Subdural Empyema from Streptococcus suis Infection, South Korea.

In Jeju Island, South Korea, a patient who consumed raw pig products had subdural empyema, which led to meningitis, sepsis, and status epilepticus. We identified Streptococcus suis from blood and the subdural empyema. This case illustrates the importance of considering dietary habits in similar clinical assessments to prevent misdiagnosis.

A Triple Combination Therapy Using 2-mm Biopsy Punch for the Treatment of Multifocal Keloids.

BACKGROUND: Keloid treatment is challenging. The surgical approach can be divided into complete excision versus partial excision. OBJECTIVE: The current study aims to introduce our novel surgical approach of partial excision using a 2-mm punch biopsy device to treat refractory multifocal keloids in the trunk. MATERIALS AND METHODS: This is a case series of 30 patients with refractory multifocal keloids treated with a triple combination therapy consisting of a punch-assisted partial excision and intralesional triamcinolone injections followed by immediate single fractional electron beam radiotherapy within 8 hours, postoperatively. The follow-up period was 12 months. The primary outcome was recorded as recurrence versus nonrecurrence or aggravation versus remission . The secondary outcome was patient satisfaction as assessed by the POSAS. RESULTS: The recurrence or aggravation of keloid was not found without complications. Scores obtained from the POSAS patient scale showed that pain, itchiness, color, stiffness, thickness, and irregularity significantly improved. CONCLUSION: Our novel surgical approach using a 2-mm punch biopsy device effectively treats refractory multifocal keloids once considered intractable. Triple combination therapy of partial excision using a 2-mm punch biopsy device, intralesional triamcinolone injections, followed by immediate single fractional electron beam radiotherapy, is a safe, efficacious, and more convenient protocol to treat this condition.

A Comparative Analysis of Postoperative Single Fraction of 9.5 Gy Versus 10 Gy for Ear Keloids.

BACKGROUND: The optimal radiotherapy doses for postoperative treatment of ear keloids are currently a topic of debate. OBJECTIVE: The authors compared the efficacy of 9.5-Gy and 10-Gy single-fraction electron beam radiation therapy after surgical excision and evaluated the impact of radiation timing on outcomes. MATERIALS AND METHODS: This study was conducted on patients with ear keloid who underwent surgical excision and postoperative electron beam radiotherapy between May 2021 and June 2024. Patients were divided into groups based on radiation dose (9.5 vs 10) and timing (within 8 hours vs 24 hours postoperatively). Recurrence rates and complications were also compared. RESULTS: The study included 182 patients (21 men and 161 women). The overall recurrence rate was 3.3% (6/182). The 10-Gy group had a significantly lower recurrence rate than the 9.5-Gy group (0.81% vs 8.47%; p = .014). Radiation timing did not significantly influence recurrence rates (2.59% vs 3.80%, p = 1). Complications were not significantly different. CONCLUSION: A postoperative single dose of 10 Gy is the most effective low-dose single fractional electron beam radiotherapy for preventing ear keloid recurrence. Once administered within 24 hours after surgery, the timing of radiotherapy has no significant impact on treatment outcomes.

Fibrous hamartoma of infancy of the spinal cord resembling conus and filum, with a coexisting sacral dimple.

Fibrous hamartoma of infancy (FHI) is a rare benign soft tissue lesion of infants and young children. It usually occurs within the first 2 years of life at the superficial layer of the axilla, trunk, upper arm, and external genitalia. FHI in the central nervous system (CNS) is extremely rare. So far, only two spinal cord FHI cases have been reported. We present a case of a 1-month-old girl who presented with a skin dimple in the coccygeal area. Her MRI showed a substantial intramedullary mass in the thoracolumbar area with a sacral soft tissue mass and a track between the skin lesion to the coccygeal tip. Her normal neurological status halted immediate surgical resection. A skin lesion biopsy was first performed, revealing limited information with no malignant cells. A short-term follow-up was performed until the intramedullary mass had enlarged on the 5-month follow-up MRI. Based on the frozen biopsy result of benign to low-grade spindle cell mesenchymal tumor, subtotal resection of the mass was done, minimizing damage to the functioning neural tissue. Both the skin lesion and the intramedullary mass were diagnosed as FHI. Postoperative 5.5-year follow-up MRI revealed minimal size change of the residual mass. Despite being diagnosed with a neurogenic bladder, the patient maintained her ability to void spontaneously, managed infrequent UTIs, and continued toilet training, all while demonstrating good mobility and no motor weakness. This case is unique because the lesion resembled the secondary neurulation structures, such as the conus and the filum, along with a related congenital anomaly of the dimple.

How to Reduce Inferomedial Orbital Wall Fracture Using a Navigation System: Tips and Pearls.

The orbit is a confined space with a defined bony structure. Bony protrusion into the ethmoid or maxillary sinuses by the blowout fracture can displace orbital tissues, including rectus muscles and adjacent fascial septae. Especially, reconstructing the orbit's floor and medial wall can be challenging when the inferomedial strut or posterior bony ledge is affected, leading to a loss of critical anatomic landmarks and support. Correctly positioning an implant in the precise anatomic location can be challenging. Recent updates to the navigation system have addressed this issue. Despite its early application, using a navigation system in these orbital fractures advances plastic surgeons in a way that has more confidence and accuracy in surgical planning. The video demonstrates how these 2 can be combined in an operating room. Intraoperatively, the authors check the superior, anterior, and posterior ends of the medial wall fracture and the posterior end of the floor fracture. A single orbital implant was trimmed and reshaped to match defect measurements. The implant placement was meticulously executed to repair the fracture while ensuring the inferior oblique muscle was not injured. After confirming the correct placement of the implant, it was secured to the inferior orbital rim using a single screw. Depending on the medial orbital wall fracture depth or degree of soft tissue herniation, the authors used an artificial dermal matrix or trimmed absorbable mesh plate to cover the uppermost part of the medial wall fracture to prevent postoperative enophthalmos. Finally, a forced duction test was performed. Our study shows that navigation-assisted inferomedial orbital wall reconstruction using materials readily available in the market is safe and effective.

Is Gillies Temporal Incision Necessary to Successfully Reduce Zygomaticomaxillary Fracture Combined With Orbital Wall Fracture?

Gillies temporal approach has been widely used to reduce zygoma fractures. Traditionally, it is the preferred method to reduce the isolated zygomatic arch fracture. It can be combined with other approaches, such as subciliary and intraoral incisions for more complex zygomatic fractures, so-called tripod fractures. In this study, the author hypothesized that complex zygomaticomaxillary bone fracture reduction can successfully be achieved without Gillies temporal incision. The author retrospectively analyzed the medical records and 3D facial Computed Tomography (CT) scans of 80 patients who had orbitozygomaticomaxillary fractures that affected >3 sites among the frontozygomatic suture, zygomaticomaxillary buttress, zygomatic arch, and orbital walls from May 2021 to August 2023. A single surgeon performed all surgical operations. All fractures were reduced with 2 incisions, lower eyelid incisions (subciliary or subconjunctival) and intraoral incisions (gingivobuccal approach), within a week of the initial traumatic event. After sufficient exposure to fractured sites using 2 incisions, the author reduced the fracture with a bony hook at the inferior orbital rim, lateral wall, or Boise elevator at the intraoral incision. All cases were successfully corrected without any complications. In conclusion, the author can successfully reduce complex zygomaticomaxillary fracture combined with orbital wall fractures without temporal Gillies approach.

Mechanical Ptosis by Medial Upper Eyelid Fat Prolapse.

Common symptoms of medial fat pad prolapse may include a noticeable bulge in the inner corner of the upper eyelid, puffiness, and a tired or aged appearance. In some cases, this condition may contribute to mechanical ptosis. However, mechanical ptosis caused by medial upper eyelid fat prolapse has not been reported previously. The purpose of the current study is to report the author's experience of successful treatment of ptosis caused by medial upper eyelid fat prolapse in a 67-year-old woman. The patient complained of slowly aggravating asymmetric upper eyelids starting from 5 years ago. At the time of her visit, she had to use her left forehead to open her eyes, making her left eyebrow upwardly positioned. This condition might be related to medial upper eyelid fat prolapse-related mechanical ptosis. The author explored her left upper eyelid with a 9 mm height incision. The author found a substantial amount of medial fat herniation and levator aponeurosis tear. After fat pad removal, the author fixed the levator aponeurosis tear with nylon 6-0, and transdermal sutures were done. The patient was happy with esthetically pleasing results 2 months after the initial surgery. The author successfully treated this rare condition with basic principles, such as fat removal, levator aponeurosis repair, and transdermal sutures.

Recurrent Auricular Keloid After Childbirth in a Patient With von Willebrand Disease.

The authors present a case of a 34-year-old female patient with von Willebrand disease who developed a recurrent right auricular keloid after childbirth. The patient had previously undergone surgical excision of the keloid in 2017, which led to the diagnosis of von Willebrand disease due to uncontrolled bleeding. After a successful pregnancy in 2023, the patient experienced keloid recurrence. Surgical excision and radiotherapy were performed in April 2023, followed by DDAVP administration to control postoperative bleeding. At 1-year follow-up, no recurrence was observed. This case highlights the potential impact of pregnancy on keloid recurrence and the challenges of managing keloids in patients with bleeding disorders.

The Versatility of Keystone Flaps for Skin Cancer Reconstruction of the Nose.

Nasal reconstruction has been a challenging problem for even the most experienced surgeon to provide excellent esthetic and functional outcomes. Although the bilobed flap offers distinct advantages for reconstructing these defects using an adjacent tissue with similar esthetic qualities, this flap has several potential limitations. The authors hypothesized that the conventional keystone flap and its variants provide a versatile and easily reproducible reconstructive option for nasal reconstruction after wide skin cancer excision. The authors retrospectively reviewed 12 consecutive soft tissue reconstruction data using 3 types of keystone flaps between May 2021 and July 2023. The authors reviewed all patients who underwent reconstruction with the keystone flap or its modification to repair cutaneous nasal defects following wide skin cancer excision. The authors reconstructed small- to medium-sized nasal defects ranging from 1×1 to 2.5×2.5 cm 2 with a mean size of 1.2×1.1 cm 2 using either a conventional keystone flap or its modification, including the Omega variant and rotation Hemi-keystone flap. All patients were satisfied with the esthetic outcomes. Keystone flaps are a versatile option for reconstructing the nose after cancer surgery. This strategy obviates the need for a bilobed flap after cancer removal in the nose.

Successful Reduction of Unilateral Zygoma Fracture Following Bilateral Malar Reduction Surgery.

Malar reduction surgery can increase its susceptibility to fractures in case of trauma. Patients who had malar reduction surgery and sustained a zygoma fracture pose unique challenges for treatment and management. This is a case of a 28-year-old female patient who presented with a unilateral zygoma fracture following bilateral malar reduction and augmentation rhinoplasty 6 years ago. Physical examination revealed a clicking sound when opening the mouth at the right zygomatic buttress and a depressed preauricular area, suggesting arch fracture. Computed tomography imaging demonstrated a loosened screw at the right zygomatic buttress and a depressed arch fracture. She wanted to remove all plates and treat her right fractured zygoma with absorbable materials. Through the bilateral intraoral incisions, the authors removed the plates and screws and reduced the depression with the Langenbeck elevator through the same right intraoral incision without fixation. The reduction was well-maintained without complications based on postoperative plain x-rays 1 month after surgery. She reported that the pain was mostly gone and that she did not hear any abnormal sounds when opening her mouth after the surgery. In this case, if the zygomaticomaxillary buttress is minimally displaced, but the zygomatic arch fracture is significantly depressed, the authors believe that fracture reduction with only an intraoral incision would be enough to achieve an optimal outcome. If the plates and screws used in the previous malar reduction are not well maintained, it may be necessary to remove them.

How to Safely Use the Perforator-based Keystone Island Flap in the Scalp: Basal Cell Carcinoma of the Scalp With Local Invasion to Calvarium.

Scalp reconstruction has always been a challenging problem for even the most experienced surgeon to provide good aesthetic and functional results. This is mainly because the scalp is less mobile and tight, requiring a much larger dissection for the size of the original defect. We hypothesized that the omega variant perforator-based keystone island flap at the subgaleal plane provides a versatile and easily reproducible reconstructive option for scalp reconstruction after wide skin cancer excision. We reviewed all patients who underwent reconstruction with the keystone flap or its modification to repair scalp defects following wide resection of skin cancer in the scalp abutting calvarium from May 2021 to July 2023. We designed the flap width 50% wider than original keystone flap design first introduced by Dr. Behan. We reconstructed medium- to large-sized scalp defects ranging from 2×2 to 5×5 cm 2 using an omega variant perforator-based keystone island flap. All patients were satisfied with the aesthetic outcomes without complications. Keystone flaps are a versatile option for reconstructing the scalp after cancer resection. This strategy obviates the need for skin grafting, myocutaneous flap or free flap after cancer removal in the scalp.

Efficacy of Immediate Postoperative Single Fractional 10 Gy Radiotherapy for Earlobe Keloids.

BACKGROUND: The ear is a common site for keloid formation, typically due to ear piercing or trauma. Auricular keloids are always difficult to treat and pose a challenging situation. The purpose of this study is to present our experience treating earlobe keloids through complete surgical excision followed by immediate postoperative single fraction 10 Gy radiation therapy either on the same day or the next day. METHODS: The authors retrospectively evaluated 48 patients with 71 earlobe keloids treated with complete surgical excision followed by single-fractional 10 Gy radiotherapy within 24 hours from May 2021 to December 2022. The outcome was reported with a recurrence-free rate and side effects. RESULTS: The mean follow-up period was 20.8 months. All patients tolerated the treatments well. The overall recurrence-free rate was 100%. There were only 2 grade III radiation dermatitis. There were no reports of second malignancies or severe complications. CONCLUSIONS: The authors have obtained excellent outcomes from treating earlobe keloids through complete excision followed by postoperative radiotherapy with a single fractional dose of 10 Gy on the same day or the next day.

One-piece Craniofacial Bone Fracture Reduction With an Additional Single Osteotomy at the Zygomaticomaxillary Buttress: A Successful Reduction of Frontoorbitozygomaticomaxillary Fracture Associated With a Temporoparietal Bone Fracture.

A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting.

Orbitalization of Ethmoidal Sinus With Stacked Cross-linked Acellular Dermal Matrix: A New Strategy to Reconstruct Medial Orbital Wall Fracture.

BACKGROUND: The use of an acellular dermal matrix (ADM) has not been reported in medial orbital wall fracture reconstruction previously. This study aimed to share our early experience with the cross-linked ADM as an allograft material for medial orbital wall reconstruction. METHODS: In this study, the author evaluated the medical records and serial facial computed tomography scans of 27 patients with pure medial orbital wall fractures reconstructed by a single surgeon between May 2021 and March 2023. The author routinely approached the medial orbital wall with a retrocaruncular incision. Five out of 27 patients were reconstructed with trimmed, multiple folded, 1.0-mm-thick cross-linked ADM (MegaDerm; L&C Bio, South Korea). RESULTS: All cases reconstructed with cross-linked ADM improved clinically and radiologically without complications. The serial computed tomography findings revealed that implanted cross-linked ADM successfully covered the defect while providing a significant volumizing effect. CONCLUSIONS: This is the first study to show the efficacy of cross-linked ADM for orbital medial wall fracture reconstruction. Our strategy of orbitalization of ethmoidal sinus with stacked cross-linked ADM would be an excellent surgical option.

Perfecting the Outcome of Nasal Bone Fracture in the Pediatric Population With a Navigation System.

BACKGROUND: The trend of using navigation systems for treating facial bone fractures is increasing. Nevertheless, any detailed recommendation on using a navigation system to treat nasal bone fracture has never been discussed. Plastic surgeons are prone to do closed reduction of nasal bone fractures with remnant posttraumatic edema in the pediatric population. This study hypothesized that the navigation system benefits this population's treatment of nasal bone fractures. METHODS: The authors evaluated the medical records, plain x-ray, and facial computed tomography scans of 44 pediatric patients (below the age of 18) with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and postoperative computed tomography scan were used to assess the outcome. RESULTS: The average age for 44 pediatric nasal bone fracture patients was 10. Fifteen were female, while males were 29. All cases were successfully corrected clinically and radiologically without noticeable complications. CONCLUSIONS: Using navigation systems to correct nasal bone fractures provides additional benefits for the pediatric population. This technique is especially useful if the fracture is located at the junction between the nasal bone and nasal process of the maxilla and is combined with concurrent old nasal bone fractures.

Effectiveness of Cross-Linked Acellular Dermal Matrix to Correct Post-Traumatic Enophthalmos.

BACKGROUND: The use of an acellular dermal matrix is rarely reported in orbital wall fracture reconstruction. This study aimed to share the author's experience with the cross-linked acellular dermal matrix as an allograft material for enophthalmos correction. METHODS: In this retrospective study, the author evaluated the medical records and 3-dimensional facial computed tomography scans of patients with enophthalmos caused by neglected orbital fractures between May 2021 and June 2022. Facial computed tomography scans confirmed the clinical diagnosis of enophthalmos. A single surgeon performed all surgical operations. In all patients, the author accessed the orbital floor via subciliary incision while approaching the medial wall with a retrocaruncular incision. After fully exposing the lesion, the author used a 1.0-mm-thick cross-linked acellular dermal matrix (ADM) (MegaDerm; L&C Bio, South Korea). After trimming the cross-linked ADM to a proper size, the author implanted the ADM into the lesion. RESULTS: During May 2021 and June 2022, 3 cases of enophthalmos were successfully corrected with cross-linked ADM at the author's hospital. All patients were improved clinically and radiologically. CONCLUSION: This is the first study to show the effectiveness of cross-linked ADM for the correction of enophthalmos.

Penetration of a Wooden Foreign Body into the Zygomaticomaxillary Bone to the Nasal Cavity: Navigation-Guided Successful Treatment.

Penetrations of the nasal cavity through the zygomaticomaxillary bone by wooden foreign bodies have not been reported yet. Wooden foreign bodies, characterized as hypodense signals resembling air bubbles on computed tomography scans, could increase the risk of infection and abscess formation if left untreated. Therefore, any possible attempts to remove it entirely should be made in a timely manner. Also, regarding removal surgery, the complications of the surgery, such as massive bleeding or iatrogenic injury to the adjacent structure, should be considered, especially in the paranasal area. At the construction site, a 67-year-old worker hit his right cheek with a wooden foreign body. A wooden foreign body penetrated the right cheek and extended into the right nasal cavity through the zygomaticomaxillary complex. Using a navigation system, the wooden foreign body was removed from the right zygomaticomaxillary bone to the unilateral nasal cavity, and we cauterized arterial bleeding. After bleeding control, we reconstructed the bony defect with an absorbable mesh with screws. Septal reconstruction was also done, along with debridement and irrigation of the nasal cavity. We conducted a follow-up computed tomography scan a week later and confirmed that the wooden foreign body was successfully removed without any residual ones. The fracture was also reduced successfully.

Topical Anesthetic versus Lidocaine Mixture for Pain Relief During Keloid Treatment: A Prospective, Split Study.

BACKGROUND: The most common typical symptoms of keloids can be pain and itchiness. Intralesional corticosteroid administration is generally the first-line conservative treatment. Minimizing pain during intralesional corticosteroid injections into keloids should be aimed, as the treatment is often painful. There has yet to be a report on which local anesthetic technique is superior in keloid treatment between topical anesthetic versus lidocaine mixture injection. METHODS: This was a single-center prospective study. The study included 100 patients with painful multiple/multifocal keloids aged 18 to 85 years and was performed between May 2021 and December 2022. Among multiple keloid lesions in a single patient, we assigned the keloids pretreated with topical cream application versus local injection. Then, subjects received 40 mg of intralesional corticosteroid injections into the keloids with a 26G needle to treat keloids. Patients rated the pain intensity of each lesion pretreated with two different anesthetic techniques on an 11-point numeric rating scale. A separate direct question of "Which technique would you recommend if you had to be injected again?" was given. RESULTS: One-hundred patients with painful multiple/multifocal keloids were included in the study. Data on pain intensity numeric rating scale (NRS) revealed that injection techniques relieved the pain statistically significantly more than topical creams. ( P <0.001) 63% of the participants (n=63) preferred the injection technique, while 25% preferred topical anesthetics. In total, 12% of patients responded that there was no difference between the two techniques. CONCLUSION: When comparing with topical lidocaine/prilocaine (EMLA) cream, a 1:1 mixture of 1% lidocaine and epinephrine significantly alleviated pain during and after the corticosteroid injection.

The Efficacy of Sequential Intranasal Packing Removal in Overcorrected Nasal Bone Fracture: Evaluation With Computed Tomography.

BACKGROUND: Despite the evolution of new techniques to treat nasal bone fractures, closed reduction with appropriate palpation and inspection is one of the critical basic tools to treat nasal bone fractures properly. Despite its rarity, overcorrection after closed reduction of the nasal bone fracture could happen even with experienced surgeons. This study hypothesized that sequential packing removal is mandatory for optimal outcomes based on the preoperative and postoperative Computed Tomography scans in overcorrected cases. This is the first study to evaluate the efficacy of sequential nasal packing removal assessed by facial CT scans. METHODS: In this retrospective study, we evaluated the medical records and preoperative and postoperative facial Computed Tomography scans of 163 patients with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and Postoperative CT scan was routinely used to assess the outcome. Merocels were used for intranasal packing. In overcorrected cases based on immediate postoperative CT scan, we routinely removed the intranasal packing on the overcorrected side first immediately. On postoperative day 3, we removed the remaining intranasal packing on the other side. We assessed additional postoperative CT scans on postoperative two to three weeks. RESULTS: With sequential packing removal starting on the day of surgery, all overcorrected cases were successfully corrected clinically and radiologically without noticeable complications. Two representative cases were presented. CONCLUSION: Sequential nasal packing removal provides significant benefits in overcorrected cases. An immediate postoperative CT scan is also vital to do this procedure. This strategy is advantageous if the fracture is significant and there is a substantial possibility of overcorrection.

The Utility of Hyaluronidase for the Free and Pedicle Flap Salvage.

Hyaluronidase is commonly used to treat swelling and hematoma for aesthetic and reconstructive purposes. It has also been reported as a stimulator of angiogenesis. The purpose of this study was to introduce the utility of hyaluronidase in patients with flap compromise after free and pedicle flap reconstructions. This study was a retrospective study of 1 case of radial forearm free flap salvage, 2 cases of keystone perforator flap salvage, and 1 case of pectoralis major myocutaneous flap salvage. A radial forearm free flap reconstruction of unilateral mouth floor and tongue defect was complicated with hematoma formation on a postoperative day 1 after taking clopidogrel due to acute-onset non-ST-elevation myocardial infarction but dramatically resolved with hyaluronidase injection into the flap and contralateral unaffected tongue. After this intervention, the flap color dramatically returned to normal and became soft without further treatments. Two keystone design perforator flaps were performed to reconstruct the sacral defect after the debridement of pressure ulcers. Two cases were related to the patients' medical conditions, such as low platelet count caused by liver cirrhosis. We also salvaged pectoralis major myocutaneous flap in a 91-year-old female patient with large breasts. This study introduced our experience of salvaging the free and pedicled flaps using hyaluronidase. Hyaluronidase is an excellent option when arterial or venous insufficiency occurs after free and perforator flap surgeries.