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.

Full-thickness skin rejuvenation by a novel dual-length microneedle radiofrequency device: A proof-of-concept study using human skin.

BACKGROUND: A novel dual-length microneedle radiofrequency (DLMR) device has been developed to achieve full-thickness skin rejuvenation by stimulating the papillary and reticular dermis simultaneously. This device's dual-level targeting concept need to be validated on human skin, although its clinical efficacy has been demonstrated in a previous study. OBJECTIVES: This study evaluated the dual-depth targeting capability and the ability to induce rejuvenation in each layer of vertical skin anatomy, that is, the epidermis, papillary dermis, and reticular dermis, using full-thickness human facial skin samples. METHODS: Human facial skin samples were obtained from 13 Asian patients who had facelift surgery. To validate the dual-depth targeting concept, DMLR-treated skin samples were analyzed using a digital microscope, thermal imaging, and hematoloxylin and eosin (H&E) staining immediately after DLMR application. On samples stained with H&E, Masson's tricrome, and Verhoeff-Van Gieson, histological observation and morphometric analysis were performed. Total collagen assay (TCA) and quantitative real-time polymerase chain reaction (qPCR) were used to assess changes in total collagen content and mRNA expression levels of collagen types I/III and vimentin, respectively. RESULTS: The DLMR device successfully induced thermal stimulation in the papillary and reticular dermis. The thickness, stacks, and dermal-epidermal junction convolution of the epidermis treated with DLMR were significantly increased. Collagen bundles in the dermis treated with DLMR exhibited a notable increase in thickness, density, and horizontal alignment. Dermal collagen levels were significantly higher in the morphometric and TCA data, as well as in the qPCR data for dermal matrix proteins. CONCLUSIONS: Our DLMR device independently and precisely targeted the papillary and reticular dermis, and it appears to be an effective modality for implementing full-thickness rejuvenation.

Rare Case of Managing and Evaluating Viability after Replantation of a Serial Self-Amputated Bilateral Testis by a Patient with Schizophrenia: A Case Report.

Amputation of the testis is very rare in clinical situations; therefore, most surgeons have no experience with an amputated testis. In this case, a 31-year-old male with schizophrenia amputated both testes due to self-mutilation. We performed replantation surgery via microscopy. On postoperative day 1, he removed his right testis by using his hand, even though his hands were restrained. The second attack disrupted the viability of the right testis. However, after proper management, we checked the normal sex hormone level by preserving the replanted left testis. We evaluated the viability of the replanted testis by performing five examinations, namely, intraoperative indocyanine green injection, testicular scan with technetium pertechnetate, contrast-enhanced computerized tomography, Doppler ultrasonography, and serum testosterone level. In this report, we aimed to describe our rare experience about management with replantation of the amputated testes and evaluation of their viability.

Effectiveness of Botulinum Toxin Injection on Bruxism: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: The present study compiled evidence on the efficacy of botulinum toxin A (BTX) for management of bruxism. METHODS: A literature review that included randomized control, cohort, as well as observational studies published between January 2000 and November 2022 was conducted. All studies related to BTX injections administered into the masseters of patients with bruxism were included. Primary outcomes were measured by performing a meta-analysis of changes in maximal biting forces and pain severity and meta-regression of the effects of the BTX dose. RESULTS: Ten studies were included for quantitative analysis. The analysis of the maximal biting force after BTX injections demonstrated a significant reduction at 1 month or less compared with both oral splints (P < 0.000001) and saline injections (P = 0.01). BTX continued to outperform oral splinting (P = 0.001) and saline placebos (P = 0.03) at 3 months. Between 3 and 6 months, a significantly higher maximal biting strength was observed in the BTX group than the oral splinting group (P < 0.00001). No significant differences in the maximal biting force were observed between the BTX and saline placebo groups (P = 0.50). A similar trend was observed in the analysis of pain reduction after botulinum treatment. Additionally, for every unit increase in the BTX dose, pain severity decreased by 0.0831 points (P = 0.0011). CONCLUSION: BTX is effective in reducing biting strength and pain severity. BTX effects are evident at less than 4 weeks, peak between 5 and 8 weeks, and last for up to 24 weeks. Higher BTX doses result in greater improvement in pain. Although BTX benefits manifest earlier, they gradually diminish, and oral splinting exerts a more enduring effect, especially after 9-12 weeks. BTX injections into masseters are recommended as management options for bruxers, especially for those having difficulties complying with wearing oral splints or those seeking earlier symptom relief. However, future studies should determine BTX effects beyond 24 weeks and after repetitive injections and how bruxers of different ages or genders respond to treatment. LEVEL OF EVIDENCE III: 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 .

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.

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.

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.

An innovative method of reconstructed penis reduction: a case report.

Background: Surgery to reduce the size of the reconstructed penis is uncommon. Patients who have undergone total penis reconstruction may want to reduce the size of their reconstructed penis due to convenience issues. To reduce reconstructed penis size, surgical treatment is essential. However, no research has thus far reported on this methodology. Case Description: A 50-year-old Asian man experienced a nearly total loss of his penis due to trauma 30 years ago. He underwent nearly total penis reconstruction using a tubed abdominal flap. The patient's reconstructed penis showed hypospadias, which caused discomfort during urination. The length of the penis was 17 cm. The patient felt that the reconstructed penis was too large, and a reduction surgery was planned for corrective action. Y-shape incision lines were applied on both lateral sides of the reconstructed penis to reduce the circumference, and curved incision lines were applied on the front and back of the penis to construct the neomeatus and glans of the penis. The incision was made, and the remnant tissue was dissected, with attention paid to avoid damage to the neourethra. After the tissue resection, the neourethra was isolated and resected to fit the height of the penis to construct the neomeatus and correct the hypospadias. An approximation was performed after the reconstructed penis reduction. Conclusions: Two years after the surgery, there were no complications, such as urethral stricture or fistula, and the patient was satisfied with the shape and size of the reduced penis (9 cm). The surgical reconstructed penis reduction procedure introduced in this case report achieved satisfactory aesthetic and functional results.

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.

Removal of intraosseous hemangioma in frontal bone under direct vision through a small incision.

Complete surgical excision within a margin of normal healthy bone is the treatment of choice for intraosseous hemangioma. A 56-year-old man visited with complaints of a firm, mildly tender, immovable, and palpable mass on the right forehead (size: 1.5× 1.5 cm). Non-contrast brain computed tomography performed preoperatively revealed a 1.5 cm heterogenous osteolytic lesion with suspected internal trabeculation in the right frontal bone. Under general anesthesia, a 2 cm transverse incision was made on the forehead skin rather than bicoronal incision. Full-thickness en bloc resection of the frontal bone including the mass was performed. The frontal bone was removed with care taken not to damage the frontal sinus mucosa. The frontal sinus was sealed with a collagen patch (Tachocomb) and a cranioplasty was performed using bone cement. At 6 months postoperative, a clean wound was confirmed without any complications, and there was no local recurrence. Surgical excision of intraosseous hemangioma in the frontal sinus bone can be performed via direct incision or the bicoronal approach. In this case, the direct incision approach was used to achieve smaller scars and faster recovery than the bicoronal approach.

Eponychial flap elevation method for surgical excision of a subungual glomus tumor.

The clinical symptoms of glomus tumors are pain, tenderness, nail discoloration, and cold intolerance. The only treatment for subungual glomus tumors is surgical removal. In this clinical study, we present an eponychium preserving method as a new innovative surgical approach for subungual glomus tumor. We retrospectively reviewed the data of 27 patients with subungual glomus tumors who underwent tumor resection using the eponychial flap elevation method between March 2010 and 2019. After the excision of the subungual glomus tumor using the eponychial flap elevation method, wound problems, severe pain, and nail deformity other than a minimal scar were not noted. The innovative eponychial flap elevation method is a simple and straightforward method for the management of subungual glomus tumors; the tumors can be sufficiently exposed and completely excised using this method while avoiding secondary nail dystrophy. This method can be another option among several methods of subungual glomus tumor removal.

A forehead hematoma as the initial clinical sign of lung cancer.

Primary lung cancer commonly metastasizes to the brain, bones, liver, and adrenal glands. In some cases, bone metastasis serves as the first presenting sign of lung cancer with bone pain and headache, but it is not common. The incidence of skull metastasis in lung squamous cell carcinoma (SCC) is low, and there have been only a few cases of skull metastases serving as the first sign of malignancy with skull mass and epidural bleeding; however, no similar cases have been reported regarding that of hematoma. We report a case of an 84-year-old man who first presented with a simple forehead hematoma and was eventually diagnosed with SCC of the lung.

Extensive and aggressive growth of adenoid cystic carcinoma in the lacrimal gland.

Adenoid cystic carcinoma (ACC) in the lacrimal gland is a very rare disease with poor overall prognosis. Its primary treatment is surgical excision, including orbital exenteration and radical orbitectomy, which is combined with radiotherapy and chemotherapy. Age, histopathologic type, bone invasion, and tumor extent are known factors that affect the prognosis of ACC. Furthermore, perineural invasion is highly associated with local tumor recurrence and tumor base invasion. Here, we report a rare case of ACC in the lacrimal gland with superior sagittal sinus invasion that repeatedly recurred after the surgical excision.

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.

Intracranial abscess from facial cellulitis.

Cellulitis, one of most common diseases of everyday life, is often overlooked for its significance. Although cellulitis does not cause or lead to serious problems usually, its possibility to cause life-threatening problem should be known. In present case, a patient who had received acupuncture treatment a week earlier presented to the clinic with symptoms of facial cellulitis. The disease resolved within few weeks under empirical antibiotic treatment but recurred after 3 months. Under close history review of the patient, we found out that the patient had received craniectomy 20 years ago. The patient had blunt headache with no other neurological symptoms that could suspect cranial infection, but considering the risk originating from the patient's surgical history, brain computed tomography (CT) was taken. CT images revealed abscess formation in the subgaleal and epidural spaces. Craniotomy with abscess evacuation was done promptly. With additional antibiotic treatment postoperatively, the disease resolved, and the 1-month postoperative follow-up brain CT showed no signs of abscess formation.

Anaplastic Large Cell Lymphoma Mimicking Cellulitis: A Case Report.

Cellulitis is one of the most misdiagnosed disease, which could be lethal when misdiagnosed. There are a lot of diseases to consider in differential diagnosis of cellulitis. Especially when conventional treatment with antibiotics does not seem to work, other radiological examinations and biopsy should be considered to find out what is causing the symptoms. Our case presents a patient with anaplastic large cell lymphoma, who was first thought to have had cellulitis but was later found to have malignancy. We aim to highlight the significance of differential diagnosis in common symptoms.

Multiple foreign bodies causing an orocutaneous fistula of the cheek.

Foreign bodies impacted in the maxillofacial region are often a diagnostic challenge. They can be a source of chronic inflammatory reactions and infections leading to the formation of an orocutaneous fistula. Such orocutaneous fistulas cause significant morbidity in most patients, eventually requiring surgery. Recently, we encountered a very rare case of an orocutaneous fistula caused by multiple foreign bodies in the cheek. Precise removal of the foreign bodies was required, and a double-sided anterolateral thigh free flap was used to reconstruct the defect. Surgeons should be aware of the complications of multiple foreign bodies and should be able to diagnose these on careful clinical examination.

Reconstruction of Small Chest Wall Defects Caused by Tubercular Abscesses Using Two Different Flaps.

Tubercular infection of the chest wall is rare and typically progresses to abscess formation. Treatment of these abscesses combines medical therapy with surgical debridement, which can cause defects of various sizes. This case report describes reconstruction of relatively small chest wall defects caused by tubercular abscesses with the use of two different flaps: a lateral intercostal artery perforator flap and a split pectoralis major muscle flap. The use of these flap techniques may provide a novel approach to cover small chest wall defects caused by tubercular abscesses.

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.

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.