Rotational V-Y Fasciocutaneous Advancement Island Flap to Cover Deep Sacrococcygeal Defects due to Pilonidal Disease, Pressure Ulcers, and Other Inflammatory Conditions.

The sacrococcygeal area supports the lower body and endures mechanical forces during movement. However, current treatment methods for deep caudal sacrococcygeal defects have limitations, resulting in insufficient tissue for deep pocket obliteration and considering only the two-dimensional advancement plane in a three-dimensional defect topology. Our study proposes using a rotational V-Y fasciocutaneous advancement island flap to reconstruct deep caudal sacrococcygeal defects. By considering the three-dimensional nature of the defect, we distinguish a coccygeal plane of the V-Y flap from a sacral plane and set different directions and depths of movement for each plane. From March 2016 to July 2022, 12 patients underwent successful treatment with this surgery, and no complications or recurrences were observed in the study group. Our research found that patients in our study exhibited a smaller intercoccygeal angle than the average angle of the general Korean population, as previously reported. This implies a more pronounced curvature between the sacral and coccygeal planes. Therefore, our methods, which consider the three-dimensional structures of sacrococcygeal pathology, are significant. This technique provides a mechanically robust reconstruction after resecting deep sacrococcygeal pathology, with well-padded tissue to prevent dead space and wound disruption.

The changes of distance between nipples following correction of women pectus excavatum.

The breasts in women pectus excavatum patients frequently appear to be slanting medially along the inclination of the distorted ribs. This study aims to evaluate changes in the distance between the nipples and to find out whether medially slanting breasts are corrected in women pectus excavatum patients following modified Nuss procedure. This case series analysis enrolled 22 young women patients with pectus excavatum between October 2011 and September 2020. We measured all the patients' distances from the sternal midline to the right and left nipples, based on chest computerized tomography. We calculated the distances between nipples as being the sum of the right and left distances. The mean age of patients was 16.50 ± 4.73 years, and the follow-up periods were 35.59 ± 20.23 months. The postoperative Haller indices (2.89 ± 0.43) were significantly lower than the preoperative Haller indices (5.14 ± 1.96) (p = 0.000). The distances between the nipples before and after Nuss procedure were 145.17 ± 17.73 mm and 172.29 ± 19.11 mm, which is a significant increase following surgery. (p = 0.000). Our results demonstrated that skeletal correction with modified Nuss procedure in pectus excavatum increased the distance between nipples, indicating that medially slanting breasts had been corrected.

Angioleiomyoma of the Parotid Gland Fed by the Superficial Temporal Artery.

Angioleiomyoma in the head and neck area is rarely observed. This report introduces 2 cases of angioleiomyoma discovered in the parotid gland, particularly with the superficial temporal artery (STA) as the feeding vessel. Each patient was evaluated preoperatively by clinical manifestation and computed tomography scan, but the difficulty was encountered due to nonspecific radiologic features of angioleiomyoa. Surgical intervention was performed for precise diagnosis and treatment. The tumors were fed from the STA, with the diagnosis of venous type parotid angioleiomyoma. To our knowledge, there have been only one previous report of angioleiomyoma of the parotid gland fed from STA in the literature. Once parotid tumor is discovered, although rare, the possibility of angioleiomyoma should be considered, and the authors recommend prompt surgical excision for accurate diagnosis and treatment.

Full-Thickness Skin Graft according to Surrounding Relaxed Skin Tension Line Improves Scar Quality in Facial Defect Coverage: A Retrospective Comparative Study.

A full-thickness skin graft (FTSG) is useful for covering small skin and soft tissue defects. In this paper, we suggest FTSG in consideration of the relaxed skin tension line (RSTL) concept for scar quality improvement since FTSG has disadvantages, including contour irregularities and mismatches of color and texture. We conducted a retrospective chart review of twenty-one patients with skin cancer on the face who underwent wide excision and FTSG by a single surgeon from October 2013 to July 2019. Twenty-one patients with skin cancer on the face were divided into RSTL-matched and RSTL-unmatched groups, and FTSG was performed. Each group was subjected to scar assessment three months after surgery. Observer assessment was performed by five independent observers using the observer component of the patient and observer scar assessment scale (POSAS) and Vancouver scar scale (VSS). Our results indicate that there were significant differences between the RSTL-matched and RSTL-unmatched groups in the VSS and POSAS components. In addition, the RSTL-matched group showed a natural appearance with surrounding tissue in the dynamic animation phase compared to the unmatched group. RSTL-matched FTSG can be an attractive option for face skin and soft tissue defect coverage. (An earlier version of this paper has been presented at the International Conference on PRS Korea 2020.).

Traction Applying Technique on Bicanalicular Crawford Silicone Tube to Overcome the Notching Deformity After Lacrimal Canalicular Repair.

ABSTRACT: Lower eyelid avulsion injury with lower canalicular laceration generally occur just medial to the punctum with insufficient skin remnant for repair causing tension on repair margins. The inevitable blinking force, along with the tension widens the repair margin, resulting in an aesthetically challenging notch at the medial lower lid. The authors attempted to minimize this notching deformity with a traction applying technique on bicanalicular silicone tube.Fifteen patients were enrolled and divided into 2 groups: the experimental group with 10 patients which received the traction technique, and the control group with 5 patients which the traction technique was omitted. Each end of the bicanalicular silicone tube was intubated through both puncta and the lacerated canaliculus. No canalicular anastomosis was performed. The tube ends were retrieved through the nostril, followed by medial canthal tendon, orbicularis oculi muscle, and skin repair. The tube ends were pulled to create a tension on the loop, until upper and lower puncta apposed each other, creating a dimple in the medial canthal area. The tube ends were tied and anchored at internal valve of the nostril to maintain the traction tension. Medial lower lid notching (>2 mm width), epiphora, and conjunctival injection were evaluated and compared in the 2 groups.Patients with traction technique showed symmetric medial canthal angle and minimized lower lid notching deformity when compared with the control group (P = 0.025). No conjunctival injections and epiphora were observed in either group. Symmetric and aesthetically satisfactory results were achieved by traction applying technique on bicanalicular silicone tube.

Shape memory alloy as an internal splint in a rat model of excisional wound healing.

The purpose of an animal wound model is to replicate the wound healing process of humans as accurately as possible. Although rodents are attractive candidates for animal wound models, the drawback is that their major wound healing occurs by contraction, which is fundamentally different from that seen in humans, where healing is achieved mainly by re-epithelialization and granulation tissue growth. There has been an attempt to overcome such drawbacks by applying an external splint on wounded mice. This model, however, has a few problems concerning the assimilating ability of external splints with the dynamic soft tissue movements and robustness issues. The authors hereby describe a new animal wound model using an internal splint made of nitinol, one of the shape memory alloys (SMAs). SMA wire was inserted intradermally around the full-thickness excisional wound to act as the internal splint, and its ability to impede wound contraction was analyzed. In experiment 1, three different sizes of SMAs (0.18 mm, 0.24 mm, and 0.30 mm diameters of thickness) were inserted as the internal splint and their ability to impede the wound contraction was compared. The most effective size of SMA as the internal splint was selected among them. In experiment 2, contraction of the wound with the selected size of SMA inserted as the internal splint was compared with that of the unsplinted wound. SMA as an internal splint effectively impeded wound contraction without affecting the re-epithelialization rate, thereby successfully mimicking the human wound healing mechanism. In this study, the authors introduce a novel animal wound model that replicates the human wound healing mechanism. This model is robust, reliable, and easily reproducible.

Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction.

ABSTRACT: Neurogenic blepharoptosis after orbital wall reconstruction is a rare complication. It can either present as an isolated blepharoptosis, or accompany with other ocular symptoms. The authors introduce 4 cases of post-operative neurogenic blepharoptosis after reconstruction of medial orbital wall via transcaruncular approach.Immediately after the surgery, 2 adolescent patients experienced unilateral islolated complete blepharoptosis with no other ocular symptoms. The other 2 adult patients presented unilateral complete blepharoptosis accompanied by lateral displacement of the globe and evident extraocular movement limitations. The 2 adolescent patients were observed with no particular treatment, whereas the other 2 adult patients were treated with intravenous systemic steroids. The blepharoptosis symptom began to improve at 2 weeks post-operatively and completely recovered within 3 to 4 months in all patients, while the globe displacement and extraocular movement limitation started to improve at 4 weeks after the surgery and fully recovered within 6 months.Although neurogenic blepharoptosis after medial orbital wall reconstruction is a very rare complication, it can be critical once it occurs. According to the author's experience, it fortunately shows a favorable clinical course of spontaneous recovery. Post-operative neurogenic blepharoptosis usually recovers between 2 weeks and 4 months and other ocular symptoms related to oculomotor nerve injury recovers within 6 months after the surgery.

Multimodal Conservative Treatment of Complicated Open Wound After Total Knee Replacement Arthroplasty in Patients With Comorbidities.

Total knee replacement arthroplasty is a common procedure and postoperative wound complications are sometimes inevitable. Although invasive reconstructive surgery may be an option for nonhealed wounds, such procedures can limit early rehabilitation, adversely affecting the range of joint motion. Patients can achieve a wider range of motion if they undergo early rehabilitation with a conservative approach. From 2015 to 2017, 5 patients with comorbidities who underwent total knee replacement arthroplasty were referred to the reconstructive surgery department for nonhealed open wounds. Depending on their comorbidities and conditions, the patients underwent negative-pressure wound therapy based on multimodal conservative treatment. During the treatment, the patients continued rehabilitation. In the 5 patients, the mean duration of complete wound healing was 65.2 days (range = 57-81), during which all open wounds were well healed. For final wound closure, the patients underwent skin grafting, dermatotraction, or collagen dressing. Four patients achieved ranges of joint motion over 100 degrees after treatment. We believe that early coverage is important for open wounds. For complicated open wounds after total knee replacement arthroplasty in patients with comorbidities, less invasive multimodal treatment along with early rehabilitation may be more effective to achieve adequate final range of joint motion.

Antihelical Auricular Reconstruction With Adipoperichondrial Turnover Flap and Full-thickness Skin Graft.

ABSTRACT: Reconstruction of the antihelical area can be challenging because the cartilage can be easily exposed due to the thin overlying soft tissue, and it has a lack of tissue mobility. Skin graft can be hesitant to perform in antihelical defects where the bare cartilage is exposed.A 70-year-old male with squamous cell carcinoma of the antihelix of the left ear was referred to our department for surgical excision. Wide excision with tumor-free margins resulted in a defect of 2.0 × 1.0 cm with exposed bare cartilage. The authors covered the defect using adipoperichondrial turnover flap from cephalic portion of the earlobe followed by full thickness skin graft. The skin graft took well with no complication. Aesthetic result was satisfactory with no auricular deformity.This adipoperichondrial turnover flap is simple, easy, can be performed in one stage, and produces good esthetic results with no disfiguration of the ear shape.

Split Calvarial Bone Graft for Reconstruction of Skull Defect in Langerhans Cell Histiocytosis.

Langerhans cell histiocytosis (LCH) is a rare disease in which histiocytes proliferates in several tissues. It mainly occurs in children between 1 and 15 years of age, and affects bone especially the skull being the most common site of invasion. It is desirable to reconstruct the skull defect after surgical removal of the lesion with autologous bone considering the fact that this disease affects children who continuously experience the deformation and growth of the frontal head. We introduce a case report who reconstructs the skull defect using split calvarial bone graft in LCH. A 3-year-old male visited the hospital with a painful, palpable protruding mass in the frontal area lasting 1 month. Craniectomy with skull tumor removal was performed by neurosurgeon, after that we harvested a calvarial bone graft and carefully separated the outer cortex from the inner cortex. Then, we covered the donor site with the inner cortex while covered the bone defect with the outer cortex and fixed with absorbable plates. The patient showed palpable mass at 1-year follow-up but it disappeared. After 5 years, there was no recurrence, the lytic lesion of the skull was resolved, and showed cosmetically good result. We conclude that the palpable lesion was more likely to be the result of postoperative swelling of the plate. We propose split calvarial bone graft as a good treatment option for reconstruction of the skull defect in LCH.

Epidermal Inclusion Cyst Formation After Barbed Thread Lifting.

Barbed thread lifting is a widely used method because it is easier to learn, faster, and the lower frequency of complications than the invasive lifting technique. The number of reported cases about complication requiring an invasive procedure is very small, and most cases are limited to minor complications. The authors introduce a chronic, recurrent epidermal inclusion cyst that occurs after Barbed thread lifting. A 61-year-old woman visited the hospital with recurrent inflammation and scar accompanied by discharge in the temporal area lasting 2 years. She had barbed thread lifting in the area of inflammation 4 years ago. CT images showed soft tissue infiltration invading superficial fascia. intraoperative view, A multi directional barbed thread was anchored in the scar tissue. The barbed thread was pulled out and cut off inflammatory lesions, including scarring wounds, were totally excised. Histopathological examination confirmed the epidermal inclusion cyst and polydioxanone suture. After surgery, the patient recovered without any complications. In this case, the cause of epidermoid cyst is considered iatrogenic concerning history of barbed thread lifting.

Surgical Site Infection Caused by Mycobacterium Septicum Following Blepharoplasty.

BACKGROUND: M fortuitum and M chelonae are commonly reported in surgical site infections caused by nontuberculous mycobacterium, but M septicum is rarely known. Herein, the authors report the first case of surgical site infection caused by M septicum in an immunocompetent patient after blepharoplasty. METHODS: A 37-year-old woman had persisting bilateral masses on the upper eyelids at 3 months after a blepharoplasty. The excision and revision were performed in a local clinic with the administration of the empirical antibiotic (clarithromycin) for 2 months, but the masses recurred. The patient was referred to the authors' hospital after the steroid was injected. As the right eyelid skin was very thin with the pus pocket, curettage was performed, while the mass on the left eyelid was completely excised. A bacterial, Acid Fast Bacilli culture with antibiotic susceptibility testing, and a DNA-polymerase chain reaction test were performed. RESULTS: The polymerase chain reaction test identified M septicum. The antibiotic treatment was delayed to identify the susceptibility to antibiotics, but the Acid Fast Bacilli culture result showed no growth. In the meantime, the mass on the right eyelid recurred. Levofloxacin and clarithromycin were administered for 6 months in consultation with the Division of Infectious Diseases. Then the mass was excised. There was no recurrence after 1 year of follow-up. CONCLUSION: There are a few reports of M septicum catheter-related infection and pulmonary disease, but surgical site infection has not been reported. When a localized mass on a surgical site is found, surgeons should consider M septicum infection and find out the pathogen with its antibiotics susceptibility.

Identifying Preoperative Factors Associated with the Volume Discrepancy in Patients Undergoing Breast Reconstruction with the Extended Latissimus Dorsi Musculocutaneous Flap Coverage.

BACKGROUND: The latissimus dorsi (LD) flap is a versatile option for breast reconstruction. However, the indications are limited because of volume discrepancy between the breast and the flap. We conducted this study to identify preoperative factors associated with the volume discrepancy in patients undergoing breast reconstruction with the extended LD flap. METHODS: A retrospective study was performed in 69 patients (69 breasts) who underwent breast reconstruction with the extended LD flap between March 2015 and March 2018. We evaluated age, body weight, height, preoperative body mass index (BMI), postoperative BMI, breast skin defect size, breast volume, flap volume, and volume discrepancy [breast volume - flap volume]. RESULTS: Mean age, height, body weight, preoperative BMI, postoperative BMI, skin defect size, breast volume, flap volume, and volume discrepancy were 45.6 ± 7.1, 157.8 ± 0.1, 59 ± 8.1, 23.7 ± 3.2, 23.5 ± 3.3, 16.5 ± 9.3, 252.2 ± 107.1, 229.4 ± 95.6, and 32.6 ± 31.4, respectively. Spearman's rank correlation coefficients indicated significant positive linear correlations between volume discrepancy and preoperative BMI (correlation coefficient = 0.267, P = 0.027), volume discrepancy and breast volume (correlation coefficient = 0.472, P < 0.001), and between volume discrepancy and skin defect size (correlation coefficient = 0.609, P < 0.001). Stepwise multiple regression analysis yielded the following formula: predicted log volume discrepancy (ml) = 1.2891 + 0.0639 × skin defect size + 0.0025 × breast volume (R2 = 0.421). CONCLUSION: Skin defect size and breast volume were preoperative factors associated with volume discrepancy in patients who have undergone breast reconstruction with the extended LD flap. Considering these factors, we can predict the lack of volume and plan any necessary secondary procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Modified toe pulp fillet flap coverage: Better wound healing and satisfactory length preservation.

BACKGROUND: Amputation is commonly performed for toe necrosis secondary to peripheral vascular diseases, such as diabetes mellitus. When amputating a necrotic toe, preservation of the bony structure is important for preventing the collapse of adjacent digits into the amputated space. However, in the popular terminal Syme's amputation technique, partial amputation of the distal phalanx could cause increased tension on the wound margin. Herein, we introduce a new way to resect sufficient bony structure while maintaining the normal length, based on a morphological analysis of the toes. METHODS: Unlike the pulp of the finger in the distal phalanx, the toe has abundant teardrop-shaped pulp tissue. The ratio of the vertical length to the longitudinal length in the distal phalanx was compared between the toes and fingers. Amputation was performed at the proximal interphalangeal joint level. Then, a mobilizable pulp flap was rotated 90° cephalad to replace the distal soft tissue defect. This modified toe fillet flap was performed in 5 patients. RESULTS: The toe pulp was found to have a vertically oriented morphology compared to that of the fingers, enabling length preservation through cephalad rotation. All defects were successfully covered without marginal ischemia. CONCLUSIONS: While conventional toe fillet flap coverage focuses on the principle of length preservation as the first priority, our modified method takes both wound healing and length into account. The fattiest part of the pulp is advanced to the toe tip, providing a cushioning effect and enough length to substitute for phalangeal bone loss. Our modified method led to satisfactory functional and aesthetic outcomes.

BCG vaccination-induced suppurative lymphadenitis: four signs to pay attention to.

Suppurative lymphadenitis is one of the severe complication after BCG vaccination, but its diagnostic criteria and treatment guidelines have not yet been established. In this article, we describe a case of suppurative lymphadenitis caused by BCG vaccination and propose diagnostic criteria and treatment guidelines of the disease. The lymphadenitis was presented as skin involving mass and was completely extirpated. Pathological evaluation revealed a necrotising lymphadenitis, consistent with the diagnosis of BCG lymphadenitis. The patient was administered adjuvant medical treatment with anti-TB medications (Isoniazid and Rifampicin) for 3 months. At 6 months follow-up, the disease was in complete remission without complications. We recommend focus on the following four signs when diagnosing BCG lymphadenitis: (i) previous history of vaccination on the ipsilateral side of the lesion, (ii) absence of any other infection signs, (iii) absence of fever and (iv) isolated axillary or supraclavicular/cervical lymph node enlargement proven by ultrasonography or computed tomography scan. BCG vaccination-induced suppurative lymphadenitis can easily be overlooked, but prompt, accurate diagnosis followed by appropriate surgical resection should result in complete healing as in this case.

Leiomyoma originating from axilla: A rare case report and differential diagnosis.

INTRODUCTION: Leiomyoma is a form of benign tumor originated in hypertrophy of the smooth muscles, which is most prevalent in the uterus and gastrointestinal tract. However, Leiomyoma originating from smooth muscle at the vessels lying on deep soft tissue is very rare. CASE REPORT: Our case was a rare case of leiomyoma originating from the axillary region, which was initially diagnosed as a fibroadenoma on radiological examination. The mass was separated from surrounding tissues and totally resected. Pathologically, hematoxylin-eosin-stained biopsy tissue showed the typical findings of leiomyoma. Postoperative follow-up observation was done for 1 year, without any complications or recurrence. CONCLUSION: Notably, a leiomyoma in the axillary region is difficult to differentiate from other benign or malignant tumors on preoperative radiological examinations such as ultrasonography or computed tomgraphy. Therefore, when an indefinite asymptomatic mass that is not lymphadenopathy or common benign tumor is identified in the axillary region, leiomyoma can be considered as one of the differential diagnoses.

Efficacy of biodegradable synthetic polyurethane foam for packing nasal bone fractures.

BACKGROUND: Nasal bone fracture is the most common traumatic disease among facial bone fractures. General treatment of this trauma is closed reduction, followed by intranasal packing. Vaseline or Furacin roll gauze, and Merocel are commonly used packing materials, but the pain produced while removing the packing is fearful for the patients. To compensate for this shortcoming, there has been an increased use of biodegradable synthetic polyurethane foam (SPF) recently. We performed a retrospective review to analyze the effectiveness of SPF after the closed reduction of nasal bone fracture. PATIENTS AND METHODS: A retrospective review was conducted in 109 patients who underwent closed reduction for pure nasal bone fracture. One group was packed with Furacin roll gauze and the other was packed with SPF. Postoperative pain, hemostatic effect, supporting ability on the fractured segment, and healing of the injured nasal mucosa were compared between the 2 groups. RESULTS: A total of 109 patients were reviewed, with 61 patients packed with Furacin roll gauze (group A) and 48 patients packed with SPF (group B). Between the 2 groups, only visual analogue scale of pain at postoperative fourth day was statistically low in group B (P = 0.045) with other parameters showing no statistical difference. DISCUSSION: Nasal packing after closed reduction of nasal bone fractures support the reduced fractured bony segment and also has the main role on hemostasis and healing of mucosal injury. Removal of the packing is painful and fearful to the patients. SPF as nasal packing material provides superior outcome in terms of pain and satisfaction and, at the same time, is not inferior to the conventional packing materials with regard to bleeding control, mucosal wound healing, toxicity, and stability of reduced fracture segment.

Large median palatine cyst.

Median palatine cyst is a rare fissural cyst of nonodontogenic origin located in the midline of the hard palate, posterior to the palatine papilla. Only 21 cases have been reported in the literature, and documented here is a median palatine cyst of the largest dimension thus far.A 14-year-old male patient presented with a 5 × 5-cm(3) mass distal to the palatine papilla of 5 years' duration. Magnetic resonance imaging revealed a 5.3 × 4.6 × 4.2-cm(3) cystic mass involving the midline of the hard palate. Complete enucleation of the cyst was performed with no recurrence, but an oronasal fistula developed 13 months postoperatively. A 1 × 4-cm(2) posteriorly based oral mucoperiosteal rotational flap was designed, raised, and transposed to reconstruct the palate. The oral mucoperiosteal flap was viable, and no sign of fistula was found 3 years postoperatively.Treatment of medial palatine cysts through enucleation is known to be relatively simple and curative. However, large lesions may lead to large defects that require a method of reconstruction and may also elicit bony defects in the hard palate, leading to an increase in postoperative complications such as oronasal fistulas.We report our experience of a large median palatine cyst, the largest documented to date, with a brief review of the literature.