Malignant hyperthermia: a case report with a literature review

Malignant hyperthermia is an extremely rare, potentially lethal disorder that occurs in susceptible patients who are exposed to triggering agents such as volatile anesthetic gases or depolarizing muscle relaxants. The clinical manifestations of malignant hyperthermia include hypermetabolism, hyperthermia, hypercapnia, and sustained skeletal muscle rigidity, which result in cardiac arrest, brain damage, and death. It is associated with a high morbidity and mortality rate if not recognized immediately and treated appropriately. We report a case of suspected malignant hyperthermia in a young male patient undergoing axillary osmidrosis surgery.

Accidental Trichloroacetic Acid Burn Injuries on Genital Area during Gynecological Procedures

TCA is widely used in cosmetic treatments such as chemical peels, tattoo removal, and also in gynecological procedures for managing cervical intraepithelial neoplasia. However, storage of high concentration of TCA in a gynecology office is a potential hazard, as it may accidentally cause severe chemical burns. We report a case of deep dermal TCA chemical burn on genital area, which occured accidentally and resulted from misuse of high concentration (90%) of TCA coated vaginal gauze packing dressing during gynecological procedures.

Poroid hidradenoma of the scalp

Poroid hidradenoma has both features of hidradenoma and poroma. The histological hidradenoma framework consisting of solid and cystic components, and the presence of poroid and cuticular cells resembling a poroid neoplasm. Despite transforming into malignant neoplasm only in < 1% of cases, its histological characteristics may resemble those of malignant neoplasms. Although the risk of malignant transformation is very low, surgical excision is recommended to prevent growth and/or recurrence. To date, very few cases of poroid hidradenoma have been reported in the literature. Herein, we present a case of poroid hidradenoma on the scalp of a 74-year-old woman.

Ketamine-induced generalized convulsive seizure during procedural sedation

Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation for facial laceration in pediatric patients. The major benefits are its rapid onset of effects, relatively short half-life, and lack of respiratory depression. The known side effects of ketamine are hallucinations, dizziness, nausea, and vomiting. Seizure is not a known side effect of ketamine in patients without a seizure history. Here, we present the case of a patient in whom ketamine likely induced a generalized tonic-clonic seizure when used as a single agent in procedural sedation for facial laceration repair. The aim of this article is to report a rare and unexpected side effect of ketamine used at the regular dose for procedural sedation. This novel case should be of interest to not only emergency physicians but also plastic surgeons.

Accidental Trichloroacetic Acid Burn Injuries on Genital Area during Gynecological Procedures

TCA is widely used in cosmetic treatments such as chemical peels, tattoo removal, and also in gynecological procedures for managing cervical intraepithelial neoplasia. However, storage of high concentration of TCA in a gynecology office is a potential hazard, as it may accidentally cause severe chemical burns. We report a case of deep dermal TCA chemical burn on genital area, which occured accidentally and resulted from misuse of high concentration (90%) of TCA coated vaginal gauze packing dressing during gynecological procedures.

Poroid hidradenoma of the scalp

Poroid hidradenoma has both features of hidradenoma and poroma. The histological hidradenoma framework consisting of solid and cystic components, and the presence of poroid and cuticular cells resembling a poroid neoplasm. Despite transforming into malignant neoplasm only in < 1% of cases, its histological characteristics may resemble those of malignant neoplasms. Although the risk of malignant transformation is very low, surgical excision is recommended to prevent growth and/or recurrence. To date, very few cases of poroid hidradenoma have been reported in the literature. Herein, we present a case of poroid hidradenoma on the scalp of a 74-year-old woman.

Ketamine-induced generalized convulsive seizure during procedural sedation

Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation for facial laceration in pediatric patients. The major benefits are its rapid onset of effects, relatively short half-life, and lack of respiratory depression. The known side effects of ketamine are hallucinations, dizziness, nausea, and vomiting. Seizure is not a known side effect of ketamine in patients without a seizure history. Here, we present the case of a patient in whom ketamine likely induced a generalized tonic-clonic seizure when used as a single agent in procedural sedation for facial laceration repair. The aim of this article is to report a rare and unexpected side effect of ketamine used at the regular dose for procedural sedation. This novel case should be of interest to not only emergency physicians but also plastic surgeons.

Epidemiologic Study of Frostbites and Its Current Managements in Community Hospital

Purpose@#Frostbite is a hazard to people exposed to cold environments. With the progression of modern industrial development and change of leisure behavior encountering cold environments, frequent accidental exposure to frostbite injury during work and human behavior is increasing, and the predisposing factors of frostbite were greatly changed than before. The purpose of this study was to make epidemiological analysis, and to review the treatment outcomes of frostbite. @*Methods@#From March 2010 to February 2021, this study has included 27 patients with second- to third-degree frostbite injuries in Advanced Burn Reconstruction Center, Bundang Jesaeng Hosptial. A retrospective study was made about the distribution of age, gender, predisposing factors, prevalent area, type of managements, and the length of treatment period. @*Results@#In our institution, acute management of frostbite patients has included rewarming, anticoagulation therapy (acetylsalicylic acid), and agents to improve vascular perfusion (lipo-prostaglandin E1 [Eglandin Ⓡ ]). The 25 frostbite patients with second-degree frostbite (92.6%) were successfully managed by the conservative treatment alone with a mean of 20.3 days healing time. Two patients with third-degree frostbite (7.4%) also showed good outcomes after surgical reconstruction with a mean of 59 days healing time. In our clinical experiences of third-degree frostbite, definitive surgical reconstruction should be recommended to wait for more than 4∼6 weeks for identification of clear demarcation of necrotic tissue caused by frostbite. In this study, 43 frostbite injuries site in 27 frostbite patients occurred. Among them, 15 patients (55.6%) had multiple-site frostbite injury. The most common predisposing cause of frostbite was refrigerant gas accidents (44.4%), followed by outdoor activity in cold environments (40.8%), misapplying ice pack for treatment purposes (7.4%), barefoot walking on the cold ground (3.7%), and loss of consciousness in cold grounds (3.7%). The most prevalent sites of frostbite injuries revealed as the hand (58.1%), followed by the foot (32.6%), face (7.0%), and abdomen (2.3%). And in the winter season from the November to March, the incidence rate of frostbite injuries was high at 74.1%. @*Conclusion@#This study included 27 frostbite patients with 43 frostbite sites since last decade in a single institution at the com -munity hospital. The frostbite patients with second-degree frostbite (92.6%) were successfully healed by the conservative treatment alone with a mean of 20.3 days healing time. The most common predisposing cause of frostbite was refrigerant gas accidents (44.4%), followed by outdoor activity in cold environments, etc. The most prevalent site of frostbite injuries was the hand (58.1%). And the most prevalent seasonal incidence of frostbite was from November to March (74.1%).

Rhombus Subcutaneous Pedicle Skin Flap for Reconstruction of Linear Depressed Postburn Scar Band

This paper presents our clinical experiences for reconstruction of the linear depressed postburn scar band by rhombus subcutaneous pedicle skin flap (RSPF). We report new RSPF, it’s versatility, and effectiveness for correction of the mild to moderate linear depressed postburn scar band. To correct the postburn scar band, we have newly designed the Rhombus Subcutaneous Pedicle Skin Flap (RSPF), which is made as rhombus-shaped skin flap on the inside of scar band. After excision of burn scar band, the each vertex of RSPF flap is advanced into the skin defects at apex of extended skin incision, which is starting from the upper and lower portion of the removed burn scar band at a near right angle. This flap can add more extra skin to adjacent superior and inferior area of excised scar band. We have experienced 2 cases of RSPF for reconstruction of linear depressed postburn scar band deformities in lower extremity. After 3 weeks to 3 months postoperative follow ups, relatively satisfactory results were obtained in all cases. We had successfully reconstructed the linear depressed postburn scar postburn band of lower extremity using the rhombus subcutaneous pedicle skin flap. For the correction of mild to moderate sized linear depressed postburn scar band deformities in extremity, the RSPF is simple, and very effective without donor morbidity.

Solitary sclerotic fibroma on the thigh

Sclerotic fibroma is a rare fibrous tumor of the skin associated with Cowden’s disease. In 1989, Rapini described sclerotic fibroma without Cowden’s disease as solitary sclerotic fibroma of the skin. It is a solid, well-circumscribed, slow-growing nodular tumor and it looks similar to a keloid scar. Consequently, it is extremely difficult to make a differential diagnosis of solitary sclerotic fibroma with keloid scar based on clinical findings only. The authors report a case of solitary sclerotic fibroma arising at the left lateral thigh of a 25-year-old man.

Keyhole vertical mini-abdominoplasty for correction of lower abdominal striae

Striae gravidarum are a common problem in postpartum women, who may experience serious emotional distress due to multiple streaks of scars on the abdomen. There is still no consensus on the treatment method for this problem. For a postpartum woman in her late 30s, who requested striae removal from the lower mid-abdomen, we developed and performed the keyhole-shaped vertical mini-abdominoplasty. This 37-year-old woman, who had given birth to two children, presented with multiple striae on the lower mid-abdomen and periumbilical area, as well as mild bulging in this area. The keyhole-shaped vertical mini-abdominoplasty, including multiple striae on the lower mid-abdomen and periumbilical skin, was designed. An area of striated lower abdominal and periumbilical skin, measuring approximately 10×15 cm2 and weighing about 450 g, was excised. Midline reinforcement of the loosened anterior rectus sheath with 3-0 Prolene sutures was done. Both lateral abdominal skin flaps were medially advanced to close the skin defects. Postoperatively, the patient had a favorable lower abdominal appearance with markedly fewer striae on the lower mid-abdomen and periumbilical area. The keyhole vertical mini-abdominoplasty can effectively correct moderate striae on the lower mid-abdomen and periumbilical area in postpartum women in their late 30s to middle age.

Modified Abbé flap for reconstruction of Cupid’s bow and vermilion tubercle in secondary cleft lip deformity

BACKGROUND: Abbé flap technique is one of the most challenging operations to correct horizontal deficiencies in secondary cleft lip deformity. Since its first introduction, the operative method was dynamically modified from simple variation to complete conceptual change, but conventional Abbé flap has many drawbacks in esthetic and functional aspect. Our purpose was reconstructing the symmetry of Cupid's bow and central vermilion tubercle with minimal sequalae. METHODS: From 2008 to 2016, this technique was applied to 16 secondary cleft lip patients who had total or more than 60% of unilateral deficiency of Cupid's bow and central lip or tubercle pouting deficiency. A quadrangular-shaped flap was transferred from vermilion including skin and white line of central or contralateral lower lip. Pedicle division and insetting were made at 9 (unilateral) or 10 (bilateral) days after transfer. Secondary lip revision was done with open rhinoplasty after wound maturation. RESULTS: Overall satisfaction was high with modified technique. Scar was minimally noticeable on both upper and lower lip especially. Balanced Cupid's bow and symmetric vermilion tubercle were made with relatively small size of flap compared to conventional Abbé flap. An accompanying benefit was reduced ectropion of lower lip, which made balanced upper and lower lip protrusion with more favorable profile. CONCLUSION: A new modified Abbé flap technique showed great satisfaction. It is worth considering in secondary cleft lip patient who has central lip shortage and asymmetry of upper lip vermilion border line. Our technique is one of the substitutes for correction of horizontal and central lip deficiency with asymmetric Cupid's bow.

The Effects of Water Soluble Chitin on the Open Wound Healing in Rabbits

The purpose of this study was to evaluate effects of chitin on open wound healing in rabbits. Using 15 rabbits, a round, full thickness defect of skin with 2 cm in diameter was made on the ventral surface of the each ear. The experimental animals were divided into 3 groups: control group untreated group), base ointment group (group treated with base ointment), and chitin ointment group(group treated with water soluble chitin ointment). A total of 30 wounds were made and each subgroup was allocated 10. On the 7th day after initial wounding, each wound site including surrounding tissue was taken for macroscopic and histological observations. The amount of epithelialization and granulation tissue were measured by Image Analysis System. In macroscopic examination, larger amount of exudate and granulation tissue were observed in water soluble chitin ointment group compared to control and base ointment groups. In histological examination, water soluble chitin ointment group showed thick epithelium and larger amount of granulation tissue and fibroblast deposition. The areas of epithelialization and granulation tissue were significantly increased in water soluble chitin ointment group compared to control and base ointment groups. In conclusion, water soluble chitin accelerated open wound healing by accelerating reepithelization and granulation tissue formation.

Total En Bloc Reconstruction of Alar Cartilage with Conchal Cartilage in Seconday Cleft Lip Nasal Deformity

The cleft lip nasal deformity includes not only distorted lower lateral cartilage but generally also an abnormal deficient maxillary bony platform as well as distorted anterior nasal spine and deviated nasal septum. The main defect in the nose is in the position and shape of lower lateral cartilage. There were many literatures for modification of alar cartilage for nasal symmetry in the past several decades, that is, relocation, suture fixation and graft augmentation with deformed alar cartilage itself. But the various corrective techniques were unsatisfactory for both surgeons and patients. The purpose of this article is to present new concepts and surgical techniques. Author's basic concept is total replacement of deformed alar cartilage with new sources of contoured alar cartilage. The grafts were taken from conchal cartilage en bloc. The medial crus, dome, and lateral crus were replaced by the lamina tragi, isthmus and cavum conchae, respectively. The unilateral secondary cleft lip and nose deformity patients were reviewed with charts and photographs from 1991 to 1998. The surgical procedures were open rhinoplasty incision technique with reversed U-incision of nostril web and wide undermining of cartilaginous vault. The total en bloc reconstruction technique has been performed for 125 patients, aged from 5 to 40 years, and they were followed up for 6 months to 8 years. There were no surgical complications and donor site morbidities. There were no relapse and growth disturbance over time. The postoperative results showed symmetry of alar unit, alar dome projection, tip-defining points and nostrils. CONCLUSION: A new technique is described for sensational improvement of the nasal esthetics in secondary cleft lip nasal deformity by using an en bloc autogenous conchal cartilage graft. But further observation is needed for evaluating its effect on the long-term growth potentials.

The Effect of Rigid Internal Fixation on Growth of the Mandibulofacial Bone in Growing Rabbits

Craniofacial reconstructive procedures are frequently peformed with rigid fixation of the bone. During the period of active bone growth such manipulation may influence bone development. The purpose of this study was to determine the effects of metal plating of the mandible on the growth and morphology of the mandibulofacial skeleton. New Zealand white rabbits, 6 to7 weeks of age, were divided into 5 groups. They were designated as group I(nonoperated control, n=10), group II (rigid fixation of mandibular body after vertical osteotomy, n=10), group III(rigid fixation without osteotomy, n=10), group IV (interosseous wire fixation after osteotomy, n=10), and group V(rigid fixation and removal of plates and screws 4 weeks after osteotomy, n=7). Rabbits were sacrificed 12 weeks after operation and dry skull preparations were grossly measured and analyzed by direct measurement and by dorsoventral skull x-rays. Measurements taken were length, thickness, angle, and area of the mandibulofacial skeleton. Three-dimensional CT was used for volumetric measurement of the mandible. The data wee compared between the operated and nonoperated sides and significant differences between groups were evaluated using the paired t-test, the ANOVA test, and Dunn's test. The following results were obtained: 1. The length of the whole mandible and the anterior mandibular segment was decreased in groups II and III, compared with group I(p>0.05). These results show growth restriction of the plated mandible regardless of osteotomy. 2. The maxillary alveolus of the operated side was more anteriorly placed in groups II and III, compared with group I (p>0.05). 3. The thickness of the operated mandibular body showed a significant increase in groups II and III, compared with group I(p>0.05). 4. The length of the zygomatic arch of the operated side in all the experimental groups showed a significant decrease, compared with group I(p>0.05). The angular divergence of the mandibular ramus from the sagittal midline of the skull was increased in the operated side of groups II and III, compared with the nonoperated side (p>0.05). 5. Volume measurements of the mandible in groups II and III showed a significant reduction of the volume on the operated sides in the anterior mandibular segment, compared with group I(p>0.05). The volume of the operated mandibular body showed a significant increase in groups II and III, compared with group I(p>0.05). All gruops showed no significant difference in total hemiman dibular volume of the operated side compared with the nonoperated side. These results show that rigid fixation of mandibular fractures during the growth period causes a more severe growth restriction than either osteotomy or interosseous wiring.

Two Case Reports of Bone-invading Basal Cell Carcinoma

Basal cell carcinoma is the most common skin cancer, especially on the eyelid and nose. As it rarely invades to a underlying bone or metastasizes an distant site, and is usually found at an early stage, it is regarded as a curative disease. However, basal cell carcinoma on the eyelid and nose may be resected incompletely due to efforts to preserve important structures or as a result of esthetic considerations. We experienced two cases of basal cell carcinoma with local invasion to underlying bone. One was a recurred case on the nasal area extending to the nasal bone arts medial wall of the ethmoid sinus. The lesion was widely resected and covered with a radial forearm free flap. The other was on the eyelid extending to the orbit. It was treated with orbital exenteration and resection of the involved eyelid. The defect was reconstructed with the temporalis muscle flap with split-thickness skin graft. These patients were followed up for 7 months with no evidence of recurrence. Since basal cell carcinoma can invade to the bone and metastasize to a distance site, it should be resected radically in the regions of the eyelid and nose.

Case Report of Neonatal Teeth in Cleft Lip and Palate

The teeth present at birth are called natal teeth, while the teeth that appear within the first thirty days following birth are called neonatal teeth. Approximately one in 2,000 to 3,500 infants experiences the eruption of teeth at birth or within the first few weeks postpartum. Many contributing factors have been suggested for the premature eruption of primary teeth. It has been suggested that upon eruption these teeth are of normal structure according to their developmental age, but after eruption, lateral movement in the cervical area leads to disturbance of the dentin and premature degeneration of Hertwig's root sheath. In most cases, they have immature, aborted structures consisting only of caps of enamel, dentin, or a combination of both. A radiograph can show the presence or absence of enamel, dentin, or root structures, as well as supernumerary teeth. These teeth may be aspirated or swallowed during feeding. Discomfort from mobile and erupting teeth often causes the infant to refuse to feed. In addition, a nursing mother's nipples may become lacerated and infected. Extraction is the indicated treatment if these neonatal teeth cause discomfort or demonstrate mobility or incomplete, immature development. Treatment decisions must be made on an individual basis from both clinical and radiographic findings. We report four cases of neonatal teeth in complete cleft lip and palate patients.

Cranial Fasciitis: Presentation as a Temporal Mass

Cranial fasciitis is a rare morphological variant of nodular fasciitis. It is characterized by a rapid growing fibroblastic proliferative lesion that develops chiefly in childhood. It has varying size and involves the soft tissues of the scalp and the underlying skull. Accurate diagnosis and surgical excision is the key to management. Prognosis is good with rare recurrence. We report a case of cranial fasciitis in the temporal fossa of a 20-month-old girl and present a review of the literature.

A clinical review of eyelid sebaceous carcinoma

Malignant tumors of the eyelid pose a serious threat because of their proximity to the globe, brain & paranasal sinuses. Three types of carcinomas account for the vast majority of the malignant eyelid tumors: basal cell carcinoma, squamous cell carcinoma, and sebaceous gland carcinoma. In these malignancies, basal cell carcinoma is the most common. However, sebaceous gland carcinoma has a high recurrence rate and a moderately high 5-year mortality rate because of late diagnosis and incomplete surgical removal. This tumor may be clinically misdiagnosed frequently as a chronic unilateral conjunctivitis, chalazion, basal cell carcinoma, or squamous cell carcinoma in initial biopsy. Suspicious lid lesions should be managed with incisional biopsy initially. If they are positive for sebaceous gland carcinoma, wide excision and frozen section monitoring of surgical margin is the treatment of choice. The final diagnosis should be confirmed by special stain for lipid. We experienced 12 cases of malignant eyelid tumors including 3 cases of sebaceous gland carcinoma. In cases of sebaceous gland carcinoma, wide surgical excision with frozen section monitoring was performed and followed by eyelid reconstruction with intact eyelid tissue remained and adjuvant radiotheraphy. Guidelines for management are discussed.

Surgical treatment of livedo vasculitis

Livedo vasculitis is thought to be a thrombogenic disorder that is related to the autoimmune disease. It clinically shows purplish mottling and recurrent painful ulcers in the lower extremities, leaving atrophie blanche after healing of the ulcers. Histopathologic finding are thrombotic occlusion in the mid-dermal vessels without necrotizing vasculitis. The therapeutic approach has largely been made by the use of drugs that stimulate endogenous fibrinolytic activitiy, that inhibit thrombus formation, or that cause vasodilation, but surgical intervention by excision and skin graftion has rarely been reported as a primary treatment.In our experience, two patients with livedo vasculitis, who had been unresponsive to various medications, were treated with wide excision and several times of skin grafting. And they experienced complete healing without recurrence.