Methylene Blue Dye-Induced Skin Necrosis in Immediate Breast Reconstruction: Evaluation and Management

BACKGROUND: For early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported. METHODS: Immediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation. RESULTS: Six cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction. CONCLUSIONS: The complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.

Earrings Embedded within Earlobe Keloids

No abstract available.

Treatment of Foreign Body Granuloma of the Hand Associated with Unregulated Material Injection for Aesthetic Purpose

Recently, rejuvenation of the aging hand has gained popularity. Various medical fillers have recently become popular, and patients have more options to rejuvenate their aging hands. However, in our country, unregulated material injections by unlicensed practitioners are still wide spread and its related complications have been considered as a serious problem. The aim of this retrospective study is to introduce our experiences regarding 17 cases of foreign body granuloma following hand rejuvenation using unregulated material. A retrospective review from December 2002 to October 2012 was performed. We analyzed data for 17 patients who underwent perilesional surgical excision for treatment of a foreign body granuloma of the hand associated with unregulated material injection by unlicensed practitioners. Injected materials include paraffin, silicone oil, and other unknown materials. Four patients were injected with paraffin, 3 patients with silicone oil, and remaining 10 patients with unknown materials. The main symptom was palpable mass and contour deformity. The patients were asked to rate their overall satisfaction following treatment. The average patient satisfaction score was 3.7. To prevent foreign body granuloma following unregulated medical practice, it is very important to inform the public about the disastrous consequence of unregulated material injections by unlicensed practitioners.

Spontaneous Unilateral Earlobe Keloid

Keloids result from excessive production of fibrous tissue during an abnormal wound healing process. Keloids can occur after trauma, and trauma can range from laceration, piercing, bites, surgery, and burns, to other skin conditions such as acne or folliculitis. We present a case of 68-year-old man, which was characterized with a relatively firm, non-tender, mild pigmented mass in his right earlobe. We performed a local excision, together with microscopic analysis. The mass was eventually diagnosed as a keloid scar in the right earlobe. Postoperative adjuvant pressure therapy using magnets was adopted and the postoperative follow-up was maintained without any recurrence. Auricular keloids should be considered in the differential diagnosis regardless of the cause or the age of patient.

Dermatofibroma of the Lower Lip: A Case Report

PURPOSE: Dermatofibroma is a common benign dermal tumor characterized by a proliferation of fibroblast-like spindle cells. It is commonly localized on the skin of extremities and presents as a slow growing solitary nodule. To our knowledge, the occurrence of dermatofibroma in the oral cavity is rare. Herein, we report a rare case of dermatofibroma on the lower lip. METHODS: A 60-year-old woman presented with a slow growing mass that measured 1 x 0.8 cm in diameter on the lower lip. The mass was surgically excised with clear margins. RESULTS: Histologically, the mass was characterized by a nodular tumor composed of collagen bundles, fibroblasts, and histiocytes, which were findings consistent with dermatofibroma. The postoperative course was uneventful without any complications. CONCLUSION: When evaluating nodular tumors of the oral area, dermatofibroma should be considered in the differential diagnosis.

Dermatofibroma of the Lower Lip: A Case Report

PURPOSE: Dermatofibroma is a common benign dermal tumor characterized by a proliferation of fibroblast-like spindle cells. It is commonly localized on the skin of extremities and presents as a slow growing solitary nodule. To our knowledge, the occurrence of dermatofibroma in the oral cavity is rare. Herein, we report a rare case of dermatofibroma on the lower lip. METHODS: A 60-year-old woman presented with a slow growing mass that measured 1 x 0.8 cm in diameter on the lower lip. The mass was surgically excised with clear margins. RESULTS: Histologically, the mass was characterized by a nodular tumor composed of collagen bundles, fibroblasts, and histiocytes, which were findings consistent with dermatofibroma. The postoperative course was uneventful without any complications. CONCLUSION: When evaluating nodular tumors of the oral area, dermatofibroma should be considered in the differential diagnosis.

Clinical Experiences with Foreign Body Granuloma of the Nose: 7-Year Experience with 18 Patients

PURPOSE: The injection of various materials, including medical fillers and unregulated products, is widespread, potentially causing the development of foreign body granulomas. Should this occur on the nose, the contour deformity and inflammatory signs that result from these granulomas are aesthetically undesirable to patients. The purpose of our study is to share our experiences using different surgical approaches, depending on the affected portion of the nose, to optimize management of this challenging problem and to evaluate patient's satisfaction using our in-house questionnaire along with degree of improvement by two independent plastic surgeons. METHODS: We treated 18 patients who underwent surgical excision of nasal foreign body granulomas via a perilesional approach to the lesion (n=12) or by transcolumellar incision (n=6) at our hospital over a period of seven years from March 2003 to October 2010. Nonparametric statistics were used and are presented as medians (25th-75th). Patient satisfaction was evaluated on a scale of 1 to 5 using an in-house questionnaire. All pre-and post-operative photographs were analyzed by two independent plastic surgeons. Post-operative outcomes were evaluated based on the surgeons' consensus ratings. RESULTS: All patients receiving the transcolumellar approach reported a high level of satisfaction with the results. All but two patients who received the perilesional approach were satisfied with the outcome. No outcomes were rated as no change or worse by the consensus ratings. CONCLUSION: For the upper two-thirds of the nose, perilesional surgical excision can lead to substantial patient satisfaction with modified contour deformity and infection control. The transcolumellar approach resulted in better outcomes and patient satisfaction for the lower one-third of the nose.

Nodular Fasciitis of the Zygomatic Area: A Case Report and Its Aesthetic Considerations

Nodular fasciitis is the most common benign mesenchymal tumor that can be mistaken both clinically and pathologically for soft tissue sarcoma due to its infiltrative growth pattern. It most commonly appears in the extremities and trunk. However, occurrence in the zygomatic area is extremely rare. We present a case of 28-year-old man, who was characterized with a firm, tender, clearly visible mass in his left zygomatic area. We performed a local excision, together with microscopic and immunohistochemical analysis. The mass was eventually diagnosed as nodular fasciitis in the zygomatic area. No postoperative oncological treatment was done and the postoperative follow-up was maintained up to the present time without any tumor recurrence. Nodular fasciitis should be considered in the differential diagnosis when a rapid growing subcutaneous mass is detected in this area. Accurate diagnosis, appropriate treatment and follow-up are mandatory to avoid overly aggressive treatment and limit treatment-related morbidities. Moreover, the disease itself and its surgical treatment may cause aesthetic compromise and the aesthetic implications have been discussed.

Cellular Blue Nevus of the Finger: A Case Report

We experienced an unusual case of the cellular nevus on the dorsal surface of the second metacarpophalangeal joint. We performed a local excision followed by immunohistochemical analysis. Cellular blue nevus should be considered in the differential diagnosis when a characteristic blue-black mass is found in the finger. Accurate diagnosis based on immunohistochemical analysis, appropriate surgical treatment and vigilant follow-up are mandatory to prevent any malignant transformation.

Staged Scar Revision of Angulated Facial Scar

Scar revision techniques are chief among the most important skills for facial plastic and reconstructive surgeons. In order to achieve the least amount of scarring following a surgical procedure, it is crucial that the surgeon always consider skin tension. In our hospital, staged scar revision was conducted on patients with angulated facial scars in order to reduce skin tension. We conducted a retrospective chart review of patients undergoing staged scar revision for angulated facial scars at our hospital from July 2002 to September 2010. The follow-up period was at least six months. All pre-and post-operative photographs were analyzed by two independent plastic surgeons. And the patients were asked to rate their overall satisfaction with their scar revision as very satisfied(5), satisfied(4), neutral(3), dissatisfied(2) or completely dissatisfied(1). Staged scar revision was used in 51 patients with angulated facial scars. Overall, a significantly improved scar and above(score > or =4), graded by an independent plastic surgerns, was notes in 47 patients(92.1%). And, 45 patients(88.2%) were satisfied with their scar revisions. In all cases, the postoperative clinical course was uneventful without any complications. In conclusion, staged scar revision is considered a good option for the treatment of angulated facial scar.

120 Cases of Facial Foreign Body Granuloma

PURPOSE: As the use of soft tissue fillers becomes more popular, complications such as foreign body granuloma (FBG) are increasing. We report 120 cases of facial FBG and review the available literatures. METHODS: 120 patients of facial FBG in our clinic from Mar. 2003 to Feb. 2008 were complied and analyzed. A retrospective chart review was done and patient satisfaction was evaluated with a questionnaire using 5 score scale. Patients with severe inflammation sign or bizarre deformity underwent surgical excision and those with minimal symptoms or a history of hyaluronic acid injection received injection therapy using hyaluronidase. RESULTS: 100 females and 20 males were observed. The average age was 43.7 years(from 16 to 74). 84 patients received surgical therapy and 36, injection therapy. Deformity of facial contour, foreign body sensation and inflammation sign were the three main chief complaints. 84 patients did not know what the injection materials were. The known materials are as follows: collagen, hyaluronic acid, silicone oil, paraffin. 92 cases were performed by unlicensed practitioners, 29 by physicians. Anatomical site most frequently affected by the foreign body granuloma was the cheek (25.8%), followed by forehead(19.2%), lips (15.8%), nose (9.2%), mentum(8.3%), eyelid and eyebrow (4.3%) and temple(0.8%). In 21 patients(17.5%), FBGs were found on multiple sites. Patients with inflammation sign got the highest satisfaction(3.19+/-0.73)(p=0.001) among 3 chief complaints. And patient satisfaction was statistically higher in surgical therapy group(3.43+/-0.72) than in injection therapy group(2.97+/-0.88)(p=0.003). CONCLUSION: We suggest that it may be beneficial to tailor the type of treatment for FBG relying on wound state and patient's chief complaints. In surgical therapy, resolute approach is necessary to correct facial deformity definitely and to minimize inflammation. Injection therapy could be another option for those with minimal symptoms or a history of hyaluronic acid injection. To prevent foreign body granuloma, not only plastic surgeons but also other physicians should inject soft tissue fillers with great caution and we should warn the public of disastrous consequences associated with illegal medical practice.

Clinical Analysis of Result of Scar Revision According to Scar Hardness

Wound healing proceeds, fibroblasts play a major role in controlling the composition and amount of extracellular matrix and collagen metabolism. As the amount of collagen product is increased, the scar becomes more thicker and harder. Firmness of the scar can significantly influence the outcome of scar revision depending on the amount of collagen. This study aimed to classify the results of surgical scar revision according to the hardness of the scar and to compare histological differences and effectiveness in scar revision surgery between each classification. We selected subjects who had undergone scar revision and examined their scar pathology and surveyed the satisfaction levels of patients and Vancouver scar scale in each group. As the scar hardness increased from soft to hard, more collagen fiber bundle and elastic fiber tangling were noted. On the other hand, the satisfaction of patients was increased as the scar hardness was decreased from hard to soft. In this study, therefore, we concluded that as the scar becomes harder, the tangling of elastic fibers and the amount of collagen fiber bundles increase. Such patients revealed a robust collagen metabolism, and showed worse results of scar revision.

Power-Assisted Liposuction and Periareolar Pull-Out Technique for the Treatment of Gynecomastia

Gynecomastia is an abnormal increase in the volume of the male breast. Surgical techniques include a variety of incisions, excisions, suction-assisted lipopectomy, ultrasound-assisted liposuction, power-assisted liposuction, or some combination of these methods. The purpose of this article is to introduce the authors' method of using power-assisted liposuction and periareolar pull-out technique. Six men were treated from June 2005 through August 2008 for gynecomastia. Fatty breast tissue is removed by power-assisted liposuction. The periareolar pull-out technique is then performed to glandular enlargement. A mean of 120cc of breast tissue was aspirated, and 18.3g of glandular tissue were excised per breast. There were no complications such as skin flap necrosis or hematoma. The cosmetic outcome was good in all and the patients' satisfaction was high. Power-assisted liposuction in combination with periareolar pull-out technique effectively corrects gynecomatia. This combination has little morbidity, minimize scars, and leads to good cosmetic results.

A Case Report of Langerhans Cell Histiocytosis of Frontal Area

PURPOSE: Langerhans cell histiocytosis is a heterogenous group of Langerhans cell proliferative disorders and includeseosinophilic granuloma, Letterer-Siwe diseases, and Hand- Schuller Christian disease. We report a case of eosinophilic granuloma on frontal area. METHODS: A 17-year-old male presented with swelling and tenderness on Lt. frontal and periorbital area. CT and MRI showed a 33 x 25 mm sized mass that involved Lt. frontal calvarium, frontotemporal meninges, and orbital roof. RESULTS: Total excision of the mass and adjacent soft tissue, calvarium, and orbital roof was performed. Orbital roof defect was reconstructed with absorbable plate and calvarial defect was done with outer cortex of temporal bone flap. The histology revealed proliferation of histiocytes and eosinophils. Immunologically, these histiocytic cells expressed S-100 protein and CD1a. The patient is currently taking conservative treatment. CONCLUSION: The severity of these disease and their prognosis and treatments are various. For unifocal cranial Langerhans cell histiocytosis, complete excision is the treatment of choice. We report this case with review of literature.

Early Metabolic Changes and Its Considerations after Liposuction

PURPOSE: Advanced techniques now make it possible to remove considerable amounts of subcutaneous adipose tissue more safely with minimum blood loss. However, few have analyzed the metabolic consequences of liposuction. The purpose of this study was to identify the early effects of the surgical removal of subcutaneous fat on metabolic changes in patients who have undergone liposuction. METHODS: Nineteen patients were evaluated from June 2005 to December 2005. Preoperative body weight, serums levels of lipids, apolipoprotein A1, dehydroepiandrosterone(DHEA), uric acid, insulin, and glucose were evaluated. Insulin resistance was determined using the homeostasis model assessment of insulin resistance (HOMA-IR), which is based on fasting glucose and insulin concentrations. All of these data were remeasured in 1 and 4 weeks postoperatively. Tumescent fluid was infiltrated using the superwet technique. The liposuction device used was a Liposlim(R) power-assisted unit. RESULTS: Average volumes of infiltrate and aspirate were 3,268mL and 2,892mL, respectively. Results in 1 week postoperatively demonstrated a significant difference in high-density lipoprotein(HDL) cholesterol, apolipoprotein A1, insulin, and HOMA-IR levels. However, all values were within normal limits and returned to baseline in 4 weeks postoperatively. CONCLUSION: This study provides little to support the presumed therapeutic effect of liposuction. And, it is unclear whether liposuction can prevent or be used to treat the metabolic complications of obesity. However, the results of the present study lead us to believe that liposuction is a metabolically safe procedure.

Cranioplasty Using Pericranial flap and Split-Rib Graft: Case Report

PURPOSE: The goals of cranioplasty are to protect the brain from trauma and restore normal cranial contour with as few complication as possible. In patient who suffered from cranial defect, the most satisfactory form of cranioplasty may be archived with autogenous bone grafts. We report on the treatment of large frontal bone defect using pericranial flap and split-rib graft. METHODS: A 29-year-old male was referred to our department. He was involved in an automobile accident resulting in large frontal bone and sinus defect and skull basal defect. The reconstruction was undertaken using galeal frontalis myofascial flap and split-rib cranioplasty using bicoronal incision. RESULTS: The postoperative course was successful. For 9 months follow up period, there was no complication about hematoma, infection, CSF leakage and washboard deformity. He was pleased with the results even when absolute symmetry was not achieved. CONCLUSION: We experienced large frontal bone and sinus defect and skull basal defect patient and successfully treated with split-rib graft and galeal frontalis myofascial flap.

Self Induced Foreign Body Injection Patient: A Case Report

PURPOSE: In the past, laymen or beauty parlor employees commonly injected people with unproven foreign material such as paraffin, silicone, and cooking oil. We have treated a patient who injected foreign material into her face and neck. METHODS: For the last 20 years, a 43-year-old woman has been injecting herself in the face and neck with foreign material. There was no tenderness, erythema, pain, ulceration, or necrosis. However many visible, touchable subcutaneous masses were found. Her face was extremely ugly and disfigured by the foreign material. We could not recognize the boundary between her neck and mandible. The occipital scalp drooped extremely. Over the past 3 years, from February 2005 to October 2007, we performed 15 operations. RESULTS: We conducted a cephalometric facial analysis to compare preoperative and postoperative facial diameter. The patient's upper face diameter decreased from 67cm to 60 cm, the mid face diameter from 82cm to 59cm, the lower face diameter from 63 cm to 50cm, and the neck circumference diameter from 53cm to 44cm, respectively. The mid sagittal diameter decreased from 26 cm to 23cm. The total excised tissue weight was 4023.7 gram after 15 operations. CONCLUSION: Serial excision of face and neck masses in a patient who injected herself with foreign material resulted in a satisfactory outcome.

Treatment of Partial Thickness Skin Defect with Cultured Allogenic Keratinocytes (Kaloderm.)

PURPOSE: Grafting with autograft skin remains the most effective method for treating skin defects. When insufficient donor sites are present or patients are afraid of the operation, a skin graft is impossible. Cultured allogenic keratinocytes speed wound healing by providing cover and by producing growth factors and extracellular matrix protein. We report an application of cultured allogenic keratinocytes (Kaloderm., Tegoscience, Seoul, Korea) in the treatment of an acute partial thickness skin defect. METHODS: From March 2005 to January 2006, 20 patients with a partial thickness skin defect were treated with cultured allogenic keratinocytes. The wound was covered with a sheet of cultured allogenic keratinocytes and ointment with Bactigras. gauze. The wound was inspected every two or three days. We regarded completion of epithelialization as wound healing. RESULTS: The mean period between time of injury and time of Kaloderm. application was 7.5 days. The time taken from application of Kaloderm. to complete closure of the wounds was 7.2 days. CONCLUSION: In view of the favorable outcome, cultured allogenic keratinocytes are safe and effective biologic dressing materials for use in the treatment of open wounds.

Treatment of Various Auricular Diseases Using Magnetic Disks

PURPOSE: The earlobe is one of the areas which are most vulnerable to trauma. Various auricular diseases need compression treatment. We report a new compression method using magnetic disks. METHODS: Seventeen patients with auricular diseases were treated from October 2002 to September 2006. The mean age was 29.1 years. The diseases details were osteochondroma in 2 patients; cauliflower's ears in 2 patients; acute otohematoma in 1 patient; and hypertrophic scars in 11 patients. The most common cause of their disease was ear piercing. The mean follow-up period was 8.9 months. All surgical procedures were performed under local anesthesia. To compress immediately, a pair of magnetic disks was applied to the anterior and posterior surface of the earlobe. RESULTS: The results were generally good. Major complications, such as recurrence, necrosis, dehiscence, or infection, did not occur. CONCLUSION: A pair of magnetic disks are useful compression tool in various auricular diseases.

ROM(Reducing Opposed Multilobed) Flap Repair for the Treatment of Medium Sized Skin Lesion

PURPOSE: Circular skin lesions between 10 and 35 mm in diameter generate problems often. Direct closure of the lesion risks excessive wound tension or wound dehiscence. Skin grafts heal slowly and often remain unsightly. Traditional skin flaps have a limited role. We treated this circular medium-sized skin lesion(10 - 35 mm sized) by reducing opposed multilobed(ROM) flap. METHODS: ROM flap involves a series of semicircular lobes extending both cephalic and caudal from the defect. Direction of the semicircular multilobed flap is set parallel to relaxed skin tension line(RSTL) to minimize scar formation. First semicircle is drawn 60% in diameter of the defect. Second semicircles are drawn at the cephalic and caudal aspects of the original semicircles. These semicircles are 60% in diameter of the first semicircle. Additional semicircles are repeatedly drawn until the tension of skin flaps becomes free. ROM flap has a length-to-base ratio of 0.5 resulting in lower theoretical risk of end flap necrosis than a random pattern flap with a large ratio. The technique involves lobes most distant from the primary defect being transposed in turn closer to the defect. RESULTS: The ROM flap reduces skin tension concerns, lowers the risk of flap necrosis and allows for quicker and more aesthetic healing. Results were generally good and major complications, such as dehiscence, infection, or delayed healing, did not occur. CONCLUSION: ROM flap repair allows the plastic surgeon an additional option when faced with a circular medium-sized skin lesion.