Two Cases of Lower Body Contouring with a Spiral and Vertical Medial Thigh Lift

Massive weight loss results in skin excess, leading to an unsatisfying body contour. Various thigh lift procedures can correct flabby skin in the lower leg. We present a lower body contouring technique with a report on two patients. The procedure is determined by the body contour of the patient. As the skin excess in the thigh area tended to appear mostly on the medial side, a vertical medial thigh lift was considered. Moreover, for patients with a pear/guitar-shaped body contour, we added the spiral thigh lift for skin excess in the buttocks and the lateral thigh area. The extent of tissue to excise was determined by pinching the patient in a standing position. The inferior skin flap was fixed to non-movable tissue, which was helpful for lifting the tissue and preventing the widening of the scar. After the operation, a drain was kept for 3 to 4 days. A compressive garment was used after removing the drain. There were no complications. The patients were discharged 6 to 8 days after the operation. In conclusion, skin excess, especially in the lower body, can be corrected by a thigh lift combining several procedures, varying from person to person.

Systemic Pemphigus Vulgaris: A Case Report

PURPOSE: Pemphigus vulgaris, a rare autoimmune blistering disease of the skin and mucous membranes remains a challenging disease to treat. Management is focused on immunotherapy against autoimmune antibodies that target keratinocyte cell adhesion molecules, and antibiotics preventing secondary infections. There is no established dressing protocol and skin is usually manipulated the least amount possible in order to minimize irritation. The authors suggest that early initiation of aggressive bathing and debridement of skin lesions, with nutritional support, is essential in accelerating resolution. METHODS: A 40 year-old male previously diagnosed with pemphigus vulgaris was admitted due to exacerbation of mucocutaneous lesions involving the epidermis and mucosa of the whole body. Steroids, immunosuppressants, intravenous immunoglobulin and antibiotics were administrated, but infection and de-epithelialization progressed, while his general condition deteriorated with a weight loss of over 20 kilograms. The plastic surgery department intervened with daily bathing, debridement of unhealthy debris and non-traumatizing coverage of growing epithelium. Total parenteral nutrition and mobilization with rehabilitation therapy was initiated as early as possible. RESULTS: After bathing, healthy epithelium gradually covered the patient's entire body, while his general condition improved with a corresponding weight gain of 14 kgs. CONCLUSION: Treatment of pemphigus vulgaris focuses on immunotherapy and infection control. However, an equal amount of attention should be laid on early intervention with daily dressings including bathing and irrigation, nutritional support, and exercise as this accelerates resolution of existing infections, promotes healthy epithelialization and leads to faster recovery.

Comparative Analysis about the Effect of Isolated Phosphatidylcholine and Sodium Deoxycholate for the Viability of Adipocyte

PURPOSE: Lipobean(R)s, widely used in lipodissolving techniques, contain phosphatidylcholine and sodium deoxycholate as its main substances. They have been approved only as medication for liver disease by the FDA. However, they have been used under various clinical settings without exact knowledge of its action mechanism. The authors designed an in vitro study to analyze the effects of different concentrations of phosphatidylcholine and sodium deoxycholate on adipocytes and other types of cells. METHODS: Human adipose-derived stem cell were cultured and induced to differentiate into adipocytes. Fibroblasts extracted from human inferior turbinate tissue, and MC3T3-E1 osteoblast lines were cultured. Phosphatidylcholine solution dissolved with ethanol was applied to the culture medium at differing concentrations (1, 4, 7, 10 mg/mL). The sodium deoxycholate solution dissolved in DMSO applied to the medium at differing concentrations (0.07, 0.1. 0.4. 0.7 mg/mL). Cells were dispersed at a concentration of 5 x 10(3) cells/well in 24 well plates, and surviving cells were calculated 1 day after the application using a CCK-8 kit. RESULTS: The number of surviving cells of adipocytes, fibroblasts and osteoblasts decreased as the concentration of sodium deoxycholate increased. However, all types of cells that had been processed in a phosphatidylcholine showed a cell survival rate of over 70% at all concentrations. CONCLUSION: This study shows that sodium deoxycholate is the more major factor in destroying adipocytes, and it is also toxic to the other cells. Therefore, we conclude that care must be taken when using Lipobean(R)s as a method of reducing adipose tissue, for its toxicity may destroy other nontarget cells existing in the subcutaneous tissue layer.

Predicting the Degree of Breast Size in Augmentation with Cohesive Gel Implant

PURPOSE: Predicting the change in breast size for a specific patient's need is a challenging problem in breast augmentation. We intended to investigate the post-augmentation degree of breast size according to the size of cohesive silicone gel implant. METHODS: To predict post-augmentation breast size, we measured 100 patients' pre-and postoperative 3 month's bust circumference. All patients were performed by total subfascial breast augmentation with moderate profile cohesive silicone gel implant through areolar omega (transareolar-perinipple) incision. RESULTS: According to this study, each additional one pair of 100mL in implant size yielded an approximate 1.5cm increase in bust circumference(p=0.006). CONCLUSION: From this result, we conclude that each additional one pair of 100mL in implant volume yielded about 1.5cm increase in bust circumference. Although this result may not be applied to every patient, we believe that it yields a practical chart that can help to predict the amount of increase in breast size with the use of cohesive silicone gel implant of a specific size preoperatively.

Effective Reconstruction of Extensive Orbital Floor Fractures Using Rapid Prototyping Model

PURPOSE: Orbital bone is one of the most complex bones in the human body. When the patient has a fracture of the orbital bone, it is difficult for the surgeon to restore the fractured orbital bone to normal anatomic curvature because the orbital bone has complex curvature. We developed a rapid prototyping model based on a mirror image of the patient's 3D-CT (3 dimensional computed tomography) for accurate reduction of the fractured orbital wall. METHODS: A total of 7 cases of large orbital wall fracture recieved absorbable plate prefabrication using rapid prototyping model during surgery and had the manufactured plate inserted in the fracture site. RESULTS: There was no significant postoperative complication. One patient had persistent diplopia, but it was resolved completely after 5 weeks. Enophthalmos was improved in all patients. CONCLUSION: With long term follow-up, this new method of orbital wall reduction proved to be accurate, efficient and cost-effective, and we recommend this method for difficult large orbital wall fracture operations.

Management of Intractable Cerebrospinal Fluid Collection after Cerebellar Tumor Resection: A Case Report

PURPOSE: CSF (Cerebrospinal fluid) leakage is the most common complication of neurosurgery. Early management with conservative care or surgery must be followed appropriately due to the increased risk of lethal complications, such as meningitis. We report a case of intractable CSF leakage that occurred after a cerebellar tumor resection, which was treated successfully. METHODS: A 53-year old male consulted our department for continuous CSF leakage for 3 months after having received conservative care and lumbar drainage. CSF collection was observed in the dead space of the posterior fossa after a cerebellar tumor resection and postoperative radiotherapy. Using a free latissimus dorsi muscle flap, the dead space within the skull was filled and the defects were covered successfully. RESULTS: At 6 weeks after surgery, the follow-up MRI and CT revealed proper coverage and filling in the area where cerebellar tumor had been removed. No CSF leakage was observed at the postoperative 3 month follow-up. CONCLUSION: Recurrent CSF leakage was treated after cerebellar tumor resection with a relatively satisfactory result. In terms of the patient's treatment, much better results can be achieved by performing dead space filling using a flap with a sufficient size, in addition to coverage of the defects of the dura.

Bilateral Fasciocutaneous Sliding V-Y Advancement Flap for Meningomyelocele Defect

PURPOSE: Meningomyelocele is the most common type of neural tube defect disease. Early surgical treatment is recommended to prevent central nervous system infection. Several reconstruction methods were reported previously regarding surgical wound defect closure following meningomyelocele excision. In this article, we report two successful patients using the bilateral fasciocutaneous sliding V-Y advancement flap as a covering for meningomyelocele defects. METHODS: Two patients with meningomyelocele were evaluated. Both patients were male and received their operations on the 1st and 4th day of life. After neurosurgeons completed their part of the operation, the V-Y advancement flap was used to close the defect. Initially a bilateral V-shape incision design was made on the skin such that the base of the V-flap measures identical to the size of the wound defect. An incision was made down to the fascia in order to allow the V-flaps to slide into the defect. Subfascial dissection was performed up to 1/3 to 1/4 the length of the V-flap from the wound while minimizing injury to the perforating vessels. RESULTS: Both patients were treated successfully and there was no evidence of complication in 2 months follow up. CONCLUSION: Several reconstruction methods such as local flaps, skin graft and myocutaneous flaps were reported regarding meningomyelocele surgical wound defect closure. Bilateral fasciocutaneous sliding V-Y advancement flap is an easy method without involving the underlying muscles or a secondary skin graft in a short operation time. Therefore we recommend this treatment option for reconstruction of the wound defect following meningomyelocele excision.

A New Flap for 3-Dimensional Vulvar and Vaginal Reconstruction: The "Butterfly Flap"

PURPOSE: Traditional radical surgery for vulvar cancer produces severe skin and soft tissue defects in the vulvar and vaginal area. Vulvoperineal V-Y advancement fasciocutaneous flaps have limitations in advancement and tension at the wound margin and vaginal orifice area, causing wound disruption or vaginal wall exposure. Therefore, we designed the "Butterfly flap" using a vulvoperineal V-Y advancement fasciocutaneous flap and an inguinal rotational skin flap for 3-dimensional reconstruction of vagina and vulvar area. METHODS: A 27 year-old female was diagnosed with vulvar intraepithelial neoplasia. Radical vulvectomy and full-thickness-skin-graft was performed. We designed a vulvo-perineal V-Y advancement fasciocutaneous flap as the greater wing and inguinal rotational skin as the lesser wing. After flap elevation, the inguinal flap was rotated 180degrees to reconstruct the labia major and vaginal orifice. The perineum was reconstructed using V-Y advancement flaps. RESULTS: The flap survived completely, without any complications. After 6 months, the patient was able to perform normal sexual activities and after 18 months, the patient was able to give birth to normal child by caesarean section. CONCLUSION: The traditional vulvoperineal V-Y advancement fasciocutaneous flap is thin, reliable, easily elevated and matches local skin quality. However, the vaginal wall becomes exposed due to limited advancement and tension of the flap. The "Butterfly flap" using a vulvoperineal V-Y advancement fasciocutaneous flap and an inguinal rotational skin flap is useful for the release of vaginal orifice contracture, reconstruction of the labia major, and 3-dimensional reconstruction of vagina and vulvar area.

Wound Infection of Spinal Cord Stimulator: A Case Report

PURPOSE: Nowadays spinal cord stimulator is frequently used for the patients diagnosed as complex regional pain syndrome. The lead is placed above the spinal cord and connected to the stimulation generator, which is mostly placed in the subcutaneous layer of the abdomen. When the complication occurs in the generator inserted site, such as infection or generator exposure, replacement of the new generator to another site or pocket of the abdomen would be the classical choice. The objective of our study is to present our experience of the effective replacement of the existing stimulation generator from subcutaneous layer to another layer in same site after the wound infection at inexpensive cost and avoidance of new scar formation. METHODS: A 50-year-old man who was diagnosed as complex regional pain syndrome after traffic accident received spinal cord stimulator, Synergy(R) (Medtronic, Minneapolis, USA) insertion 1 month ago by anesthetist. The patient was referred to our department for wound infection management. The patient was presented with erythema, swelling, thick discharge and wound disruption in the left upper quadrant of the abdomen. After surgical debridement of the capsule, the existing generator replacement beneath the anterior layer of rectus sheath was performed after sterilization by alcohol. RESULTS: Patient's postoperative course was uneventful without any complication and had no evidence of infection for 3 months follow-up period. CONCLUSION: Replacement of existing spinal cord stimulation generator after sterilization between the anterior layer of rectus sheath and rectus abdominis muscle in the abdomen will be an alternative treatment in wound infection of stimulator generator.

Body Contouring of Breast and Abdomen with Belt Dermolipectomy after Massive Weight Loss: A Case Report

PURPOSE: Obese proportion is increasing universally, estimating more than a billion. So reducing the weight became one of the topic in medical market. Not only diet, exercise, medication, but also many surgical procedures are being developed, such as sleeve gastrectomy, gastric bypass surgery. After massive weight loss, skin excess and laxity occurs, leading to unsatisfying body contour. Body contouring surgery including abdominoplasty, breast reduction is performed when skin excess is present in abdomen and breast. When skin excess is present circumferentially, belt dermolipectomy is the treatment of choice. METHODS: A 23-year-old man had weight gain since he was 12 of age. A year before visiting to our department, his height was 168 cm, weight was 150 kg and body mass index (BMI) was 53.15 kg/m2. The patient lost 55 kg of his weight through exercise and diet control. When he visited again, his weight was 95 kg and BMI was 33.66 kg/m2. In physical examination, skin excess and laxity was seen in both breast and abdomen circumferentially and lateral folds were seen in the back. Abdominal contour deformity (Pitman classification type 6) and pseudogynecomastia (grade 3) were present in both breast. Belt dermolipectomy of abdomen, both breast and lateral folds was performed, resecting 6,400 g of tissue and additive 1,200 g through revisional operation. RESULTS: The patient lost 6,500g of his weight and BMI reduced by 2.3 kg/m2. The patient's hospital course was uneventful during 5 weeks of hospitalization and he was satisfied with his final body contour. CONCLUSION: Body contouring with belt dermolipectomy in patient who has circumferential skin excess and laxity after massive weight loss can be a treatment of choice.

Body Contouring of Breast and Abdomen with Belt Dermolipectomy after Massive Weight Loss: A Case Report

PURPOSE: Obese proportion is increasing universally, estimating more than a billion. So reducing the weight became one of the topic in medical market. Not only diet, exercise, medication, but also many surgical procedures are being developed, such as sleeve gastrectomy, gastric bypass surgery. After massive weight loss, skin excess and laxity occurs, leading to unsatisfying body contour. Body contouring surgery including abdominoplasty, breast reduction is performed when skin excess is present in abdomen and breast. When skin excess is present circumferentially, belt dermolipectomy is the treatment of choice. METHODS: A 23-year-old man had weight gain since he was 12 of age. A year before visiting to our department, his height was 168 cm, weight was 150 kg and body mass index (BMI) was 53.15 kg/m2. The patient lost 55 kg of his weight through exercise and diet control. When he visited again, his weight was 95 kg and BMI was 33.66 kg/m2. In physical examination, skin excess and laxity was seen in both breast and abdomen circumferentially and lateral folds were seen in the back. Abdominal contour deformity (Pitman classification type 6) and pseudogynecomastia (grade 3) were present in both breast. Belt dermolipectomy of abdomen, both breast and lateral folds was performed, resecting 6,400 g of tissue and additive 1,200 g through revisional operation. RESULTS: The patient lost 6,500g of his weight and BMI reduced by 2.3 kg/m2. The patient's hospital course was uneventful during 5 weeks of hospitalization and he was satisfied with his final body contour. CONCLUSION: Body contouring with belt dermolipectomy in patient who has circumferential skin excess and laxity after massive weight loss can be a treatment of choice.

Central Giant Cell Granuloma of the Mandible: A Case Report

PURPOSE: Central giant cell granuloma is a rare, benign giant cell tumor which commonly develops in areas near the teeth. It accounts for approximately less than 7% of benign tumors of the mandible. Clinically, central giant cell granuloma is classifed into aggressive and non-aggressive type, and usually requires surgical treatment. There has been no report of central giant cell granuloma in plastic surgery field of the country, and we report a case with a brief review of the diagnosis and treatment of the disease. METHODS: A 23-year-old male presented with a hard, non-tender, growing mass with the size of 4.0 x 3.0 cm on mandible for several months. Computed tomography scan showed a solid mass within thinned outer cortex on mandible. The thinned outer cortex was excised with the mass and the inner cortex was partially removed burring. After the tumor removal, mandible was fixed by reconstruction plate. RESULTS: Pathologic report showed numerous large multinucleated giant cells, diffusely distributed in a background of ovoid-to-spindle-shaped mononuclear cells. There was no evidence of recurrence after 1 year follow up. Bony defect was regenerated and we removed the reconstruction plate. CONCLUSION: Removal of central giant cell granuloma results in defect of outer cortex, which can be reconstructed by using reconstruction plate, autologous bone graft or bone cement. We used reconstruction plate as a conservative method to induce secondary healing of the outer cortical defect area, which resulted in normal mastication and occlusion with no recurrence.

Central Giant Cell Granuloma of the Mandible: A Case Report

PURPOSE: Central giant cell granuloma is a rare, benign giant cell tumor which commonly develops in areas near the teeth. It accounts for approximately less than 7% of benign tumors of the mandible. Clinically, central giant cell granuloma is classifed into aggressive and non-aggressive type, and usually requires surgical treatment. There has been no report of central giant cell granuloma in plastic surgery field of the country, and we report a case with a brief review of the diagnosis and treatment of the disease. METHODS: A 23-year-old male presented with a hard, non-tender, growing mass with the size of 4.0 x 3.0 cm on mandible for several months. Computed tomography scan showed a solid mass within thinned outer cortex on mandible. The thinned outer cortex was excised with the mass and the inner cortex was partially removed burring. After the tumor removal, mandible was fixed by reconstruction plate. RESULTS: Pathologic report showed numerous large multinucleated giant cells, diffusely distributed in a background of ovoid-to-spindle-shaped mononuclear cells. There was no evidence of recurrence after 1 year follow up. Bony defect was regenerated and we removed the reconstruction plate. CONCLUSION: Removal of central giant cell granuloma results in defect of outer cortex, which can be reconstructed by using reconstruction plate, autologous bone graft or bone cement. We used reconstruction plate as a conservative method to induce secondary healing of the outer cortical defect area, which resulted in normal mastication and occlusion with no recurrence.

Superior Gluteal Artery Perforator Turn-Over Flap Coverage for Lumboscaral Soft Tissue Defect in Ambulatory Patient

PURPOSE: Extensive lumbosacral defects after removal of spinal tumors have a high risk of wound healing problems. Therefore it is an effective reconstructive strategy to provide preemptive soft tissue coverage at the time of initial spinal surgery, especially when there is an instrument exposure. For soft tissue reconstruction of a lumbosacral defect, a variation of the gluteal flap is the first-line choice. However, the musculocutaneous flap or muscle flap that is conventionally used, has many disadvantages. It damages gluteus muscle and causes functional disturbance in ambulation, has a short pedicle which limits areas of coverage, and can damage perforators, limiting further surgery that is usually necessary in spinal tumor patients. In this article, we present the superior gluteal artery perforator turn-over flap that reconstructs complex lumbosacral defects successfully, especially one that has instrument exposure, without damaging the ambulatory function of the patient. METHODS: A 67 year old man presented with sacral sarcoma. Sacralectomy with L5 corpectomy was performed and resulted in a 15 x 8 cm sized complex soft tissue defect in the lumbosacral area. There was no defect in the skin. Sacral stabilization with alloplastic fibular bone graft and reconstruction plate was done and the instruments were exposed through the wound. A 18 x 8 cm sized superior gluteal artery perforator flap was designed based on the superior gluteal artery perforator and deepithelized. It was turned over 180 degrees into the lumbosacral dead space. Soft tissue from both sides of the wound was approximated over the flap and this provided in double padding over the instrument. RESULTS: No complications such as hematoma, flap necrosis, or infection occurred. Until three months after the resection, functional disturbances in walking were not observed. The postoperative magnetic resonance imaging scan shows the flap volume was well maintained over the instrument. CONCLUSION: This superior gluteal artery perforator turn-over flap, a modification of the conventional superior gluteal artery perforator flap, is a simple method that enabled the successful reconstruction of a lumbosacral defect with instrument exposure without affecting ambulatory function.

Superior Gluteal Artery Perforator Turn-Over Flap Coverage for Lumboscaral Soft Tissue Defect in Ambulatory Patient

PURPOSE: Extensive lumbosacral defects after removal of spinal tumors have a high risk of wound healing problems. Therefore it is an effective reconstructive strategy to provide preemptive soft tissue coverage at the time of initial spinal surgery, especially when there is an instrument exposure. For soft tissue reconstruction of a lumbosacral defect, a variation of the gluteal flap is the first-line choice. However, the musculocutaneous flap or muscle flap that is conventionally used, has many disadvantages. It damages gluteus muscle and causes functional disturbance in ambulation, has a short pedicle which limits areas of coverage, and can damage perforators, limiting further surgery that is usually necessary in spinal tumor patients. In this article, we present the superior gluteal artery perforator turn-over flap that reconstructs complex lumbosacral defects successfully, especially one that has instrument exposure, without damaging the ambulatory function of the patient. METHODS: A 67 year old man presented with sacral sarcoma. Sacralectomy with L5 corpectomy was performed and resulted in a 15 x 8 cm sized complex soft tissue defect in the lumbosacral area. There was no defect in the skin. Sacral stabilization with alloplastic fibular bone graft and reconstruction plate was done and the instruments were exposed through the wound. A 18 x 8 cm sized superior gluteal artery perforator flap was designed based on the superior gluteal artery perforator and deepithelized. It was turned over 180 degrees into the lumbosacral dead space. Soft tissue from both sides of the wound was approximated over the flap and this provided in double padding over the instrument. RESULTS: No complications such as hematoma, flap necrosis, or infection occurred. Until three months after the resection, functional disturbances in walking were not observed. The postoperative magnetic resonance imaging scan shows the flap volume was well maintained over the instrument. CONCLUSION: This superior gluteal artery perforator turn-over flap, a modification of the conventional superior gluteal artery perforator flap, is a simple method that enabled the successful reconstruction of a lumbosacral defect with instrument exposure without affecting ambulatory function.

Aggressive Squamous Cell Carcinoma of the Scalp with Invasion into the Skull and Dura Mater

PURPOSE: Squamous cell carcinoma of the scalp sometimes exhibits unusually aggressive behavior. We report a case of extradordinarily aggressive squamous cell carcinoma of the scalp with invasion into the skull and dura mater. Method: The patient is a 38-year-old man with two cystic masses on the occipital area. He was diagnosed as squamous cell carcinoma in that region and have undergone surgical resections including cortical osteotomy of the skull, several years ago. On this occasion, 3-dimensional computed tomographic imaging revealed an erosive lesion on the occipital bone and magnetic resonance imaging showed two cystic masses invasion into the skull and dura mater. RESULTS: He has undergone wide resection of the masses and cranioplasty with dural repair. Histopathologic examination indicated squamous cell carcinoma with moderate differentiation of the masses, bone marrow and dura mater. CONCLUSION: Squamous cell carcinoma on the scalp can readily penetrate the full thickness of the cranium and invade the dura mater, sagittal sinus and brain. We suggest wide resection of the scalp and split thickness skin graft with sentinel lymph node biopsy, following by postoperative radiation therapy.

Aggressive Squamous Cell Carcinoma of the Scalp with Invasion into the Skull and Dura Mater

PURPOSE: Squamous cell carcinoma of the scalp sometimes exhibits unusually aggressive behavior. We report a case of extradordinarily aggressive squamous cell carcinoma of the scalp with invasion into the skull and dura mater. Method: The patient is a 38-year-old man with two cystic masses on the occipital area. He was diagnosed as squamous cell carcinoma in that region and have undergone surgical resections including cortical osteotomy of the skull, several years ago. On this occasion, 3-dimensional computed tomographic imaging revealed an erosive lesion on the occipital bone and magnetic resonance imaging showed two cystic masses invasion into the skull and dura mater. RESULTS: He has undergone wide resection of the masses and cranioplasty with dural repair. Histopathologic examination indicated squamous cell carcinoma with moderate differentiation of the masses, bone marrow and dura mater. CONCLUSION: Squamous cell carcinoma on the scalp can readily penetrate the full thickness of the cranium and invade the dura mater, sagittal sinus and brain. We suggest wide resection of the scalp and split thickness skin graft with sentinel lymph node biopsy, following by postoperative radiation therapy.

Arteriovenous Fistula on Forehead after Autologous Fat Injection: A Case Report

PURPOSE: Autologous fat injection is ideal for patients who wish to add contour, projection and gross volumization of the aging, atrophic face and is claimed to be a safe procedure. However, there are several case reports in the literature where patients have suffered from acute visual loss and cerebral infarction after facial fat injection. This paper explores a rare case of vessel related complication, an arteriovenous fistula that occurs after fat injection on forehead. METHODS: A 28-year-old female who showed a non- tender, soft 1.0x2.5cm sized mass on forehead for 3 weeks. A thrill could be detected on the tortuous dilatated vessel-like structure around the mass. She had a fat injection on forehead for soft tissue augmentation 3 months prior to developing the mass. 3-dimensional brain CT angiography showed arteriovenous fistula. RESULTS: The fistula is totally excised with ligation of feeding vessels. Pathology report showed an atypical vessel which had intimal thickening, myxoid degeneration and thrombus formation. There were no evidences of recurrence at least for 2 months of follow-up. CONCLUSION: An occurrence of arteriovenous fistula after autologous fat injection is very rare. After perforation of artery and vein by coincidence, blood extravasates with the formation of a hematoma capsule and a pseudocapsule around it. The hematoma capsule would expand and clot would reabsorb resulting in a cavity leading to fistula formation. Other vessel related complications like acute visual loss or cerebral infarction are very severe. Therefore, surgeons should be cautious during facial fat injection to avoid vessel injuries.

A Case of Leiomyoma of the Thumb

PURPOSE: Leiomyoma is a rare benign tumor of nonstriated muscles. Leiomyoma is most commonly found in the uterus or rarely occur in the hand. 150 cases of leiomyoma of the hand have been reported in the English literature; however, to the best of our knowledge only four of these have been in children and none were reported in Korean literature. We present a case of leiomyoma in the hand of a 8-year-old boy, which is a rare site for localization and unusual for age. METHODS: A 8-year-old boy presented with a painless mass on the ulnar side of his thumb. Physical examination revealed a 1.2x1.2cm round, rubbery mass that was nontender to palpation. The vascular, sensory, and motor exams were otherwise unremarkable. Further evaluation with CT demonstrated an enhancing mass at dorsoulnar aspect of 1st proximal phalangeal region suggestive of a hemangioma versus other enhancing solid mass. The diagnosis of a leiomyoma was confirmed following surgical excision with histologic evaluation. RESULTS: In 3 months follow-up, the incision was healed, motor and sensory function were intact, and full range of motion was recovered. Neither recurrence nor postoperative complication were observed. CONCLUSION: Leiomyoma is a rare tumor of the hand, especially in children. Diagnosing hand tumors in children is more difficult than in adults, hand surgeons should be aware of the diagnostic possibilities based on examination and imaging of a hand tumor; however, surgical excision with histologic examination is required for definitive diagnosis.

Great Toe Pulp Graft for the Reconstruction of the Postburn Flexion Contracture in the Fingers

PURPOSE: In case of postburn flexion contracture of the fingers, skin graft, geometrical relaxation techniques, local flap, and free flap have been used. Among these procedures, full-thickness skin grafts from the inguinal area are widely used to reconstruct a postburn flexion contracture in the fingers. But there are many esthetic and functional problems in this procedure. Especially, hyperpigmentation of the skin-grafted fingers poses a troublesome problem, particularly in the patients who have dark colored skin. To solve the problem, we have used pulp graft which was harvested from the lateral aspect of great toe. In the present study, we report pulp graft, with which we have obtained a good result in the treatment of postburn flexion contracture of the fingers. METHODS: Between September of 2004 and August of 2006, great toe pulp graft was performed to 20 sites of 15 patients. After release of the postburn flexion contracture using Z-plasty, the composite tissue (pulp) harvested from the lateral aspect of great toe was grafted on the raw surface. Moisture dressing with ointment and foam dressing material was performed. Stratum corneum of the graft got stripped off in two to four weeks after pulp graft. The color of the pulp graft was slightly reddish, then it became similar to the adjacent tissue. RESULTS: There was complete take in all the patients who were treated with pulp graft. Great toe pulp graft provided similar color and texture to the adjacent skin, high rate of graft take, and left only a minimal scar at donor site. CONCLUSION: Thick keratin layer and inelastic nature of the pulp make this type of the graft much easier and simpler, and ensure a better take. Pulp graft is useful method for the reconstruction of the postburn flexion contracture in fingers.