Salvage of a nasal chondrocutaneous flap after a traumatic avulsion injury using a combination of treatments polydeoxyribonucleotide injection, continuous non-rebreather mask oxygen therapy, and chemical leeching: a case report

Skin avulsions are severe traumatic injuries, in which sections of skin and subcutaneous tissue are torn off from the body, and the surgical management and salvage of these injuries are quite challenging due to their high morbidity and mortality. The entire or partial loss of an avulsed flap is prone to occur. If this happens, scars can be particularly conspicuous, and additional surgery, such as skin grafts or local flaps or even composite grafts, might be required. A 24-year-old male patient presented to the emergency room with a severe traumatic avulsion injury on his nose. We used a combination of three therapies to minimize the loss of the distal portion of the avulsed flap: polydeoxyribonucleotide injection, continuous non-rebreather mask oxygen therapy, and chemical leeching. We achieved complete flap salvage of the avulsed wound, and the patient showed full satisfaction in both aesthetic and functional aspects. Although this report is confined to a single case of severe avulsed injury, we suggest this triple-combination therapy as a good combined modality for maximizing the salvage of an avulsed flap on the basis of this case and a literature review.

A novel subdermal anchoring technique for the effective treatment of congenital melanocytic nevus using de-epithelialized dermal flaps

Background@#In patients with congenital melanocytic nevus (CMN), single-stage removal of large lesions can be difficult because the high tension created by excising and repairing a large lesion may result in scar widening. Herein, we introduce a method to effectively excise lesions while minimizing scarring and compare its outcomes to those of existing surgical methods. @*Methods@#We compared patients who underwent surgery using the anchoring technique (n=42) or the conventional elliptical technique (n=36). One side of the lesion was removed via en bloc resection up to the superficial fascia. The other side of the lesion was removed via de-epithelialization. The de-epithelialized dermal flap was then fixed by suturing it to the superficial fascia on the opposite side. The length of the lesion’s long axis and amount of scar widening were measured immediately after surgery and at 2, 6, and 12 months postoperatively. At 12 months, patients were assessed using the Patient and Observer Scar Assessment Scale. @*Results@#The lesion locations included the face, arms, legs, back, and abdomen. The anchoring method resulted in shorter and smaller scars than the conventional method. There were no cases of postoperative hematoma or wound dehiscence. Significant differences in postoperative scar widening were found in the arm and leg areas (P<0.05). @*Conclusions@#The anchoring method introduced in this study can provide much better outcomes than the conventional method. The anchoring method is particularly useful for the removal of CMN around the joints or extremities, where the surgical site is subjected to high tension.

A practical approach to nasal reconstruction in Asian patients

Background@#The study aimed to evaluate nasal reconstruction techniques customized for Asians. The currently available nasal reconstruction guidelines are based on Caucasian patients, and their applicability is limited in Asian patients due to differences in anatomical and structural features. @*Methods@#A retrospective analysis was performed of the medical records of 76 patients who underwent nasal reconstruction at a single center between January 2010 and June 2020. A comprehensive evaluation was conducted of patients’ baseline demographics and clinical characteristics, including age, sex, medical history, defect size and location, reconstructive procedure, pathological diagnosis, postoperative complications, and recurrence. @*Results@#In 59 cases (77%), nasal defects resulted from tumor ablation, and the remaining 17 cases involved post-traumatic (20%) and infection-induced (3%) tissue damage. The most common defect location was the alae, followed by the sidewalls, tip, and dorsum. Forehead flaps were the most commonly used reconstructive technique, followed by nasolabial advancement flaps, rotation flaps, and skin grafts. Each procedure was applied considering aspects of structural anatomy and healing physiology specific to Asians. Complications included nasal deformity, hypertrophic scarring, secondary infection, and partial flap necrosis, but no cases required additional surgical procedures. Tumors recurred in two cases, but tumor recurrence did not significantly affect flap integrity. @*Conclusion@#Nasal reconstruction techniques applied considering Asians’ facial features resulted in fewer postoperative complications and higher patient satisfaction than the approaches that are currently in widespread use. Therefore, this study is expected to serve as an essential reference for establishing treatment guidelines for nasal reconstruction in Asians.

Bilateral symmetrical lipoma of the buccal fat pad as an incidental finding in a woman with weight gain after tamoxifen: a case report

Although lipoma is a common benign tumor, it occurs relatively infrequently in the oral and maxillofacial areas, and only 31 cases of lipoma in the buccal fat pad have been reported. Herein, we present an extremely rare case of symmetric lipomas in both buccal fat pads. These masses were incidentally discovered during a facelift procedure in a 50-year-old woman with a 4-year history of tamoxifen use. during which she had gained 10 kg. The patient stated that cheek protrusion had developed concomitantly with weight gain and was exacerbated by an injection lipolysis procedure she had received 1 year previously. This case underscores the importance of paying careful attention to the patient’s medication use and surgical history when evaluating suspected cases of lipoma, and sheds light on tamoxifen use and subcutaneous injections of phosphatidylcholine and deoxycholate as potential risk factors for lipoma development.

Modified temporalis tendon transfer extended with periosteum for facial paralysis patients

Background@#We have devised a novel surgical method, termed as temporalis muscle tendonperiosteum (T-P) compound surgical method, by modifying pre-existing techniques. Our method is characterized by elevation of temporalis muscle tendon and the periosteum of the mandibular ramus as a single compound. Here, we describe the concept and clinical outcomes of our method. @*Methods@#We conducted both a cadaveric study and a clinical study. First, we used four human cadavers (two males and two females) to confirm the anatomy of the temporalis muscle tendon and availability of sufficient length extension through the elevation of the T-P compound. Moreover, we obtained measurements of the mouth angle and the philtrum angle from a total of six patients (two males and four females) and compared them between preoperatively and postoperatively. @*Results@#The mean length of the periosteal portion was measured as 2.43± 0.15 cm (range, 2.2–2.6 cm). There was an improvement in the mouth angle postoperatively as compared with preoperatively (7.2°± 3.0° vs. 14.5°± 4.7°, respectively). Moreover, there was also an improvement in the philtrum angle postoperatively as compared with preoperatively (7.2°± 3.4° vs. 17.2°± 6.5°, respectively). @*Conclusion@#Our method is a simple, minimally-invasive modality that is effective in achieving good clinical outcomes. Its advantages include an ability to achieve a firm extension of the temporalis muscle tendon as well as a lack of requirement for a donor site that may cause complications.

Modified temporalis tendon transfer extended with periosteum for facial paralysis patients

Background@#We have devised a novel surgical method, termed as temporalis muscle tendonperiosteum (T-P) compound surgical method, by modifying pre-existing techniques. Our method is characterized by elevation of temporalis muscle tendon and the periosteum of the mandibular ramus as a single compound. Here, we describe the concept and clinical outcomes of our method. @*Methods@#We conducted both a cadaveric study and a clinical study. First, we used four human cadavers (two males and two females) to confirm the anatomy of the temporalis muscle tendon and availability of sufficient length extension through the elevation of the T-P compound. Moreover, we obtained measurements of the mouth angle and the philtrum angle from a total of six patients (two males and four females) and compared them between preoperatively and postoperatively. @*Results@#The mean length of the periosteal portion was measured as 2.43± 0.15 cm (range, 2.2–2.6 cm). There was an improvement in the mouth angle postoperatively as compared with preoperatively (7.2°± 3.0° vs. 14.5°± 4.7°, respectively). Moreover, there was also an improvement in the philtrum angle postoperatively as compared with preoperatively (7.2°± 3.4° vs. 17.2°± 6.5°, respectively). @*Conclusion@#Our method is a simple, minimally-invasive modality that is effective in achieving good clinical outcomes. Its advantages include an ability to achieve a firm extension of the temporalis muscle tendon as well as a lack of requirement for a donor site that may cause complications.

Traumatic subcutaneous emphysema after liposuction

Traumatic subcutaneous emphysema, which is the infiltration of air into subcutaneous tissues due to trauma, is caused by various factors such as chest and/or abdominal trauma, facial fractures, and barotrauma caused by mechanical ventilation. In this case report, a 32-year-old woman developed traumatic subcutaneous emphysema after undergoing abdominal liposuction at a local clinic. She was subsequently admitted to Busan Paik Hospital, and with early diagnosis and conservative treatment, she was discharged on the seventh day of hospitalization with no complications. However, because traumatic subcutaneous emphysema may accompany other injuries for various reasons, radiological examination and various tests should be performed to prevent serious complications and sequelae.

Comparison of complete surgical excision and minimally invasive excision using CO₂ laser for removal of epidermal cysts on the face

BACKGROUND: Epidermal cysts are benign, slow growing cysts that often develop on the head, neck, chest, and back of adults. The most common method of surgical excision involves the use of a scalpel and often leaves a scar proportional to the size of the cyst. Therefore, minimally invasive techniques are required. Among these techniques, the CO2 laser-based technique is minimally invasive and has lower complication rate, shorter recovery times, and lesser scarring. This paper aimed to compare the results and postoperative complications associated with a CO2 laser-based excision against conventional surgical excision for epidermal cysts. METHODS: We surveyed 120 patients, aged 16 to 65 years, with epidermal cysts on the face measuring 0.5 to 2.2 cm in diameter. Twelve months later, we compared the scar length, recurrence rate, patient satisfaction, and complications between patients treated with CO2 laser excision versus surgical excision. RESULTS: The mean scar length (12 months postoperative) after CO2 laser excision was 0.30± 0.15 cm, and that following surgical excision was 1.23± 0.43 cm (p= 0.001). The procedure time (time from incision after local anesthesia to the end of repair) was 16.15± 5.96 minutes for CO2 laser excision versus 22.38± 6.05 minutes for surgical excision (p= 0.001). The recurrence rates in the surgical excision group and CO2 laser excision group were 3.3% and 8.3%, respectively; this difference was not statistically significant (p= 0.648). CONCLUSION: The cosmetic outcome of CO2 laser excision is excellent. For epidermal cysts measuring 2.2 cm or smaller, CO2 laser excision is recommended, especially when aesthetic outcome is considered important.

A surgical approach to linear scleroderma using Medpor and dermal fat graft

Linear scleroderma en coup de sabre (LScs) is a variant of localized scleroderma. This disease typically occurs in patients in their 20s or younger individuals and predominantly occurs in the forehead area. A 26-year-old man with linear scleroderma was surgically treated at our center with Medpor (porous polyethylene) and dermal fat graft for the forehead lesion. After 26 months of postoperative follow-up, the depressed lesion that appeared scarred as well as the margins improved significantly. The surgical treatment of LScs using Medpor and dermal fat graft is an effective treatment modality that can increase patient satisfaction.

Usefulness of indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture associated with orbital blowout fracture

BACKGROUND: Nasal fracture and orbital blowout fracture often occur concurrently in cases of midface blunt trauma. Generally, these multiple fractures treatment is surgery, and typically, the nasal bone and orbit are operated on separately. However, we have found that utilizing a transconjunctival approach in patients with concurrent nasal bone fracture and orbital blowout fracture is a useful method. METHODS: The participants in the present study included 33 patients who visited the Plastic Surgery outpatient department between March 2014 and March 2017 and underwent surgery for nasal fracture and orbital blowout fracture. We assessed patients’ and doctors’ satisfaction with surgical outcomes after indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture with associated orbital blowout fracture. RESULTS: According to the satisfaction scores, both patients and doctors were satisfied with transconjunctival approach. CONCLUSION: We presented here that our method enables simultaneous operation of nasal fracture accompanied by orbital blowout fracture, rather than treating the two fractures separately, and it allows precise reduction of the nasal fracture by direct visualization of the fracture site without any additional incisions or difficult surgical techniques. Also, by preventing the use of excessive force during reduction, this method can minimize damage to the nasal mucosa, thereby reducing the incidence of nasal bleeding.

Delayed degradation according to the location of fixation with using an absorbable plate

BACKGROUND: The ideal absorbable plating system should provide sufficient rigidity and then be absorbed within a timely manner. The Resorb-X has been recently developed as a plating system with a mixture ratio of 50:50 poly(D, L-lactide). METHODS: We present seven of 121 patients who experienced delayed degradation with this absorbable plate. One hundred twenty-one patients with facial bone fracture underwent surgical treatment from March 2011 to March 2015, and rigid fixation was achieved with the Resorb-X. RESULTS: Of 121 patients, seven (5.8%) developed complications at the surgical sites. Six of 102 cases underwent fixation of the infraorbital rim and one of 73 underwent fixation of the frontozygomatic buttress; the other sites of fixation did not develop delayed degradation. Foreign body granuloma developed at the earliest by postoperative 20 months and at the latest by postoperative 28 months (average, 23.5 months). CONCLUSION: We observed that the use of absorbable plates in incision sites or areas with thin skin can increase the possibility of delayed degradation. When performing surgery in these areas, the normal skin above the fixed location should be covered sufficiently.

Delayed Granulomas after Filler Injection in an Immunosuppressed Patient: A Case Report

Recently, dermal fillers have been used with increasing frequency to improve facial contours for cosmetic purposes. The appreciable increase in such filler procedures has led to more adverse events and complications. Herein, we report the clinical significance and differential diagnosis of delayed multiple granulomas that occurred in a patient with a history of an injection of an unknown substance as a filler 20 years previously. She was also taking oral steroids and tacrolimus for immune suppression after a kidney transplant that she received 10 years before she presented with granulomas.

Simultaneous Development of Three Different Neoplasms of Trichilemmoma, Desmoplastic Trichilemmoma and Basal Cell Carcinoma Arising from Nevus Sebaceus

Nevus sebaceus is a hamartoma of the sebaceous gland that occurs congenitally, from which various secondary tumors can arise with a prevalence of 5%–6%. Benign neoplasms commonly arise from nevus sebaceous, but they have a very low malignant potential. Two neoplasms may occasionally arise within the same lesion, but it is rare for three or more neoplasms to occur in a nevus sebaceus simultaneously. A 61-year-old male patient was admitted to our hospital for a 4 cm×2.5 cm growing tumor in a verrucous form arising within a periauricular nevus sebaceus in the post auricle of the left ear that had developed 30 years earlier. The nodule was diagnosed as 3 different types of tumors: trichilemmoma, desmoplastic trichilemmoma, and basal cell carcinoma. To our knowledge, this is the first report of the coexistence of three different tumors arising from nevus sebaceous. It contain malignant neoplasm also. Surgeons should be aware of the need for close monitoring and early complete surgical excision of sebaceous nevus in order to improve patient outcomes.

Usefulness of a Transconjunctival Approach in the Reconstruction of the Medial Blow-Out Wall Fracture

BACKGROUND: A transcaruncular approach is typically used for reconstructions of medial wall fractures. However, others reported that a transconjunctival approach was conducive for securing an adequate surgical field of view. In this study, we aimed to examine the extent of repair of medial wall fracture via a transconjunctival approach. METHODS: We retrospectively reviewed the medical records of 50 patients diagnosed as having medial wall fracture via preoperative computed tomography and who underwent surgery between March 2011 and February 2014. The fracture location was defined by dividing each of the anterior-posterior and superior-inferior distances into three compartments. RESULTS: A transcaruncular approach was used in 7 patients, while the transconjunctival approach was performed in the remaining 43 patients. The transconjunctival approach enabled a relatively broad range of repair that partially included the front and back of the medial wall, and was successful in 86% of the entire study population. CONCLUSION: It is known that more than 50% of total cases of the medial wall fracture occur mainly in the middle-middle portion, a majority of which can be reconstructed via a transconjunctival approach. We used a transconjunctival approach in identifying the location of the fracture on image scans except for cases including the fracture of the superior portion in patients with medial wall fracture. If it is possible to identify the location of the fracture, a transconjunctival approach would be an useful method for the reconstruction in that it causes no damages to the lacrimal system and is useful in confirming the overall status of the floor.

Late Complication of a Silicone Implant Thirty Years after Orbital Fracture Reconstruction

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Late Complication of a Silicone Implant Thirty Years after Orbital Fracture Reconstruction

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Skin Necrosis with Oculomotor Nerve Palsy Due to a Hyaluronic Acid Filler Injection

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient's clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.

Clinical Analysis of Lobular Keloid after Ear Piercing

BACKGROUND: Lobular keloid appears to be a consequence of hypertrophic inflammation secondary to ear piercings performed under unsterile conditions. We wish to understand the pathogenesis of lobular keloids and report operative outcomes with a literature review. METHODS: A retrospective review identified 40 cases of lobular keloids between January, 2005 and December, 2010. Patient records were reviewed for preclinical factors such as presence of inflammation after ear piercing prior to keloid development, surgical management, and histopathologic correlation to recurrence. RESULTS: The operation had been performed by surgical core extirpation or simple excision, postoperative lobular compression, and scar ointments. Perivascular infiltration was noted in intra- and extra-keloid tissue in 70% of patients. The postoperative recurrence rate was 10%, and most of the patients satisfied with treatment outcomes. CONCLUSION: Histological perivascular inflammation is a prominent feature of lobular keloids. Proper surgical treatment, adjuvant treatments, and persistent follow-up observation were sufficient in maintaining a relatively low rates of recurrence.

Cephalometric Angular Measurements of the Mandible Using Three-Dimensional Computed Tomography Scans in Koreans

BACKGROUND: We conducted this study to analyze the values of the key cephalometric angular measurements of the mandible using 3-dimensional (3D) computed tomography scans. METHODS: In the 106 enrolled patients, a 3D cephalometric analysis was performed to measure the angular variables of the mandible. These values were compared between the two sides and between the two sexes. RESULTS: The frontal measurements revealed that the mandibular body curve angle was larger on the left (Lt) side (right [Rt], 141.24+/-7.54; Lt, 142.68+/-6.94; P=0.002) and the gonial angle was larger on the right side (Rt, 134.37+/-8.44; Lt, 131.54+/-7.14; P0.05). Further, the transverse measurements revealed that the mandibular body curve angle was larger on the right side (Rt, 140.28+/-7.05; Lt, 137.56+/-6.23; P<0.001). CONCLUSIONS: These results provide an average of the mandibular angular measurements for the Korean population, establishing a standard for determining surgical patient groups and outcome evaluations in the field of mandible contour surgery.

Transient Anisocoria during Medial Blowout Fracture Surgery

Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.