A patient with macrodystrophia lipomatosa bilaterally affecting the entire upper extremity: reporting of a rare case and literature review.

The patient, a 58-year-old Asian female, had the progressive, bilateral overgrowth of the entire upper extremity since her childhood and has undergone debulking surgery twice in her country. However, overgrowth progressed after surgery. The patient was diagnosed with Macrodystrophia lipomatosa (MDL) by physical and imaging findings in our departments.

[Anterior Interosseous Nerve Palsy with Isolated Flexion Palsy of the Thumb or Index Finger as an Initial Symptom:Two Case Reports].

Case 1: A 73-year-old man who had undergone neurolysis for right cubital tunnel syndrome complained of difficulty using chopsticks. Froment's sign test showed that the interphalangeal(IP)joint of the right thumb that had flexed preoperatively was extended. This finding was considered to indicate recovery from ulnar neuropathy, and the patient was closely followed up. One year later, the patient was unable to push a camera shutter button and was unable to flex the IP joint of the thumb and the distal interphalangeal(DIP)joint of the index finger, a characteristic symptom of anterior interosseous nerve(AIN)palsy. Therefore, the patient underwent AIN neurolysis and subsequently reported slight improvement in his condition. Case 2: A 60-year-old woman reported difficulty performing computer mouse clicks with her right hand. As flexing the index finger DIP joint was difficult, a local lesion was suspected, and the patient was closely followed up. One year later, the patient was unable to push the button of a ballpoint pen with her thumb. Extension of the thumb and index finger indicated AIN palsy. The patient refused treatment and was only followed up. The following year, the patient reported that the weakness improved. Simultaneous flexion palsy of the thumb and index finger can lead to a diagnosis of AIN palsy. However, flexion palsy of a single finger in incomplete AIN palsy, as reported here, is often overlooked because of its similarity to the flexor tendon rupture. Awareness regarding this incomplete form of AIN palsy is needed for early and correct diagnosis.

[Lymphorrhea at the Site of Repeated Fascia Lata Harvesting:A Case Report].

This 74-year-old man had undergone a third re-operation for anaplastic meningioma in the convexity six weeks before he was referred to us. He presented with a bulge on the lateral aspect of the left thigh. We observed a fresh fascia lata harvesting scar that extended peripherally from an old proximal scar. The bulge was colorless. The aspirated subcutaneous fluid(more than 200mL)was watery and yellowish;there was no evidence of abscess or hematoma. Although the bulge shrank after aspiration and the placement of a compression bandage, it recurred in three days. Surgery-associated lymphorrhea was the diagnosis given. Goreisan, a herbal medicine for hydrostatic modulation, was administered. One week later, the bulge diminished in size. Harvesting of the fascia lata in the lateral aspect of the thigh is usually safe. However, additional dissection and peripheral extension due to repeated harvesting risks damaging the superficial lymphatic pathways because of scar formation after earlier surgeries and the hyperdense distribution of the lymphatic pathways in the peripheral part. When subcutaneous fluid collection after fascia lata harvesting is refractory, lymphorrhea must be considered in the differential diagnosis.

[Formation of a Subcutaneous Amputation Neuroma after Incomplete Endoscopic Carpal Tunnel Release Resulting in Complex Regional Pain Syndrome:A Case Report].

This 64-year-old woman had undergone endoscopic carpal tunnel release(ECTR)for right carpal tunnel syndrome 16 months earlier. Thereafter, she reported persistent dysesthesia in the thumb and index finger, developed burning pain in the middle and ring finger, paleness, coldness, and edema of the hand, a decreased range in hand motion, and a painful subcutaneous nodule just distal to the portal in the forearm. Based on physical, radiological, and electrophysiological studies, the diagnosis was incomplete carpal tunnel release associated with complex regional pain syndrome(CRPS). At open revision surgery, the carpal tunnel was released completely and the nodule was removed. Symptoms other than hypesthesia in the middle and ring fingers improved. Pathologically, the nodule was an amputation neuroma. Her CRPS was attributed to ECTR complications; i.e., persistence of median nerve compression and the formation of an amputation neuroma in the palmar cutaneous branch of the ulnar nerve at the portal. Surgeons must be aware that ECTR, a less invasive technique, may result in serious complications including CRPS.

Video-assisted thoracic surgery and jejunal reconstruction in a case of situs inversus totalis with esophageal cancer.

A 78-year-old man with situs inversus totalis who had a previous history of distal gastrectomy for gastric cancer was referred to our hospital for treatment of esophageal cancer. He was diagnosed as cT2N0M0 and underwent video-assisted thoracic surgery and open completion gastrectomy with jejunal reconstruction via the ante-thoracic route. The postoperative period was uneventful except for transient palsy of the right recurrent laryngeal nerve. Based on a preoperative assessment of anatomical abnormality and an intraoperative adaptation to the mirror image of the standard procedure, video-assisted esophagectomy was considered safe and feasible. It can be recommended for patients with esophageal cancer complicated by situs inversus totalis. This is the first case report of a patient with situs inversus totalis who underwent video-assisted esophagectomy with jejunal reconstruction. Relevant literature is also discussed and reviewed.

Five-year efficacy of finasteride in 801 Japanese men with androgenetic alopecia.

Finasteride is standard medical treatment for androgenetic alopecia; however, no large studies with 5 years or more of follow up have been performed in Japan. The authors followed Japanese men with androgenetic alopecia treated with finasteride for 5 years to evaluate long-term treatment efficacy. Of 903 men treated with finasteride (1 mg/day), 801 patients were evaluated over 5 years by modified global photographic assessment. Although the proportion of improvement was high (99.4%), modified global photographic assessment scores after 5 years of treatment were lower in patients with more advanced disease as measured by the modified Norwood-Hamilton scale. After separating patients into "sufficient" and "insufficient" efficacy groups according to the modified global photographic assessment score after 5 years (scores ≥6 and <6, respectively), multivariate analysis showed that independent risk factors of insufficient efficacy were age at start of treatment of 40 years or more (P = 0.021) and classification on the modified Norwood-Hamilton scale (P < 0.001), whereas presence of stress at start of treatment was a negative predictor (P = 0.025). In conclusion, continuous finasteride treatment for 5 years improved androgenetic alopecia with sustained effect among Japanese. Younger age and less advanced disease at start of treatment were the key predictors of higher finasteride efficacy.

Free flap transfer to preserve main arterial flow in early reconstruction of open fracture in the lower extremity.

The selection of recipient vessels is crucial when reconstructing traumatized lower extremities using a free flap. When the dorsalis pedis artery and/or posterior tibial artery cannot be palpated, we utilize computed tomography angiography to verify the site of vascular injury prior to performing free flap transfer. For vascular anastomosis, we fundamentally perform end-to-side anastomosis or flow-through anastomosis to preserve the main arterial flow. In addition, in open fracture of the lower extremity, we utilize the anterolateral thigh flap for moderate soft tissue defects and the latissimus dorsi musculocutaneous flap for extensive soft tissue defects. The free flaps used in these two techniques are long and include a large-caliber pedicle, and reconstruction can be performed with either the anterior or posterior tibial artery. The preparation of recipient vessels is easier during the acute phase early after injury, when there is no influence of scarring. A free flap allows flow-through anastomosis and is thus optimal for open fracture of the lower extremity that requires simultaneous reconstruction of main vessel injury and soft tissue defect from the middle to distal thirds of the lower extremity.

Clinical features of primary vein grafts in free tissue transfers.

The outcomes of free tissue transfers combined with vein grafts have been inconsistent, and discussions continue regarding their appropriate use. Of the 142 free tissue transfers that we performed from January 2004 to December 2011, we retrospectively analyzed 15 consecutive patients who underwent free tissue transfers in combination with vein grafts. Etiologies included trauma (8 patients), infection (4), and tumor (3). Types of free tissue transfers were fibula (4), anterolateral thigh (3), groin (3), jejunum (3), latissimus dorsi (1), and dorsal pedis (1). Vein grafts were used for the artery (6), vein (2), or both (7). The donor veins were the saphenous vein (12) and the external jugular vein (3). The mean length of the grafted veins was 10.8 cm (range: 4-18 cm). Even though complications of congestion occurred in 2 patients, these flaps survived by reexploration. The flap success rate was 15 of 15 (100%) of vein grafted free flaps versus 124 of 127 (97.6%) of free flaps not requiring vein grafts. To improve the success rate of free tissue transfers combined with vein grafts, securing healthy recipient vessels, meticulous surgical handling, a reliable vascular anastomosis technique, and strict postoperative monitoring are crucial.

Single-stage reconstruction of a full-thickness alar defect using a folded nasolabial flap combined with a redundant skin turnover flap.

BACKGROUND: The reconstructive strategy for full-thickness nasal skin defects should include recreation of a cutaneous cover, support, and internal nasal lining. The most challenging aspect of this procedure is provision of the nasal lining. These reconstructions typically require a 2-step process. Satisfactory nasal skin reconstruction in a single operation is ideal. OBJECTIVE: We used a folded nasolabial flap combined with a turnover flap for reconstruction of full-thickness alar defects. METHODS: The donor material of the lining flap was a combination of the distal portion of the nasolabial flap and redundant skin resected during its transposition. The redundant skin flap was turned upside down, with the skin surface inside the nasal cavity. The remaining portion of the defect was covered with a folded nasolabial flap. RESULTS: This procedure was successful in all 5 patients. All flaps survived completely without evidence of necrosis or narrowing of airways. Aesthetic concerns, including effacement of the nasofacial sulcus, were minor. CONCLUSION: This method has the advantage of providing well-vascularized tissue of appropriate color, texture, and thickness for external coverage, as well as a satisfactory internal lining in a single-stage procedure.

Charting weight four times daily as an effective behavioural approach to obesity in patients with type 2 diabetes.

Although many obese people successfully lose weight by dieting and/or behavioural therapy, most of them subsequently regain the lost weight. Thus, new therapeutic strategies are required to maintain weight loss. We report a woman with type 2 diabetes and moderate obesity who succeeded in achieving good glycaemic control and long-term weight loss with weaning from insulin therapy, while charting her weight four times daily. This charting method might be useful for long-term maintenance of weight reduction in obese diabetic patients. Obese patients can monitor their irregular weight fluctuations produced by overeating and correct both their food intake and their lifestyle. Further studies, including randomized control trials, will be needed to confirm the efficacy of this approach in patients with type 2 diabetes.

Surgical management of breast deformity in a young patient with localized scleroderma: a case report and literature review.

Localized scleroderma in the chest region of adolescent girls leads to incomplete breast development and breast asymmetry, for which patients may require treatment. The site of localized scleroderma, its activity, the surgeon, and the patient's desires influence the selection of treatment method. There have been few reports on surgical treatment of this disease. In the current report, we present a case in which improved breast asymmetry was achieved through multiphased surgery, and we review treatment methods and indications of this disease.

Preoperative risk factors of lymph node metastasis in cutaneous squamous cell carcinoma.

Lymph node metastasis of cutaneous squamous cell carcinoma ("SCC") affects the prognosis. A variety of risk factors of lymph node metastasis have been reported. Predicting lymph node metastasis prior to surgery, which is a major treatment method for cutaneous SCC, contributes to the effects of treatment. Factors that can be obtained prior to surgery were weighed between a lymph node metastasis group and a non-metastasis lymph node group. One hundred and sixty-four cutaneous SCC patients were operated on. The following factors, which can be obtained prior to surgery, were compared between the lymph node metastasis group and the non-metastasis lymph node group: age, sex, tumour size, symptom period, lesions, and local recurrence. The detection rate from lymph node metastasis of the sentinel lymph node biopsy using the blue dye technique was studied. Among all subjects, lymph node metastasis was observed in 17 cases (10.4%). Lower lip SCC was observed only in the higher metastasis rate. Significant local recurrence occurred more frequently in the lymph node metastasis group. For other factors, no significant difference was observed between the lymph node metastasis group and the non-metastasis lymph node group. A sentinel lymph node biopsy was given in 21 cases, two false-negative cases were observed, and local recurrence and lymph node metastasis were observed postoperatively. Operation should be given to the lower lip SCC and local recurrence cases considering lymph node metastasis. It is hard to say that the sentinel lymph node biopsy of cutaneous SCC using the blue dye technique has sufficient detection rates.

Proliferative diabetic retinopathy is a predictor of coronary artery disease in Japanese patients with type 2 diabetes.

A retrospective cohort study was performed to investigate the relationship between diabetic retinopathy and coronary artery disease in 371 Japanese adult patients with type 2 diabetes. We found that proliferative retinopathy was significantly associated with an increased risk of coronary artery disease, even after adjustment for classical coronary risk factors.

Medical treatment for burn patients with eating disorders: a case report.

There have been many cases of burn patients who also suffer from psychiatric problems, including eating disorders. We present a case of a 38-year-old female with an eating disorder and depression who became light-headed and fell, spilling boiling water from a kettle on herself at home sustaining partial thickness and full thickness burns over 5% of her total body surface area: left buttock and right thigh and calf. Eating disorders (in the present case, anorexia nervosa) cause emaciation and malnutrition, and consent for hospitalization from the patient and/or family is often difficult. During the medical treatment of burns for these patients, consideration not only of physical symptoms caused by malnutrition but also the psychiatric issues is required. Therefore, multifaceted and complex care must be given to burn patients with eating disorders.

Three-dimensional analysis of forehead wrinkles.

It is important to understand the anatomical characteristics of forehead wrinkles in order to perform a forehead lift. This study aimed to elucidate the mutual relationships among tissues composing the forehead using computer software that enables the stereoscopic observation of the tissues studied in arbitrary directions. The specimens were obtained from five cadavers and prepared in serial sagittal sections. Three-dimensional images were prepared by inputting the forehead wrinkle data obtained from serial sagittal sections. Consequently, the forehead skin was found to be fixed to the superficial galea aponeurotica through fibrous septa, suggesting that movement of the frontalis muscle would be transmitted to the skin, not through the fibrous septa alone, but from the superficial galea aponeurotica closely attached to the frontalis muscle through the fibrous septa. Since the forehead muscles exhibit a stereostructure where the corrugator supercilii muscle supports three superficial forehead muscles, including the frontalis muscle, the orbicularis oculi muscle, and procerus muscle on the periosteal side, it was presumed that a sufficient effect would not be attained unless the corrugator supercilii muscle was operated on concurrently in conjunction with these muscles during a procedure involving the superficial forehead muscles in a forehead lift. Based on the findings from the three-dimensional images obtained, effective tissue treatments could be achieved by performing (1) dissection between the superficial galea aponeurotica and the frontalis muscle, (2) dissection between the deep galea aponeurotica and the periosteum, and (3) a procedure incorporating the forehead muscles in order.