Orbital Exenteration and Reconstruction Using a Free Radial Forearm Flap in Conjunctival Melanoma: Old but Gold.

Conjunctival melanoma is a rare and potentially deadly tumor. Therefore, adequate oncological resection is essential, commonly leading to total orbital exenteration, which causes patients' extensive functional and cosmetic impairment. As a result, it is essential to reconstruct the orbital region post-exenteration to obliterate the cavity, provide adequate and pliable cutaneous covering, and restore a stable vascularized tissue that can withstand adjuvant radiotherapy. In recent years, the techniques used for orbital reconstruction have included the transorbital temporoparietal fascial flap, the anterolateral thigh flap, and local flaps, such as the paramedian forehead flap. A free radial forearm flap is currently not commonly used for orbital reconstruction due to potential donor site morbidity and cosmetic issues. In our case, we report a free radial forearm fasciocutaneous flap that has been utilized with promising surgical outcomes to reconstruct the orbital region following orbital exenteration.

Long-Term Nasolabial Appearance Post-Unilateral Cleft Lip Repair in a Single Center: A Descriptive Study.

Introduction Modern treatments still aim to keep the impact of surgical intervention low and the outcome of surgeries as good as a surgeon can. Assessing the long-term nasolabial appearance of patients who underwent cleft lip (CL) repair surgery is one of the methods of evaluating the outcomes of cleft surgery. Methods This is a retrospective cross-sectional descriptive study of data records of unilateral CL patients. The data records of all patients who underwent unilateral CL repair by the reconstructive science unit at Hospital Universiti Sains Malaysia (HUSM) within the first two years of their lives and whose current age is 14 years or above were accessed and analyzed. Results The data records of 50 patients were analyzed, including 13 (26%) males and 37 (74%) females. The surgeons opined that 28% of the patients had an acceptable nasolabial appearance, while there were 10 (20%) patients whose nasolabial appearance was considered unacceptable by the reviewing surgeons. Fifteen (30%) patients were described as having an acceptable lip appearance with secondary nasal deformity, and 11 (22%) patients had an acceptable nasal appearance with secondary lip deformity. There were no surgical modifications or postoperative complications among the patients. None of our variables reported a significant association with long-term nasolabial appearance. Conclusion The long-term evaluation of the nasolabial appearance in individuals with CL following surgical correction significantly improves the service and care provided to patients to achieve optimum results. Although our results showed no relationship between gender, age at operation, type or diagnosis of cleft, and family history and long-term nasolabial appearance, frequent assessments will enhance surgical results.

The heart-lung machine in major limb replantation: Report of two cases.

Replantation of amputated limbs after long ischemic hours almost always comes with reperfusion syndrome and poor outcomes. An ischemic time of greater than 6 h is often considered unsuitable for major limb replantation. However, usage of extracorporeal perfusion has been shown to prolong the viability of major limbs in animal studies. The aim of this report is to show that extracorporeal perfusion with cardiopulmonary bypass machine (CPBM) is a safe and reliable technique in improving limb survival as illustrated by our cases. We report two cases of successful major limb replantation with late presentation. One case involved a 31-year-old man with shoulder disarticulation and the other involved a 30-year-old man sustained proximal transtibial amputation. Both patients, who were generally fit, were involved in major road traffic accidents. The amputated segments were connected to a CPBM to expedite reperfusion and to flush away anaerobic metabolic products. The major vessels were cannulated and connected to a bypass machine that was initially primed with heparinized saline and perfused with packed cells at 100% oxygen concentration. The perfusion was carried out at 35°C with low pressure to prevent edema and low flow to reduce reperfusion injury. Venous blood was drained completely before replantation. Total ischemia times were 7 h 40 min and 9 h, respectively. No evidences of perioperative reperfusion syndrome were seen. Both of the replanted limbs survived and patients had regained better-than-expected limb functional outcomes at 5-year and 2-year follow-up, respectively. CPBM may be safely used in major replantation surgery to enhance limb survival and therefore warrants further research.

Bi-pedicled Visor Flap for Coverage of Two Skull Defects: A Practical Flap Option for Metastatic Scalp Lesions With a Favorable Cosmetic Outcome.

Reconstruction of the scalp after acquired defects poses a great challenge to reconstructive surgeons. In oncologic resections, the defect must be covered with well-vascularized tissue to withstand radiotherapy post-surgery. However, due to the limited scalp tissue mobility, primary closure or loco-regional flaps are challenging and limited in choice. Fortunately, with the current understanding of the robust blood supply system to the scalp tissue, they can survive with the closure under tension. In this paper, we present a case of scalp reconstruction using a bi-pedicled visor flap to cover the two skull defects after ablative surgery. In addition, this article highlights the reason for the option, the surgical procedure, and the cosmetic outcome of the surgery.

Atypical Presentation of Lip Nodules in Clinically Diagnosed Juvenile Hyaline Fibromatosis.

Juvenile hyaline fibromatosis (JHF) is a rare, hereditary disease characterized by abnormal hyaline deposits within the skin, soft tissues, joints, and bones. The condition itself is often debilitating, with no curative treatment available. A definitive diagnosis is established by genetic testing. However, the hallmarks of gingival hypertrophy, subcutaneous scalp nodules, and joint contractures can be used as a clinical guide when genetic testing is unavailable. Here, we report an unusual case of a five-year-old child clinically diagnosed with juvenile hyaline fibromatosis with atypical nodules exclusively confined to the perioral region.

Surgical correction of Tessier cleft no. 7: A single center 18-year experience.

INTRODUCTION: Tessier cleft 7 are rare craniofacial clefts. Live-birth incidence varies from 1/80,000 to 1/300,000, with the incidence of 1 in 120 craniofacial clefts among Asians. Its clinical presentation varies widely in severity, thus, complicating diagnosis and contributing to the lack of consensus regarding its surgical management. The aim of this study is to describe clinical findings, types of Tessier cleft 7 soft tissue repair, and its outcomes in Kuala Lumpur Hospital. METHODS: This retrospective study reviewed records of children operated from January 2001 to July 2019. Data regarding concurrent congenital anomalies, complications, type of surgery, etc., were collected from outpatient records, operative notes, and clinical photographs. RESULTS: Twenty-eight children were treated, and 33 clefts (5 bilateral) were repaired. The male-to-female ratio was 1.3:1 (16 males and 12 females). Twenty-three patients had unilateral clefts (82.14%), with 14 right (60.86%) and 8 left (34.78%). Bilateral clefts were less common (17.86%). Twenty-three patients (82.14%) were Malay, 3 (10.71%) Chinese, 1 (3.57%) Indian, and 1 (3.57%) Cambodian. Eleven medical records were untraceable (discontinued due to duration of inactivity). There were 10 straight-line repairs, 5 Z-plasties, and 1 W-plasty performed; 3 cases did not detail the type of repair. One child required scar revision, and 1 had hypertrophic scarring requiring corticosteroid injection-no disturbances in speech or oral incompetency while eating were reported. Duration of follow-up ranged from 3 to 14 years. CONCLUSION: Our center has a higher rate of Tessier cleft 7 attendance. Straight-line cutaneous repairs combined with inferior vermilion mucosal flap can be used with low rates of complication and revision surgery.

Carcinosarcoma: A Rare and Aggressive Breast Tumor in a Young Lady.

Carcinosarcoma of the breast is a subtype of metaplastic breast carcinoma characterized by differentiation of the neoplastic epithelium toward mesenchymal-looking elements. It is a highly aggressive rare subtype of invasive breast neoplasm that exhibits a distinct histologic entity. Only a limited number of reports related to this type of disease have been reported. Here, we present a case of breast carcinosarcoma in a lady in her early 20s, which is relatively young among all cases published. It was challenging to achieve diagnosis preoperatively with histopathological evaluation of the ultrasound-guided tru-cut biopsy sample. With no evidence of distant metastasis clinically and radiologically, a surgical option was opted for. Left mastectomy and left chest wall reconstruction with deep inferior epigastric artery free flap were performed. Post-excision specimen was confirmed to be carcinosarcoma.

Atypical Chest Pain in a Patient With Breast Implant.

Breast implant surgery typically improves patient breast satisfaction and health-related quality of life. However, breast implants are also linked to long-term local problems like capsular contracture and breast discomfort. Chest pain is one of the reasons that patients with breast implants seek consultations, which is not typically attributable to cardiovascular reasons. The potential reasons for atypical chest pain are diverse. The absence of a precise diagnosis may also result in incorrect examinations and management, leading to further worry and wasted work time. A 55-year-old woman with a breast implant 10 years prior to the incident, presented with atypical chest pain on and off for a year and was treated as a case of unstable angina, costochondritis, and vasospastic spasm. Despite multiple visits, her symptoms did not resolve. Later, the patient presented with a lump over the left breast, associated with constitutional symptoms. Examination revealed a left breast implant with capsular contracture grade III, and ultrasonography showed signs of a ruptured implant. Symptoms eventually resolved after the removal of the breast implant.

Cutaneous squamous cell carcinoma with secondary parotid metastasis: a case report.

Background: Majority of cutaneous squamous cell carcinoma (cSCC) originate in the head and neck region, with 1-3% have been found to have parotid or periparotid lymph nodes metastases. The significance of secondary parotid metastases from cSCC lies in its propensity of cervical lymph node spread and distant metastases leading to a dismal prognosis, and therefore the importance of early diagnosis and prompt treatment. Case Description: An 85-year-old gentleman with prior history of right temporal squamous cell carcinoma (SCC) presented with a new onset left cheek cSCC. He underwent complete excision with clear margin. Four months following initial surgery, he developed ulcerative mass at left angle of mandible. CT scan revealed an underlying left parotid gland tumor, which was confirmed to be SCC by fine needle aspiration cytology (FNAC). He was then surgically treated with nerve-sparing total parotidectomy, modified radical neck dissection, soft tissue reconstruction using free anterolateral thigh fasciocutaneous flap and adjuvant radiotherapy with satisfactory outcomes. Conclusions: Although rare, metastatic cutaneous SCC to parotid gland represents a unique group of locally advanced cutaneous SCC. Multimodal treatment approach consisting of total parotidectomy, ipsilateral neck dissection and adjuvant radiotherapy has been shown to improve the locoregional control of the disease and limit the propensity to distant metastasis.

Changes in Spinal Alignment of Women Who Underwent Unilateral Mastectomy with Immediate Autologous Breast Reconstruction Compared To Mastectomy without Breast Reconstruction.

INTRODUCTION: The impact of breast reconstruction on spinal alignment is not well studied, especially in immediate autologous breast reconstruction. Studies on body posture have shown greater asymmetry among those without reconstruction. This study compared the changes in spinal alignment pre- and post-operatively among women who underwent unilateral mastectomy without reconstruction (MA) versus immediate autologous breast reconstruction (IABR). METHODS: A cross sectional, retrospective study analysed MA and IABRs performed from January 2007 to December 2017 and their pre- and post-operative anterior chest radiographs. The change in Cobb's angle (degrees) less than 1 year, 1 to 2 years, more than 2 years post-operatively were analysed using GE Healthcare Centricity Picture Archive and Communications Systems. RESULTS: 537 patients underwent mastectomy; 76 fulfilled the inclusion criteria (36 IABR, 40 MA). No significant difference existed between mean pre- and post-operative Cobb's angle change across all 3 groups, less than 1 year (MA 3.57±3.84, IABR 3.316±2.72, p=0.81), 1 to 2 years (MA 1.84±4.81, IABR -2.68±3.21, p=0.577) and more than 2 years post-operatively (MA -1.14±5.30, IABR -0.94±5.10, p=0.898). However raw data indicated IABR improved spinal alignment in the short and intermediate period post-operatively. Among IABR, free flap breast reconstruction improved spinal alignment compared to pedicled flaps [free flaps: 2.21±3.28, pedicled flaps: 0.01±3.67 (p=0.027)]. CONCLUSION: IABR has a positive impact on spinal alignment in early and intermediate post-operative period compared to MA, especially in women with larger breast volume. Physical benefits of IABR should be highlighted to improve patient's access to breast reconstruction globally.

A Lucky Case of Successful Free Fibula Osteocutaneous Flap Harvest in Peronea Arteria Magna.

The free fibula flap (FFF) is based on the peroneal artery (PA) system, and it is well known that several anatomical variations of the lower limb vascular system exist, including peronea arteria magna (PAM). PAM is a rare congenital variation in which both anterior tibial artery and posterior tibial artery are either aplastic or hypoplastic, and as a result, PA will be the dominant blood supply to the foot. This variation was described as type III-C in Kim-Lippert's Classification of the Infra-Popliteal Arterial Branching Variations. The awareness of its existence is crucial as it often precludes FFF from being harvested due to the risk of significant limb ischemia and limb loss. Despite some literature reporting donor site complications and impending limb loss following FFF harvest in PAM, preoperative vascular mapping before FFF transfer remains controversial among the microsurgeons. We present a case with an incidental intraoperative finding of PAM that had a successful FFF harvest by luck, without preoperative vascular mapping.

Master of mimicry: Rare primary cutaneous anaplastic large cell lymphoma presenting as fungating parotid tumor-case report and review.

INTRODUCTION: Primary cutaneous anaplastic large cell lymphomas (PC-ALCL) are rare. They fall within non-Hodgkin's lymphomas spectrum. Commonly misdiagnosed, this malignancy involving the skin has favorable prognosis. To the best of our knowledge, this is the first reported case of PC-ALCL involving the parotid gland. This clinical presentation can mislead surgeons. We highlight this diagnostic conundrum. CASE PRESENTATION: A 73-year-old gentleman presented with two painless, ulcerating nodules over the right pre-auricular and angle of the mandible. Prior to that, he had right pre-auricular swelling that enlarged over a year. Skin nodules erupted few weeks before seeking treatment. Computed Tomography scan reported homogenously enhancing masses at posterior part of parotid gland's superficial lobe with diffuse lobe enlargement and no regional lymphadenopathy. A hypodense lesion at the liver indicated metastasis. Biopsy revealed PC-ALCL. He responded well to chemotherapy. DISCUSSION: PC-ALCL commonly presents as solitary nodules that can ulcerate over the head and neck region. Reports of PC-ALCL involving the eyelids, lips, and breast were found in our literature review. Multifocal lesions occur in 20% of cases. Malignant parotid tumors are aggressive and require parotidectomy which carry the risk of facial nerve injury. Treatment of PC-ALCL however, is local excision and radiotherapy for solitary lesions; and chemotherapy for those with extracutaneous spread. The 5-year survival rate is 90% in PC-ALCL. CONCLUSION: PC-ALCL is a master of mimicry. To prevent serious morbidity, awareness regarding this entity as a differential diagnosis compared to the common malignant parotid tumors need to be raised.

The Impact of Abdominoplasty vs Non-abdominoplasty on Weight Loss in Bariatric and Non-bariatric Malaysian Patients: A Multicentre Retrospective Study.

Background and aims Weight loss associated with abdominoplasty remains controversial as to whether it is contributed by the procedure alone, or if there are other patient factors. Therefore, we evaluated the relationship between weight loss in pre- and post-abdominoplasty and compared the weight loss of those who do not undergo abdominoplasty in bariatric and non-bariatric patients. Methods This study measured weight changes at designated time points in four different groups comprising 98 patients. The groups were abdominoplasty after bariatric surgery (group A), patients with abdominoplasty alone (B), bariatric surgery alone (group C), and diet alone (group D). Results are compared within and between the groups. Results Patients in groups A and B (patients who had abdominoplasty regardless with or without bariatric surgery) had a significant weight loss after six months (mean difference=10.70kg, 95% CI=4.05, 17.34, p<0.001) compared to pre abdominoplasty weight. Patients in group B were statistically significant (mean difference=4.01kg, 95% CI=0.92, 7.10, p=0.007) with 3.60kg weight reduction (4.59%). Patients in group A had clinically significant weight reduction (4.45kg, 5.14%) but it was not statistically significant (p>0.05) and had no significant additional weight reduction as compared to non-abdominoplasty (group C) patients (p=0.650). Patients in group C had a statistically significant difference from those in group D (F [1.00, 48.00] = 8.56, p=0.005) with an average weight loss of 3.60kg (4.59%) vs 2.56kg (2.8%) respectively. Conclusions All patients with abdominoplasty had significant weight loss after six months. Bariatric patients did not experience significant additional weight loss with abdominoplasty. Weight reduction after abdominoplasty alone was greater than diet alone.

Reversed Abdominoplasty in Aggressive Locally Advanced Breast Cancer Defect: A Safe Option for High Recurrence Risk Patients.

The reverse abdominoplasty technique has uses that extend past cosmetic surgery into the field of reconstructive surgery. With a thorough understanding of the technique and modifications, this method may be used to cover extensive chest wall defects post-mastectomy in select patients. Reconstructive algorithms for locally advanced breast cancer tend to favor microsurgical techniques. However, the surgeon needs to choose the optimal reconstructive option based on the defect size, disease stage, future oncological therapeutic approach, and patients' general condition. Patients with aggressive forms of breast cancer have higher risks of recurrence despite advances in chemotherapy. This subset of patients may be poor responders to adjuvant or neoadjuvant oncological drugs, may require postoperative radiotherapy, or be at high risk for early recurrence. In this subset of patients, we advocate the use of a reverse abdominoplasty for immediate autologous soft tissue coverage of the chest wall after breast cancer resection. It provides a robust soft tissue cover for radiotherapy and spares potential future autologous donor sites for delayed breast reconstruction while facilitating early clinical detection of recurrence. Here, we discuss a case treated with this technique and explore the surgical technique, pitfalls, and advantages of this technique with the outcome that validates decision-making.

Perception of the most perfect female breast shape among Malays, Chinese, and Indians community.

Researchers have long tried to search for the 'perfect' aesthetic outcome of breast surgery. Although lots of anthropometric studies have been done, there is no consensus when dealing with harmony, abstract, and proportion that make up for its ideal shape. This study was convened via a survey to find the most perfect breast shape by assessing the upper pole contour and upper pole to lower pole ratio (UP:LP) preference among the Malays, Chinese, and Indians races. Hundred thirty-five individuals partook in this survey. Most of the participants generally preferred a more convex shape of upper pole contour with the Malay (50%) and Indian (35.7%) favored a more convex shape while the Chinese preferred it to be just slightly convex (42.8%). Single unmarried individuals (64.7%) significantly preferred a more convex upper pole contour (p = 0.018). The UP:LP ratio of 45:55 (p = 0.002) was the most significantly preferred proportion (37.8%) which largely comprised of the Chinese (51%), followed by Indian (21.6%) and Malay (19.6%). With these findings, using a controlled perception-preference method is a more preferred choice when describing an ideal breast shape as compare to an anthropometric measurement that might be less accurate. Therefore, breast and plastic surgeons alike need to look beyond the anthropometric numbers and should consider the other 'abstract' aesthetic shape which difficult to measure including the upper pole breast that has more convexity and the UP:LP ratio of 45:55 which showed to be the most aesthetically perfect form as agreed in the current works of literature.

The cost-effectiveness of maintaining an in-house glycerol-preserved skin bank.

INTRODUCTION: Glycerol-preserved skin allograft (GPA) plays a vital role, especially in the management of burns injury. Where it is utilized as temporary wound closure, the considerably cost-effective, simpler handling and storage of GPA makes it preferable in almost all clinical indications. The GPA was first introduced to the Hospital Universiti Sains Malaysia in 2001. The supply was imported from Euro Skin Bank, Beverwijk, The Netherlands. In the year 2013, our center had started maintaining an in-house glycerolized skin bank. METHOD: We preserved donor skin grafts from patients who underwent plastic surgery-related procedures in 85% glycerol and stored them at +2 °C to +10 °C. Cost estimation of the GPA per cm2 was calculated to analyze the effectiveness of its preservation technique. RESULTS: The cost of GPA from our skin bank is estimated to be almost 90% reduction in cost as compared to the supply from Euro Skin Bank. CONCLUSION: The selective and strategic use of the GPA in major burn patients assure effective advantages in the treatment of burns. The clinical significance of skin allograft usage is very high. The cost-effectiveness of maintaining an in-house skin bank made it possible for various centers for skin allograft usage.

Adipose-Derived Stem Cell: "Treat or Trick".

Stem cells have been widely used for treating disease due to the various benefits they offer in the curing process. Several treatments using stem cells have undergone clinical trials, such as cell-based therapies for heart disease, sickle cell disease, thalassemia, etc. Adipose-derived stem cells are some of the many mesenchymal stem cells that exist in our body that can be harvested from the abdomen, thighs, etc. Adipose tissue is easy to harvest, and its stem cells can be obtained in higher volumes compared to stem cells harvested from bone marrow, for which a more invasive technique is required with a smaller volume obtained. Many scientists have expressed interest in investigating the role of adipose-derived stem cells in treating disease since their use was first described. This is due to these stem cells' ability to differentiate into multiple lineages and secrete a variety of growth factors and proteins. Previous studies have found that the hormones, cytokines, and growth factors contained in adipose tissue play major roles in the metabolic regulation of adipose tissue, as well as in energy balance and whole-body homeostasis through their endocrine, autocrine, and paracrine functions. These are thought to be important contributors to the process of tissue repair and regeneration. However, it remains unclear how effective and safe ADSCs are in treating diseases. The research that has been carried out to date is in order to investigate the impact of ADSCs in disease treatment, as described in this review, to highlight its "trick or treat" effect in medical treatment.

Calcaneal Reconstruction With Free Deep Circumflex Iliac Artery Osseocutaneous Flap Following Aggressive Benign Bone Tumor Resection.

BACKGROUND: Advances in limb-salvage techniques have made total calcanectomy and primary reconstruction possible in managing calcaneal aggressive benign tumors and selected cases of intraosseous malignant tumors. However, there is still no consensus on the operative approach, oncologic margin, and the best reconstruction method to date. These 2 cases describe our experience in calcaneal reconstruction with the free deep circumflex iliac artery (DCIA) osseocutaneous flap in benign aggressive calcaneal tumors. METHODS: We reported 2 consecutive male and female patients, with an average age of 25 years (age 19 and 31, respectively), who underwent total calcanectomy and primary calcaneal reconstruction with the free DCIA osseocutaneous flaps for calcaneal chondroblastoma and giant cell tumor. A marginal resection of the entire calcaneus through the subtalar and calcaneocuboid joints (intra-articular approach) was performed in the first case and a wide local resection leaving 1 cm normal calcaneal bone margin anterosuperiorly (intraosseous approach) was performed in the second case. RESULTS: The follow-up period averaged 48 months. Negative oncologic margins were achieved in both cases. The first case was complicated with venous thrombosis; however, the graft remained viable after emergency reexploration. Normal foot function was restored with good solid osseous union and bony hypertrophy observed. Both patients achieved good short-term functional and aesthetic outcomes with no donor site pain or disability. No local recurrence was reported either. CONCLUSION: Primary calcaneal reconstruction with the free DCIA osseocutaneous flap can lead to good short-term functional and aesthetic outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Rapidly Growing Huge Lower Back Malignant Peripheral Nerve Sheath Tumour.

Malignant peripheral nerve sheath tumours (also called neurofibrosarcomas) are a rare, highly aggressive soft tissue sarcomas that arise from the peripheral nerves or cells associated with the nerve sheath, such as Schwann cells, peri-neural cells and fibroblasts. It is representing 10% of all soft tissue sarcomas in which it is considered as an extremely rare malignancy, especially in patients with neurofibromatosis type I. In the general population, it affects approximately 1 in 100,000 people. This article is reporting a 56-year-old Malay female patient who is a known case of neurofibromatosis type I for 20 years, presented with a lower back, pruritic, gradually increasing swelling during the last five months. Last month before the presentation, the lesion rapidly grows, reaching a size of (15×15 cm), accompanied by foul-smelling discharge and pain exacerbated with movement. Although no history of preceding trauma or accident, the mass bleeds within contact. In conclusion, only a few cases of giant malignant peripheral nerve sheath tumours reported in the literature describing its location and growth progression. We present a massive, extremely rapid growth of cutaneous exophytic malignant peripheral nerve sheath tumours over the lower back.