Age Group-Specific Improvement of Vertebral Scoliosis after the Surgical Release of Congenital Muscular Torticollis.

Background Congenital muscular torticollis (CMT) is a common musculoskeletal disorder in children. Secondary scoliosis can occur in patients with CMT; however, the extent of inclination and improvement of scoliosis after surgical correction of CMT have not been adequately studied. In this study, we aimed to evaluate and measure the improvement in vertebral tilting after surgical correction according to age at the time of surgery. Methods Between June 2007 and January 2020, 831 patients with CMT underwent sternocleidomastoid release. Among them, 426 patients were enrolled, and their medical records were retrospectively reviewed. Ultimately, 210 patients available for radiological evaluation and analysis were enrolled in this study. The patients were divided into four groups according to age at the time of surgery to determine the relationship between age and changes in scoliosis. Results Our findings showed an improvement in scoliosis in all age groups after surgery. The results for follow-up after 1 year confirmed long-term improvement in vertebral tilting. The degree of improvement in scoliosis was significantly higher in the younger age group than in patients aged 18 years or older. Conclusion The effect of surgical release on scoliosis was significant in all age groups. The findings of this study suggest that CMT should be corrected before the age of 3 years to ensure an optimal surgical mitigation of scoliosis. Furthermore, in cases of neglected CMT, surgical release should be actively attempted because there is significant improvement.

Intramuscular hemangioma in the zygomaticus minor muscle: a case report and literature review.

Intramuscular hemangioma is a rare vascular benign proliferation that can occur within any muscle, particularly in the trunk and extremities. In the head and neck region, the masseter muscle is most commonly involved, followed by the periorbital and sternocleidomastoid muscles. Diagnosing intramuscular hemangioma is challenging because there are no characteristic symptoms; instead, magnetic resonance imaging is the best imaging modality to diagnose these lesions. Complete surgical resection is the treatment of choice, although the local recurrence rate is high. Herein, we report a rare case of intramuscular hemangioma located in the zygomaticus minor muscle, which is related to smiling and usually runs along the orbicularis oculi muscle. Distinguishing or separating these two muscles is challenging. However, based on the muscle vector of the midface and radiological findings, the two muscles were successfully separated. The zygomaticus minor was cut very slightly to approach to the lesion and the muscle fibers were split to excise it. A follow-up examination revealed no nerve damage or muscle dysfunction at 4 weeks postoperatively. This rare case may serve as a reference for managing intramuscular hemangioma in the head and neck region.

Basal cell carcinoma misdiagnosed as trichoepithelioma.

Trichoepithelioma is a benign hair follicle tumor that can undergo malignant transformation into basal cell carcinoma in rare cases. Due to the similar clinical and histological features of trichoepithelioma and basal cell carcinoma, distinguishing between these types of tumors can be a diagnostic challenge. Punch biopsy obtains only a small sample of the entire lesion, and thus inherently involves a risk of misdiagnosis between histologically similar diseases. Therefore, if the possibility of misdiagnosis can reasonably be suspected, clinicians should conduct an excisional biopsy or immunohistochemical staining (e.g., CD10 and Bcl-2) to ensure an exact diagnosis. Although trichoepithelioma is benign, the surgical excision of solitary trichoepithelioma should be considered in order to avoid the possibility of malignant transformation, which has occasionally been documented for multiple familial trichoepitheliomas. Herein, we report a case that was initially misdiagnosed as trichoepithelioma before ultimately being diagnosed as basal cell carcinoma through excision and immunohistochemical staining.

Clinical factors in patients with congenital muscular torticollis treated with surgical resection.

BACKGROUND: Congenital muscular torticollis (CMT) is characterized by persistent head tilt toward the affected side. No consensus exists regarding the cause of this disorder. In this study, we analyzed various clinical factors in patients with CMT who were treated with surgical release. This analysis enabled us to identify potential causative factors of CMT and to establish a basis for surgical interventions. METHODS: In total, 584 patients who underwent surgical intervention for CMT from October 2007 to December 2016 were included in this study. Their demographic characteristics, birthrelated factors, and clinical features were analyzed. RESULTS: Data from 525 patients were analyzed in this study after exclusion of those with insufficient information. Before birth, 31 patients (5.9%) were diagnosed with oligohydramnios, and 87 (16.6%) had a breech presentation. Seven (1.3%) cases of clavicle fracture and two (0.4%) cases of cephalohematoma were noted at birth. Before surgery, 397 patients (75.6%) underwent physiotherapy and 128 patients (24.4%) did not. The duration of physiotherapy ranged from 1 to 50 months (average, 6 months). CONCLUSIONS: Our study shows that 16.6% of the CMT patients presented in the breech position, which is a much higher rate than that observed in the general population (3%-4%). We hypothesize that being in the breech position as a fetus appears to exert a significant influence on shortening and fibrosis of the sternocleidomastoid muscle.

Analysis of Facial Injuries in Motor Vehicle Accidents According to the Location of the Seat and Seat-Belt Use.

The purpose of this study was to evaluate facial trauma in accidents involving a passenger car. In particular, the authors assessed differences in types of facial trauma and severity according to the location of the seat and seat-belt use. A 7-year retrospective review of data was conducted for 419 patients with facial trauma resulting from motor vehicle accidents. Patients who used a seat belt faced a lower risk of severe soft-tissue injury in comparison with having mild soft-tissue injury than patients who did not use a seat belt (P = 0.0129). Additionally, patients who used a seat belt had a lower risk of accompanying facial bone fracture requiring surgical operation than patients who did not use a seat belt (P = 0.0168). In terms of facial bone fracture according to seat location, patients who had sat in the back seat had more risk of accompanying facial bone fracture than patients who had sat in the passenger's seat (P = 0.0392). In terms of facial bone fractures requiring surgical operation, the patients who had sat in a back seat faced more risk of needing a surgical operation than patients who had sat in the driver's seat (P = 0.0479). The results of the study reveal that wearing a seat belt effectively reduces severe facial soft-tissue injury and facial bone fracture requiring surgical operation. In particular, the authors note that sitting in a back seat is riskier in terms of facial bone injury than sitting in a front seat.

Analysis of prognostic factors affecting poor outcomes in 41 cases of Fournier gangrene.

PURPOSE: We present our experience involving the management of this disease, identifying prognostic factors affecting treatment outcomes. METHODS: The patients treated for Fournier gangrene at our institution were retrospectively reviewed. Data collected included demographics, extent of soft tissue necrosis, predisposing factors, etiological factors, laboratory values, and treatment outcomes. The severity index and score were calculated. Multivariate regression analysis was used to determine the association between potential predictors and clinical outcomes. RESULTS: A total of 41 patients (male:female = 33:8) were studied. The mean age was 54.4 years (range, 24-79 years). The most common predisposing factor was diabetes mellitus (n = 19, 46.3%). Sixteen patients (39.0%) were current smokers. Seven patients had chronic kidney disease. The most frequent etiology was urogenital lesion (41.5%). The mortality rate was 22.0% (n = 9). Multivariate regression analyses showed that extension of necrosis beyond perineal/inguinal area and pre-existing chronic kidney disease were significant and independent predictors of mortality. Extension of necrosis beyond perineal/inguinal area was a significant predictor of increased duration in the intensive care unit and hospital stay. In addition, pre-existing chronic kidney disease was a significant predictor of flap reconstruction in the wound. CONCLUSION: Fournier gangrene with extensive soft tissue necrosis and pre-existing chronic kidney disease was associated with poor prognosis and complexity of patient management. Early recognition of dissemination and premorbid renal function is essential to reduce mortality and establish a management plan for this disease.

Solitary mastocytoma presenting at birth.

Mastocytosis is a rare disease which occurs in both children and adults, and it can manifest as a solitary or multiple skin lesions. Both can cause cutaneous or systemic symptoms. Because of the heterogeneity of clinical presentation of mastocytosis and its rare prevalence, it can be hard to suspect the mastocytosis at the first time. Most solitary mastocytomas are about 1-5 cm in diameter and have features of brownish-yellow, minimally elevated plaques with a smooth shiny surface. This article presents a case of solitary mastocytoma which occurred in neonate and that we treated through surgical excision. In histopathological examination, it consisted of c-kit-positive mast cells. Although pediatric cutaneous mastocytosis might regress spontaneously, clinicians should keep in mind that it could be associated with systemic mastocytosis which involves hematopoietic system.

Postoperative Analgesic Effect of Ultrasound-Guided Intermediate Cervical Plexus Block on Unipolar Sternocleidomastoid Release With Myectomy in Pediatric Patients With Congenital Muscular Torticollis: A Prospective, Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Unipolar sternocleidomastoid release with myectomy (USRM) for correction of congenital muscular torticollis in pediatric patients produces moderate to severe postoperative pain. The objective of this trial was to examine the effect of ultrasound-guided intermediate cervical plexus block on postoperative pain after USRM. METHODS: Thirty-two patients (1-7 years old) were enrolled in this parallel-group, patient- and observer-blinded, randomized controlled trial. In the block group, 0.25% ropivacaine (0.2 mL/kg) was injected into the interfascial plane between the sternocleidomastoid muscle and the prevertebral fascia under ultrasound guidance at the fourth to fifth cervical vertebral level. The primary outcome measure was the face, legs, activity, cry, and consolability (FLACC) score at 5 minutes after entering the postanesthesia care unit (PACU), and secondary outcome measures were the FLACC score at discharge from the PACU and 3, 6, and 24 hours after operation and the use of rescue analgesic in the PACU and ward. RESULTS: The FLACC score at 5 minutes after admission to the PACU was significantly reduced (3 vs 8; median difference, 4; 95% confidence interval, 1-7; P = 0.044), and the fentanyl dose and the number of patients requiring rescue analgesics in the PACU were significantly lower (0.0 vs 0.5 µg/kg, P = 0.014; 5 [29.4%] vs 12 [75.0%], P = 0.032) in the block than in the control group. However, after discharge from PACU, there was no difference in FLACC scores and use of rescue analgesics between groups. CONCLUSIONS: Ultrasound-guided intermediate cervical plexus block decreased immediate postoperative pain and opioid requirements in the PACU in pediatric patients who underwent USRM. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02651311.

Free-Flap Transfer for Coverage of Transmetatarsal Amputation Stump to Preserve Residual Foot Length.

Surgical management of soft-tissue defects of the forefoot and midfoot caused by trauma or diabetic complications can be challenging because locoregional tissue is insufficient to provide adequate flap. This deficiency necessitates higher-level amputations, such as Chopart or even transtibial amputation, resulting in far more debilitating functional outcomes than are seen with partial foot amputation. The purpose of this study was to examine the surgical outcomes after transmetatarsal amputation and a free-flap transfer to preserve foot length. This prospective case series was conducted from January 2011 to December 2015 at the Department of Plastic and Reconstructive Surgery at our institute. A total of 16 patients (11 men and 5 women) were enrolled in this study, all of whom were candidates for higher-level amputation because of inadequate soft-tissue coverage after debridement. Each patient underwent transmetatarsal amputation and reconstruction of the amputation stump using free-flap transfers to preserve foot length. Preoperative and postoperative data were collected to evaluate the postoperative outcomes. All 16 free-flap transfers were successful, with no major complications. In 2 cases, partial flap necrosis required additional skin grafting. The mean follow-up period was 24.3 months (range = 7-55 months). Flap coverage was stable, and all the patients were comfortable with their prostheses at long-term follow-up. Use of a free flap to reconstruct a transmetatarsal amputation stump provided stable coverage, preserved maximal foot length, and resulted in good functional outcomes.

Effectiveness of Acellular Dermal Matrix on Autologous Split-Thickness Skin Graft in Treatment of Deep Tissue Defect: Esthetic Subjective and Objective Evaluation.

BACKGROUND: A split-thickness skin graft (STSG) is performed to cover a large full-thickness skin defect. Esthetic and functional deficits can result, and many studies have sought to overcome them. This study compared the effectiveness of the acellular dermal matrix (ADM) graft and STSG concerning esthetic and functional effectiveness of ADM on scar quality. METHODS: Of the patients who underwent anterolateral thigh free flap from 2011 to 2015, patients who received skin graft only (n = 10) or skin graft with ADM (n = 20) for coverage of the donor site were enrolled. In all cases, autologous STSG was performed with 1:1.5 meshed 0.008-0.010-inch-thick skin. In the skin graft with ADM group, 0.008-0.013-inch-thick meshed ADM (CGderm®; CGBio, Inc., Seungnam, Korea) was co-grafted. Negative-pressure wound therapy (CuraVAC®; CGBio, Inc., Seungnam, Korea) was applied to both groups in continuous mode at -120 mmHg. We investigate early outcomes (skin loss rate, duration of negative-pressure wound therapy, days to removal of stitches, days to achieve complete healing, and complications) and late outcomes in terms of scar quality (vascularity, pigmentation, pliability and height) and graft-related symptoms (itching sensation and pain). Assessments used the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale. Skin fold was measured to evaluate the elasticity of scar tissue. RESULTS: In the Vancouver Scar Scale, vascularity subscore (p = 0.003) and total score (p = 0.016) were significantly lower in the skin graft with ADM group. In Patient and Observer Scar Assessment Scale, the pain (p = 0.037) and stiffness subscores (p = 0.002), and total score (p = 0.017) were significantly lower in the skin graft with ADM group. CONCLUSIONS: Skin graft with ADM results in better scar quality in objective and subjective aspects. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 .

Use of Acellular Dermal Matrix in Treatment of Congenital Muscular Torticollis in Patients Over Eight Years of Age.

BACKGROUND: Treatment for neglected or recurred congenital muscular torticollis should be differentiated from primary patients due to the long-standing adjacent tissue contracture. The aim of this study was to evaluate the effect of acellular dermal matrix (ADM) on surgery of recurred and neglected patients of congenital muscular torticollis. METHODS: Forty-nine patients were included in the study. All patients underwent resection at the distal end of the sternocleidomastoid muscle. In the study group of 18 patients (ADM group), the defect caused by myectomy and scar tissue removal was covered with ADM. Passive range of neck motion, head tilt, cosmetic and functional satisfaction, and scar was evaluated and compared with the control group of 31 patients (non-ADM group) during follow-up. Logistic and linear regression analyses with adjustment by propensity score were performed to determine the association between ADM implantation and postoperative variables. RESULTS: The mean follow-up period was 18.8 months. No patient required further operation for recurrence during follow-up. The improvement of neck motion in ADM group was significantly superior to non-ADM group at the 1-year follow-up, and the overall assessment score was significantly higher in the ADM group. Acellular dermal matrix implantation was not associated with increased discharge of total drain. CONCLUSIONS: In patients over 8 years of age with recurred or neglected congenital muscular torticollis, use of dermal substitute to fill the defect caused by torticollis release is effective in achieving satisfactory neck motion. Surgical sectioning of the sternocleidomastoid muscle and ADM graft should be considered in recurred and neglected torticollis.

Use of revascularized artery as a recipient in microvascular reconstruction of the lower leg: An analysis of 62 consecutive free flap transfers.

BACKGROUND: This study aimed to demonstrate the safety and reliability of combined preoperative angioplasty and free flap transfer in patients with peripheral arterial occlusive disease (PAOD) by analyzing the surgical outcomes. METHODS: Between October 2011 and October 2015, patients who had undergone lower extremity angiography and subsequent free flap transfer were retrospectively reviewed. Data collected included demographics, perioperative data, and postoperative outcomes. The cases were divided into two groups: one group with microanastomosis performed on revascularized artery by balloon angioplasty and the other group performed on native artery. Multiple logistic regression model using propensity score and linear regression was computed to determine the association between preoperative angioplasty and the surgical outcomes. RESULTS: A total of 62 lower limb reconstruction cases (19 angioplastied cases and 43 nonangioplastied cases) were included in the study. Complications occurred in 6 cases in the angioplastied group and in 11 cases in the control group. The overall limb salvage rate was 100% during the average follow-up of 29.5 months in the angioplastied group and 97.7% in the nonangioplastied control group during the average follow-up of 31.1 months. Preoperative angioplasty was not a significant predictor of increased complications and longer postoperative downtime in logistic and linear regression model, both in the weighted and unweighted model. CONCLUSIONS: The combined approach of preoperative endovascular revascularization and free flap transfer for limb reconstruction in PAOD patients can be performed safely and effectively with acceptable morbidity.

Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions.

In our hospital, an adverse event reporting system was initiated that alerts the plastic surgery department immediately after suspecting contrast media extravasation injury. This system is particularly important for a large volume of extravasation during power injector use. Between March 2011 and May 2015, a retrospective chart review was performed on all patients experiencing contrast media extravasation while being treated at our hospital. Immediate treatment by squeezing with multiple slit incisions was conducted for a portion of these patients. Eighty cases of extravasation were reported from approximately 218 000 computed tomography scans. The expected extravasation volume was larger than 50 ml, or severe pressure was felt on the affected limb in 23 patients. They were treated with multiple slit incisions followed by squeezing. Oedema of the affected limb disappeared after 1-2 hours after treatment, and the skin incisions healed within a week. We propose a set of guidelines for the initial management of contrast media extravasation injuries for a timely intervention. For large-volume extravasation cases, immediate management with multiple slit incisions is safe and effective in reducing the swelling quickly, preventing patient discomfort and decreasing skin and soft tissue problems.

Prediction of the development of late enophthalmos in pure blowout fractures: delayed orbital tissue atrophy plays a major role.

PURPOSE: To retrospectively evaluate the risk factors for the development of late enophthalmos in pure blowout fractures. METHODS: We reviewed 49 cases of pure blowout fractures diagnosed in Ajou University Hospital, South Korea, from January 2005 to June 2015. We assumed that several factors influence the development of late enophthalmos, including bony defect size, volume of displaced soft tissue, number of fracture sites, involvement of floor, soft tissue incarceration through the bony defect, and patient age. RESULTS: Twenty-one patients were diagnosed with late enophthalmos (group 1) while 28 patients were not (group 2). Soft tissue incarceration, presumably causing the soft tissue injury, was the only factor that increased the risk for late enophthalmos in this study (p = 0.04, odds ratio 4.5). In contrast with previous studies, there were no meaningful correlation between bony defect size or volume of displaced soft tissue and development of late enophthalmos. Number of fracture sites, involvement of floor, and patient age did not increase the risk for late enophthalmos. CONCLUSIONS: We suggest that the delayed orbital tissue atrophy due to soft tissue injury plays a more important role than other hypotheses in the development of late enophthalmos. It is necessary to overcorrect to some extent if there is soft tissue incarceration through the bony defect in the initial computed tomography, and clinicians should warn patients about the development of late enophthalmos despite orbital reconstructive surgery.

Reduction of Closed Frontal Sinus Fractures through Suprabrow Approach.

BACKGROUND: The traditional approach for reduction of frontal sinus fractures is coronal incision. Inherent complications of the coronal approach include long scar, hair loss, and long operation time. We describe a simple approach for the reduction of frontal sinus anterior wall fractures using a suprabrow incision that is commonly used for brow lift. METHODS: From March 2007 to October 2016, the authors identified patients with anterior wall frontal sinus fractures treated by open reduction through a suprabrow incision. Only cases with photographic/radiographic documentation and a minimum follow-up of 6 months were included. The incision line was designed to be at the upper margin of the eyebrow. Medical records and radiographic data were retrospectively reviewed. Surgical outcomes, cosmetic results, and complication were assessed. The patient scale of the patient and observer scar assessment scale was used to assess patient satisfaction for incisional scar at the 6-month follow-up. RESULTS: Thirty-one patients underwent fracture reduction through a suprabrow approach during the study period, with a mean follow-up of 41 months. No patients showed any recurrent displacement, eyebrow asymmetry, or infection during follow-up. Thirteen patients reported their forehead paresthesia postoperatively, and 12 of them had preoperative symptom. One patient complained of incisional scar and underwent scar revision. All patients were satisfied with their eyebrow and forehead contour. CONCLUSION: The suprabrow approach allowed for an accurate reduction of the fractures in the anterior wall frontal sinus by providing direct visualization of the fracture. This transcutaneous approach can effectively restore forehead contour with acceptable postoperative complications and patient satisfaction.

Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection.

Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.

Change of Facial Asymmetry in Patients With Congenital Muscular Torticollis After Surgical Release.

BACKGROUND: A number of studies have shown that facial asymmetry improves in congenital muscular torticollis (CMT) patients after surgical release. This study confirmed the improvement in facial asymmetry, and analyzed factors that affect the change of facial asymmetry in CMT patients after surgical release by using objective and quantitative methods. METHODS: Facial asymmetry was analyzed in 60 CMT patients who underwent surgical release before 10 years of age. Horizontal and lower facial asymmetry angles (HFAA and LFAA) in the clinical photograph were used to measure facial asymmetry. Postoperative improvements in HFAA and LFAA were evaluated in each age group, after grouping the patients by age. Patients were divided into 2 groups according to the postoperative head tilt and functional deficit. Postoperative improvements in HFAA and LFAA were compared between 2 groups. The relationships between postoperative improvements in HFAA and LFAA and independent variables (age, follow-up period, preoperative HFAA or LFAA, postoperative head tilt, and postoperative functional deficit) were analyzed. RESULTS: Mean age at operation was 34.8 months (range, 6-120 mo). Horizontal facial asymmetry angle was improved significantly postoperatively in groups <5 years of age. Lower facial asymmetry angle was improved significantly postoperatively in all age groups. No significant difference was found in the postoperative improvements in HFAA and LFAA between 2 groups according to the postoperative head tilt and functional deficit. In the correlation analysis, postoperative improvements in HFAA and LFAA were proportional to the follow-up period (r = 0.256, P = 0.048) and preoperative HFAA or LFAA (r = 0.600, P < 0.001). CONCLUSIONS: Facial asymmetry in CMT patients can be improved in part if surgical release is performed before 10 years of age and the possibility of improvement may be different according to the area of the face. After surgical release, facial asymmetry will improve over a long period of time, and patients with more severe facial asymmetry have a better remodeling potential to achieve facial symmetry.