Simultaneous diagnosis and resection of orofacial rhabdomyosarcoma with frozen section biopsy: a case report.

Rhabdomyosarcoma is the most common soft tissue sarcoma in children, accounting for 4.5% of all cases of cancer in childhood. Although the head and neck are the most common sites of rhabdomyosarcoma, oral lesions are relatively rare and account for only 10% to 12% of head and neck rhabdomyosarcoma cases. This is a case report of a girl aged 2 years and 1 month who initially presented with an upper lip mass that invaded the oral mucosa, oral skin, and nostril skin, causing narrowing of the airway. Through our case, we show that rapidly growing small round cell malignancies, especially rhabdomyosarcoma, can be effectively diagnosed and treated at the same time using primary resection with intraoperative frozen section biopsy and that the time spent waiting for the results of preoperative biopsy can be saved in this way, particularly when the patient's symptoms are intensifying rapidly and require immediate operation.

Intravelar veloplasty in submucous cleft palate without lateral relaxing incision or nasal mucosal incision.

BACKGROUND: Surgical treatment is recommended for patients with symptomatic submucous cleft palate once velopharyngeal insufficiency has been proven. This study describes the procedure and clinical outcomes of minimally invasive intravelar veloplasty. METHODS: From August 2013 to March 2017, seven patients (median age, 36 months; range, 16-60 months, 5 females and 2 males) with submucous cleft palate underwent intravelar veloplasty. Neither a nasal mucosal incision nor a lateral relaxing incision was applied. Follow-up was performed at least twice: once at three weeks postoperatively and again between two and three years postoperatively (average, 31 months; range, 26-35 months). Speech was assessed by speech-language pathologists when the patients were at least 3 years old. RESULTS: There were no cases of oronasal fistula or noticeable disturbance of facial development. All seven patients showed no or mild hypernasality and air emission and competent or at least borderline competent velopharyngeal function. CONCLUSION: Intravelar veloplasty could serve as another option for managing submucous cleft palate with velopharyngeal insufficiency, resulting in satisfactory improvement in velopharyngeal function. Because neither a lateral nor a nasal incision was used, the burden of facial growth and risk of oronasal fistula can be minimized.

The Key of Pocket Dissection in Transaxillary Dual-plane Breast Augmentation: How to Control Inferior Malposition of Smooth Implants.

BACKGROUND: Inferior implant malposition after breast augmentation is the second most common reason for revision surgery. This article introduces the new concept of dual-plane pocket formation in transaxillary breast augmentation to prevent inferior implant malposition by preserving the continuity of the superficial layer of the deep pectoralis fascia. METHODS: Patients who underwent transaxillary endoscopic breast augmentation performed from January 2017 to December 2019 were retrospectively reviewed. With the aid of the endoscope, dissection proceeded. During pectoralis muscle origin detachment, the superficial layer of deep pectoralis fascia was preserved. After making the pocket, silicone gel implants were inserted. A retrospective chart review was done to collect data on postoperative complications. RESULTS: A total of 251 patients were performed, and the mean follow-up time was 20.6 months. In a total of 28 cases of complications (9.6%), there were 2 cases of reoperations. In a total of three patients (1.2%) of implant malposition, one patient (0.4%) developed mild bilateral bottoming-out deformity. CONCLUSIONS: Meticulous dissection by endoscopy could avoid the destruction of the superficial layer of the deep pectoralis fascia during pocket dissection and produce an intact fascial system with its own continuity at the inframammary fold (IMF). A well-controlled envelope over the implant and a supporting structure underneath it are important in breast augmentation to prevent inferior implant malposition.

Long-Term Outcomes of Secondary Nasal Tip Plasty After Degradation of a Polycaprolactone (PCL) Mesh.

BACKGROUND: In secondary nasal tip plasty, it is often difficult to harvest appropriate septal extension grafts for sufficient tip projection. Therefore, studies using numerous alloplastic materials in rhinoplasty have been reported. This study aimed to evaluate the nasal tip change over time after tip plasty using a PCL mesh. METHODS: We conducted a retrospective study of 86 Asian patients who received secondary tip plasty by septal extension grafting with a PCL mesh as a batten graft. Patient demographics and surgical outcomes were examined. The outcome variables were nasolabial angle, nasofrontal angle and Goode ratio. Measurements were performed with photographs obtained at short-term (postoperative 4-6 months) and long-term (more than postoperative 24 months) follow-ups. Aesthetic outcomes and safety were assessed using the Global Aesthetic Improvement Scale. RESULTS: Among 86 patients, 56 had a long-term follow-up. The mean age was 33.33 years, and the male-to-female ratio was 17.44:82.56. The nasolabial and nasofrontal angles did not change significantly between the short-term and long-term follow-ups. The Goode ratio, which is a useful tool to evaluate nasal projection, was decreased by 5.00%. Nevertheless, all patients were satisfied, and the long-term aesthetic outcomes were improved in 54 (96.4%) patients. There were two cases (2.33%) of complications, including one infection and one case of PCL-mesh protrusion. CONCLUSIONS: The present study demonstrated the usefulness and safety of PCL meshes when used in septal extension grafts as batten grafts. Although biodegradation seems to affect the nasal projection, PCL is still useful in secondary tip plasty along with other alloplastic materials. LEVEL OF EVIDENCE IV: 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 .

Nasolabial Sulcus Rejuvenation: Paranasal Augmentation Using a Folded Dermal Graft.

BACKGROUND: Nasolabial sulcus rejuvenation is steadily gaining popularity among Asians. Though many treatment options using synthetic grafts and autografts have been introduced, none of them has yet been accepted as an ideal technique. This study describes the operative procedure and evidence-based clinical outcomes of paranasal augmentation using dermal grafts. METHODS: From March 2015 to August 2019, 56 patients underwent paranasal augmentation. The dermal graft, harvested from the buttock, was folded into 4 to 6 layers and inserted into the supraperiosteal pocket through a gingivobuccal incision. Ultrasonographic evaluation was performed at postoperative months 1, 6, 12, and 18 to appraise the change in the thickness of the graft. RESULTS: No major complications, including foreign body sensation and graft extrusion, occurred. The average dermal thickness was 10.31 mm at postoperative month 1 and 6.30 mm, 5.21 mm, and 5.17 mm at postoperative months 6, 12 and 18, respectively. The average absorption rates were 38.72%, 49.36%, and 49.92% at postoperative months 6, 12, and 18, respectively. CONCLUSIONS: Paranasal augmentation using a folded dermal graft serves as a useful method to rejuvenate the midface with durable and aesthetically satisfactory outcomes. By virtue of biocompatibility, complications occurred rarely compared with the artificial implants. LEVEL OF EVIDENCE IV: 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.

Correction of a Leaking Stoma: Using Silicone Block Insertion.

BACKGROUND: Changes in abdominal contour, including peristomal indentations, can cause leakage of stoma effluent and other complications. PURPOSE: To describe the case of a 39-year-old patient with a urostomy who experienced very frequent urine leakage as a result of a peristomal indentation. CASE STUDY: The patient presented with a history of cystectomy and urostomy surgery for chronic interstitial cystitis and dysfunction of the bladder due to a neurogenic problem, and very frequent appliance changes due to urine leakage. Modest improvement occurred following fasciocutaneous V-Y advancement flap surgery. After 7 months, a silicone block was inserted in the peristomal indentation. After 1 year of follow-up, the outcome remained satisfactory and no additional procedures were needed. CONCLUSION: In this case, silicone block insertion was an effective and minimally invasive alternative to manage stomal leakage refractory to other procedures.

Forehead Reduction Surgery via an Anterior Hairline Pretrichial Incision in Asians: A Review of 641 Cases.

BACKGROUND: Forehead reduction is gaining in popularity, as facial proportions that include shorter upper and lower thirds are currently more aesthetically pleasing. In this first large-scale study, we present an analysis of several important aspects of surgical design and postoperative complications associated with forehead reduction performed via a pretrichial skin excision. METHODS: Patients who underwent surgery from 2006 to 2018 were reviewed retrospectively. Data included the amount of skin excised, postoperative complications experienced during the first three months, and forehead length measured 2 years postoperatively. Objective outcomes reported by three independent surgeons and subjective satisfaction reported by patients at three months postoperatively were evaluated on 5-point Likert scales that addressed both postoperative scarring and overall aesthetics. RESULTS: A total of 641 patients underwent forehead reduction surgery. The average lengths of the skin excisions were 16.64 mm, 15.36 mm, and 15.33 mm from regions at the center and at the left and right mid-pupillary lines, respectively. Long-term follow-up of 85 patients revealed forehead lengthening that exceeded the initial postoperative measurements by 2.44 mm (15.04%), 1.98 mm (11.53%), and 2.51 mm (15.8%) at the left, center, and right, respectively. Means (standard deviation [SD]) for subjective and objective measures of postoperative scarring were 1.32 (0.49) and 1.78 (0.66), respectively. The means (SD) for subjective and objective postoperative aesthetic scores were 4.38 (0.47) and 3.98 (0.39), respectively. CONCLUSIONS: Forehead reduction surgery via a pretrichial skin excision is a straightforward procedure that is easy to perform, has few complications, and result in high rates of patient satisfaction. LEVEL OF EVIDENCE IV: 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 .

Early Hypoglobus in Orbital Floor Reconstruction With Resorbable Implants.

BACKGROUND: Among the variety of materials developed for facial bone surgery, resorbable implants are widely used in orbital wall reconstruction. There are many advantages in selecting resorbable implants, such as minimal foreign body reaction and adjustability within the damaged orbital floor. Resorbable implants are supposed to remain in place over 1 to 2 years to hold the structure of immature healing tissue surrounding the bony defects. However, some patients who have undergone orbital wall reconstruction surgery with resorbable implants suffer from early hypoglobus. METHODS: This retrospective study was performed from January 2014 to August 2019 and follows 39 patients with unilateral pure orbital floor fractures. All orbital floor reconstruction was performed using resorbable implants via the transconjunctival approach. Exophthalmometer measurements and CT scans showing the degree of implant sagging were used to provide an index of hypoglobus. RESULTS: Most patients showed hypoglobus over 3 to 4 months follow-up. The size of bony defect in the orbital floor showed positive correlation with follow-up exophthalmometer measurement and degree of implant sagging. CONCLUSION: Orbital floor reconstructed with resorbable implant tends to lose load-bearing strength gradually, especially in large bony defects. Therefore, surgeons should be cautious about using resorbable implants for the maintenance of reconstructed orbital floor, especially in large bony defects.

Epithelioid sarcoma associated with neurofibromatosis type I.

In general, patients with neurofibromatosis type I have a higher risk than those with other types of neurofibromatosis of developing soft-tissue sarcomas related to the nervous system. We here present a 42-year-old man with neurofibromatosis type I who developed a protruding mass over only 2 weeks. The histopathological diagnosis was epithelioid sarcoma. Epithelioid sarcomas are rare and, to the best of our knowledge, no epithelioid sarcomas have been reported in patients with neurofibromatosis type I. Radical excision of the primary lesion was performed and postoperative radiotherapy and chemotherapy administered, as is recommended for epithelioid sarcoma. Our case emphasizes that patients with neurofibromatosis type I may develop malignant tumors.

Malignant melanoma on a thermal burn scar.

Chronic burn scars often cause various skin malignancies at rates of up to 2%. These lesions are usually squamous cell carcinomas, but rarely, malignant melanoma is reported. We report a 67-year-old male with a malignant melanoma on a burn scar with regional metastasis. This patient presented an ulcerative lesion only in 2 weeks. After histopathological diagnosis, we performed only palliative surgery on patient's demand, and followed up the subsequent deterioration course. Our case reemphasizes the need for rapid diagnosis and treatment when suspect lesions are present on chronic burn scar. Also, physician should be in mind and inform the patient about malignant melanoma and its aggressive course.

Nasal Elongation with Septal Half Extension Graft: Modification of Conventional Septal Extension Graft Using Minimal Septal Cartilage.

BACKGROUND: In Asian rhinoplasty, a septal extension graft can be used for both tip projection and derotation of the alar cartilage. However, patients often do not have enough harvestable septal cartilage to create the septal extension graft. We therefore devised a method with which to fix the derotated alar cartilage with a small amount of septal cartilage. METHODS: From January 2012 to December 2016, 23 patients underwent short nose correction with a septal half extension graft made of septal cartilage and were postoperatively monitored for at least 6 months. The alar cartilage was completely separated from the adjacent structures, especially the scroll area and hinge complex, for caudal derotation. The septal half extension graft was then harvested from the septal cartilage and secured to the caudal septum and the lateral crura of the alar cartilage. Photographs of the patients were compared immediately before surgery and 1 year after surgery. RESULTS: Of the 23 patients, 21 (91%) had satisfactory results without short nose recurrence. Two (9%) patients developed recurrence: undercorrection and poor tip projection in one patient each. Aesthetic assessment of short nose correction was performed by comparing the columellar labial angle before and after surgery. Our method reduced the columellar labial angle by 6.2% (paired t test, p < 0.05, t = 31.698). CONCLUSION: In patients who cannot undergo conventional septal extension graft due to insufficient amounts of septal cartilage, the septal half extension graft could be a promising alternative technique for short nose correction with minimal septal cartilage harvesting. LEVEL OF EVIDENCE IV: 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 .

Epicanthal Restoration Surgery with Scar Excision in Severe Epicanthal Scar.

BACKGROUND: Medial epicanthoplasty is a common aesthetic surgery in Asia to remove the epicanthal fold. With increasing use of this surgery, unsatisfactory results have grown. Several methods have been developed to correct it. However, there are limitations in restoration if the patient has a severe scar or does not have enough skin for reconstruction. By aggressively removing scar tissue, the authors present a better reverse redraping epicanthoplasty. METHODS: The procedure was performed on 512 patients who had complications of medial epicanthoplasty from May 2011 to October 2015. The mean age was 31.3 years. Those who had already undergone reconstruction were 15.4% (n = 79). Of these, 68 patients received a V-Y flap and the rest had V-Y modification surgery. After the design, the skin-muscle flap was dissected and elevated. The upper and lower eyelid skin was pulled medially. The previous scar tissue was widely excised while removing skin excess, and the new epicanthal fold was created without a rectangular shape. RESULTS: The mean interepicanthal distance has been increased from 32.8 to 36.6 mm. The mean lengthening effect is 3.8 mm. Lacrimal lake exposure, fierce and narrow appearance, and incomplete medial eyelid closure were improved. CONCLUSIONS: Medial epicanthoplasty is a common cosmetic surgery in the Asian population. A demand for an effective reconstructive method has grown in association with higher complication rates. The authors have better results to make a natural epicanthal fold through aggressive scar removal in the reverse redraping epicanthoplasty. LEVEL OF EVIDENCE IV: 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 .

New anthropometric data for preoperative planning in orbital wall fracture treatment: the use of eyelid drooping.

BACKGROUND: The presence of enophthalmos is an important determinant in the decision of orbital wall fracture surgery. We proposed eyelid drooping as a new anthropometric diagnostic measure and analyzed whether eyelid drooping is associated with enophthalmos. METHODS: This retrospective study was performed from January 2014 to December 2016. A total of 75 patients with blowout fractures were studied. One experimenter measured the degree of enophthalmos using a Hertel exophthalmometer at 1 week after trauma and at 3 months after surgery. The height change of the upper eyelid was measured using the marginal reflex distance (MRD) on both sides, and the degree of eyelid drooping was calculated by comparing the two lengths. We analyzed statistically the correlation between enophthalmos and eyelid drooping. RESULTS: We found a highly significant correlation between the degree of enophthalmos and the reduction rate of MRD (RRM, as an indicator of eyelid drooping) at 1 week after trauma (r = 0.845). Approximately 2.0 mm of enophthalmos was associated with a 30.8% reduction in MRD on the affected side as compared with the normal side. At 3 months after surgery, patients showed improved eyelid appearance, with a moderate association between enophthalmos and RRM. CONCLUSION: We demonstrated that the degree of enophthalmos, measured using an exophthalmometer, is associated with a change in the height of the upper eyelid. Thus, upper eyelid drooping can be used as another indicator for orbital wall fracture surgery. Compared with conventional methods, measurements of eyelid drooping are easy to perform, offering a great advantage and understanding to the patient.

Pyogenic Granuloma: A Retrospective Analysis of Cases Treated Over a 10-Year.

BACKGROUND: Pyogenic granuloma (PG) is a benign vascular lesion of the mucosa and skin. Recent studies of the epidemiology of PG are rare. We aimed to retrospectively analyze characteristics of PG cases in South Korea. METHODS: We reviewed the medical records of 155 patients treated for PG between March 2005 and May 2014. The male-to-female ratio was 1:1.2 (70 males, 85 females). The mean age of patients was 35.3 years. RESULTS: A high occurrence was observed in the first and third decades in males, and the fourth to fifth decades in females. There was a statistically significant difference between genders according to age group (p<0.05). The average lesion diameter was 0.84±0.46 cm (long axis). The most frequently involved site was the face (n=47). Bleeding was the primary complication (n=41). PG was mostly treated with excisional biopsy (n=74). The recurrence rate was 7.7% (n=12). CONCLUSION: We concluded that most common site of PG was the face, the age of female with PG is higher than previous studies, and finger is associated with trauma more than other sites. The most recent epidemiological information on PG of this study will support the treatment and diagnosis of PG and future research objectives.

Septal Cartilage/Ethmoid Bone Composite Graft: A New and Improved Method for the Correction Underdeveloped Nasal Septum in Patients with Short Noses.

BACKGROUND: Septal extension grafts are an effective means of extending nasal length in patients with a short nose. However, such grafts can be challenging in patients who only have small quantities of weak septal cartilage, such as some East Asian patients. We developed a rhinoplasty technique using ethmoid bone to create a cartilage-bone complex to overcome this issue, allowing adequate nasal lengthening. METHODS: Sixty-four women with short noses and inadequate septal cartilage determined by preoperative computed tomography underwent septal extension grafting with a cartilage-bone complex between January 2009 and December 2014. Septal cartilage and ethmoid bone were harvested during open rhinoplasty and secured to the septal cartilage. RESULTS: Most patients were in their twenties or thirties. All patients underwent septal extension grafting using a cartilage-bone complex and dorsal augmentation with silicone implants. Short nasal length, decreased nasolabial angle and increased nostril show, were rectified. There was no recurrence during a mean follow-up period of 12.3 months, although one patient (1.5%) requested revision surgery. CONCLUSION: Septal extension grafting with a cartilage-bone complex can be used to correct a short nose, especially in Asians who have relatively small amounts of septal cartilage. The ethmoid bone augments the inadequate septum and provides structural support. LEVEL OF EVIDENCE V: 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 .

A Straightforward Method of Predicting Enophthalmos in Blowout Fractures Using Enophthalmos Estimate Line.

PURPOSE: Measuring the change in orbital volume may help to predict enophthalmos, but it is time consuming and difficult to apply. We devised a new and straightforward method with which to estimate the degree of enophthalmos. MATERIALS AND METHODS: This retrospective cohort study was performed from January 2013 to December 2015. Patients who underwent initial computed tomography (CT) examination and surgical reconstruction in our hospital were selected. An imaginary line connecting the edges of the bony defects (defect line) was drawn on 2-dimensional CT images. The distance from the defect line to the farthest fracture segment or soft tissue was defined as the length of the enophthalmos estimate line. The length of this line was a predictor variable, and the degree of enophthalmos at 1 week after the injury was an outcome variable. Age, gender, and type of injury are other variables that may affect the results. We statistically analyzed each variable using SPSS software (IBM, Armonk, NY). RESULTS: Of the patients, 22 had isolated inferior wall fractures, 14 had isolated medial wall fractures, and 17 had inferomedial wall fractures. There was high correlation between the length of the enophthalmos estimate line and the degree of enophthalmos in patients with isolated inferior fractures, medial wall fractures, and inferomedial wall fractures with internal orbital buttress fractures (Pearson correlation coefficient [r] = 0.783, r = 0.806, and r = 0.820, respectively). Approximately 2.0 mm of enophthalmos was associated with 9.3- and 10.0-mm enophthalmos estimate lines in patients with isolated inferior wall fractures and medial wall fractures, respectively. CONCLUSIONS: The most important advantages of our method are its simplicity, convenience, and swiftness. Using only 2-dimensional CT images, we identified the correlation between the degree of orbital wall fracture and enophthalmos and calculated the predicted value of enophthalmos. This technique is expected to provide useful information to clinicians and patients to determine if an operation is needed.

Augmentation Genioplasty Using Double Folded Dermal Graft.

INTRODUCTION: The chin is a very important aesthetic subunit of the face. The diverse materials and methods for chin augmentation can be classified according to autologous tissues and artificial ones. Among them, reports on the effectiveness of dermal graft for chin augmentation are scarce. The authors report on our new techniques and surgical results regarding chin augmentation using a dermal graft. PATIENTS AND METHODS: From July 2010 to January 2013, the authors performed supraperiosteal chin augmentation using a double folded dermal graft for 58 patients (15 men and 43 women; range of age: 20-45, average was 29.4). Periodic sonography was performed routinely to measure the change of thickness of the dermal graft (preoperative, postoperatively 1, 6, and 12 months). RESULTS: Thickness of the survived dermal graft was 8.33 ± 1.21 mm and 7.99 ± 1.19 mm at postoperative 6 and 12 months separately. Statistics showed that the average resorption rate was 32.17% (SD = 10.99) at postoperative 6 months and 34.93% (SD = 10.74) at postoperative 12 months. Of 56 patients 54 (2 patients were excluded from the study) did not request additional surgery during the 3-year follow-up period and showed a high level of satisfaction with the surgical results. CONCLUSIONS: The authors consider that our unique design and surgical techniques of double folded dermal graft have many advantages and provide consistent evidence-based results to meet patients' desire for a natural appearance after chin augmentation, particularly patients who refuse to get artificial implants.

Reconstruction of Inferior Orbital Wall Fractures Using Bone Fragments.

INTRODUCTION: Various materials have been used as implants in orbital floor fractures. The fractured bone fragments, however, are not usually used because of their small size and delicate characteristics. To overcome this limitation, the authors used autologous bone fragments combined with fibrin glue and an absorbable plate to repair inferior orbital wall fractures. METHODS: Thirty-four patients with orbital floor fractures treated in a single center from January 2013 to September 2014 were prospectively evaluated. Patients' demographic characteristics, clinical signs and symptoms, physical examination findings, postoperative complications, and preoperative and postoperative computed tomography findings were assessed. Fracture repair by a transconjunctival approach in which bone fragments were merged with fibrin glue and an absorbable plate was performed in all the patients. RESULTS: Postoperative computed tomography showed good orbital fracture reduction and soft tissue restoration in all the patients. Five patients developed postoperative diplopia; however, this symptom resolved spontaneously. Exophthalmometry showed that the degree of enophthalmos had improved significantly. CONCLUSION: Based on the results of this study, the combination of autologous bone fragments and absorbable mesh appears to be a safe and feasible option for the reconstruction of orbital floor fractures.