Reconstruction of a medium-sized congenital melanocytic nevus defect using a thin thoracodorsal artery perforator free flap: a case report

Congenital melanocytic nevus (CMN) is a benign condition that either is present at birth or develops in the first weeks of life. Surgical removal is typically performed to improve cosmetic appearance and reduce the risk of malignant transformation. In this report, we present the case of a 26-year-old woman with a medium-sized CMN on her left breast. The nevus measured 14×8 cm, and the patient desired a single-stage excision. However, this approach would result in a large skin defect that would be challenging to reconstruct using a local flap or skin graft. Moreover, it could potentially compromise the maintenance of natural sagging and the contour of the breast. Consequently, we opted to place a thin thoracodorsal artery perforator free flap following the removal of the CMN. The patient was satisfied with the overall surgical results. By utilizing this free flap for reconstruction, we successfully preserved the natural shape and contour of the breast without complications such as postoperative hypertrophic scarring or contracture at the recipient site.

Scar folding for the treatment of nostril stenosis after open rhinoplasty: a case report

A 25-year-old woman was referred for discomfort when breathing through her left nose. The patient had undergone augmentation rhinoplasty 5 years ago, after which hypertrophic scarring occurred in the left nostril. Several corticosteroid injections were administered as the first line of treatment, but with no symptom improvement. Therefore, we proceeded with surgical scar removal, with the use of a nasal conformer. However, scarring in the left nostril recurred. Accordingly, we proceeded with further surgical treatment using the scar folding technique. After scar folding, neither scarring nor nostril stenosis recurred during 1 year of postoperative follow-up. To summarize, herein, we report a case of hypertrophic scarring in the nostril that was successfully treated with the scar folding technique.

Serratia marcescens infection in a patient after a fat graft: a case report

Serratia marcescens is a Gram-negative, facultatively anaerobic bacillus that has been implicated in hospital-acquired infections. Because no previous cases of delayed infections caused by S. marcescens after autologous fat injection have been reported, we introduce a case report. A 74-year-old woman underwent fat injection for aesthetic purposes and visited our hospital for left cheek swelling after this procedure. Blood tests showed a slightly elevated white blood cell count. Facial computed tomography demonstrated an abscess and emergency surgery was performed. A work-up of the necrotic tissue and drained abscess contents was conducted. Cultures showed growth of S. marcescens. Based on the culture results , a proper antibiotic was prescribed. Follow-up blood tests showed normal findings, and there was no recurrent infection or inflammation. In most acute infections after a fat graft, Staphylococcus aureus or Staphylococcus epidermidis can be suspected, while mycobacterial infections are often suspected in cases of delayed infection and chronic inflammation. However, clinicians should keep in mind that there may be infections of uncommon bacteria. When an atypical delayed infection is suspected after an autologous fat graft, it is important to perform aseptic wound culture and biopsy as soon as possible, use appropriate antibiotics, and conduct proper surgical treatment.

Minimally invasive removal of facial foreign body granulomas

Background@#Various materials, commonly called fillers, have been developed and are now used for cosmetic and reconstruction purposes. Indiscriminate injections of illegal and unknown substances have various side effects, among which foreign body granulomas are particularly difficult to treat. Surgical resection can be considered for small and well-defined foreign body granulomas, but complete resection is often impossible for wide facial granulomas, and postoperative deformities may occur. Therefore, this study presents cases where foreign bodies were evaluated using imaging studies and removed through minimally invasive procedures depending on their characteristics. @*Methods@#Thirty-five patients with chronic granulomas after illegal filler injections treated from 2012 to 2019 were enrolled. Clinically, these granulomas were classified into cystic and infiltrating groups according to the imaging study patterns. Patients in the cystic group underwent puncture and drainage, and those in the infiltrating group were first treated with intralesional laser treatment and then suctioned. If the results were insufficient, surgical removal combined with a lifting procedure was performed. @*Results@#All 35 patients were women, and their average age was 51 years. Surgery was successful in almost all cases, but four cases of insufficient removal and contour deformity were encountered during follow-up. Two patients underwent reoperation and two patients improved naturally. @*Conclusions@#In this study, we classified the characteristics of granulomas using preoperative imaging studies. Aesthetically favorable results were obtained using puncture and drainage and tumescent suction, along with, if necessary, surgical removal accompanied by a lifting procedure when removing facial foreign body granulomas.

Open reduction of zygoma fractures with the extended transconjunctival approach and T-bar screw reduction

BACKGROUND: Zygomaticomaxillary complex (ZMC) fractures mostly occur in the form of tripod fractures. The surgical field is accessed using a combination of three classic approaches. However, the subciliary incision may have unfavorable aesthetic results. Herein, the authors report the advantages of the extended transconjunctival approach (ETA) combined with T-bar screw reduction in minimizing scarring and complications for the treatment of ZMC fractures. METHODS: A total of 26 patients underwent ZMC reduction through the ETA and intraoral approach. A skin incision measuring roughly 5 to 8 mm in length was placed following the lateral canthal skin crease. After releasing the inferior crus of the lateral canthal tendon for canthotomy, the medial periosteum of the lateral orbital rim was preserved for canthal reattachment. A limited subperiosteal dissection and partial relaxing incision of the orbicularis oculi were performed to expose the fracture line of the inferior orbital rim and zygomaticofrontal suture. Reduction was performed using a T-bar screw through the transconjunctivalincision and an elevator through the intraoral incision. RESULTS: The aesthetic and functional results were excellent. Successful reduction was achieved and the skin incision was less than 8 mm in 20 cases (76.9%). Only six patients had an additional skin incision (less than 5 mm) to achieve reduction. No cases of ectropion, entropion, or excessive scarring were noted. CONCLUSIONS: The ETA using a T-bar screw is a useful method for maximizing aesthetic results in ZMC fractures, with the advantages of minimal scarring, faster recovery, and maintenance of pretarsal fullness.

Recurrent Chondroid Syringoma of the Alar Rim

Chondroid synringoma (CS), pleomorphic adenoma of skin, is a benign tumor found in the head and neck region. CS was first reported in 1859 by Billorth for the salivary gland tumor. The usual presentation is an slowly growing, asymptomatic mass. A 53-year-old female with a history of chondroid synringoma had presented with multiple firm, nodular masses found in the left nostril area. The lesion had been excised 8 years prior and was diagnosed histopathologically, but had gradually recurred. Excision of the mass located in subcutaneous layer revealed four whitish, firm tumors surrounded with capsular tissue. Neither recurrence nor complications occurred during the 18 months follow-up period. In the head and neck region, chondroid syringoma should always be considered in differential diagnosis of soft tissue masses despite its rare incidence. For that reason, excisional biopsy with clear margin is the optimal diagnostic as well as therapeutic choice. We report a case of recurred chondroid syringoma on the nose in female patient.

Delayed Orbital Hemorrhage around Alloplastic Implants after Blowout Fracture Reduction

Alloplastic implants have been used to repair orbital wall fractures in most cases. Orbital hemorrhage is a rare complication of these implants and has been reported rarely in Korea. The purpose of this article is to report a late complication case focusing on their etiology and management. A 20-year-old male patient underwent open reduction with Medpor (porous polyethylene) insertion for bilateral orbital floor fractures. The initial symptom occurred with proptosis in the right side as well as vertical dystopia, which had started 4 days earlier, 8 months after surgery. Any trauma history after the surgery was not present. We performed an exploration and removal of hematoma with Medpor titanium meshed alloplastic implant. A case of delayed orbital hematoma following alloplastic implant insertion was identified. It occurred within the pseudocapsule of the implant. One week after surgery, overall symptoms improved successfully, and no complications were reported during the 11-month follow-up period. Although rare, orbital hemorrhage is a potential complication of alloplastic orbital floor implants, which may present many years after surgery. As in the case presented, delayed hematoma should be included in the differential diagnosis of late proptosis or orbital dystopia.

The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects

No abstract available.

Adult-Type Intrathoracic Xanthogranuloma: Excision and Reconstruction Using a Latissimus Dorsi Muscle Flap

No abstract available.

Delayed Reduction of Facial Bone Fractures

Except for special situations, it is generally agreed that best results in the treatment of facial fractures is expected if reduction is done within the first 2 or 3 weeks after injury. We reduced facial bone fractures at 4 to 7 weeks after trauma. A 44-year-old female patient underwent open reduction for her right zygomaticomaxillary complex fracture at 7 weeks after injury. A 59-year-old female patient underwent surgery for the right mandible body and left parasymphysis fractures at 4 weeks after injury. Using traditional approaches, granulation tissue and callus were removed from the fracture sites, and malunited fracture lines were separated by a small osteotome. We reduced the displaced fractured zygoma and mandible to their normal anatomical positions and fixed them using titanium plates. No complications such as asymmetry, malunion, malocclusion, or trismus were seen. Unfavorable asymmetric facial contours were corrected, and we obtained good occlusion with favorable bony alignment. The functional and aesthetic outcomes were satisfactory. Through removal the callus and limited osteotomy, a successful approach to the previously fractured line was possible, and an exact correction with symmetry was obtained. This method can be a good option for obtaining good mobility and clinical results in treating delayed facial bone fractures.

Chronic Ulcerating Lesions due to Limited Form of Wegener's Granulomatosis on the Face: Cosmetic Consideration

Wegener's granulomatosis (WG) is a systemic disease characterized by necrotizing granulomas and vasculitis involving the upper and lower respiratory tract as well as the kidneys. Limited form of WG usually involves the head and neck, lacks renal involvement, and may not progress to generalized disease. We report the case of limited form of WG who presented not systemic symptom but several times relapsed multiple ulcerating lesions on the face, uveitis and keratoconjunctivitis. A 23 year-old female initially presented with ulcerative skin lesions on the left cheek and nose. The skin lesion had commenced as an ulcerative and nodulopapular lesion on her right cheek initially, 8 months ago. Subsequently, there was progression of the disease to her left cheek and nose. The patient was treated with oral prednisolone and oral cyclophosphamide. Two weeks later, skin lesion had started to heal, oral prednisolone tapered to 15 mg. Eight weeks later, all of skin lesions were healed well. With silicone gel sheets and Laser therapies, we gained excellent cosmetic results. In the aesthetic aspect, early recognition of rare variants of limited form of WG, facial chronic ulcerative wounds that are nonresponsive to conservative treatment, is very important as appropriate therapy can prevent facial mutilation.

Aesthetic Consideration of Management in Encephalocutaneous Lipomatosis: How we do it

Encephalocraniocutaneous lipomatosis (ECCL) is a rare congenital neurocutaneous syndrome that was characterized by unilateral, smooth, hairless fatty tissue nevi of the scalp, termed nevus psiloliparus, facial lesions, multiple anomalies involving the eye, and ipsilateral porencephalic cysts with cortical atrophy, cranial asymmetry, marked developmental delays, and mental retardation. A 12-month-old boy was referred to our clinic for evaluation of non-scarring alopecia on the left side with an underlying fatty mass in the left parietal scalp and left-sided multiple periocular masses. It showed a large lipomatous mass on the scalp with overlying alopecia. Multiple skin tags and defects in the left periocular area were also observed. Additional ocular anomalies included epibulbar lipodermoid, iris coloboma, and localized peripapillary hypopigmentation lesions. After complete excision, the wound was covered with a local flap. The histologic examination revealed a mass surrounded by a well-developed capsule within the dermal layer, adipose tissue and connective tissue septa extending into the reticular dermis. No recurrence was observed at follow-up. It is essential to differentiate suspected ECCL from other syndromes which present with epibulbar chorisotomas. Neuroimaging, and pathological studies may be helpful for correct diagnosis. We will correct multiple periocular lesions in preschool age and follow up developmental problems like developmental delay and mental retardation constantly.

Reconstruction of the Head and Neck Region Using Lower Trapezius Musculocutaneous Flaps

BACKGROUND: Recent literature has indicated that free flaps are currently considered the preferred choice for head and neck reconstruction. However, head and neck cancer patients are frequently treated with chemoradiotherapy, which is often associated with a poor general and local condition, and thus, such patients are ineligible for free flap reconstruction. Therefore, other reconstruction modalities should be considered. METHODS: We used lower trapezius musculocutaneous (LTMC) flap based on the dorsal scapular artery to reconstruct head and neck defects that arose from head and neck cancer in 8 patients. All of the patients had undergone preoperative chemoradiotherapy. RESULTS: There were no complications except one case of partial flap necrosis; it was treated with secondary intention. Healing in the remaining patients was uneventful without hematoma, seroma, or infection. The donor sites were closed primarily. CONCLUSIONS: The LTMC flap is the preferred flap for a simple, reliable, large flap with a wide arc of rotation and minor donor-site morbidity. The authors recommend this versatile island flap as an alternative to microvascular free tissue transfer for the reconstruction of defects in the head and neck region, for patients that have undergone preoperative chemoradiotherapy.

Modified Submental Intubation in Panfacial Bone Fracture Patients

PURPOSE: Nasotracheal or oral intubation procedure is widely used for facial bone fractures. However, during the operation intubated tube can interfere or obstruct the view of the operator. We authors used a modified submental intubation method in panfacial bone fracture patients for intact airway and the operation view. METHODS: After intravenous induction of anaesthesia, traditional orotracheal tubation was done. A horizontal incision was made 2cm from the midline, 2cm medial to and parallel with the mandible in the submental region.1 In order to approach to the floor of the oral cavity, a haemostat was pushed through the soft tissues. A chest tube front cover was applied to the intubation tube and the tube was inserted through the submental tunnel. Orotracheal tube was disconnected and pulled back through the soft tissue and secured with a suture. RESULTS: The procedure took about 30 minutes and there were no problems during the intubation. Intraoral manipulation and occlusal checks were free without any interference. Extubation was also easily done without any complications such as lung aspiration, infection, hematoma, or fistula. CONCLUSION: Submental endotracheal intubation is fast, safe, easy to use and free from the concern about the tube being pull back again. Conventional submental intubations are being held without any coverage of the tip. We authors applied the modified method to the trauma patients and obtained satisfactory results. From the above advantages, modified submental intubation can be widely available not only in fractured patients, but also in aesthetic or orthognathic surgeries.

Comparative Study for Compatibility of Acellular Dermis (SureDerm(TM)) and Synthetic Material(PROCEED(R)) on Abdominal Wall Defect in Rabbit Models

PURPOSE: Deficiencies of the abdominal wall can be the a result of infection, surgery, trauma, or primary herniation. For abdominal wall reconstruction, synthetic materials have been shown to provide a better long-term success rate than primary fascial repair. But, synthetic materials cannot elicit angiogenesis or produce growth factor and are therefore plagued by an inability to clear infection. As a result of the inherent drawbacks of synthetic, significant effort has been spent on the identification of new bioprosthetic materials. The aim of our study is to evaluate the effectiveness of a synthetic material(PROCEED(R)) and an ADM(SureDerm(TM)) to repair abdominal wall defects in a rabbit models. METHODS: We measured the tensile strength of the SureDerm(TM) and PROCEED(R) by a Tension meter(Instron 4482). 16 Rabbit models were assigned to this study for abdominal wall reconstruction. Abdominal defect of 8 rabbits were reconstructed by PROCEED(R) and the rest were reconstructed by SureDerm(TM). We assessed gross and histologic examinations for the reconstructed abdominal wall. RESULTS: The tensile strenth of SureDerm(TM) and Gore Tex(R) is 14.64+/-0.51 Mpa, 8.54+/-0.45 Mpa. PROCEED(R) was estimated above the limits of measurement. Inflammatory reaction of PROCEED(R) persisted for 32weeks, but SureDerm(TM) decreased after 16weeks. Vascular ingrowth into the SureDerm(TM) was seen after 32 weeks. The basement membrane of SureDerm(TM) changed into a form of pseudoperitoneum. In PROCEED(R), it seemed like pseudoepithelial lining was made from the fibrosis around the mesh. CONCLUSION: In our study, the SureDerm(TM) not only have less inflammatory reaction and presented more angiogenesis than the PROCEED(R), but also have pseudoperitoneum formation. It is expected that SureDerm(TM) is useful for abdominal wall reconstruction. However, a long-term study of its usage consequences are thought to be needed.

Preoperative Evaluation of the Facial Artery Using Facial Angio Computed Tomography

PURPOSE: Previous studies of the facial artery have shown significant anatomical variability in this region. The vascular anatomy of the region is considered unreliable in predicting the ideal pedicle. Preoperative imaging has been suggested as a means of improving preoperative awareness, with Doppler ultrasound as useful tools. Multi-detector row angiographic computed tomography (angio CT) is a significant improvement, providing non- invasive operator-independent details of the vascular anatomy. This tool was used to perform an in vivo anatomical study of the facial artery, demonstrating the usefulness of facial angio CT in planning the facial reconstruction. METHODS: Eleven consecutive patients underwent facial angio CT of the facial vasculature with the anatomical details of the facial artery assessed. RESULTS: Facial angio CT could demonstrate the size and course of the facial vasculature, particularly the facial artery. CONCLUSION: The vascular anatomy of the facial artery is highly variable, and thus there is a role for preoperative imaging. Facial angio CT can demonstrate cases where there is an aberrant or non-preferred anatomy, or select the method of a facial reconstruction.

Medial Epicanthoplasty Using Direct Excision and Redraping Technique

Recently, new epicanthoplasty methods with reduced scarring have been developed, such as skin redraping method, periciliary epicanthoplasty, etc. Although these methods increase the length of horizontal palpebral fissure, the remnant skin and orbicularis oculi muscle portion that covers one third of medial canthus reduce satisfaction of aesthetic outcome. In order to overcome this limitation, the authors performed redraping after direct excision of medial orbicularis oculi muscle and excess skin to correct epicanthal fold. From April of 2006 to March of 2009, the authors performed medial epicanthoplasty using direct excision and redraping method to correct epicanthal folds in the eyelids of 72 Asian patients. The epicanthoplasty was performed combining with incisional or non-incisional double eyelid operation, ptosis correction, augmentation rhinoplasty and lateral canthal lengthening. Mean follow up was 11 months(6 months to 2 years). Most of the patients were satisfied with the results. Our technique has delivered esthetically superior results with minimal postoperative scar and no major complication. The advantages of our direct excision and redraping technique are as follows: 1) simple in design, 2) versatile in its application, 3) double fold looks clear especially in the medial 1/3 by eliminating the redundant skin and orbicularis muscle.

Correction of Saddle Nose Deformity in Wegener's Granulomatosis

The nasal manifestations of the Wegener's granulomatosis commonly results in destruction of the cartilaginous support of the nose and a severe saddle nose deformity. It is so difficult to correct the saddle nose deformity because surgeons have fear about relapse of the Wegener's granulomatosis and cannot use the septal cartilage as a donor site. However we reconstructed the deformity with chondro-osseous rib graft successfully. A 49-year-old woman had a saddle nose deformity after resecting Wagener's granulomatosis, and suffered from not only aesthetic problem but also dyspnea and nasal airway obstruction while physical exercise. She underwent a rhinoplasty with rib graft. The correction came out to be successful and the nasal airway complaint was resolved. She had a recurrence of Wegener's granulomatosis at postoperative 6 months and was admitted for medical treatment of the inflammation at the nasal septum. The follow-up computed tomographic image study revealed good maintenance of the graft. Saddle nose deformity that arises from Wagener's granulomatosis should be reconstructed with chondro-osseous rib graft. Even though the disease might recur, influence to the grafted cartilage is minimal. Active treatment with plastic surgery is thought to be no problem for reconstruction.

Clinical Experiences of Facial Asymmetries in Zygomaticomaxillary Complex Bone Fracture Patients

PURPOSE: Zygomaticomaxillary complex(ZMC) fracture is one of the most common facial injuries after facial trauma. As ZMC composes major facial buttress, it is a key element of the facial contour. So, when we treat these fractures, the operator should have a concern with the symmetry to restore normal appearance and function. But sometimes, unfavorable results may occur. The aim of this study is to analyze the unsatisfied midfacial contour after ZMC fractures reduction retrospectively and to point out the notandum. METHODS: 369 patients, treated for fractures of the ZMC were included in the study. After the operation, such as open reduction and internal fixation(ORIF with titanium or absorbable materials), open reduction, and closed reduction, midfacial contour was evaluated with plain films and 3-dimensional computed tomography. And unfavorable asymmetric midfacial contours were correcterd by secondary correction and re-evaluated. Gross photographs were obtained at outpatient clinic. RESULTS: Total of 38 patients had got a facial asymmetry and among of them 24 patients were treated secondary revisional ORIF operations for correction of unfavorable result of after primary reduction. Two of them had received tertiary operations, three patients had got osteotomy more than after one year and six patients had got minor procedures. The etiology of asymmetry were lateral displaced simple fracture of arch(n=2), lateral displaced comminuted fracture of arch(n=6), comminuted arch fracture combined posterior root fracture(n=9), and communited arch and body fracture(n=12), severely contused soft tissue(n=9). After the manipulations outcomes were acceptable. CONCLUSION: To prevent the asymmetry in ZMC fracture reduction, complete analysis of fracture, choice of appropriate operation technique, consider soft tissue, and secure of zygoma position are important. Especially, we should be more careful about communited fracture of zygomatic body and lateral displacement, root fracture of zygomatic arch. Because they are commom causes that make facial asymmetry. To get optimal result, ensure the definite bony reduction.

A Case of Inflammatory Myofibroblastic Tumor at the Upper Medial Canthal Region

PURPOSE: Inflammatory myofibroblastic tumor(IMT) is characterized by clonal proliferation of myofibroblastic spindle cells and accompanied by lymphoplasmacytic infiltration. IMT is an uncommon lesion reported to arise in various organs, and is believed to be a reactive inflammatory condition. IMT forms a spectrum of lesions ranging from benign, infection-related lesions to low- grade malignancies, capable of local recurrences and rarely distant metastasis. IMT occurs mostly in the lung, but rarely in the craniofacial region. METHODS: A 28-year-old male with painless swelling in the medial canthal area was referred to our department for the last 2 months. A 2cm sized mass was palpated. He was treated with complete local excision. RESULTS: In the study by computerized tomography, a 2.0x0.8x1.0cm mass was found in the subcutaneous tissue layer. Grossly, the mass was well-circumscribed, smooth-surfaced, flesh colored, and hard. The tumor was well demarcated from the other tissues. Histopathologic examinations showed bland spindle- shaped cells loosely arranged with scattered lymphoid cells. Immunohistochemical examinations demonstrated a positive reactivity for alpha-SMA and a negative reactivity for desmin and CD34. No recurrence was noted 12 months after surgery. CONCLUSION: Emphasis is given to complete resection of the tumor for both diagnostic and therapeutic purposes. Further evaluation to find other lesions in different sites should be considered. Continued follow-up is recommended.