Lateral Tarsoplasty Combined with a Full-Thickness Skin Graft for Managing Severe Lower Eyelid Ectropion Following the Subciliary Approach for Infra-Orbital Rim Fracture: A Retrospective Observational Study.

Subciliary incision is a common approach for facial fracture surgery; however, it has a higher incidence of lower lid ectropion, which can be particularly challenging for beginning surgeons to manage. This study reports the usage of lateral tarsoplasty combined with a full-thickness skin graft (FTSG) to correct severe ectropion following the subciliary approach for infra-orbital rim fractures. We retrospectively reviewed all facial fracture cases involving infra-orbital rim fractures through a subciliary approach treated in our department between March 2021 and May 2023. Electronic medical records and clinical digital photographs of patients who met the inclusion criteria were reviewed. After reviewing 196 cases that used the subciliary approach, we found 6 patients (3.06%; 4 males and 2 females; mean age, 68.5 ± 4.89 years) with postoperative severe ectropion managed using lateral tarsoplasty and FTSG. The mean ectropion development and correction times after facial fracture surgery were 0.78 ± 0.24 and 0.91 ± 0.37 months, respectively. At the 12-month follow-up, all patients showed favorable outcomes, and the position of their lower eyelids was well maintained without ectropion recurrence. Based on these successful outcomes, lateral tarsoplasty combined with FTSG is proposed to be an effective and straightforward method for managing lower eyelid ectropion caused by facial fracture surgery.

Associations of concentrations of eight urinary phthalate metabolites with the frequency of use of common adult consumer and personal-care products.

This study analyzed the relationship between urine concentrations of phthalate metabolites (UCOM) and personal care products (PCPs) used in adults and examined the change in UCOM according to the usage frequency of PCPs based on raw data from the 3rd Korean National Environmental Health Survey conducted between 2015 and 2017. The relationship between PCP use frequency and UCOM was analyzed using multiple regression analysis, adjusting for baseline factors. The regression model consisted of a Crude Model with log-transformed UCOM before and after adjustment for urine creatinine concentrations. Model 1 was additionally adjusted for age, sex, and obesity, while Model 2 was additionally adjusted for smoking, alcohol consumption, pregnancy history, average monthly income of the household, and PCP exposure within the past 2 days. PCP usage frequency was significantly associated with the UCOM without adjustment for urine creatinine and correlated with demographic characteristics, urine creatinine concentration, and PCP exposure within the past 2 days. This study on exposure to urinary phthalates will play a crucial role in Korean public health by aligning with the fundamentals of research priorities and providing representative data on phthalate exposure for conducting population-level studies.

Reconstruction of cervical necrotizing fasciitis defect with the modified keystone flap technique: Two case reports.

BACKGROUND: Cervical necrotizing fasciitis (CNF) is a rare, aggressive form of deep neck space infection with significant morbidity and mortality rates. Serial surgical debridement acts as the cornerstone of CNF treatment; however, it often results in defects requiring complex reconstructions. CASE SUMMARY: We report two cases in which the keystone flap (KF) was used for CNF defect coverage: Case 1, an 85-year-old patient with CNF in the anterior neck, and Case 2, a 54-year-old patient with CNF in the posterior neck. Both patients received empirical intravenous antibiotic therapy and underwent serial debridement, enabling adequate wound preparation and stabilization. The final defect size measured 5.5 cm × 12 cm in Case 1 and 6 cm × 11 cm in Case 2. For defect coverage, we employed an 8 cm × 19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm × 18 cm type II KF based on perforators from the transverse cervical artery in Case 2. Both flaps showed complete survival. No postoperative complications occurred in both cases, and favorable outcomes were observed at 7- and 6-month follow-ups in case 1 and 2, respectively. CONCLUSION: We effectively treated CNF-associated defects using the KF technique; KF is viable for covering CNF defects in carefully selected cases.

Single-Stage Peninsular-Shaped Lateral Tongue Flap for Personalized Reconstruction of Various Small- to Moderate-Sized Intraoral Defects: A Retrospective Case Series with Tongue Function Evaluation Using the Functional Intraoral Glasgow Scale.

Herein, we present our experience using a single-stage peninsular-shaped lateral tongue flap (pLTF) to cover various intraoral defects and confirm the versatile utility and effective application of pLTF in intraoral defect reconstruction. This study included eight cases (six males and two females; average age 60.3 ± 16.9 years) of intraoral defect reconstruction performed by a single surgeon between August 2020 and May 2023 using the single-stage pLTF technique. Electronic medical records and photographs of the patients were collected and analyzed. The functional intraoral Glasgow scale (FIGS) was used to evaluate preoperative and postoperative tongue function. Defect sizes ranged from 3 cm × 3 cm to 4 cm × 6 cm. Notably, all defects were successfully covered with pLTFs, and the flap sizes ranged between 3 cm × 4.5 cm and 4.5 cm × 7.5 cm. The flaps completely survived without any postoperative complications. At follow-up (average, 9.87 ± 2.74 months), no patient had tumor recurrence or significant tongue functional deficits. The mean preoperative and postoperative FIGS were 14.75 ± 0.46 and 14.00 ± 0.92, respectively (p = 0.059). Thus, the single-stage pLTF technique is a good reconstructive modality for various small to moderate intraoral defect coverage in selected cases for personalized intraoral reconstruction.

Comparison of the Characteristics of Three Acellular Dermal Matrices Subjected to Distinct Processing Methods Using Five Types of Histochemical Staining.

BACKGROUND: Acellular dermal matrix (ADM) is treated using various devitalization and aseptic processing methods. The processing effects on ADM were evaluated by histochemical tests. METHODS: From January 2014 to December 2016, 18 patients [average age, 43.0 (range, 30-54) years] who underwent breast reconstruction with an ADM and tissue expander were prospectively enrolled. During the permanent implant replacement, a biopsy of the ADM was performed. We used three different human-derived products, namely, Alloderm®, Allomend®, and Megaderm®. Hematoxylin and eosin, CD68, CD3, CD31, and smooth muscle actin were used to evaluate the collagen structure, inflammation, angiogenesis, and myofibroblast infiltration. Each ADM was semi-quantitatively analyzed. RESULTS: Significant differences in collagen degradation, acute inflammation, and myofibroblast infiltration were observed among the ADMs. Collagen degeneration (p<0.001) and myofibroblast infiltration (smooth muscle actin-positive, p=0.018; CD31-negative, p=0.765) were the most severe in Megaderm®. Acute inflammation, represented by CD68, was most severe in Alloderm® (p=0.024). Both radiation and freeze-drying treatment physically damaged the collagen structure. Collagen degeneration was most severe in Megaderm®, followed by Allomend® and Alloderm®. Since Alloderm® is treated using chemicals, an assessment of the chemical irritation is warranted. CONCLUSIONS: The biopsy results were inconclusive. Therefore, to better interpret processing, more large-scale, serial, histochemical studies of each ADM are needed. LEVEL OF EVIDENCE IV: This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

Modified Keystone Perforator Island Flap Techniques for Small- to Moderate-Sized Scalp and Forehead Defect Coverage: A Retrospective Observational Study.

We aimed to demonstrate the effective application of keystone perforator island flap (KPIF) in scalp and forehead reconstruction by demonstrating the authors' experience with modified KPIF reconstruction for small- to moderate-sized scalp and forehead defects. Twelve patients who underwent modified KPIF reconstruction of the scalp and forehead from September 2020 to July 2022 were enrolled in this study. In addition, we retrospectively reviewed and evaluated the patient's medical records and clinical photographs. All defects (size range, 2 cm × 2 cm to 3 cm × 7 cm) were successfully covered using four modified KPIF techniques (hemi-KPIF, Sydney Melanoma Unit Modification KPIF, omega variation closure KPIF, and modified type II KPIF) with ancillary procedures (additional skin grafts and local flaps). All flaps (size range, 3.5 cm × 4 cm to 7 cm × 16 cm) fully survived, and only one patient developed marginal maceration that healed with conservative management. Furthermore, through the final scar evaluation with the patient satisfaction survey and Harris 4-stage scale, all patients were satisfied with their favorable outcomes at the average final follow-up period of 7.66 ± 2.14 months. The study showed that the KPIF technique with appropriate modifications is an excellent reconstructive modality for covering scalp and forehead defects.

Learning curve of transoral robotic thyroidectomy.

BACKGROUND: Transoral thyroidectomy has superior cosmesis and better postoperative voice outcomes than conventional thyroidectomy. However, it usually requires a steep learning curve and longer operative time. The transoral robotic thyroidectomy (TORT) learning curve has not been well investigated. This study aimed to evaluate the TORT learning curve and factors affecting operative time. METHODS: We retrospectively studied 173 consecutive patients who underwent TORT with or without central neck dissection from July 2017 to August 2021. We assessed the TORT learning curve using operative time, complication rate, and surgical success (procedure conversion) rate. The operative time and surgical success rate learning curves were calculated using the cumulative summation (CUSUM) method. Additionally, we analyzed factors affecting operative time in TORT. RESULTS: Total thyroidectomy operative time was significantly longer than those of lobectomy and isthmusectomy (p < 0.001). In correlation analysis, a significantly positive correlation was observed between body mass index (BMI) and operative time (R2 = 0.04, p = 0.025). The TORT learning curve was 52 cases in the CUSUM operative time analysis. In the CUSUM surgical success rate chart, the turning point was the 55th case. Complication and procedure conversion rates were significantly decreased after the learning curve. CONCLUSIONS: The CUSUM learning curve of TORT was about 52-55 cases, and the operative time, total complication rate, and procedure conversion decreased significantly after the learning curve. The operative time was associated with the extent of thyroidectomy and BMI.

Modified Keystone Perforator Island Flap for Tension-Reducing Coverage of Axillary Defects Secondary to Radical Excision of Chronic Inflammatory Skin Lesions: A Retrospective Case Series.

Axillary defect coverage is often challenging after radical excision of chronic inflammatory skin lesions, such as complicated epidermoid cysts and hidradenitis suppurativa. This retrospective case series aims to demonstrate our experience with axillary reconstruction using the modified keystone perforator island flap (KPIF) technique, emphasizing its tension-reducing effects. All patients who presented for axillary reconstruction after radical excision of chronic inflammatory skin lesions between May 2019 and December 2020 were identified using the medical record database. Eleven patients ranging in age from 17 to 71 years underwent modified KPIF axillary reconstruction. Four types of modifications (modified type II KPIF, omega variation closure, Sydney melanoma unit modification, and hemi-KPIF) were used. All defects (size range, 2.5 × 3 cm2 to 8 × 13 cm2) were successfully covered using these modified KPIF techniques. All flaps (size range, 3.5 × 3.5 cm2 to 11 × 30 cm2) fully survived without complications. All patients exhibited favorable functional outcomes, and no cases of recurrence or limitations in joint range of motion were observed during the follow-up period (range, 4-5 months). Modified KPIF techniques may represent a reliable, effective alternative reconstructive modality for managing axillary defects.

Ruptured pseudoaneurysm of the internal maxillary artery in zygomaticomaxillary fracture: a case report.

Post-traumatic pseudoaneurysms of internal maxillary artery are rare, but may be life-threatening. When arterial damage leads to pseudoaneurysm formation, delayed intractable epistaxis can occur. We report our experience with the diagnosis and management of a ruptured internal maxillary arterial pseudoaneurysm that was discovered preoperatively in a patient with a zygomaticomaxillary complex (ZMC) fracture. He presented to the emergency room with epistaxis, which ceased shortly, and sinus hemorrhage was observed with a fracture of the posterior maxillary wall. The patient was scheduled for open reduction and internal fixation (ORIF) of the ZMC fracture. However, immediately before surgery, uncontrolled epistaxis of unknown origin was observed. Angiography indicated a pseudoaneurysm of the posterior superior alveolar artery. Selective endovascular embolization was performed, and hemostasis was achieved. After radiologic intervention, ORIF was successfully implemented without complications. Our case shows that in patients with a posterior maxillary wall fracture, there is a risk of uncontrolled bleeding in the perioperative period that could be caused by pseudoaneurysms, which should be considered even in the absence of typical symptoms.

Efficacy of phosphodiesterase type 5 inhibitors in patients with erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis.

Background: Nerve-sparing radical prostatectomy (NSRP) had to be performed because approximately 94% of patients are diagnosed with localized prostate cancer (PCa). Although NSRP is generally done to improve functional outcomes, erectile dysfunction (ED) is one of the most prevailing complications after radical prostatectomy (RP). Phosphodiesterase type 5 inhibitors (PDE5-Is) are the most well-known treatment agent for postoperative ED. This study aimed to assess the efficacy of PDE5-Is in patients with ED after NSRP. Methods: In this systematic literature review, randomized controlled trials on the efficacy and safety of PDE5-Is in patients who underwent NSRP were searched in MEDLINE, EMBASE, and the Cochrane Controlled Trials Register using the OVID platform. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Review Methods. The quality of the evidence of the outcome data was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: A total of 14 trials involving 2,822 patients were included. Significant improvements in the International Index of Erectile Function-Erectile Function (IIEF) domain score [mean difference (MD) =4.93; 95% confidence interval (CI): 4.14-5.71; P<0.00001] and erectile function recovery events [odds ratio (OR) =2.06; 95% CI: 1.45-2.94; P<0.0001] were observed after PDE5-I treatment. A higher positive response to Sexual Encounter Profile (SEP) question 2 (OR =2.27; 95% CI: 1.80-2.86; P<0.00001) and question 3 (OR =2.78; 95% CI: 1.97-3.91; P<0.00001) was also found after PDE5-I treatment. However, the incidence of treatment-emergent adverse events (TEAEs) was higher after PDE5-I treatment than after placebo treatment (OR =2.91; 95% CI: 1.84-4.61). Furthermore, the incidence of headache (OR =3.38; 95% CI: 2.40-4.75) and flushing (OR =9.44; 95% CI: 4.30-20.70) was also significantly higher after PDE5-I treatment (P<0.00001). In terms of the quality of the evidence of the outcome data, inconsistency problems were detected in all outcomes and imprecision problems in most outcomes. Discussion: PDE5-I treatment was more effective to placebo treatment in patients with ED after NSRP. No clinically serious complications were found in spite of the incidence of TEAEs being higher after PDE5-I treatment.

High-flow nasal cannula application in an infant patient with laryngomalacia during general anesthesia: A case report.

RATIONALE: Laryngomalacia is defined as the collapse of supraglottic structures and can cause not only strider but also trigger difficulties with ventilation and endotracheal intubation during anesthesia management. High-flow nasal cannula (HFNC) has been used to manage patients at high risk of hypoxemia in the intensive care unit; however, limited literature information is available for the application of HFNC to infant patients with laryngomalacia during anesthesia practice. PATIENT CONCERNS: A 2-month-old male infant was scheduled to undergo surgery for inguinal hernia and undescended testis with general anesthesia. DIAGNOSIS: The patient had subcostal retraction while breathing and frequent oxygen desaturation events and was diagnosed laryngomalacia. INTERVENTIONS: After the patient was supplied oxygen via HFNC and then given general anesthesia, the initial 2 attempts of endotracheal intubation with a rigid laryngoscope were unsuccessful because the vocal cords were obscured by the epiglottis. A third intubation attempt was performed and successful with a 3.0-sized, uncuffed endotracheal tube within 20 minutes of the initial attempt. OUTCOMES: No airway complications emerged and oxygen saturation remained at greater than 98% during general anesthesia. The patient was discharged 5 days after surgery without any adverse side effects. LESSONS: Continuous oxygenation via HFNC is a good choice to prevent desaturation during difficult tracheal intubations in infant patients with laryngomalacia. This device is expected to be useful for intubation not only in patients with laryngomalacia, but also in infant patients with a predicted high risk of oxygen desaturation events during general anesthesia.

A comparative study for tension-reducing effect of Type I and Type II keystone perforator island flap in the human back.

The keystone perforator island flap (KPIF) is popular in reconstructive surgery. However, despite its versatility, its biomechanical effectiveness is unclear. We present our experience of KPIF reconstruction in the human back and evaluate the tension-reducing effect of the KPIF. Between September 2019 and August 2020, 17 patients (51.82 ± 14.72 years) underwent KPIF reconstruction for back defects. In all cases, we measured wound tension at the defect and donor sites before and after KPIF reconstruction using a tensiometer. All defects occurred after complete excision of complicated epidermoid cysts and debridement of surrounding tissues. The defects were successfully covered with Type IIA KPIFs. All flaps survived, and there were no significant postoperative complications. The mean "tension change at the defect after Type I KPIF" and "tension change at the defect after Type II KPIF" were - 2.97 ± 0.22 N and - 5.59 ± 0.41 N, respectively, (P < 0.001). The mean "rate of tension change at the defect after Type I KPIF" and "rate of tension change at the defect after Type II KPIF" were - 36.54 ± 1.89% and - 67.98 ± 1.63%, respectively, (P < 0.001). Our findings confirm the stepwise tension-reducing effect of KPIF and clarify the biomechanics of this flap.

The Effect of Bone Morphogenetic Protein-2 on the Irradiated Allogenic Cartilage of Rats.

ABSTRACT: Autogenous cartilage graft is associated with the problem of chondrocyte dedifferentiation. Bone morphogenetic protein-2 (BMP-2) plays an important role in the differentiation and matrix maturation of chondrocytes, and preventing their dedifferentiation.This study was performed on 48 rats, divided equally into 3 groups. In group I, the xiphoid process cartilage was harvested and irradiated, and broken into 2 pieces. Each piece was implanted on the back. The same process was performed in Groups II and III, but further treated with BMP-2, Group II with 25 µg, and Group III with 50 µg. The implanted cartilage pieces were reharvested at postoperative weeks 2 and 4. The weight change was measured and histological evaluation was performed.The extent of the weight change was higher in Groups II and III than in Group I. The extracellular matrix between the chondrocytes showed increased in Groups II and III. The fibrous tissue on the surface of the cartilage increased in Groups II and III. Ossification of the chondrocytes was observed in Groups II and III.The use of BMP-2 increased the matrix between chondrocytes and the fibrous tissue of the cartilage and facilitated the ossification of chondrocytes. The effect of BMP-2 increased with its increasing concentration, and maintenance of its effectiveness over time was confirmed.

Keystone Flaps for Coverage of Defects in the Posterior Neck and Lower Occipital Scalp: A Retrospective Clinical Study.

ABSTRACT: The coverage of the posterior neck and lower occipital scalp defects should be approached carefully. Thick, stiff, and inelastic skin properties of these areas tend to make coverage of even small defects difficult. Herein, the authors present a retrospective review of our experience with posterior neck and lower occipital scalp reconstruction using the keystone flap (KF) and describe the expanding versatility of KF reconstruction. The medical records of 17 patients who underwent KF reconstruction to cover the posterior neck and lower occipital defect from April 2017 to May 2020 were reviewed. Clinical and operative data were collected. All defects were successfully covered with the KFs. The defect sizes ranged from 2.5 × 3.5 cm to 6 × 11 cm, and the flap sizes ranged from 3 × 5.5 cm to 9 × 18 cm. All flaps fully survived, although marginal maceration developed in one case; however, it healed with conservative management. The final results were favorable, and all patients were satisfied with their final outcomes. Consequently, the KF can be considered as a good reconstruction modality with few complications and provides an alternative to other reconstructive options for coverage of the posterior neck and lower occipital defects.

Use of Keystone Flaps in Consideration of the Facial Aesthetic Subunit Concept as an Alternative Reconstructive Option for Nasal Defect Coverage.

ABSTRACT: Nasal defect coverage has some challenging aspects for plastic surgeons because of the midfacial location of the nose and the relationship between convexities and concavities of nasal subunits. The authors described our experience with performing keystone flap (KF) nasal reconstruction in accordance with the facial aesthetic subunit concept and demonstrated the expanding versatility of KFs in nasal reconstruction. Between January 2017 and February 2020, 15 patients (average age, 72.07 ±â€Š13.00 years, range: 38-88 years) underwent KF reconstruction for nasal defects. We performed KF reconstruction in accordance with the facial aesthetic subunit concept. Data, including the defect causes and locations, defect sizes, flap sites and sizes, types of KFs, flap survival, complications, and follow-up period for each patient were reviewed retrospectively. Cosmetic outcomes were evaluated by independent plastic surgeons and patients through satisfactory postoperative surveys. Sixteen defects occurred in 15 patients. The defect sizes ranged from 0.8 × 1 cm to 2.5 × 3 cm. The flap sizes ranged from 1.5 × 3.5 cm to 4 × 6 cm. All defects were successfully covered with KFs from adjacent subunits. All flaps survived without any postoperative complications. At the mean follow-up period of 8.33 ±â€Š2.92 months, the objective cosmetic outcomes were rated favorably, and the average subjective patient satisfaction score was 7.93 ±â€Š1.28 on a scale of 1 to 10. We suggest that using KF reconstruction in consideration of the facial aesthetic subunit concept can be a promising alternative modality for covering nasal defects with outstanding aesthetic outcomes.

Intravenous Iron Isomaltoside 1000 Reduces Postoperative Anemia in Patients Undergoing Elective Urologic Surgery and Those with Urosepsis.

PURPOSE: Postoperative anemia is associated with increased morbidity and mortality in patients undergoing surgery. Anemia is also a common feature during sepsis. Therefore, here, we aimed to investigate the safety and efficacy of intravenous iron isomaltoside 1000 (Monofer®) in patients undergoing elective urologic surgery and in those with urosepsis. MATERIALS AND METHODS: This multicenter study was conducted through the review of the medical records of patients with postoperative anemia undergoing elective urologic surgery or with urosepsis in a multicenter hospital. Patients received a single intravenous iron isomaltoside (IIM), and their hemoglobin (Hb) level was evaluated before and after administration of IIM. Safety data included adverse effects and hypersensitivity reactions. In addition, the patients were divided into three groups (200 mg, 400 mg, and 600 mg IIM) to compare Hb changes before and after the administration of IIM. RESULTS: The study analyzed 52 men and 30 women with a mean age of 67 years. There was a significant difference between pre-treatment Hb and post-treatment Hb according to the type of the surgery after administration (p=0.01) of IIM in patients with postoperative anemia, and the mean preoperative Hb before IIM administration was 8.5 g/dL and that after IIM administration was 9.9 g/dL (p=0.006) in patients with urosepsis. The mean preoperative Hb changed from 10 g/dL to 11 g/dL after administration (p<0.001) of IIM in the whole cohort. There were no side effects due to the administration of intravenous IIM. CONCLUSION: A single perioperative intravenous injection of IIM 1000 significantly increased the Hb level in patients with anemia who underwent urologic elective surgery. Moreover, this treatment can be considered to have potential clinical benefits for anemia caused by sepsis.

Keystone design perforator island flap in facial defect reconstruction.

Facial defect coverage is a common subject in the field of reconstructive surgery. There are many methods for facial defect reconstruction, and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement. Among various options for facial reconstruction, the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture, which is consistent with the ideal goal of reconstruction (replacement of like-with-like). Keystone design perforator island flap (KDPIF), devised by Behan in 2003, has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity, robust vascular supply, and reproducibility. Several studies have reported KDPIF reconstruction of facial defects, such as large parotid defects, small-to-moderate nasal defects, and eyelid defects. However, KDPIF has been used relatively less in facial defects than in other body regions, such as the trunk and extremities. The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF, modifications, physiology, mechanism of flap movement, consideration of facial relaxed skin tension lines and aesthetics, surgical techniques, clinical applications, and precautions for successful execution of KDPIF reconstruction.

Reconstruction of bilateral inferomedial gluteal defects after resection of hidradenitis suppurativa with symmetrical keystone flaps designed parallel to relaxed skin-tension lines: A case report.

RATIONALE: Surgical treatment of hidradenitis suppurativa (HS) is challenging. Wide excision of affected lesions followed by skin graft or flap coverage has been recommended to achieve remission and prevent recurrence. Herein, we present our experience of bilateral inferomedial gluteal defects coverage using symmetrical keystone flaps (KFs) designed parallel to relaxed skin-tension lines (RSTLs). PATIENT CONCERNS: An 18-year-old man was admitted for chronic inflammatory lesions in both inferomedial gluteal areas. DIAGNOSES: Physical examination revealed multiple sinuses with broad surrounding scars in both inferomedial gluteal areas, which led to a diagnosis of HS. INTERVENTIONS: We performed wide excision on all affected lesions. The size of the final defects was 6 × 10 cm on the right side, and 5 × 9 cm on the left side. We covered the defects with KFs 9 × 15 cm (right) and 8 × 12 cm (left), which were based on the hotspots of the interior gluteal artery and internal pudendal artery perforators, and parallel to RSTLs. OUTCOMES: The flaps were inset without tension on each side, and the donor sites were closed primarily. All flaps fully survived and there were no postoperative complications. The patient was satisfied with the final outcome after 6 months of follow-up. LESSONS: Successful reconstruction of bilateral inferomedial gluteal defects was achieved after resection of HS using symmetrical KFs designed parallel to RSTLs. The KF technique considering RSTLs could be a good reconstructive option for gluteal HS.

Circumferential penile defect reconstruction with pull-up double-opposing keystone-designed perforator island flaps: A case report.

RATIONALE: The challenges with reconstruction of penile defects are plenty. In addition, no single and universally accepted reconstructive method exists for penile defect repair. Herein, we present the application of a circumferential penile shaft defect reconstruction using pull-up double-opposing keystone-designed perforator island flaps (KDPIFs) in one patient. This is the first case report of a circumferential penile shaft defect reconstruction using KDPIFs. PATIENT CONCERNS: A 43-year-old man who injected petroleum jelly into his penis 10 years ago presented with multiple firm nodular mass-like lesions adherent to the overlying skin along the penile shaft. Our urologic surgeon removed the foreign bodies and performed a primary closure with undermining. However, wound dehiscence developed, and skin necrosis was exacerbated 5 days postoperatively. DIAGNOSES: We performed debridement, and the final post-debridement defect was circumferential (5.5 × 12 cm) from the base of the glans to the midpoint of the penile shaft. INTERVENTIONS: We covered the defect using pull-up double-opposing KDPIFs (10 × 13 cm each) based on the hot spots of the superficial external pudendal artery perforators on each side from the suprapubic area to the scrotum. OUTCOMES: The flaps survived perfectly, with no postoperative complications. The patient was satisfied with the final outcome and had no erectile dysfunction or shortening of penile length after a 6-month follow-up. LESSONS: We successfully reconstructed a circumferential penile defect with pull-up double-opposing KDPIFs both esthetically and functionally. Our technique can be a good alternative modality for extensive penile defect reconstruction.