Clinical analysis of factors affecting the failure of free flaps used in head and neck reconstruction.

BACKGROUND: Free tissue transfer is the preferred method of reconstructing head and neck defects, with a success rate of approximately 95%. Although flap failure is uncommon, it has a major impact on patient morbidity and diminishes quality of life, making it is important to investigate the causes of flap failure. METHODS: This retrospective chart review analyzed patients who underwent free tissue transfer during head and neck reconstruction at a single institution between 2016 and 2021. RESULTS: During the study period, 58 patients underwent 60 free flap procedures. Revision surgery was needed in 14 patients. Subsequent free flap surgery was performed in one patient, and three free flaps (5%) could not be salvaged. Cardiovascular disease was significantly associated with flap failure, and venous congestion (thrombosis) was the most common reason for revision surgery. CONCLUSION: Cardiovascular disease clearly emerged as a factor related to the failure of free flap surgery, and this issue warrants particular attention in patients for whom free tissue transfer is planned.

Treatment of malignant perivascular epithelioid cell tumor (PEComa) on the knee with an anterolateral thigh free flap: A case report.

RATIONALE: The World Health Organization defines a perivascular epithelioid cell tumor (PEComa) as a mesenchymal neoplasia composed of perivascular epithelioid cells with characteristic morphological and immunohistochemical features. Although PEComas have the potential to behave in a malignant fashion, malignant PEComas are extremely rare. PATIENT CONCERNS: An 83-year-old man visited our clinic presented with palpable, painless, and movable mass in the right knee area. DIAGNOSES: Malignant PEComa was diagnosed by incisional biopsy. No metastases was confirmed by radiologic imaging including PET/CT, magnetic resonance imaging, high resolution computed tomography. INTERVENTIONS: We performed wide excision of the mass and used an anterolateral thigh free flap to reconstruct the defect on the right knee. OUTCOMES: The permanent histopathology showed malignant PEComa was totally resected. The flap which was performed to cover the defect was survived and the patient discharge without any complications. LESSONS: PEComa can metastasize to various anatomical regions. Although there is no established standardized treatment, radical resection is still considered the cornerstone of treatment. Rapid and appropriate defect coverage is important to improve the patient's prognosis.

Malignant melanoma associated with a plaque-type blue nevus of the cheek: a case report.

Blue nevi, which are characterized by collections of pigment-producing melanocytes in the dermis, have a variety of clinicopathological characteristics. Plaque-type blue nevus (PTBN) is a variant of blue nevi. PTBN presents at birth or arises in early childhood, and it shows a combination of the features found in common blue nevus and cellular blue nevus. It is typically found on the dorsal surface of the hands and feet or on the head and neck, and it is usually benign and stable over time. However, reports have occasionally described malignant melanomas developing in or associated with a PTBN. Malignant blue nevi are most commonly found on the scalp. We report the case of an 88-year-old woman with a malignant melanoma associated with a PTBN of the cheek.

A Rare Case of Metal Exposure After Internal Fixation of Facial Bone Fracture With Autogenous Bone Graft.

Few studies have reported complications in metal fixation systems, such as infection or device exposure. Here, we report our experience with exposed metal screws after the reduction of facial bone fracture. This will be a useful guide to using a metal fixation system in situations in which metal fixation systems should not be used.

Limited eye movement caused by clumping of fibrin glue used in blowout fracture surgery: a care report.

Fibrin glue is a topical agent widely used for hemostasis, wound healing, and surgical adhesion. Complications of fibrin glue itself are extremely rare because it is absorbed over time, but can occur as a result of inappropriate application. We report a case of a postoperative complication caused by inappropriate application of fibrin glue in blow-out fracture surgery. A 65-year-old male patient presented with periorbital swelling and an open wound on the right infraorbital area. Computed tomography showed a right orbital floor fracture. After reduction of the herniated tissue into the orbit, an implant was inserted and fibrin glue was applied to stabilize the implant. This procedure was performed without difficulty, but the patient complained of persistent diplopia and limited eyeball movement after surgery. An imaging study showed a mass-like lesion, which was not a hematoma, in the orbital cavity. In a second operation, the mass was identified as clotted fibrin glue that had not been applied properly. After removal, the patient's symptoms were relieved without further complications. Appropriate and careful application of fibrin glue is necessary to avoid unnecessary complications.

Reconstruction of a total defect of the lower eyelid with a temporoparietal fascial flap: a case report.

The reconstruction of total lower eyelid defects is challenging to plastic surgeons due to the complicated anatomical structure of the eyelid. In addition, in the setting of cancer excision, the resection is deep, which requires some volume augmentation. However, in some cases, free tissue transfer is not applicable. We report a case of using a temporoparietal fascia flap (TPFF) for reconstructing a total lower eyelid defect. A large erythematous mass in an 83-year-old woman was diagnosed as squamous cell carcinoma by biopsy. After wide excision, the defect size was about 8× 6 cm. The lower eyelid structures including the tarsus were removed. The TPFF including the superficial temporal artery was elevated and inset to the defect area. After the flap inset, a split-thickness skin graft with an acellular dermal matrix was performed on the fascial flap. There were no wound problems such as infection, dehiscence, or necrosis. After the patient's discharge, partial skin graft loss and ectropion occurred. The complications resolved spontaneously during the postoperative period. We report a case of reconstructing a lower eyelid defect using a TPFF. A TPFF can be applied to patients with large defects for whom free tissue transfer surgery is not appropriate as in this case.

Useful Extension of a Retroauricular Hairline Incision in a Parotidectomy Provides Coverage of a Preauricular Skin Defect.

This report outlines the treatment of an 82-year-old man with squamous cell carcinoma of the left cheek. The wide excision and simultaneous superficial parotidectomy were planned. Various incision methods have been widely introduced such as retroauricular hairline incision, modified Blair incision, or face-lift incision. For coverage of preauricular skin defect and parotidectomy, we modified retroauricular hairline incision that the end of the incision was bent to make transposition flap. The operation has been successfully finished using this extension of a retroauricular hairline incision.

A Comparative Assessment of Scars Resulting From Skin Grafts in Facial Defects.

PURPOSE: The authors compared facial scars after split-thickness skin grafts (STSGs) performed with a dermal substitute or after full-thickness skin grafts (FTSGs) in facial defect. MATERIALS AND METHODS: The medical records of patients who had undergone FTSG or STSG with dermal substitute after skin cancer surgery between March 2016 and December 2018 were retrospectively reviewed. The scars resulting from skin grafts were assessed using the patient and observer scar assessment scales (PSAS and OSAS) in our clinic after a minimum of 6 months postoperatively. RESULTS: Of the 50 study subjects, 35 patients (FTSG group) received FTSG only and 15 patients (STSG group) received STSG with the dermal substitute. The total scores of PSAS and OSAS were significantly lower in the FTSG group and it is suggested that both patients and observers thought that better scar outcomes were achieved when FTSGs were used. However, for defects smaller than 1.8 cm2 and defects located in the periorbital area, there was no statistically significant difference in the scores of PSAS and OSAS in the 2 groups. Interestingly, for defects located in the periorbital area, although there was no significant difference, PSAS and OSAS scores were lower in the STSG group than in the FTSG group. In other word, scar outcomes in the STSG group were better. CONCLUSIONS: Although there was no significant difference, unlike what we usually know, our result shows that STSG with dermal substitute tended to produce comparable or rather better results than FTSG under some conditions.

Soft-tissue osteoma of the temple.

A 65-year-old woman presented with a solid mass on the right temporal area. The mass had grown for over 2 years without any initiating event of trauma or inflammation. Before excision, the patient went through a computed tomography scan, revealing a calcified mass without bony connection. Under general anesthesia, an excisional biopsy was performed. Microscopic examination confirmed a diagnosis of soft tissue osteoma. Soft tissue osteoma is rare, especially in the head and neck region. Osteomas in the temporal region have not been reported yet. Due to its rarity, osteoma might be misdiagnosed as another soft tissue or bone origin tumor. Its treatment of choice is simple excision. In this review, we present an unusual clinical form of soft tissue osteoma.

Effects of perioperative radiation treatment on stricture and fistula formation in hypopharyngeal reconstruction: a meta-analysis.

Hypopharyngeal reconstruction is a surgically challenging procedure, and postoperative management is important due to a high rate of complications following surgery. In particular, stricture and fistula formation is the most common long-term postoperative complication. Through systematic review and meta-analysis of 21 studies, a significant radiation effect of stricture and fistula formation was found in patients who underwent hypopharyngeal reconstruction. The perioperative radiation must be seen as a critical factor for stricture and fistula formation in hypopharyngeal reconstruction.

Prognosis of Patient With Resorbable Plates and Screws Under the Incision Site.

Various resorbable plates and screws were used for facial bone fractures because of several strengths. However, there are few studies on their clinical course and long-term follow-up concerning their degradation and resorption time. The authors present rare case of long term follow-up of resorbable plates and screws under the incision site.

Protruding Meningioma of the Forehead With Extensive Hyperostosis Mimicking Skull Osteoma.

Meningioma is the most common intracranial benign tumor in adults. Hyperostosis accompanies about 4.5% of meningiomas. The authors report a rare case of hyperostotic meningioma that may have been misdiagnosed as giant osteoma.A 42-year male visited our clinic due to an egg-sized, hard mass on his left forehead. The mass suspected to be giant osteoma was about 4.2 × 4.0 cm sized, hard, non-movable, and non-tender. But based on radiologic findings, the mass was diagnosed as meningioma with extensive hyperostosis.Without neurologic symptoms, the diagnosis of meningioma associated with hyperostosis can be challenging and be misdiagnosed as fibrous dysplasia and osteoma by simple examination without enhanced CT and MRI.Therefore, although osseous lesions are strongly suspected to be osteomas, surgeons should consider other diagnoses, and if necessary, use contrast enhanced CT or MRI to differentiate these bony lesions.

Reconstruction of Congenital Cranial Defect Using Autologous Bone Graft in Aplasia Cutis Congenita.

Many methods have been devised to repair cranial defects. Here, we report the use of a simple technique for the repair of a congenital cranial defect associated with aplasia cutis congenita (ACC).A newborn baby at 39 weeks of gestation was consulted with a scalp and cranial defect at the vertex measuring 3 × 1.5 cm. A 3-D CT scan of the skull confirmed the presence of a cranial defect at the sagittal suture and a normal brain structure. On the 13 day of life, the newborn was taken to an operating room. An autologous bone graft was harvested from adjacent normal parietal bone and grafted into the debrided congenital cranial defect. The soft tissue defect was then covered by rotation flaps.The postoperative 3-D CT scan presented a well-positioned autologous bone graft. At 1 month postoperatively, the skull contour was normal and there was no palpable defect.We report a successful surgical outcome for a congenital cranial and soft tissue defect in ACC treated using an autologous bone graft and rotation flaps. Although conservative therapy may be an alternative option, we recommend appropriate surgical reconstruction in patients at risk of potentially fatal complications.

Usefulness of Ramified Cephalic Vein Graft in the Wrist for Connection With Concomitant Vein in Head and Neck Reconstruction.

A vein graft in head and neck reconstruction is essential in some circumstances. The cephalic vein in the wrist has a suitable caliber for both a concomitant vein and the internal jugular vein (IJV). A vein graft involving the cephalic vein and its branches was used in 2 cases of head and neck reconstruction. The ramified distal vein was anatomized with a concomitant vein, and the proximal larger vein was anastomosed with the IJV using an end-to-side technique. After placement of vein grafts using the cephalic vein, the flaps were stable with no venous complications. To overcome the size difference between concomitant veins and the IJV, the authors recommend the cephalic vein including its distal branches in the wrist area.

Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank: A case report.

RATIONALE: Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown. PATIENT CONCERNS: We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank. DIAGNOSES: The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy. INTERVENTIONS: The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap. OUTCOMES: No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively. LESSONS: In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

Can we predict vascular status and culture result based through wound status in diabetic foot infection?

Diabetic foot infection (DFI) should be treated by a multidisciplinary team to prevent amputation and morbid status. As physicians encountering DFI in outpatient clinic, a proper selection of antibiotic treatment and diagnostic approach for a vascular status is essential. We retrospectively investigated the patients with DFI from 2016 to 2017. All patients were examined for vascular status, wound status, and pathologic culture preceding the treatment. No statistical significance was observed between PEDIS grade 1 and 2 and 3 and 4 in culture status and culture results. Association analysis between vascular status and other variables, such as wound score and culture results, has no significant difference. Through these results, the helpful epidemiologic result of microbiology and necessity of examination for peripheral arterial disease were verified.

3-Dimensional Volumetric Analysis of Relationship Between the Orbital Volume Ratio and Enophthalmos in Unoperated Blowout Fractures.

PURPOSE: Blowout fractures are common in midfacial trauma and often involve other parts of facial bones. Sometimes, patients have complications caused by inadequate management. Surgical indications, such as clinical symptoms, can be inaccurate owing to post-traumatic swelling or hematoma formation. Previous studies on the prediction of enophthalmos used the orbital volume ratio (OVR) or only the volume of herniated tissue. This study examined which of these values is more predictive of the degree of enophthalmos. In addition, the predictive values for a 2-mm enophthalmos in unoperated blowout fractures were assessed. PATIENTS AND METHODS: A total of 191 patients underwent nonoperative treatment for blowout fractures at our institution; they were divided into 2 groups according to the degree of enophthalmos (>2 mm vs 0 to 2 mm) and were further divided into 3 subgroups according to the location of the fracture (inferior, medial, or inferomedial). Multifactor logistic regression analysis was performed to determine the relationship between the degree of enophthalmos and these values. RESULTS: We observed a correlation between the OVR and the degree of enophthalmos, as well as a correlation between the volume of herniated tissue and the degree of enophthalmos. Regarding the anatomic location of herniation, the orbital floor was found to be more correlated with the amount of enophthalmos. CONCLUSIONS: The OVR is a more reliable predictor than measurement of the volume of herniated tissue. The relationship found between radiologic examination findings and the degree of enophthalmos can be used as a surgical indication in addition to consideration of the anatomic location.

Use of resorbable mesh and fibrin glue for restoration in comminuted fracture of anterior maxillary wall.

BACKGROUND: The facial bone has a complex structure compared to other bones, and various types of fractures can occur due to its characteristics. Among them, in comminuted fractures of anterior maxillary wall, multiple depressed and impacted bony segments cannot be reduced easily when performing internal fixation using plates and screws or wires, and inadequate restoration leads to a range of complications. This paper introduces an alternative technique using a resorbable mesh with fibrin glue to restore comminuted fractures of anterior maxillary wall. METHODS: Thirteen patients were diagnosed with comminuted fractures of anterior maxillary wall between March 2017 and February 2018 in the authors' hospital. All patients with comminuted fractures of anterior maxillary wall underwent restoration using resorbable mesh with fibrin glue. The patients' demographics, causes of facial trauma, mean operation time, length of hospital stay, follow-up period, and complications were recorded. RESULTS: No major complications and only one hypoesthesia of the skin area was noted. Three months after surgery, the hypoesthesia recovered completely. After surgery (mean, 3.9 months; range, 2-12 months), computed tomography showed that the bone fragments in all patients were fixed successfully in their anatomical places. CONCLUSION: In comminuted fractures of anterior maxillary wall, the use of a resorbable mesh with fibrin glue can be an advantageous and effective method for a successful restoration without complications.

Buried umbilicus with inflammation due to retained rubber foreign body after liposuction: A case report.

INTRODUCTION: Liposuction is one of the most widely performed aesthetic surgeries. It is mainly used for the correction of deep and superficial fat accumulations and remodeling of the body contour. CASE PRESENTATION: We present a rare case of unusual rubber foreign body found within the periumbilical area during the reconstruction of buried umbilicus after liposuction.A 61-year-old female had undergone a liposuction surgery 10 years ago. Last year, she experienced signs of inflammation around the periumbilical area. The patient was treated with antibiotics and daily dressing at a local clinic. However, her symptoms did not improve with treatment.After admission, we decided to reconstruct the umbilicus and explore the previous operative site. During reconstruction of umbilicus, we finally discovered a rubber foreign body in the periumbilical area and buried umbilicus. CONCLUSION: Retained surgical foreign body can clinically manifest as acute reaction, such as an inflammatory response, infection, or abscess within days or weeks after the operation. Patients may complain of pain and discomfort, even months or years after the procedure.Our patient had suffered from delayed inflammation due to retained surgical foreign body after liposuction surgery. We emphasize the need for excellent communication within the surgical team to prevent the incidence of retained surgical bodies.