Reconstruction of Hand Dorsum Defect Using Double Perforators-Based Anterior Interosseous Artery Island Flap: A Case Report and Description of a New Anterior Interosseous Artery Perforator.

The anterior interosseous artery (AIA) perforator flap is not commonly used in hand dorsum reconstruction compared with alternatives. However, it is a versatile flap with several advantages. Literature on the AIA perforator flap is based on the dorsal septocutaneous branch (DSB), which branches from the AIA and passes through fascia between the extensor pollicis longus (EPL) and extensor pollicis brevis muscles. In the described case, the authors reconstructed a hand dorsum defect in a 78-year-old man using an AIA perforator flap with double perforators supplied by the DSB and a new perforator branching from the distal than DSB. No complication was encountered, and the flap survived completely. A retrospective computed tomography review revealed the presence of the new perforator in 14 of 21 patients. Two types of new perforator were observed. One passed through the ulnar side of the extensor indicis proprius (EIP) muscle and penetrated fascia between the extensor digitorum minimi and extensor digitorum communis tendons, whereas the other passed between the EPL and EIP muscles. This report describes the anatomical location and clinical application of the new AIA perforators. The double perforators-based AIA flap provides a straightforward, reliable means of reconstructing hand dorsum defects.

Surgical treatment of postauricular hidradenitis suppurativa with delayed diagnosis: a case report and literature review.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition that is difficult to diagnose, with a period of 10.0± 9.6 years from symptom onset to diagnosis. A 32-year-old Asian man presented with bilateral postauricular abscesses that first appeared 5 years previously. Despite several incisions and drainage, the symptoms only temporarily improved and continued to recur. On physical examination, chronic scars and sinus tracts were observed around the lesion. Postauricular HS was diagnosed, and surgical treatment was performed. We performed a wide excision and reconstructed the defect using a posterior auricular artery perforator-based keystone flap. Histological examination confirmed the diagnosis of HS. The reconstruction was successful, and there was no recurrence for 2 years after surgery. HS is difficult to diagnose without specific attention. Although the postauricular region is not a typical site of HS, it can occur in this area. Therefore, if a patient presents with recurrent abscesses in the postauricular region, HS should be considered. Additionally, if HS is diagnosed in the postauricular region, wide excision with reconstruction using a posterior auricular artery perforator-based keystone flap can lead to a favorable outcome.

Coexistence of condyloma acuminatum and extramammary Paget's disease on penis and scrotum: A rare case report.

RATIONALE: Extramammary Paget's disease (EMPD) is a rare skin cancer that commonly occurs in sites rich in apocrine glands, such as perineum, vulva, axilla, scrotum, and penis. On the other hand, condyloma acuminatum (CA; also referred to as anogenital warts) is a common benign neoplasm caused by human papillomavirus. Few cases of coexistent EMPD and CA have been reported because of the rarity of the condition. PATIENT CONCERNS AND DIAGNOSIS: A 72-year-old man with a genital mass, which appeared to be composed of multiple papillomatous masses, was referred for surgical resection. The lesion was first noticed 6 months previously and grew rapidly. CO2 ablative laser therapy was performed twice at a primary clinic, but the mass recurred. INTERVENTION AND OUTCOMES: Excisional biopsy revealed the presence of coexistent EMPD and CA. Additional wide excision was performed, and postoperative biopsy confirmed no residual tumor. Two years after surgery, no recurrence had occurred. LESSONS: CA can co-occur with several types of skin malignancies, and a skin malignancy coexisting with CA is difficult to diagnose visually. Therefore, even if a skin lesion in the genital region is considered to be CA, we recommend punch biopsy before treatment because it can benefit prognosiss.

Pseudoaneurysm of the superficial temporal artery after blunt trauma: case report and literature review.

An 88-year-old man presented with a left temporal pulsatile mass that developed after blunt trauma. Based on suspicion of hematoma, needle aspiration was performed with the removal of approximately 15 mL of blood. No evident improvement was noted, and active arterial bleeding was observed at the needle puncture site. Doppler ultrasonography revealed a "yin-yang" sign, and the mass was diagnosed as a pseudoaneurysm of the left superficial temporal artery. Under general anesthesia, the superficial temporal artery was ligated and the pseudoaneurysm was removed. Superficial temporal artery pseudoaneurysm is a rare facial tumor that generally occurs after blunt trauma. Due to its rarity, pseudoaneurysms are often misdiagnosed as hematoma. The treatment of choice is excision, although endovascular intervention is a potential treatment option. However, when a pseudoaneurysm is small, conservative treatment can be used.

Surgical Results and Patient Satisfaction After A New Surgical Technique for Asian Medial Epicanthoplasty: A Modified Skin Redraping Method Using a Horizontal Point Incision and Staged 'Y-Shaped' Dog Ear Correction.

BACKGROUND: The double eyelid operation is the most common cosmetic procedure conducted in Asians. However, the epicanthal fold presents a conundrum that limits the cosmetic results of double eyelid surgery. Despite not being a pathologic condition, numerous procedures have been developed and introduced to address this issue, but these techniques have potential disadvantages that include an unnatural ciliary position of the lower lids and prominent scarring. METHOD: A total of 156 patients who underwent a double eyelid operation with medial epicanthoplasty using the modified skin redraping method using a horizontal point incision and staged dog ear correction between 2015 and 2019 at our medical center were enrolled in the study. A single senior plastic surgeon performed all surgical procedures. The Patient-Reported Outcome Measures (PROM) questionnaire was used to obtain objective satisfaction scores, and patient satisfaction scores were obtained using some criteria. RESULT: Of 147 patients, 8 (0.05) complained of visible scarring at the medial epicanthal and upper fold line region; there were only 2 (0.01%) epicanthal fold recurrences and 1.36% wound-related complications. The PROM scores and patient satisfaction scores showed a strong positive linear correlation according to linear regression analysis (P < 0.001). CONCLUSION: We performed double eyelidplasty with epicanthoplasty by using "a modified skin redraping method using a horizontal point incision and a staged 'Y-shaped' dog ear correction." Few complications were encountered, and almost all patients were satisfied with their surgical outcome as determined by the PROM questionnaire.

A new technique in Asian nasal tip plasty: Non-incisional double-layered conchal cartilage graft.

BACKGROUND: The columellar strut graft based on the use of back-to-back autogenous conchal cartilage is one of the most commonly employed invisible grafts used for nasal tip projection. This graft provides an effective means of achieving nasal tip projection but is limited by its flexibility, especially with respect to cephalic rotation. We designed an effective technique that addresses these limitations. METHOD: A total of 38 patients received augmentation rhinoplasty with non-incisionally bent double-layered conchal cartilage columellar strut graft with nasal tip onlay graft. Projection and location of the nasal tip, nasal length, and nasolabial angle were measured using lateral view photographs. Pre- and postoperative results were compared. RESULT: Pre- and postoperative nasal tip projection ratios and nasal tip location ratios were significantly different. Revision surgery was not required in any case and no direct graft-associated complication occurred. CONCLUSION: We performed tip plasty with a modified columellar strut graft, that is, a non-incisionally bent double-layered conchal cartilage columellar strut graft. In most cases, this method resulted in a significant tip projection increase.

A case of acute skin failure misdiagnosed as a pressure ulcer, leading to a legal dispute.

It is difficult to differentiate acute skin failure (ASF) from pressure ulcer (PU). ASF is defined as unavoidable injury resulting from hypoperfusion caused by severe dysfunction of another organ system. We describe a case of ASF mistaken as PU that resulted in a legal dispute. A 74-year-old male patient was admitted to our intensive care unit with sepsis due to bacterial pneumonia. Despite the use of air cushions and regular position changes, skin ulcerations occurred over his occiput, back, buttock, elbow, and ankle. After improvement in his general condition, he was transferred to the department of plastic and reconstructive surgery. Debridement was performed immediately, followed by conservative treatment (including a vacuum-assisted closure device) for 6 weeks. The buttock and occiput wounds were treated surgically. Despite complete healing, his caregivers sued the hospital for failing to prevent PU formation. ASF is a pressure-related injury resulting from hemodynamic instability due to organ system failure. Unlike PU, ASF may occur despite the implementation of all appropriate preventive measures. Furthermore, misdiagnosis of ASF as PU can lead to litigation. Therefore, it is critical for the proper diagnosis to be made quickly, and for physicians to explain that ASF occurs despite proper preventative treatment.

Eccrine Poroma of the Postauricular Area.

Eccrine poroma is a common benign cutaneous tumor that originates in an intraepidermal eccrine duct. This tumor exhibits acral distribution (sole, palm), and is rarely encountered in the head and neck area. In fact eccrine poroma in the postauricular area has only been rarely reported. A 55-year-old female visited our hospital with a main complaint of a mass that first developed in the left postauricular area about a year previously. The mass was painless, soft, protruding, domed, and dark red in color, and had slowly enlarged (at presentation it measured 1×1 cm). Excisional biopsy was performed. Histological examination showed distinct features, and eccrine poroma was diagnosed. Follow-up at 6 months postoperatively showed no recurrence. The frequency of eccrine poroma is dependent on eccrine sweat glands density, and thus, usually occurs on the palms or soles. For eccrine poroma in the head and neck region, the differential diagnosis must rule out other masses, such as nevus, skin tag, pyogenic granuloma, cyst, basal cell carcinoma, and seborrheic keratosis. Importantly, 18% of poromas show malignant transformation, and can develop into porocarcinoma. For these reasons, an eccrine poroma in the facial area requires histological examination, complete excision, and follow-up.

Pediatric Orbital Medial Wall Trapdoor Fracture with Normal Computed Tomography Findings.

With advances in diagnostic technology, radiologic diagnostic methods have been used more frequently, and physical examination may be neglected. The authors report a case of pediatric medial orbital trapdoor fracture in which the surgery was delayed because computed tomography (CT) findings did not indicate bone displacement, incarceration of rectus muscle, or soft tissue herniation. A healthy 6-year-old boy was admitted to the emergency room for right eyebrow laceration. We could not check eyeball movement or diplopia, because the patient was irritable. Thus, we performed facial CT under sedation, but there was normal CT finding. Seven days later, the patient visited our hospital due to persistent nausea and dizziness. We were able to perform a physical examination this time. Lateral gaze of right eye was limited. CT still did not show any findings suggestive of fracture, but we decided to perform exploratory surgery. We performed exploration, and found no bone displacement, but discovered entrapped soft tissue. We returned the soft tissue to its original position. The patient fully recovered six weeks later. To enable early detection and treatment, thorough physical examination and CT reading are especially needed when the patient shows poor compliance, and frequent follow-up observations are also necessary.

Extramammary Paget disease of the vulva: minimal excision with adjuvant radiation treatment for optimal aesthetic results.

AIMS AND BACKGROUND: Extramammary Paget disease (EMPD) is an uncommon malignant neoplasm that occurs in areas containing apocrine glands, and the vulva is the most commonly involved site. Wide surgical excision with subsequent defect reconstruction is widely accepted as the first-line treatment for EMPD. More recently, radiation treatment has been considered an appropriate primary or adjuvant treatment. In an effort to replace wide excision and avoid unfavorable aesthetic results and sexual dysfunction, we decided to excise the tumor minimally and to add adjuvant radiation treatment. METHODS: A 71-year-old woman had EMPD at the right labium majus. The patient was treated by minimal excision with a 1-cm safety margin and by adjuvant radiation treatment weekly from 1 month to 3 months after surgery to a total dose of 70.2 Gy. Four months after completing the radiation treatment, a 10-point surgical biopsy around the site of previous resection was performed. Radiation treatment caused hypertrophy of the left labium minus, which was treated by additional labiaplasty (labium minus reduction) to obtain optimal aesthetic results. RESULTS: Surgical biopsy revealed no definite evidence of recurrence. Currently, the patient had no EMPD symptoms, is satisfied with a symmetrical vagina, and experiences no discomfort during ordinary activities or intercourse. CONCLUSIONS: Minimal tumor excision (with a 1-cm safety margin), adjuvant radiotherapy, and additional labiaplasty were performed to treat EMPD. Complete tumor removal without recurrence, an aesthetically satisfactory result, and normal sexual function were achieved in this patient.

Delayed-Onset Methicillin-Resistant Staphylococcus aureus Infection at 18 Months after Absorbable Plate Fixation for Zygomaticomaxillary Complex Fracture.

None of the reports of delayed infection mentioned a latent period exceeding 13 months. we report an infection that developed 18 months after implantation of an absorbable plate. A 16-year-old adolescent girl had undergone reduction and fixation with an absorbable plate for Lefort I and zygomaticomaxillary complex fractures 18 months prior at our hospital. In her most recent hospital visit as an outpatient, abscess was observed in periocular area. Computed tomography revealed sinusitis with an abscess above the infraorbital rim. Wound culture yielded methicillin-resistant Staphylococcus aureus . Despite conservative treatments, wound state did not improve. Therefore, our department decided to perform surgery. Absorbable plate had been mostly absorbed but remained a bit. Bony depression of infraorbital rim and mucosal exposure of maxillary sinus anterior wall were observed. After the surgery, the patient recovered. We believe that the reason the wound infection and sinusitis manifested at the same time is because of several factor such as alcohol abuse, smoking, and mucosal exposure of maxillary sinus anterior wall. Absorbable plate takes 9 months to 3 years to be completely absorbed, thus we suggest studies with a follow-up of at least 3 years be undertaken to determine the outcomes of patients with many risk factors.

A Retrospective Clinical View of Basal Cell Carcinoma and Squamous Cell Carcinoma in the Head and Neck Region: A Single Institution's Experience of 247 Cases over 19 Years.

BACKGROUND: The two most common skin cancers are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The purpose of this study was to describe the detailed clinical behavior of BCC and SCC in the head and neck region over 19 years at a single institution. METHODS: A retrospective analysis was performed for all patients with non-melanoma skin cancer who had undergone surgical resection over an 18-year period. Patient charts were reviewed for demographic information, tumor size, onset-to-diagnosis, anatomic location, clinical subtype, histologic differentiation, method of surgical treatment, and recurrence. RESULTS: The review identified 265 cases of either BCC or SCC in 226 patients. Of the 226 patients, 80 (35.4%) were men and 146 (64.6%) were women. BCC (n=138, 55.9%) was more frequent than SCC (109, 44.1%). The most frequent age group was 70-to-79 year olds (45 patients, 35.2%) for BCC and 80-to-89 year olds (41 patients, 41.8%) for SCC. By aesthetic units of the face, the most common location was the nasal unit (44 cases, 31.9%) for BCC and the buccal unit (23 cases, 21.1%) for SCC. The most common clinical subtype of BCC was the nodular type (80 cases, 58.0%). Local flaps were most commonly used to cover surgical defects (136 cases, 55.1%). Recurrent rates were 2.2% for BCC and 5.5% for SCC. CONCLUSION: In our study, many characteristics of BCC and SCC were compared to previously published reports were generally similar, except the ratio of BCC to SCC. Further study can help to establish the characteristics of BCC and SCC.

Correction of Sunken Upper Eyelids by Anchoring the Central Fat Pad to the Medial Fat Pad during Upper Blepharoplasty.

BACKGROUND: Many methods have been proposed for the correction of sunken upper eyelids. These methods include surgical treatments, such as micro-fat, dermofat, or fascia-fat grafts, or the use of alloplastic materials. Here, we present our experience of sunken upper eyelid correction involving the simple addition of anchoring the central fat pad to the medial fat pad during upper blepharoplasty. METHODS: We performed 74 cases of upper blepharoplasty with sunken upper eyelid correction between October 2013 and September 2014. The lateral portion of the central fat pad was partially dissected to facilitate anchoring. The medial fat pad was gently exposed and then pulled out to facilitate anchoring. After the rotation of the dissected lateral portion of the central fat pad by 180° to the medial side, it was anchored spreading to the medial fat pad. Photographs taken at 6 months postoperatively were presented to three physicians for objective assessment. Of the 74 patients, 54 patients followed at 6 months postoperatively were included in this retrospective, objective assessment. RESULTS: Sunken eyelids were effectively corrected in 51 of the 54 patients, but 3 had minimal effect because preaponeurotic fat pads had been removed during previous upper blepharoplasty. In addition to correcting sunken eyelids, lateral bulging was corrected and a better definition of the lateral portion of upper lid creases was obtained. CONCLUSIONS: Anchoring the central fat pad to the medial fat pad provides an effective means of correcting sunken upper eyelids during upper blepharoplasty.

Rapidly light-activated surgical protein glue inspired by mussel adhesion and insect structural crosslinking.

Currently approved surgical tissue glues do not satisfy the requirements for ideal bioadhesives due to limited adhesion in wet conditions and severe cytotoxicity. Herein, we report a new light-activated, mussel protein-based bioadhesive (LAMBA) inspired by mussel adhesion and insect dityrosine crosslinking chemistry. LAMBA exhibited substantially stronger bulk wet tissue adhesion than commercially available fibrin glue and good biocompatibility in both in vitro and in vivo studies. Besides, the easily tunable, light-activated crosslinking enabled an effective on-demand wound closure and facilitated wound healing. Based on these outstanding properties, LAMBA holds great potential as an ideal surgical tissue glue for diverse medical applications, including sutureless wound closures of skin and internal organs.

A simple and precise diagnostic method for spinal muscular atrophy using a quantitative SNP analysis system.

A simple and precise diagnostic method for spinal muscular atrophy (SMA) using high-resolution CE-based single-strand conformation polymorphism (CE-SSCP) was developed in this study. SMA is a common genetic disorder caused by an abnormality in the relative copy numbers of SMN1 and its centromeric copy SMN2, which differ only in two nucleotides, namely at exons 7 and 8. Therefore, the precise discrimination of the differences in sequence as well as their relative quantities is crucial for the diagnosis of SMA. Multiplex ligation-dependent probe amplification and sequence-sensitive DNA separation using hydroxyethyl cellulose and hydroxypropyl cellulose blended polymer matrix are currently the available methods used in the diagnosis of SMA. However, these methods are limited by their extended hybridization step and low resolution. In this study, the simultaneous discrimination of SMN exons 7 and 8 was successfully demonstrated using high-resolution CE-SSCP. Unlike the previously reported alternative method, single base differing amplicons were baseline-separated because of its extraordinary resolution, thus providing accurate and precise quantification of each paralog.

Intravenous Nefopam Reduces Postherpetic Neuralgia during the Titration of Oral Medications.

BACKGROUND: The recently known analgesic action mechanisms of nefopam (NFP) are similar to those of anticonvulsants and antidepressants in neuropathic pain treatment. It is difficult to prescribe high doses of oral neuropathic drugs without titration due to adverse effects. Unfortunately, there are few available intravenous analgesics for the immediate management of acute flare-ups of the chronic neuropathic pain. The aim of this study was to determine the additional analgesic effects for neuropathic pain of NFP and its adverse effects during the titration of oral medications for neuropathic pain among inpatients with postherpetic neuralgia (PHN). METHODS: Eighty inpatients with PHN were randomly divided into either the NFP or normal saline (NS) groups. Each patient received a 3-day intravenous continuous infusion of either NFP with a consecutive dose reduction of 60, 40, and 20 mg/d, or NS simultaneously while dose titrations of oral medications for neuropathic pain gradually increased every 3 days. The efficacy of additional NFP was evaluated by using the neuropathic pain symptom inventory (NPSI) score for 12 days. Adverse effects were also recorded. RESULTS: The median NPSI score was significantly lower in the NFP group from days 1 to 6 of hospitalization. The representative alleviating symptoms of pain after using NFP were both spontaneous and evoked neuropathic pain. Reported common adverse effects were nausea, dizziness, and somnolence, in order of frequency. CONCLUSIONS: An intravenous continuous infusion of NFP reduces spontaneous and evoked neuropathic pain with tolerable adverse effects during the titration of oral medications in inpatients with PHN.

A multiplex single nucleotide polymorphism genotyping method using ligase-based mismatch discrimination and CE-SSCP.

Accuracy, simplicity, and cost-effectiveness are the most important criteria for a genotyping method for SNPs compatible with clinical use. One method developed for SNP genotyping, ligase-based discrimination, is considered the simplest for clinical diagnosis. However, multiplex assays using this method are limited by the detection method. Although CE has been introduced as an alternative to error prone microarray-based detection, the design process and multiplex assay procedure are complicated because of the DNA size-dependent separation principle. In this study, we developed a simple and accurate multiplex genotyping method using reaction condition-optimized ligation and high-resolution CE-based SSCP. With this high-resolution CE-SSCP system, we are able to use similar-sized probes, thereby eliminating the complex probe design step and simplifying the optimization process. We found that this method could accurately discriminate single-base mismatches in SNPs of the tp53 gene, used as targets for multiplex detection.

Multiplex ligase-based genotyping methods combined with CE.

In this genomic era, the ability to assay multiple genomic hot spots that have strong clinical implications is greatly desired. Conventional PCR-based methods suffer from frequent false-positive detections, particularly when a multiplex analysis is desirable. As an alternative to the error-prone conventional methods, multiplex ligase-based genotyping methods combined with CE have a strong potential. In this review, both previously developed methods and emerging methods are described to reveal the specificity, sensitivity, and simplicity of the ligase-based methods. For each step (ligation, amplification, and separation), the principles of several alternative methods are discussed along with their applications to explore the future development of ligase-based diagnostic methods.

A robust and simple-to-design multiplex DNA methylation assay based on MS-MLPA-CE-SSCP.

Aberrant DNA methylation is a potential diagnostic marker for complex diseases, such as cancer. With the increase in the number of genes known to exhibit disease-associated aberrant methylation, the need for accurate multiplex assays for quantifying DNA methylation has increased. Methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) is one method that has been highlighted in this context. However, two limitations make the custom design of MS-MLPA assays impractical: the need for long probes containing stuffer sequences and a reliance on only one restriction enzyme. Here, we developed a variation of MS-MLPA that employs a simpler probe-design process. To overcome the above-mentioned limitations, we used stuffer-free MS-MLPA probes that are subsequently analyzed using high-resolution capillary electrophoresis-based single-strand conformational polymorphism (CE-SSCP) instead of conventional length-dependent CE. Moreover, multiple methylation-sensitive restriction enzymes (HhaI, HpaII, and AciI) were used simultaneously; thus, probes satisfying desired criteria were available for all targets. Using this assay concept, we analyzed 17 genes associated with hepatocellular carcinoma. Our results showed that the custom-designed assay based on MS-MLPA-CE-SSCP provided robust multiplex quantification of DNA methylation levels.