Nose and upper lip reconstruction for purpura fulminans.

BACKGROUND: Purpura fulminans (PF) is a rare syndrome of intravascular thrombosis and haemorrhagic infarction of the skin. The initial symptom of PF is peripheral purpura which progresses to necrosis very rapidly. The prognosis of PF is poor, and the mortality is reported to be around 40%. Even if the patient survives, the patient may require amputation or reconstruction for limbs and facial necrosis. CASE REPORT: A 48-year-old male suffered from PF following a left cerebellopontine angle tumour excision. His nose and upper lip fell into necrosis afterwards. We performed nose and upper lip reconstruction at 8 months after the onset. We used a forehead flap for the nasal reconstruction and a free forearm flap for the lining. His upper lip was reconstructed with bilateral nasolabial orbicularis oris myocutaneous flaps. RESULTS: The colour and texture match of the reconstructed nose and lip is good. He could open his mouth wide enough and close completely. CONCLUSIONS: Facial reconstruction after PF is very difficult, because the patient has extensive scarring around the defect and there is little intact facial tissue. However, we performed a facial reconstruction using local flaps as much as possible, and obtained good results.

New way to raise the V-Y advancement flap for reconstruction of the lower lip: bipedicled orbicularis oris musculocutaneous flap technique.

We describe a new way to raise the V-Y advancement flap, which is useful for reconstruction of the lower lip. Various other methods have been reported in the past, but it has been necessary to choose the most suitable method for each particular case. A V-Y advancement flap from the submandibular region is one of the useful techniques to reconstruct the lower lip, and it is suitable for a wide horizontal defect. However, the conventional V-Y flap is insufficiently mobile and the reconstructed vermilion is thin because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embarrassing defect. We developed a new way to raise the flap to obviate these problems. We use the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision of the tumour, and use a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap is then raised as a bipedicled musculocutaneous flap, which has adequate movement. After the flap has been sutured, the superior margin of the flap is de-epithelialised, and used to create the volume of the vermilion border. Functionally and cosmetically good results were achieved.

Three cases of giant pilomatrixoma--considerations for diagnosis and treatment of giant skin tumours with abundant inner calcification present on the upper body.

BACKGROUND: Pilomatrixoma frequently occurs as a solitary, small tumour on the face or upper extremities of people younger than 20 years. METHODS: We report three cases of giant pilomatrixoma. In all these cases, outward appearances and imaging investigations suggested malignant tumours. Preoperative biopsies suggested that case 1 was a basal cell carcinoma, but cases 2 and 3 had no malignant features on biopsy. Two of the cases experienced rare complications - hypercalcaemia caused by parathyroid-related protein (PTHrP) production and multiple occurrences. RESULTS: All three tumours were removed with a 1-3-cm margin. The postoperative histopathologies showed pilomatrixoma in all three cases. CONCLUSIONS: Rarely, pilomatrixoma develops to a giant size with various atypical outward appearances consistent with a malignant tumour. Preoperative clinical appearances frequently lead to misdiagnosis, and preoperative examinations are unreliable. Therefore, when a giant tumour with abundant inner calcification is present in a young patient, the possibility of a pilomatrixoma should be considered.

A new technique for harvesting costal cartilage with minimum sacrifice at the donor site.

With conventional procedures for harvesting costal cartilage, several large, full-thickness cartilage blocks are harvested from the chest wall and are cut, shaped, and joined to create the desired form. Many pieces of unused cartilage are discarded excluding those preserved for future use. Conventional procedures for costal cartilage harvesting are also associated with severe problems such as pain, deformity of the chest wall, and a long scar. We developed a new technique that permits only the necessary size and shape of cartilage to be directly harvested with the use of a chisel. With this technique, both sides and the bottom of the cartilage remain intact at the donor site. The anterior perichondrium can be harvested simultaneously. This technique was performed in 28 patients. The required quantities could be harvested in all patients without severe complications such as perforation of the pleura and excessive bleeding. The procedure required 30 min or less in all patients. The length of the skin incision was less than 3 cm in 25 patients and greater than 3 cm in two obese patients and a young man who had hard subcutaneous connective tissue. Pain intensity was markedly lower than that after conventional techniques. Twenty-six patients could walk 1 day after the operation. There were virtually no deformities of the thorax, even in children younger than 10 years. The structure of the reconstructed site was maintained during at least 2 years follow-up in all patients. Our technique for harvesting costal cartilage is associated with smaller scars, less pain, and less deformity of the chest wall than conventional procedures. In addition, it is minimally invasive and can be performed in a short time.

One-stage reconstruction of a large defect of the lower lip and oral commissure.

Large lower lip defects including the oral commissure are very difficult to reconstruct and obtain an aesthetic appearance and an acceptable function. We report two patients who had a large defect in the lower lip including oral commissure and were treated using free radial forearm flap and temporal muscle transfer in one-stage. For the cutaneous defects, in one a local flap was elevated from the adjacent cheek and in the other a turned over area of the forearm flap was used. In each case, the reconstructed lower lip could maintain adequate elevation of oral the commissure using the temporal muscle was worked. The first case which used a local flap externally could avoid sialorrhea and had good sensation, and could close the mouth firmly soon after surgery. The appearance was acceptable. In the other case, leakage of oral contact and air occurred at the oral commissure because of the thickness of the forearm flap but improved after minor correction some 8 months after the surgery.