A Case of Multiple Radiation-related Complications during Long-term Follow-up after Sacral Ulcer Surgery.

We report the clinical course of a patient who developed a sacral radiation ulcer 19 years after treatment for cervical cancer. The patient's postoperative course after a free latissimus dorsi muscle flap transfer was favorable, but various late radiation complications, including rectal perforation, a rectal fistula, sacral necrosis, a rectointestinal fistula, and sacroiliac joint osteomyelitis, occurred within 11 years. Plastic surgeons who treat such ulcers need to know that patients may develop other serious radiation-related complications. Being aware of these complications will allow appropriate measures to be taken and aid decisions regarding future surgical strategies. More careful assessment of sacral necrosis and bone resection may have ameliorated some of the complications. When encountering similar patients, we believe that careful magnetic resonance imagery (MRI) and intraoperative evaluation are warranted, as sacral necrosis may be detectable in some patients.

Costal Cartilage Graft to Prevent Drooping after Free Flap Reconstruction of the Lower Lip.

For large lower lip defects, a thin flap combined with a tendon is the standard reconstructive option. However, this method can result in flap ptosis, which occurred in two of our patients. To correct the ptosis, we transplanted costal cartilage into the reconstructed lower lips, which produced good or moderate results. We report our experience based on long-term follow-up. In case 1, reconstruction was performed with a latissimus dorsi myocutaneous flap. Within 10 years of the first cartilage transplant, two additional surgeries were required due to cartilage/screw breakage. These problems may have been triggered by the bulkiness of the flap and/or the angle at which the cartilage was anchored in place. There have not been any further problems for 3 years. In case 2, reconstruction was performed with a free anterolateral thigh flap. The skin around the flap had poor extensibility, and the patient had marked Class II occlusion. We grafted cartilage without fixing it to the mandible. However, temporary interference with the maxillary dentition was observed. In conclusion, costal cartilage grafts are effective against flap ptosis after free flap reconstruction of the lower lip in patients without Class II occlusion. To achieve long-term stability, the optimal angle and positioning of the cartilage and the extensibility of the skin must be thoroughly investigated before surgery, and a thick piece of cartilage must be firmly fixed in place.

A Case of Dissecting Cellulitis which Was Initially Suspected to Be a Trichilemmal Cyst.

We treat infected cysts on a daily basis, but it is difficult to diagnose similar lesions produced by inflammatory conditions that are not primarily caused by bacteria. Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory disease that results in disfiguring, painful, and purulent lesions. It often takes a long time to diagnose. The pathophysiology of DCS remains unclear. Various treatments for DCS have been proposed, depending on the severity of the disease. However, none of these treatments are clearly superior to the others. If DCS spreads to the entire occipital region, aggressive surgical treatment may be beneficial in terms of the patient's quality of life. However, surgical interventions, such as drainage, are not effective at preventing the progression of the disease. Herein, we report the case of a young female patient who developed a cyst in the occipital region. We initially suspected that the lesion was a normal infected trichilemmal cyst. However, DCS was subsequently suspected because the lesion exhibited an unusual course after drainage and debridement. We consider that we made a diagnosis relatively early, but if we had sufficient knowledge about DCS we could have made a diagnosis even earlier by performing debridement sooner. Minocycline was administered for 5 months, which caused the lesion to disappear. After 2 years, no recurrence had been observed.

A case of cryptococcal necrotizing fasciitis and immune reconstitution inflammatory syndrome in a renal transplantation recipient.

INTRODUCTION AND IMPORTANCE: Immunocompromised patients are at high risk of unexpectedly serious infections caused by uncommon bacteria or fungi. We experienced a case of Cryptococcus neoformans-induced necrotizing fasciitis (NF) of the lower extremities. The progress so far has been reported by the urology department [1]. Moreover, after the NF had been treated, the patient developed immune reconstitution inflammatory syndrome (IRIS). We report from surgeon's view point. CASE PRESENTATION: A 51-year-old male renal transplant patient complained of pain in both lower extremities (LE). After the initial debridement, periodic acid-Schiff after diastase digestion (D-PAS) staining confirmed the diagnosis. No symptoms were seen in the lungs or cerebrospinal system. The patient was reluctant to undergo surgical treatment but several debridement improved patient's condition. After the LE wound healed, prednisolone was discontinued, then painful nodules appeared on both LE. Based on the negative culture results and the fact that the patient had been treated with flucytosine and fluconazole, we suspected that the nodules had been caused by IRIS. CLINICAL DISCUSSION: It was difficult to diagnose Cryptococcus-induced NF and paradoxical IRIS. Cooperation from other specialists was essential. CONCLUSION: We think this patient needed earlier and more definitive debridement. Fortunately, we were able to save the patient's life and maintain his LE function. In immunocompromised patients, cryptococcus can be a pathogen. In addition, IRIS can occur during treatment. Management of IRIS is the capital point of sepsis management, careful anti-inflammatory drug control by specialists is required.

Successful salvage of an infected breast prothesis by changing from continuous to intermittent suction under continuous irrigation.

INTRODUCTION: Implant-based breast reconstruction is a widely performed procedure. However, prostheses are susceptible to infection and there are currently no established guidelines on treatment. In the present case, a prosthesis was salvaged by changing from continuous irrigation and suction to continuous irrigation and intermittent suction. This case report has been reported in line with the SCARE criteria [1]. PRESENTATION OF CASE: A 50-year-old female patient underwent implant-based breast reconstruction following surgery for breast cancer. One month later, the left breast prosthesis was infected with abscesses. Surgical treatment and continuous irrigation were performed as postoperative therapy. However, recurrent infection was detected a few days after surgery. Continuous irrigation was changed to continuous irrigation with intermittent aspiration, which successfully controlled the infection. DISCUSSION: Factors that limit the effectiveness of continuous irrigation and aspiration have not yet been identified. Inflow/discharge shunt routes may be established in continuous aspiration, and, thus, sufficient cleaning may not be possible. On the other hand, the storage of water throughout the wound in intermittent aspiration may facilitate cleaning. CONCLUSION: Intermittent suction worked well in this patient and, thus, warrants further study.

Squamous cell carcinoma developed in a chronic radiation-induced chest wall ulcer that is difficult to undergo thorough preoperative histological examination.

INTRODUCTION: We report a case in which squamous cell carcinoma (SCC) developed in a large chronic radiation-induced thoracic ulcer after flap surgery in areas where preoperative histological examinations are difficult. PRESENTATION OF CASE: The patient was a 75-year-old female. She had undergone resection and radiotherapy for left breast cancer 15 years earlier. Six years ago, the ulcer expanded from the subclavian to xiphoid levels, exposing the lung and pericardium. A histopathological examination, which avoided the lung and pericardium, was performed. Inflammation was diagnosed. We reconstructed the chest wall with a pedicled rectus abdominis flap. Eighteen months later, three verrucous tissue-lined fistulas formed. A histological examination revealed well-differentiated SCC. Six months later, the patient died of massive bleeding from a fistula. DISCUSSION: It is unclear exactly when the SCC occurred. As three fistulas formed at the margins of the flap around the pericardium, we suspect that the cancer developed within or near the pericardial region. We need to reflect on the lack of a thorough biopsy. As no pericardial biopsy was performed, we should have asked a thoracic/cardiac surgeon to conduct a biopsy during the debridement operation. If the tumor had been localized to the pericardium, it could have been removed. CONCLUSION: It is necessary to consider the best method for performing the most thorough histological examination possible, even in areas where histological examinations are difficult, as all ulcers can contain tumors.