Correction of Internal Nasal Valve Obstruction Induced by Posttraunmatic Scar Constriction: A Case Report

The borders of the internal nasal valve are defined by the caudal edge of the upper lateral cartilage supero-laterally, the cartilaginous septum medially, and the nostril floor inferiorly. It is the narrowest portion of the nasal airway and one of the primary regulator of nasal air flow. internal nasal valve collapse is a serious problem associated with prior nasal surgery, previous trauma, aging, or primary weakness of the upper lateral cartilage. We report a case of the internal nasal valve obstruction due to an uncommon mucocutaneous scarring. A 55-year-old male patient complained of headache, severe nocturnal snoring and unilateral nasal obstruction. He had a linear depressed 1.5cm in length scar on the nose dorsum, caused by a lacerated wound. The intranasal examination revealed a concentric narrowing of the left internal nasal valve area by mucocutaneous scar constriction and a left sided septal deviation, but inferior turbinate hypertrophy was not seen. After an open rhinoplasty incision, the nasal airway obstruction was relieved by scar release with the five flap Z-plasty, submucosal resection of deviated septal cartilage and unilateral spreader graft using autogenous septal cartilage. He was pleased with a significant relief of nasal obstructive symptoms. The cross- sectional size of the internal nasal valve area was maintained until postoperative 8 months. Correction of internal nasal valve obstruction must involve surgery on all the structures that make up the valve: septum, upper and lower lateral cartilage, intranasal mucosa, and the inferior turbinate.

Color Analysis of Forehead Flap and Full Thickness Skin Graft in Facial Reconstruction

PURPOSE: For facial reconstruction, skin color match is crucial to achieve great aesthetic result. Forehead flap and full thickness skin graft have been used for many years to reconstruct facial defect. Their results are aesthetically valuable with remarkable resemblance and harmony of the skin color between donor and recipient sites. The purpose of this study is to evaluate and compare the aesthetic outcome of the two methods as the analysis of skin color match. METHODS: From January 1995 to December 2005, ten forehead flaps and ten full thickness skin grafts were performed. The reconstructed areas of forehead flaps were five noses and five eyelids. Recipient sites of full thickness skin grafts were seven eyelids, two noses and one forehead. In order to obtain the objective validity, the skin color of flap(or graft) and the recipient sites were measured by chromameter. The skin colors were quantified according to a three-dimensional coordinate system used in chromameter, L*(brightness), a*(redness), and b*(yellowness). RESULTS: There was no significant color difference between forehead flap site and adjacent skin in all color values. On the other hand, the L* and b* values of graft sites were significantly lower than those of the adjacent skins. The a* values of graft sites were higher than those of the adjacent skins. CONCLUSION: This study reveals that skin color match of forehead flap is greater than that of full thickness skin graft. As forehead flap has adequate volume and great color match, it can be useful to reconstruct deep facial defect such as nasal defect. On the other hand, full thickness skin graft can be used for superficial defect like partial eyelid defect.

A Comparison of Ipsilateral Upper Limb Sensory Changes after Mastectomy Alone and Mastectomy with Immediate Breast Reconstruction

PURPOSE: Sensory changes in the upper limb are complications of a mastectomy with immediate breast reconstruction with the treatment of breast cancer. The purpose of this study is to clarify whether immediate breast reconstruction worsens the sensory changes. METHODS: From March 2004 to December 2005, 20 patients who had a mastectomy with immediate breast reconstruction(reconstruction group) were compared with 23 patients who had a mastectomy alone(control group). All patients had stage I or II breast cancer. The sensory changes were assessed in a blind manner by one examiner that used light touch sensation, static two-point discrimination, pain, vibration, hot and cold temperature perception. The sensory changes were identified along the sensory dermatome for diagnosing the damaged nerves. The following factors and their relationship with the sensory changes were analyzed:age, complications, and the mastectomy method. RESULTS: There was no statistical difference in the static two-point discrimination, pain, vibration, hot and cold temperature perception between the two groups. However, the ability to recognize light touch was significantly better(p=0.045) in the reconstruction group than in the control group. The main site of sensory change was the proximal and medial portion of the upper limb in both groups. At these sites, the mean value of Semmes-Weinstein monofilament was 1.01g/ mm2(reconstruction group 0.82, control group 1.17) and 2-point discrimination was 51.74(converted to perfect score of 100; reconstruction group 42.50, control group 59.78). The total rate of early complications was found to be significantly lower(p=0.006) in the reconstruction group than in the control group. CONCLUSION: These findings suggest that an immediate breast reconstructive procedure following a mastectomy is as safe as or safer than a mastectomy alone with respect to postoperative sensory changes of the ipsilateral upper limb.

Schwannoma in the Postauricular Sulcus being Misdiagnosed as Lipoma: A Case Report

Schwannomas or neurilemmomas are the most often found as solitary, slow-growing, asymptomatic, well-encapsulated, firm yet transversely mobile benign mass in head and neck region. Most of Schwannomas appear in the cranial nerve, especially vestibular nerve, but must always be considered to be able to appear in any parts where the nerve tissues are distributed. Sometimes, inaccurate preoperative clinical diagnosis leads to accidentally resecting the affected nerve and produces permanent neurological deficits. We experienced a extremely rare schwannoma being confused with lipoma in upper left postauricular sulcus. After simple mass excision without considering possibility of schwannoma, the patient complained of dull sensation and pinprick pain in the superior part of the ipsilateral postauricular area. When clinical symptom and physical examinations are insufficient to distinguish schwannoma from other benign soft masses, and the mass along the critical nerve pathway can possibly be originated from the designated nerves, we would like to recommend radiologic examinations such as ultrasonography and/or MRI for correct diagnosis prior to operation. Moreover, when it is adjacent the neurovascular structures, meticulous microscopic surgery must always be performed so as not to impair the important structures.

Chondroid Syringomas arising on the Nasal Dorsum and the Upper Lip: Two Cases of Report

PURPOSE: Chondroid syringoma, previously known as 'mixed tumor of the skin', is a rare benign tumor. It usually presents an asymptomatic solitary firm intradermal or subcutaneous slowly growing nodule. It occurs frequently in the head and neck region of middle-aged men. We would like to report an uncommon chondroid syringoma about the clinical and histologic presentation. about the clinical and histologic presentation. METHODS: We experienced two cases of chondroid syringoma on the nose and the upper lip, each other. Both masses were totally excised with clear margin. RESULTS: On histologic examination, the masses showed a biphasic pattern-an epithelial component exhibiting apocrine/eccrine differentiation and a stromal component exhibiting myxoid/collagenous change-consistent with the diagnosis of chondroid syringoma. There have been no evidence of recurrence and malignant transformation during postoperative follow-up. CONCLUSION: There is no one distinctive clinical feature that is specific for chondroid syringoma. However, it should be included in the differential diagnosis of a solid nodule in head and neck region with long standing duration, such as epidermal inclusion cyst, pilomatrixoma, dermoid cyst, sebaceous cyst, neurofibroma, and basal cell carcinoma.

Surgical Treatment Guideline of Meningococal Induced Purpura Fulminans

PURPOSE: Purpura fulminans is a rare but rapidly progressive, serious, often life-threatening disorder in childhood, which is complicated with septic shock or disseminated intravascular coagulopathy during acute infection. It occurs first as acute-onset petechial rash, and spreads rapidly into full thickness skin and soft tissue necrosis. In the past, it had high mortality rate, up to 80%, but recently, survival rate has increased due to early diagnosis, and rapid advancement of critical care and antibiotics. From our experiences of PF management, we would like to review the pathophysiology and suggest the surgical treatment guideline about meningococcal induced purpura fulminans. METHODS: Two cases of purpura fulminans over the last 3 years were reviewed retrospectively about reconstructive management. After they were treated resuscitative management initially by the critical intensive care, reconstructive surgery was performed by plastic surgeon as soon as the patients were vitally and mentally stable. RESULTS: There were 6 procedures in case 1, and 3 procedures in case 2. The mean delayed period from admission with sepsis to the first surgical debridement was 24 days and 42 days, respectively. Total hospitalization period was 103 days and 69 days, respectively. All of them were treated with debridement and split thickness skin graft, but delayed debridement was superior to early one in the point of preserving much more tissues. CONCLUSION: From our experience, we suggest that conservative therapy to the wounds appears to be the best tool in the initial vitally unstable period in order to preserve as much tissues and functions as possible if no active inflammation and compartment syndrome are detective.

Surgical Treatment Guideline of Meningococal Induced Purpura Fulminans

PURPOSE: Purpura fulminans is a rare but rapidly progressive, serious, often life-threatening disorder in childhood, which is complicated with septic shock or disseminated intravascular coagulopathy during acute infection. It occurs first as acute-onset petechial rash, and spreads rapidly into full thickness skin and soft tissue necrosis. In the past, it had high mortality rate, up to 80%, but recently, survival rate has increased due to early diagnosis, and rapid advancement of critical care and antibiotics. From our experiences of PF management, we would like to review the pathophysiology and suggest the surgical treatment guideline about meningococcal induced purpura fulminans. METHODS: Two cases of purpura fulminans over the last 3 years were reviewed retrospectively about reconstructive management. After they were treated resuscitative management initially by the critical intensive care, reconstructive surgery was performed by plastic surgeon as soon as the patients were vitally and mentally stable. RESULTS: There were 6 procedures in case 1, and 3 procedures in case 2. The mean delayed period from admission with sepsis to the first surgical debridement was 24 days and 42 days, respectively. Total hospitalization period was 103 days and 69 days, respectively. All of them were treated with debridement and split thickness skin graft, but delayed debridement was superior to early one in the point of preserving much more tissues. CONCLUSION: From our experience, we suggest that conservative therapy to the wounds appears to be the best tool in the initial vitally unstable period in order to preserve as much tissues and functions as possible if no active inflammation and compartment syndrome are detective.

Dystrophic Calcification after a Local Injection of a Foreign Body into the Dorsum of the Hand

PURPOSE: Dystrophic calcification occurs in damaged or devitalized tissues in the presence of a normal calcium and phosphorus metabolism. There are many reports on dystrophic calcification caused by injections of various types of drugs. The aim of this report is to highlight the fact that dystrophic calcification can be caused by the injection of a foreign body for aesthetic augmentation. METHODS: This case report describes a patient presenting with dystrophic calcification caused by an injection of an unknown foreign body approximately 50 years ago. An 80-year-old man had localized cellulitis with swelling and ulceration on the dorsum of the left hand. The radiographs demonstrated a 5x3.5x1.7 cm lesion between the first and second metacarpal bones and a 5x2.5x1.5cm lesion in the hypothenar region. The laboratory data and physical examinations were generally within the normal limits. The microscopic examination revealed dead bone fragments and dense collagenous tissue with dystrophic calcification. RESULTS: After surgically removing the masses, the resulting defects were treated with an abdominal flap. The result was satisfactory in terms of symptoms and appearance. CONCLUSION: This case suggests that dystrophic calcification can be caused by an injection of a foreign body for aesthetic augmentation.

Dystrophic Calcification after a Local Injection of a Foreign Body into the Dorsum of the Hand

PURPOSE: Dystrophic calcification occurs in damaged or devitalized tissues in the presence of a normal calcium and phosphorus metabolism. There are many reports on dystrophic calcification caused by injections of various types of drugs. The aim of this report is to highlight the fact that dystrophic calcification can be caused by the injection of a foreign body for aesthetic augmentation. METHODS: This case report describes a patient presenting with dystrophic calcification caused by an injection of an unknown foreign body approximately 50 years ago. An 80-year-old man had localized cellulitis with swelling and ulceration on the dorsum of the left hand. The radiographs demonstrated a 5x3.5x1.7 cm lesion between the first and second metacarpal bones and a 5x2.5x1.5cm lesion in the hypothenar region. The laboratory data and physical examinations were generally within the normal limits. The microscopic examination revealed dead bone fragments and dense collagenous tissue with dystrophic calcification. RESULTS: After surgically removing the masses, the resulting defects were treated with an abdominal flap. The result was satisfactory in terms of symptoms and appearance. CONCLUSION: This case suggests that dystrophic calcification can be caused by an injection of a foreign body for aesthetic augmentation.

A Case of Pressure Sore in Congenital Insensitivity to Pain with Anhidrosis

PURPOSE: Congenital insensitivity to pain with anhidrosis(CIPA) is a rare form of autosomal recessive peripheral sensory neuropathy. Patients with CIPA show loss of pain sensation, which leads to corneal ulcers and opacities, self-mutilation of the tongue and fingertips, as well as fractures with subsequent joint deformities and chronic osteomyelitis. The purpose of this report is to highlight the fact that pressure sores also are a potential complication of CIPA. METHODS: This case report describes a patient presenting with pressure sores resulting from CIPA. A 5-year-old boy was referred to our department for the treatment of a 5x5cm sacral pressure sore as a result of a hip spica cast applied for the treatment of a left hip joint dislocation. He had a history suggesting CIPA such as multiple bony fractures, mental retardation, recurrent hyperpyrexia, anhidrosis, and clubbing fingers due to oral mutilation. A microscopic examination of the sural nerve showed mainly large myelinated fibers, a few small myelinated fibers and an almost complete loss of unmyelinated fibers. After wound preparation for two weeks, the exposed bone was covered with two local advancement flaps. RESULTS: Two weeks later, complete wound healing was achieved. A 16-month follow-up showed no recurrence. However, the patient presented with a new pressure sore on the left knee due to orthosis for the treatment of the left hip joint dislocation. CONCLUSION: The early diagnosis of CIPA and special care of pressure sores are important for preventing and treating pressure sores resulting from CIPA.

Compatibility of Ankle Skin as a Full Thickness Donor Site for Palmar Reconstruction

Although full-thickness skin grafts from the groin donor site are widely used to reconstruct a palmar skin defect, there are many aesthetic and functional problems. To solve the problems, we evaluated the compatibility of ankle skin as a full-thickness donor site for palmar reconstruction. In this study, a grafting method using ankle skin harvested from the just distal area of the lateral malleolus was performed in 17 patients to correct the post-graft contracture of the palm grafted from the groin area. Postoperative course was uneventful except 1 case of donor site disruption. Patient satisfaction rate and color difference rate using color chart manual between the grafts from the groin and ankle were assessed during the follow-up period. The parameters involved color matching, texture matching, durability, mobility, hair growth, hypertrophic marginal scar, donor site scar, patient satisfaction rate, and luminosity, yellowness, and redness in color difference. Most parameters were excellent in the graft from the ankle than that of the groin and significant difference in color was found between the 2 grafts(p < 0.05). The normal skin specimens of the palm, ankle, and groin were examined to compare their histological characters. Ten specimens were taken respectively from both sexes in each site. The skin of the palm and that of the ankle was histologically similar, but it is significantly different from the groin skin, especially in thickness(p < 0.05). Therefore, despite size limitation, the ankle should be considered as a useful option in case of palmar resurfacing of the digits and hand.

A Reconstruction of Upper Lip using Abbe Flap

Reconstruction of upper lip defects presents a challenge to the facial plastic and reconstructive surgeons. Flatness, shortness, and retrusion of the upper lip of cleft patients are caused by a combination of the initial maxillary hypoplasia, the subnormal maxillary growth, and the lack of upper lip soft tissue. Although the routine use of Abbe flaps has been questioned, various modifications of the flap have been used for the repair of deficient upper lip soft tissue. Between 1991 and 2000, the author performed a variety of Abbe flaps in 10 patients. The patients consisted of 5 males and 5 females (3 unilateral clefts, 3 bilateral clefts, 2 cancers and 2 traumas). Mean age at the time of the procedures was 28.5 years (from 16 to 48 years). The pedicles of the flaps were divided 10 to 14 days postoperatively. The follow-up period ranged from 9 to 27 months (mean=17 months). To evaluate the outcome of Abbe flaps objectively, an anthropometic ratio was measured in preoperative and postoperative photographs. This values were compared with the values found in non-cleft patients. Each patient showed a more natural contour of the upper lip. We have found that Abbe flaps were clinically useful, and our results were functionally and cosmetically acceptable. This study indicates that the lips are in better harmony postoperatively than they were preoperatively.