Basal cell carcinoma with signet ring cell morphology accumulating the ubiquitinated cytokeratin 5/6.

Basal cell carcinoma (BCC) showing signet ring (SR) cell morphology is a very rare variant of BCC. Here, we report BCC with SR cell morphology developed in the right cheek skin of a 79-year-old man. Histopathologic examination showed irregularly shaped islands of basaloid cells with characteristic peripheral palisading. Inside of the cancer islands, many tumour cells showed an enlarged fine granular cytoplasm with the peripherally compressed nuclei, being similar to the SR cell. Immunohistochemical examination revealed dense accumulation of cytokeratin (CK) 5/6 and a faint signal of 34ßE12 in SR cells. The reported myoepithelial markers were not detected. Interestingly, ubiquitin, a component of the ubiquitin-proteasome protein degradation system, was co-localised in the SR cells. These suggest, for the first time, that accumulation of the undegraded CK5/6 with ubiquitination results in the SR cell morphology. Our report showed that the aberrant keratin turnover is associated with the SR cell BCC.

The Modified 3-square Flap Method for Reconstruction of Toe Syndactyly.

Bandoh reported the 3-square-flap method as a procedure for interdigital space reconstruction in patients with minor syndactyly. We recently modified this flap design so that it could be used in the treatment of toe syndactyly involving fusion of the areas distal to the proximal interphalangeal joint. With our method, the reconstructed interdigital space consists of 4 oblong flaps (A through D). Flaps A and D are designed on the dorsal side, flap B is designed on the frontal plane of the interdigital space, and flap C is designed on the plantar side. Flaps A, B, and C are raised immediately below the dermis in a manner that allowed slight fat tissue to adhere to each flap. Flap D is freed to a degree minimally needed for dislocation, while leaving a thick subcutaneous pedicle. Flaps A, B, and C are each folded in 90 degrees; flap D is dislocated to the proximal plane of the reconstructed digit, followed by skin suturing. In this process, suturing is avoided between flaps A and C, between flaps A and D, and between flaps B and D. During the period of 2011 to 2015, we treated 8 patients of toe syndactyly involving fusion distal to the proximal interphalangeal joint. Cases of congenital syndactyly received surgery between the ages of 8 and 11 months. Using this technique, flap ischemia/necrosis was not observed. During the postoperative follow-up period, the interdigital space retained sufficient depth without developing any scar contracture. No case required additional surgery.

Usefulness of Titanized Polypropylene Mesh and an Anchor System for Correction of Lower Lid Retraction.

Because of the lower eyelid's free edge anatomy, it is difficult to preserve its contours after reconstruction. We recently attempted a new operative procedure to treat 2 cases of lower lid retraction by using a titanized polypropylene mesh and an anchor system. As the lower lid skin is elevated laterally in an oblique upward direction, the location of the mesh insertion is decided and the site is marked accordingly. The mesh to be inserted is approximately 20 × 10 mm. A skin incision is rendered from the medial to the lateral side of the lower eyelid edge, and the line of incision is raised beyond the lateral canthus along the skinfold. The mesh insertion site is then developed in the deep fat layer. After hemostasis, the mesh is densely sutured with the fat tissue. Next, the lateral orbital rim is exposed under the periosteum, and 2 anchors, each 2 mm in diameter, are driven into place. The thread connected to each anchor is passed through the mesh and subcutaneous tissue and placed in the lateral orbital rim. Excess skin is trimmed, and the wound is closed. Both patients had complained of dry eye and lacrimation before treatment. No postoperative complications were observed, and in both cases, the symptoms disappeared, and the patient's appearance was improved. During the follow-up period, which lasted from 15 to 29 months, elevation of the lower eyelid edge was kept at a favorable level, and neither case exhibited a relapse of retraction.

Usefulness of Simple-Designed Bilobed Flap for Reconstruction of Ischial Decubitus Ulcer.

The pressure ulcer of the ischial region is often accompanied by complete paraplegia in patients with spinal cord injury and is attributable to the compression and breakdown of tissue arising from constant sitting. Characteristically, a pressure ulcer of this region is circular and deep. We recently reconstructed ischial decubitus ulcer of 8 patients using simple-designed bilobed flap. In all cases, the flap survived completely without any complication. Moreover, none of the patients in this group experienced any pressure ulcer relapse during the postoperative follow-up from 1 year 1 month to 9 years. In the vicinity of the ischial region, the buttock contains the most abundant amount of fatty tissue. Therefore, for our technique, we create the first flap in the buttock neighboring the defect and the second flap on the posterior thigh. Using this approach, it is possible to cover the skin or soft tissue defect of the ischial region with the flap from the buttock having a thickness large enough to bear the patient's weight during sitting. The first flap is arranged parallel to the gluteal sulcus, and the second flap from the thigh is moved to the first-flap donation site. This technique allows closure of the wound without producing tension along the suture line. The bilobed flap, which does not require the artery to be included in the flap, is applicable for patients with relapsing pressure ulcer having a history of surgery. Our flap operative procedure is particularly useful in the reconstruction of ischial decubitus ulcer.

Usefulness of S-shaped Incision in Large Nevus Sequential Excision.

SUMMARY: We devised the S-shaped incision as a technique for large nevus sequential excision. Using this technique reduces the number of operations needed to complete nevus resection and also shortens the final length and width of the scar. We report this technique after performing it on 7 patients and confirming its usefulness.

Usefulness of Ω-shaped Incision in Skin Tumor Excision.

SUMMARY: We devised the Ω-shaped incision as a technique for skin tumor resection on the areas of skin with an arc-shaped fold. With this technique, the dog-ear that is formed during 6 wound closure can be resected within the range of the first skin incision. We report this technique after performing it on the face or trunk of 18 patients and confirmed its usefulness.

A new surgical procedure for little toe polysyndactyly without skin graft.

We developed a new operative procedure involving the combination of 5 flaps to treat little toe polysyndactyly. We applied this procedure to 4 toes of 3 patients who had severe polysyndactyly involving skin fusion of the area from the distal interphalangeal joint to the periphery. In all 3 patients, this procedure allowed easy transfer of the flaps, caused no tension to the wound during skin suturing, and did not disrupt blood flow through the flap. The morphology of all 4 toes was favorable, and no scarring was evident. A sufficiently deep fourth interdigital space was created with this procedure without the need for skin grafting.

Rhomboid flap with multiple Z-plasty for treatment of hypertrophic scar on the pubic area.

The pubic area is prone to the development of hypertrophic scars; however, few studies have reported on the valid means of treating hypertrophic scars affecting this area. We have recently devised a new operative procedure, 'rhomboid flap with multiple Z-plasty', for the treatment of this condition. For this operative procedure, the defect after resection of the scarred tissue in the pubic area is first covered with a rhomboid flap elevated from the hypogastric area, followed by applying multiple Z-plasty to the suture wound of the donor site. By avoiding excessive suturing of the defect in the pubic area, and by covering the defect with a rhomboid flap, the tension on the wound margin can be sufficiently reduced. This is followed by multiple Z-plasty for the longitudinal wound of the hypogastric area, erasing all suture lines perpendicular to the natural folds. Here, we report two cases that underwent this procedure with favourable outcomes.

Treatment of severe deformities of the toenails by the modified Zadik method with artificial skin.

A number of operations have been devised to treat ingrowing toenails and pincer nails, and they have given good aesthetic and functional results. However, there have been few reports of operations for the treatment of severe nail deformities caused by damage to the matrix of the nail by injury, or by inappropriate removal of the nail or intractable onychomycosis or cardiovascular or neurological disorders. In 1950, Zadik reported a radical technique for ingrown nails and pincer nails: after avulsion of the nail, the matrix was excised completely and the posterior nail wall was sutured to the nail bed as an advancement flap. We have treated 23 severe deformities other than ingrown nails and pincer nails in 14 patients by the modified Zadik method with artificial skin. As a result, symptoms including pain were alleviated in all patients. The nail plate did not regenerate, and no patient had aesthetic complaints.

Correction of auricular deformity caused by high ear-piercing: case report.

In recent years, high ear-piercing and wearing earrings in the cartilaginous region of the auricle have become popular. The frequent occurrence of subsequent complications also has been pointed out. The present case is of a 17-year-old girl with an auricular deformity caused by infections occurring after piercing in the scapha. The authors performed an auriculoplasty by excision of the deformed cartilage and autologous cartilage graft from the ipsilateral concha. At present, 1 year and 5 months after the operation, no sign of recontracture is noted, and the auricle remains in a gratifying shape.

Exposed artificial bone in the forehead covered with a transverse orbicularis oculi myocutaneous flap.

We have reconstructed the forehead by covering exposed artificial bone with a transverse orbicularis oculi myocutaneous flap. This technique had the following advantages: good circulation in the flap extended the arc of rotation; the flap matched the forehead in colour and texture; the scar of the flap donor site was not conspicuous, and no dysfunction was seen; and the technique is simple and not invasive.