Brugada Syndrome Unmasked by Cellulitis of the Face.

A 35-year-old male patient with no specific history visited an emergency medical center with a chief complaint of facial swelling accompanied by fever (38.3°C). Contrast-enhanced facial computed tomography confirmed diffuse soft tissue swelling and facial infiltration of inflammation. Additional laboratory findings revealed elevated white blood cell count and C-reactive protein level. The patient also complained of chest pain; therefore, electrocardiography was performed, which confirmed a curved pattern-like ST-segment elevation (≥2 mm) of V2 without elevated cardiac enzyme levels. Based on various test results, the patient was diagnosed with Brugada syndrome. He was administered intravenous empirical antibiotics and intravenous ibuprofen as an antipyretic for the treatment of facial cellulitis and Brugada syndrome. After the resolution of the symptoms, his body temperature normalized. A subsequent electrocardiogram confirmed a normal sinus rhythm pattern. This case report shows that Brugada syndrome, a rare but life-threatening disease, can be unmasked by facial cellulitis. Because antipyretics can immediately reduce the critical rate of sudden cardiac death, Brugada syndrome should be differentially diagnosed, with an evaluation of facial cellulitis, to prevent sudden cardiac death.

Reconstruction of a Full-thickness Lateral Alar Defect Using a Superiorly Based Folded Nasolabial Flap Without a Cartilage Graft: A Single-stage Operation.

ABSTRACT: When reconstructing a lateral alar defect of the nose, satisfactory aesthetic and functional results are difficult to achieve through a single-stage surgery alone. Here the authors describe a new innovative surgical technique using a superiorly based folded nasolabial flap through a single-stage surgery alone. An 85-year-old male patient visited plastic surgery clinic with sudden enlargement of a mass 3 or 4 days before the visit. On the basis of the biopsy test results, a diagnosis of basal cell carcinoma on the right lateral alar was made. A full-thickness lateral alar resection was performed while maintaining the shape of the right alar rim (outer skin defect: 2.2 × 2 cm2 and inner mucosal defect: 1.4 × 1.3 cm2). Next, a single-stage reconstruction with a superiorly based folded turnover nasolabial flap was performed for the full-thickness lateral alar defect. Six months after the reconstructive surgery, no wound complication and nostril collapse occurred. The surgical method used in this case has many advantages. First, the authors' method is performed only in a single stage. Second, the flap is based on a rich vascular supply from the angular artery, which eliminates the possibility of flap necrosis through multiple turnovers. Third, because the turnover nasolabial flap is a construct of the epidermis, dermis, and subcutaneous fat, the flap is quite stiff thus reducing the possibility of nostril collapse. Fourth, the procedure leaves no scars in the superior area of the nose other than the nasolabial fold scar.

Comparison of the Effects of Acellular Dermal Matrix and Montelukast on Radiation-Induced Peri-implant Capsular Formation in Rabbits.

PURPOSE: Capsular contracture (CC) is a troublesome complication after breast surgery with breast implants, and the risk increases in breast cancer patients after radiotherapy. Studies investigating leukotriene antagonists (eg, montelukast, zafirlukast) found that the acellular dermal matrix (ADM) can help prevent CC. We aimed to compare the effects of ADM and montelukast on CC after irradiation. METHODS: Eighteen New Zealand white rabbits were randomly divided into 3 groups of 6 each. Miniature cohesive gel implants were inserted into the pocket under the latissimus dorsi muscle. The lateral part was uncovered by the latissimus dorsi muscle. Six animals were included in the control group. In experimental group A (EG-A) (n = 6), the site was partially wrapped with ADM but not covered with muscle. Montelukast (Singulair, 0.2 mg/kg) was administered in experimental group B (EG-B) (n = 6) daily. Groups were irradiated at postoperative day 21 with Co-60 γ rays (25 Gy, single fraction) at the peri-implant area. Rabbits were sacrificed 12 weeks after surgery; implants with peri-implant capsule were harvested. Capsule thickness, collagen pattern, myofibroblast, and transforming growth factor (TGF) ß1/2 levels in the peri-implant capsule were evaluated. RESULTS: On histological evaluation, the capsule was thinner on the lateral aspect (covered with ADM) in EG-A (P = 0.004) and the entire capsule in EG-B (P = 0.004) than in the control group. However, there was no significant difference between EG-A and EG-B (P = 0.073). The collagen distribution pattern was more parallel with low density in the lateral capsular aspect in EG-A, but in the entire capsule in EG-B. The myofibroblast amount (EG-A, P = 0.031; EG-B, P = 0.016) and levels of TGF-ß1 and TGF-ß2 were reduced in the experimental groups (TGF-ß1, EG-A, P = 0.019; TGF-ß1, EG-B, P = 0.045; TGF-ß2, EG-A, P = 0.018; TGF-ß2, EG-B, P = 0.022). There was no significant difference between EG-A and EG-B (myofibroblast, P = 0.201; TGF-ß1, P = 0.665; TGF-ß2, P = 0.665). CONCLUSIONS: Acellular dermal matrix and montelukast have a prophylactic effect for CC even when the breast is irradiated. There was no significant difference between ADM and montelukast in preventing capsular formation. The difference is that ADM will only have the effect of covering the capsular formation with ADM and montelukast can cause systemic effects or complications.

Preventive Effect of Synthetic Tryptophan Metabolite on Silicone Breast Implant-Induced Capsule Formation.

BACKGROUND: In the field of plastic surgery, capsular contracture after silicone breast implant surgery is a major clinical problem. This experimental study confirms that the synthetic tryptophan metabolite N-(3',4'-dimethoxycinnamonyl) anthranilic acid (Tranilast) reduces capsule formation and prevents capsular contracture. METHODS: Eighteen New Zealand white rabbits were divided into 2 groups. In the experimental group, implants were inserted into each rabbit, and oral synthetic tryptophan metabolite was administered daily at a dose of 5 mg/kg in 10 mL of saline. In the control group, rabbits received implants and the same amount of saline without the metabolite. After 2 months, peri-implant tissues were harvested and analyzed. RESULTS: The thickness of the capsules and the inflammatory cell counts were decreased in the experimental group (P < 0.001). The collagen fibers in the experimental group were thinner, less dense, and more organized than in control group. The results of reverse transcription quantitative polymerase chain reaction analysis showed that the genes for transforming growth factor ß1 (P = 0.002), alpha smooth muscle actin (P < 0.001), and collagen types I (P = 0.002) and III (P = 0.004) were underexpressed in the experimental groups. Furthermore, the counts of T-cell immunity-related cytokine presenting cells were decreased in the experimental groups (CD3, 4, 25, 45RA, 45RO, 69, interleukin-2, 4 [P < 0.001], and interferon γ [P = 0.028]). CONCLUSIONS: This study confirms that a synthetic derivative of a tryptophan metabolite decreases capsule formation and prevents capsular contracture by inhibiting the differentiation of fibroblasts to myofibroblasts, selectively inhibiting collagen synthesis, and decreasing specific T-cell immune responses by changing anti-inflammatory cytokine expression.

Nasal Columellar Reconstruction With Reverse Lateral Nasal Artery Pedicled Nasolabial Island Flap.

Nasal columellar is a complex area to reconstruct due to its unique esthetic and functional characteristics. Malignancy, trauma, infection, and esthetic surgery complications can cause columellar defect. Among many surgical plans, nasolabial island flap is most commonly used. However, flap congestions occasionally occur which inevitably lead to leech therapy. The authors introduce reverse lateral nasal artery pedicled nasolabial island flap, which has lower risk of postoperative complications.

Firm Elevation of Reconstructed Auricle Using Polydactyly Digit in Microtia.

Total ear reconstruction for microtia is usually accomplished in 2 stages which is known as Nagata technique. After framework fabrication and implantation, the elevation procedure is required as a second step surgery. The authors are introducing a novel material for augmenting projection of rib cartilage framework in microtia treatment.

Facial Artery as a Recipient Vessel for Extensive Scalp Reconstruction With Free Omental Flap Without Vein Graft.

Most patients with reconstruction for extensive scalp defects require the use of a free flap. The suitability of the recipient vessel has a major impact on the surgery and postoperative outcome. Flaps that can be used to reconstruct the total scalp with a single flap include the latissimus dorsi (LD) and omental flaps; the LD flap is generally preferred since the omental flap results in relatively larger donor site morbidity. The recipient vessel most commonly used for scalp defect reconstruction is the superficial temporal vessel. The authors report a patient with successful total scalp reconstruction using a free omental flap on a patient whose bilateral superficial temporal arteries could not be used and who did not have available LD on both sides due to previous LD free flap surgeries for recurrent scalp angiosarcoma. In this patient, direct anastomosis of the flap to the right facial artery was performed without pedicle lengthening, such as vein graft or arteriovenous loops, and favorable outcome was achieved in terms of facial contour after recovery. The free omental flap is useful for reconstruction of extensive scalp defects without additional complex surgical procedures when other flaps are not viable or when the recipient vessel is located at a far distance.

Simple Septocutaneous Free Flap Design for One-Stage Reconstruction of Pharyngocutaneous and Orocutaneous Fistulae.

Reconstruction of pharyngocutaneous fistula (PCF) or orocutaneous fistula is always a challenging task. It has many causes and is especially related to radiation therapy after resection of head and neck cancers. There are many reports of surgical procedures for fistula repair. For example, 2-stage methods, methods of combining multiple flaps, and methods of using chimeric flaps have been reported. However, there is no established simple method as a treatment of choice. The authors describe 5 patients of head and neck fistulas and recommend a useful 1-stage reconstruction method using a double skin paddle free flap.The authors modified the free flaps simply with a double skin paddle sharing 1 pedicle. The skin paddle of the flap was split into 2 parts, one skin island for inner mucosal coverage, and the other for outer skin resurfacing. The bridge between the 2 skin paddles was deepithelialized and then folded. To prevent leakage, a water-tight closure was ensured.The double skin paddle free flap method was used in 5 patients. Two patients had orocutaneous fistula, and the other 3 patients had PCF due to irradiation. Flap losses did not occur, but wound dehiscence was noted in the 3 PCF patients. Repeat wound revision procedures were performed in these patients, and the end result was good.Conventional methods are complex and require multiple flaps or repeat surgery. However, the double skin paddle free flap method allows for simple and effective 1-stage reconstruction using 1 flap, 1 pedicle, and 1 microanastomosis even for patients who received preoperative radiotherapy.

Usefulness of Subciliary Approach by Using Lacrimal Sac Stripping for Large Isolated Medial Orbital Fracture Reconstruction.

BACKGROUND: There are several approaches for isolated medial orbital wall reconstruction, such as subciliary, transcaruncular, bicoronal, and medial canthus skin approach. Among them, selecting the best method has been controversial. The purpose of this study was to determine the safety and effectiveness of the subciliary approach by using lacrimal sac stripping for large isolated medial orbital wall reconstruction. METHODS: We conducted a retrospective study of patients with medial orbital fracture during the previous 5 years (January 2007-December 2011). The medical data of 20 patients, who presented with isolated medial orbital fracture and treated via subciliary approach using lacrimal sac stripping, were reviewed. The extent of the defect and plate size, follow-up details, and complications were analyzed. RESULTS: There were 16 male and 4 female patients. According to preoperative/postoperative computed tomography, the vertical defect ranged from 8 to 22 mm, longitudinal defect ranged from 10 to 27 mm, vertical plate length ranged from 11 to 28 mm, and longitudinal plate length ranged from 16 to 30 mm. The mean follow-up period was 24.7 weeks. Two patients complained of postoperative complications, inevitable traumatic optic neuropathy, and persistent diplopia on extreme lateral gaze. However, there were no other problems of enophthalmos, lower eyelid scar formation, postoperative ectropion, or lacrimal apparatus injury. CONCLUSIONS: Subciliary approach by using lacrimal sac stripping method offers a safe access route to the defect, satisfactory exposure, as well as sufficient room for insertion of large implant, without significant postoperative morbidity.

Immediate reconstruction of the maxillary sinus after resection of preoperatively misdiagnosed unicystic ameloblastoma with an ectopic third molar.

We report a case of unicystic ameloblastoma associated with an ectopic third molar in the right maxillary sinus, which was misdiagnosed as a dentigerous cyst on preoperative small incisional biopsy. Surgical enucleation of the cystic lesion was performed under general anesthesia with immediate reconstruction of the maxillary sinus using titanium mesh plate. The patient's postoperative recovery was uneventful, and there was no evidence of tumor recurrence during the 7-month follow-up period.

The effect of botulinum toxin B pretreatment to the blood flow in the microvascular anastomosis.

BACKGROUND: Although multiple factors can lead to free flap failure, vessel-related accidents are the most important. Many methods have been developed (both intraoperative and postoperative) to prevent vessel-related complications. In this article, we study the effects of a "preoperative treatment" using botulinum toxin B that could enhance the velocity and blood flow of vascular pedicles and decrease vascular accidents. METHODS: Ten Sprague-Dawley rats were pretreated with botulinum toxin type B at the perivascular area of the femoral vessel. Ten other rats were injected with saline as a control group. After 3 days, pedicle diameter and the peak mean frequency of blood in the pedicle were measured using laser Doppler flowmetry, and the peak mean blood velocity was calculated. We performed a "pedicle division and reanastomosis" operation to compare changes in vessel diameter and peak mean blood velocity. RESULTS: Vessel diameter was significantly increased in the botox-pretreated group for both veins and arteries. A comparison of the deep femoral vein and artery blood velocities showed that the peak mean velocity was significantly higher in the botox group. The average increase in blood velocity was significantly larger in the botox group. CONCLUSIONS: Botulinum toxin B is helpful by influencing the microvascular environment through an increase in the blood velocity of the pedicle.

Clear cell hidradenocarcinoma of the ear helix: report of primary ear helix adnexal carcinoma with regional lymph node metastasis.

Clear cell hidradenocarcinoma is a rare tumor of eccrine sweat gland origin that has a predilection for the head and neck. It has an indolent growth pattern and a higher incidence of regional and distant metastases. Metastasizing adnexal carcinomas are rare; thus, currently there is no uniform treatment guideline. We report a case of an 89-year-old female patient with clear cell hidradenocarcinoma manifesting in the right ear helix that metastasized to the right parotid gland who was treated by wide local excision and radiation therapy.

A Rare Atypical Case of Asymptomatic and Spontaneous Intraneural Hematoma of Sural Nerve: A Case Report and Literature Review.

Intraneural hematoma is a rare disease that results in an impaired nerve function because of bleeding around the peripheral nerve, with only 20 cases reported. Trauma, neoplasm, and bleeding disorders are known factors for intraneural hematoma. However, here we report atypical features of asymptomatic and spontaneous intraneural hematoma which are difficult to diagnose. A 60-year-old woman visited our clinic with the complaint of a palpable mass on the right calf. She reported no medical history or trauma to the right calf and laboratory findings showed normal coagulopathy. Ultrasonography was performed, which indicated hematoma near saphenous vein and sural nerve or neurogenic tumor. We performed surgical exploration and intraneural hematoma was confirmed on sural nerve. Meticulous paraneuriotomy and evacuation was performed without nerve injury. Histological examination revealed intraneural hematoma with a vascular wall. No neurologic symptoms were observed. In literature review, we acknowledge that understanding anatomy of nerve, using ultrasonography as a diagnostic tool and surgical decompression is key for intraneural hematoma. Our case report may help establish the implications of diagnosis and treatment. Also, we suggested surgical treatment is necessary even in cases that do not present symptoms because neurological symptoms and associated symptoms may occur later.

The effect of antiadhesion agent on peri-implant capsular formation in rabbits.

PURPOSE: Capsular contracture is the most troublesome complication after aesthetic breast surgery. Capsule formation can be seen as a normal foreign body reaction caused by implant insertion into the body. Pathological capsular contracture can lead to severe symptoms including pain, tenderness, and breast distortion. Hypertrophic scar hypothesis, one of the prevailing theories, implicates hematoma, granuloma, or other factors in capsular contractures. There are also animal studies that measure adhesion-induced capsule using fibrin glue. The authors performed the experiment to evaluate reductions in capsule formation using antiadhesion agent (AAA). METHODS: Twelve smooth-surfaced cohesive-gel implants were implanted in 12 New Zealand white rabbits weighing 1.8 to 2.6 kg. These 5 × 5 × 1 cm sized miniature implants were designed in accordance with products currently used for breast augmentation. After skin incision, the exposed latissimus dorsi muscle was elevated, and a submuscular pocket was made. The rabbits were divided into 2 groups. In the experimental group (n = 6), the implant and 2 mL of AAA (Guardix) were inserted into the pocket under the muscle. In the control group (n = 6), implants and 2 mL of saline were inserted into the pocket. During the 2-month follow-up period, the rabbits were imaged monthly by 3-dimensional computed tomography to study capsule formation changes. After 2 months, the animals were euthanized, and implants with peri-implant capsule were excised. We evaluated capsule thickness, collagen pattern, and myofibroblast ratio on ventral, lateral, and dorsal aspects in a blinded fashion. RESULTS: No significant differences in capsule thickness or capsular contractures were observed on gross examination or 3-dimensional computed tomography. On histological evaluation, capsule was thinner on all aspects (ventral, P = 0.027; lateral, P = 0.027; dorsal, P = 0.028; all P < 0.05), the pattern of collagen had more parallel alignment at low density, and the myofibroblast ratio was lower (ventral, P = 0.009; lateral, P = 0.002; dorsal, P = 0.004; all P < 0.05) in the experimental group than in control group. CONCLUSIONS: We suggest that AAA can be helpful in reducing capsule formation. Later, clinical trials are needed to evaluate this finding.

Current understanding of angiosarcoma: disease biology and evolving treatment.

Angiosarcoma is a very rare soft tissue sarcoma that originates from endothelial cells and typically has a poor prognosis. It is most commonly found in elderly white men and can occur anywhere in the body, particularly in the head, neck, and scalp. Patients who have undergone previous radiation treatment or who have chronic lymphedema also face an elevated risk of this condition. Various genetic changes are suspected to contribute to the development of angiosarcoma, and these changes have been identified as potential targets for treatment. For localized disease, wide surgical resection is often the prudent course of action. A multidisciplinary approach, which may include surgery, radiotherapy, systemic chemotherapy, or immunotherapy, is typically the most effective way to achieve favorable outcomes. In this review, we discuss the general understanding of angiosarcoma and its management, with a particular focus on the current evolving treatments for the disease.

A comparison of triamcinolone acetonide and fibrin glue for seroma prevention in a rat mastectomy model.

BACKGROUND: Seroma formation is one of the most common complications after flap surgery during the postoperative period. Various methods have been developed to overcome this problem, but none of them have been used successfully. Authors used topical triamcinolone acetonide to reduce seroma formation in a rat mastectomy model and compared its effectiveness with fibrin glue. METHODS: In the rat mastectomy model, the authors administered triamcinolone acetonide (experimental group I, n=12), fibrin glue (experimental group II, n=12), and saline (control group, n=12) beneath the skin flap just before closure of the skin. Seroma collections were aspirated and quantified after 7 days, and histologic analysis of the skin flaps and chest walls of the rats was performed. RESULTS: The experimental group I had a reduced mean seroma volume of 1.79±1.32 mL, whereas the experimental group II and control group had mean seroma volumes of 4.04±1.43 mL and 8.51±2.60 mL, respectively (P<0.05). In semiquantitative analysis of inflammation, inflammatory cell count in experimental group I was significantly fewer than in the other 2 groups (P<0.001). In addition, seroma capsule formation did not occur. CONCLUSIONS: Seroma prevention using triamcinolone acetonide is simpler, more economical, and more effective than fibrin glue. In proper concentrations, triamcinolone acetonide can be used to prevent seroma formation in clinical practice.

Current concepts of Kimura disease: pathophysiology and evolution of treatment.

Kimura disease (KD) is a chronic inflammatory disorder that frequently involves the subcutaneous tissue of the head and neck regions. It often manifests as regional lymphadenopathy or salivary gland enlargement in the affected area. The histologic architecture of the lymph nodes in KD patients is preserved, while the affected tissues show follicular hyperplasia and eosinophilic infiltration. No single modality has been adopted as an optimal treatment for KD. This article concentrates on the fundamental features of KD and reviews current approaches to its treatment.

Facial injury patterns associated with stand-up electric scooters in unhelmeted riders.

BACKGROUND: In recent years, the number of people riding stand-up electric scooters in South Korea has increased rapidly. This study analyzed the facial injury patterns associated with stand-up electric scooter-related trauma in patients who visited our emergency center. METHODS: In this retrospective review, we collected data from patients who had visited our emergency center for stand-up electric scooter-related trauma between January 1, 2018 and December 31, 2020. RESULTS: The average age of the patients was 26.7 years. Of the 73 patients, 47 were male and 26 were female, highlighting a male predominance. Seven patients were injured after alcohol consumption. None of the patients had worn helmets. Additionally, upon comparing the frequency of facial injuries according to the quarter of the year, the facial injury rate was higher in the second and third quarters than in the first and fourth quarters. Facial soft tissue injuries were classified into facial cosmetic subunits and analyzed according to their location. The highest number of injuries was on the chin (n=18, 20.9%). Of the 73 patients with stand-up electric scooter-related facial injuries, 16 had acute facial osseous fractures. The commonest acute facial osseous fractures were those of the orbit (n=7, 26.9%). CONCLUSIONS: The patterns of facial trauma reported here can be helpful for quickly evaluating and treating patients with facial trauma related to stand-up electric scooters. Additionally, people riding stand-up electric scooters should be aware of the risks associated with facial trauma and the importance of wearing protective devices, such as helmets and masks.

Primary Mucormycosis Infection in the Submandibular Area After Esthetic Lipolytic Injection in An Immunocompetent Patient: A Case Report.

As the popularity of injection lipolysis increases, several side effects of injection lipolysis have been reported. In this case, A 53-year-old woman visited our outpatient clinic with a new round-shaped protruding mass (size: 5.0 cm × 3.0 cm) in the submental area. The patient had received the injection lipolysis treatment before the visit. She had received injections in the submental area at 1-week intervals (i.e., 4, 5, and 6 weeks). We performed contrast-enhanced computed tomography of the neck for differential diagnosis and found a 5.0 cm × 3.7 cm × 2.1 cm rim-enhanced fluid-density lesion in the submental. Hence, surgical removal of the lesion was planned based on the diagnosis of unspecified complicated fluid collection. The removed mass was a 3.0 cm × 2.0 cm × 2.0 cm whitish fibrous tissue. Histological examination revealed mucormycosis infection. Although several side effects of lipolysis have been reported to date, mucormycosis infection in the submental area has not been reported before.

Scalp metastasis from an adenocarcinoma of the lung mimicking a cystic mass: case report and literature review.

A 67-year-old man visited our plastic surgery clinic complaining of a palpable protruding mass (2.0 × 2.5 cm) in the right occipital region. To establish an appropriate treatment plan for the cystic mass, brain magnetic resonance imaging was performed. A 2.2 cm nodular lesion with peripheral enhancement in the right occipital region of the scalp was confirmed. In addition, two rim-enhancing nodular lesions up to 9 mm with marked perilesional edema in the right frontal lobe were confirmed. The findings suggested metastasis from cancer. After further evaluations, a mass in the right lower lung field was identified as adenocarcinoma of the lung. Histological examination characterized the excised lesion as a cutaneous metastasis from lung adenocarcinoma. This case report shows that a cystic mass, which commonly occurs in the scalp, may indicate lung cancer. In particular, if a cystic mass of the scalp is identified in a person at high risk for lung cancer, appropriate evaluation and urgent treatment should be performed.