracodorsal artery perforator flaps

Background@#The reverse sural artery (RSA) flap is widely used for lower extremity reconstruction. However, patients sometimes suffer from donor site complications such as scar contracture and paresthesia, resulting in dissatisfaction with the aesthetic outcomes. This study investigated the characteristics of donor site morbidity associated with RSA flaps and described our experiences of dealing with complications by performing resurfacing surgery using thoracodorsal artery perforator (TDAP) flaps. @*Methods@#From April 2008 to August 2018, a total of 11 patients underwent contracture release and resurfacing surgery using TDAP flaps due to donor morbidity associated with RSA flaps. All affected donor sites were covered with a skin graft, the most common of which was a meshed split-thickness skin graft (six cases). @*Results@#Eight of the 11 patients (72.7%) suffered from pain and discomfort due to scar contracture, and seven (63.6%) complained of a depression scar. The donor sites were located 6.3±4.1 cm below the knee joint, and their average size was 140.1 cm². After resurfacing using TDAP flaps, significant improvements were found in the Lower Extremity Functional Scale (LEFS) scores and the active and passive ranges of motion (AROM and PROM) of the knee joint. The LEFS scores increased from 45.1 to 56.7 postoperatively (P=0.003), AROM increased from 108.2° to 118.6° (P=0.003), and PROM from 121.4° to 126.4° (P=0.021). @*Conclusions@#Planning of RSA flaps should take into account donor site morbidity. If complications occur at the donor site, resurfacing surgery using TDAP flaps achieves aesthetic and functional improvements.

Reconstructive methods to resolve intractable fistulas that develop after radiation therapy in patients with head and neck cancer

Background@#Radiation therapy (RT) is frequently used for supportive treatment and management of advanced head and neck cancers. This study performed a retrospective review of the treatment methods that were used for intractable draining fistulas in seven patients who had received RT for head and neck cancers. Treatment methods used for two of the seven patients are presented in detail. @*Methods@#From 2009 to 2020, seven patients underwent reconstructive surgery for intractable fistulas which occurred after RT for head and neck cancers. Patient characteristics, medical history, treatment method, and treatment outcome were reviewed for each case. The type of surgery performed, failure rate, and treatment period were also analyzed. Results: In this study, a total of seven patients received additional management for radiation-induced fistulas. Patients underwent a mean of 3.3± 1.4 surgeries (maximum: six surgeries) to resolve their fistulas. The mean time interval from the first surgery to the last surgery for the patients to achieve resolution of the fistula was 8.7 months. Loco-regional flaps have performed an average of 1.9± 1.5 times. However, all loco-regional flaps failed. Instead, the patients’ intractable fistulas were resolved with the use of distant flaps or free tissue transfers. Conclusion: Fistulas that develop after head and neck cancer treatment following RT are difficult to treat with simple loco-regional flap procedures. Therefore, more aggressive treatment techniques, such as distant flap or free tissue transfer, may be needed to shorten patients’ treatment periods and avoid unnecessary surgeries.

Facial reanimation using the hypoglossal nerve and ansa cervicalis: a short-term retrospective analysis of surgical outcomes

Background@#Transferring the hypoglossal nerve to the facial nerve using an end-to-end method is very effective for improving facial motor function. However, this technique may result in hemitongue atrophy. The ansa cervicalis, which arises from the cervical plexus, is also used for facial reanimation. We retrospectively reviewed cases where facial reanimation was performed using the ansa cervicalis to overcome the shortcomings of existing techniques of hypoglossal nerve transfer. @*Methods@#The records of 15 patients who underwent hypoglossal nerve transfer were retrospectively reviewed. Three methods were used: facial reanimation with hypoglossal nerve transfer (group 1), facial nerve reanimation using the ansa cervicalis (group 2), and sural nerve interposition grafting between the hypoglossal nerve and facial nerve (group 3). In group 1, the ansa cervicalis was coapted to neurotize the distal stump of the hypoglossal nerve in a subset of patients. Clinical outcomes were evaluated using the House-Brackmann (H-B) grading system and Emotrics software. @*Results@#All patients in group 1 (n = 4) achieved H-B grade IV facial function and showed improvements in the oral commissure angle at rest (preoperative vs. postoperative difference, 6.48° ± 0.77°) and while smiling (13.88° ± 2.00°). In groups 2 and 3, the oral commissure angle slightly improved at rest (group 2: 0.95° ± 0.53°, group 3: 1.35° ± 1.02°) and while smiling (group 2: 2.06° ± 0.67°, group 3: 1.23° ± 0.56°). In group 1, reduced tongue morbidity was found in patients who underwent ansa cervicalis transfer. @*Conclusion@#Facial reanimation with hypoglossal nerve transfer, in combination with hypoglossal nerve neurotization using the ansa cervicalis for complete facial palsy patients, might enable favorable facial reanimation outcomes and reduce tongue morbidity. Facial reanimation using the ansa cervicalis or sural nerve for incomplete facial palsy patients did not lead to remarkable improvements, but it warrants further investigation.

Sickle-shaped transposition flap oriented along relaxed skin tension lines for lower eyelid reconstruction

Background@#The reconstruction of defects in the lower eyelid region is prone to complications such as ectropion and epiphora. This area is also aesthetically important; therefore, operations should be carried out with caution. We introduce a simple and easy surgical approach for the repair of small to moderate-sized lower eyelid defects. @*Methods@#A retrospective chart review was performed for all patients who underwent lower eyelid defect reconstruction using a sickle-shaped transposition flap in 2018 or 2019. Photographs were taken at each visit, and the Vancouver Scar Scale was used to evaluate residual marks every 3 months for 1 year. Patients reported their subjective satisfaction levels on a visual analogue scale that ranged from 0 to 10. @*Results@#A total of nine patients were included. No flap necrosis, ectropion, epiphora, or other complications were observed. Among the eight patients with skin cancer, no recurrence was noted during the follow-up period. The mean Vancouver Scar Scale scores were 5.50±0.99 at 3 months postoperatively, 4.61±0.85 at 6 months postoperatively, 3.05±0.80 at 9 months postoperatively, and 1.11±0.58 at 12 months postoperatively. The mean overall patient satisfaction rating was 9.11±0.78 (as rated on the visual analogue scale). @*Conclusions@#In the reconstruction of lower eyelid defects, the sickle-shaped transposition flap could be a simple, fast, and aesthetically favorable surgical option.

Exclusive tongue tip reconstruction of hemiglossectomy defects using the underrated lateral arm free flap with bilobed design

BACKGROUND: Tongue reconstruction is challenging with the unique function and anatomy. Goals for reconstruction differ depending on the extent of reconstruction. Thin and pliable flaps are useful for tongue tip reconstruction, for appearance and mobility. This study reports lateral arm free flap (LAFF) as a safe and optimal option for hemi-tongue reconstruction, especially for tongue tip after hemiglossectomy. METHODS: Thirteen LAFFs were performed for hemi-tongue reconstruction after hemiglossectomy from 1995 to 2018. Of the 13 patients, seven were male and six were female, age varying from 24 to 64 years. RESULTS: All flaps healed uneventfully without complications. Donor sites were closed primarily. The recipient vessels for microvascular anastomosis were mainly superior thyroidal artery, external jugular vein. All patients returned to normal diet, with no complaints regarding reconstructed tongue and donor site. CONCLUSION: The LAFF is hairless, thin (especially with lateral epicondyle approach), and potentially sensate. They are advantageous features for tongue tip and hemi-tongue reconstruction. Donor site sacrifices the inessential posterior radial collateral artery, and the scar is hidden under short sleeve shirts. We believe that LAFF can be considered as the first choice flap for hemitongue reconstruction, over radial forearm free flaps.

Anatomic basis for flap thinning

Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning.

Serial Tissue Expansion at the Same Site in Pediatric Patients: Is the Subsequent Expansion Faster?

BACKGROUND: Serial tissue expansion is performed to remove giant congenital melanocytic nevi. However, there have been no studies comparing the expansion rate between the subsequent and preceding expansions. In this study, we analyzed the rate of expansion in accordance with the number of surgeries, expander location, expander size, and sex. METHODS: A retrospective analysis was performed in pediatric patients who underwent tissue expansion for giant congenital melanocytic nevi. We tested four factors that may influence the expansion rate: The number of surgeries, expander location, expander size, and sex. The rate of expansion was calculated by dividing the ‘inflation amount’ by the ‘expander size’. RESULTS: The expansion rate, compared with the first-time group, was 1.25 times higher in the second-or-more group (P=0.04) and 1.84 times higher in the third-or-more group (P < 0.01). The expansion rate was higher at the trunk than at other sites (P < 0.01). There was a tendency of lower expansion rate for larger expanders (P=0.03). Sex did not affect the expansion rate. CONCLUSIONS: There was a positive correlation between the number of surgeries and the expansion rate, a positive correlation between the expander location and the expansion rate, and a negative correlation between the expander size and the expansion rate.

Discussion: The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction

No abstract available.

Treatment Outcome for Gastric Mucosa-Associated Lymphoid Tissue Lymphoma according to Helicobacter pylori Infection Status: A Single-Center Experience

BACKGROUND/AIMS: Helicobacter pylori eradication therapy has been used as a first-line treatment for H. pylori-positive gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, the management strategy for H. pylori-negative MALT lymphoma remains controversial. Therefore, the aim of this study was to examine the success rate of each treatment option for H. pylori-positive and H. pylori-negative gastric MALT lymphomas. METHODS: In total, 57 patients with gastric MALT lymphoma diagnosed between December 2000 and June 2012 were enrolled in the study. The treatment responses were compared between H. pylori-positive and H. pylori-negative gastric MALT lymphomas. RESULTS: Of the 57 patients, 43 (75%) had H. pylori infection. Forty-eight patients received H. pylori eradication as a first-line treatment, and complete remission was achieved in 31 of the 39 patients (80%) with H. pylori-positive MALT lymphoma and in five (56%) of the nine patients with H. pylori-negative MALT lymphoma; no significant difference was observed between the groups (p=0.135). The other treatment modalities, including radiation therapy, chemotherapy, and surgery, were effective irrespective of H. pylori infection status, with no significant difference in the treatment response between H. pylori-positive and H. pylori-negative MALT lymphomas. CONCLUSIONS: H. pylori eradication therapy may be considered as a first-line treatment regardless of H. pylori infection status.

Xanthogranuloma in Adolescence

No abstract available.

Ophthalmopathy Induced by Bilateral Carotid Cavernous Fistula in a Patient with Graves' Disease

Graves' disease (GD) can lead to specific eye afflictions including proptosis, periorbital swelling, conjunctival injection, chemosis, and opthalmoplegia, which then become a condition called Graves' ophthalmopathy or thyroid-associated ophthalmopathy (TAO). A carotid cavernous fistula (CCF) is an abnormal vascular communication between the carotid artery and the cavernous sinus. The clinical signs of CCF are very similar to TAO and should be considered as a differential diagnosis of TAO. We would like to present an interesting case of a bilateral ophthalmopathy induced by CCF in a GD patient. A 54-year-old man with a 6-year history of GD presented with bilateral exophthalmos and conjunctival injection for two months. The orbital CT scan findings were consistent with CCF, and an angiography revealed bilateral CCF. He received a bilateral coil embolization for the CCF and his ophthalmic signs were immediately improved. We recommend orbital imaging to exclude other coexisting diseases in patients who are suspected of TAO, especially when the diagnosis is uncertain or when determining whether medical or surgical intervention is appropriate.

Correction of Asymmetric Crying Facies with Botulinum Toxin A Injection: A Case Report

PURPOSE: Asymmetric crying facies is caused by agenesis or hypoplasia of the depressor anguli oris muscle and is often associated various anomalies. Several static and dynamic surgical interventions have been reported, but their effects are unreliable. We report on the successful use of botulinum toxin A in an asymmetric crying facies patient. METHODS: A 4-year-old girl presented with a facial asymmetry on crying or smiling. Physical examination revealed that her face had no asymmetry at rest. However, the patient showed characteristic asymmetry when smiling, crying, and with other normal facial movements. Asymmetric crying facies was clinically suspected and the weakness of left depressor anguli oris was present on electrophysiology study. Fifteen units of botulinum toxin type A were injected to the right depressor anguli oris muscle. RESULTS: The patient showed the prominent improvement in the facial symmetry without significant complication and the effect persisted until 3 months post injection. CONCLUSION: Asymmetric crying facies was treated successfully with botulinum toxin A and this method was easy and noninvasive.

Alteration of Left Ventricular Function with Dobutamine Challenge in Patients with Myocardial Bridge

BACKGROUND/AIMS: The aim of this study was to identify changes in left ventricular (LV) performance in patients with a myocardial bridge (MB) in the left anterior descending coronary artery during resting and in an inotropic state. METHODS: Myocardial strain measurement by speckle-tracking echocardiography and conventional LV wall-motion scoring was performed in 18 patients with MB (mean age, 48.1 +/- 1.7 years, eight female) during resting and intravenous dobutamine challenge (10 and 20 microg/kg/min). RESULTS: Conventional LV wall-motion scoring was normal in all patients during resting and in an inotropic state. Peak regional circumferential strain increased dose dependently upon dobutamine challenge. Longitudinal strains of the anterior and anteroseptal segments were, however, reduced at 20 microg/kg/min and showed a dyssynchronous pattern at 20 microg/kg/min. Although there were no significant differences in radial strain and displacement of all segments at rest compared with under 10 microg/kg/min challenge, radial strain and displacement of anterior segments at 20 microg/kg/min were significantly reduced compared with posterior segments at the papillary muscle level (44.8 +/- 14.9% vs. 78.4 +/- 20.1% and 5.3 +/- 2.3 mm vs. 8.5 +/- 1.8 mm, respectively; all p < 0.001), and showed plateau (40%) or biphasic (62%) patterns. CONCLUSIONS: Reduced LV strain of patients with MB after inotropic stimulation was identified. Speckle-tracking strain echocardiography identified a LV myocardial dyssynchrony that was not demonstrated by conventional echocardiography in patients with MB.

A Case of Central Pontine Myelinolysis in a Type 2 Diabetic Patient without Electrolyte Changes

Central pontine myelinolysis (CPM) by complicating rapid correction of severe hyponatremia has been widely reported. Additionally, CPM was occasionally reported among patients with post-liver transplantation, burns, chronic renal failure with dialysis, or other diseases associated with or not associated with other electrolyte changes or hyperosmolarity. However, there have been a few reports of CPM occurring in diabetic patients without documented electrolyte changes. This report is, to the best of our knowledge, the first report of CPM in type 2 diabetic patients without electrolyte changes in Korea. A 40-year-old man with type 2 diabetes mellitus with abruptly developed dysarthria and ataxia was admitted to our facility. He suffered from poor glucose control and multiple diabetic complications. Brain magnetic resonance imaging (MRI) revealed a well-defined bilateral symmetric hyperintense lesion in the central portion of the pons on T2- and diffusion-weighted images, which was consistent with CPM. After the patient's blood glucose and blood pressure normalized, his dysarthria and ataxia improved. Six months after discharge, follow-up MRI showed a persistent, but greatly reduced symmetric lesion in the central pons. It is certainly possible for CPM to be overlooked clinically in diabetic patients, but more cases could be diagnosed if careful attention was paid to this syndrome.

Negative-Pressure Wound Therapy Using Modified Vacuum-Assisted Closure in Patients with Diabetic Foot Ulcers / 임상당뇨병

Diabetic foot ulcers (DFU) are common and serious complications of diabetes mellitus. The prognosis of DFU may be very poor even during early stages depending on the general conditions of patients, and amputation is often required to manage DFU. Various therapeutic approaches to DFU have been introduced, and among these negative-pressure wound therapy using vacuum-assisted closure (VAC-NPWT) is particularly noteworthy. We performed VAC-NPWT in three patients with complicated DFU. We used a modified VAC-NPWT protocol, which used wall suction and curaVAC(R). Dressing changes were performed every week, which was longer than standard method. All of our cases improved with granulating wound beds and were cleared of bacterial infection by the end of modified VAC therapy. These modifications reduced the costs of VAC-NPWT without introducing associated side effects. We recommend the active application of VAC-NPWT for complicated DFU, although this recommendation should be confirmed by large randomized controlled studies.

A Case of Bullous Pemphigoid Arising after Infliximab Therapy in a Patient with Rheumatoid Arthritis / 대한류마티스학회지

Bullous pemphigoid is an autoimmune, subepidermal blistering disease commonly seen in the elderly. It is known as autoimmune bullous dermatoses with an estimated prevalence of 1 in 40,000 and shows no gender or racial predilection. It has an autoimmune nature with immunoglobulin (Ig) G and/or C3 complement targeting hemidesmosomal antigens located in the epidermal basement membrane zone. Drug-induced pemphigoid, although rare, can occur in patients taking penicillamine, furosemide, captopril, penicillin, or sulfasalazine, but infliximab-induced pemphigoid has not been reported. We experienced a case of infliximab-induced pemphigoid in 54-year-old woman with a 17-year history of rheumatoid arthritis.