Correction of infraorbital dark circles using collagenase-digested fat cell grafts.

BACKGROUND: A number of factors, including visibility of the orbicularis oculi muscle through thin skin, can cause dark circles around the eyes. Fat grafts have been used to augment the lower eyelid skin to correct dark circles, but irregularities caused by leaving visible lumps of the fat can occur. We used collagenase-digested fat cell grafts to correct these deformities. METHODS AND MATERIALS: Fat was aspirated from the medial thigh using the Coleman method. After centrifugation, the middle fat layer was segregated, digested using Clostridium histolyticum-derived type II collagenase, and mixed with Hartman's solution. The grafts were injected into the infradermal layer using blunt 22-G needles. RESULTS: Eighty-two patients were evaluated for improvement using photographic evidence; 55 (67.1%) showed improvement, 23 (28%) showed no difference, and four (4.9%) had worsened from preoperative findings. There were no visible lumps of fat, contour irregularities, or fat necroses. Postoperative edema and ecchymosis were minimal. CONCLUSION: Collagenase-digested fat cell grafts provide another option for correcting dark circles by augmenting thin skin. Further histologic evaluation of the grafted collagenase-digested fat cells is recommended.

A basosquamous cell carcinoma of the periorbital region arising from a chronic wound created by laser ablation of a basal cell carcinoma.

Basosquamous cell carcinomas (BSCs) are very rare and behave aggressively, with features of both basal cell carcinoma and squamous cell carcinoma. The diagnosis of BSC includes a spectrum of histologic definitions, ranging from coexistence of basal cell carcinoma and squamous cell carcinoma with or without a transition zone, to any basal cell carcinoma with evidence of keratinization.A 63-year-old man presented with a BSC within a chronic periorbital wound, which was confirmed through a postoperative histologic examination. The wound was created from a previous laser ablation of a diagnosed basal cell carcinoma. The BSC was excised without causing any deformity, and coverage of the defect was obtained using a local perforator-based flap. No recurrence was observed during a 5-month follow-up.

Reconstruction of postinfected scalp defects using latissimus dorsi perforator and myocutaneous free flaps.

In severe, infected scalp defects, locally available tissues are not sufficient for reconstruction and are often unhealthy. In this situation, healthy free tissue transfer offers abundant vascularity of uncompromised tissue that can control infections and a single-stage reconstruction. Between March 2002 and May 2010, 18 patients (20 cases) underwent traumatic scalp defect reconstruction with coincident infections as follows: 16 cases of postcranioplasty infections with previous traumatic open skull fractures and 4 cases of traumatic defects with infections without cranioplasties. Eighteen patients underwent 20 latissimus dorsi free flaps: 8 cases were latissimus dorsi perforator flaps without muscle and 12 cases were latissimus dorsi myocutaneous flaps. The mean flap size was 214 cm. All patients healed well during the follow-up period. A latissimus dorsi flap in the supine position is an alternative for reconstruction of scalp defects with postcranioplasty or traumatic infections.

Pulmonary artery re-thrombosis following interruption of anti-thrombotic therapy for bilateral carpal tunnel release surgery: an update of current protocols.

In the perioperative period, patients who are under anti-thrombotic therapy should be managed with care, although there is no clear consensus on this matter. For hand surgery, several authors have advocated no interruption of the anti-thrombotic therapy, but the choice differs between institutes according to protocols and surgeons' preference. We report a case of massive pulmonary embolism after stopping warfarin for carpal tunnel release in a patient with a previous history of pulmonary embolism. Although the patient recovered after thrombolytic therapy and intensive care unit (ICU) care, this case has struck the authors as a valuable lesson. In managing anti-thrombotic therapy, we should weigh the risks and benefits of the patients carefully before making a decision.

Reconstruction of extensive lower limb defects with thoracodorsal axis chimeric flaps.

BACKGROUND: Extensive defects of the lower extremities are usually reconstructed with microvascular free flaps because of inadequate local tissues and wound complexity. Many attempts have been made to reconstruct such defects using the chimeric flap concept, enabling flaps with larger surface areas to be used while maintaining economical tissue use. The latissimus dorsi chimeric flap is one of the most useful tools for resurfacing extensive limb defects. METHODS: Twelve patients with extensive lower leg defects underwent reconstruction with latissimus dorsi chimeric flaps between January of 2008 and March of 2012. A skin flap based on the cutaneous perforators, a latissimus dorsi muscle flap based on the muscular branches, and a serratus anterior muscle flap based on the branch from the thoracodorsal artery were harvested accordingly; the flap design depended on the dimensions and characteristics of the defect. RESULTS: A total of 12 chimeric flaps were harvested and used, with the average surface area, including skin and muscle components, being 614 cm. The mean surface area of the skin flaps used was 355.6 cm. The mean area of the latissimus dorsi muscle flap was approximately 228 cm, and the surface areas of the three serratus anterior flaps used were 56 cm, 70 cm, and 180 cm. Flaps survived in all cases. Primary closure was used for all of the donor sites except one, and there was minimal donor-site morbidity. CONCLUSION: The authors' results show that the latissimus dorsi chimeric free flap is a useful and versatile reconstructive option for extensive defects of the lower extremities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Lateral thoracic perforator flap: additional perforator flap option from the lateral thoracic region.

BACKGROUND: Perforator flaps from the lateral thoracic region have not been as popular as other donor sites because of the misconception that the vascular anatomy in this region is less than predictable. However, the skin over the lateral thoracic region is vascularised by three rows of perforators of varied vascular dominance. Two perforator flaps from this region based on the middle and the posterior row of perforators from the thoracodorsal artery have been described. The lateral thoracic perforator flap based on the anterior row of perforators is another useful option. PATIENTS AND RESULTS: Nine patients underwent reconstructions using the lateral thoracic perforator flap for various defects in the head and neck region and lower limbs as a result of tumour extirpation, crush injury and chronic wound with osteomyelitis. All flaps were raised in the supine position. Three flaps were raised in a chimaeric fashion. The largest flap was 20×12 cm and the mean size was 106 cm2. All flaps survived without major complication. CONCLUSION: The lateral thoracic perforator flap is a reliable reconstructive option. It can be readily configured in terms of size, thickness and tissue composition. However, it is not the first-choice flap from this region because the resultant donor scar tends to extend visibly beyond the anterior axillary fold and the arterial and venous pedicles frequently have separate courses. The lateral thoracic region has become a versatile and universal donor site for free-style flap harvest with this additional flap option.

Life-threatening bleeding and radiologic intervention after aesthetic surgeries with minimal invasive approaches: report of two cases.

In this article, the authors report two cases of life-threatening bleeding after cosmetic surgeries that have been successfully treated with radiologic intervention. A 25-year-old female and a 35-year-old female presented at their institutions because of postoperative bleeding after intraoral mandibular angle ostectomy and endoscopic-guided trans-axillary breast augmentation, respectively. A ruptured traumatic pseudo-aneurysm of the right superficial temporal artery was diagnosed in the first case and a haematoma posterior to the right pectoralis major, due to active bleeding from a perforator of internal mammary artery, in the second case. Attempts were made to stop the haemorrhage using standard methods, but failed. Therefore, superselective microcatheter angioembolisation has been successfully performed in both the cases. At 22-month follow-up for the first case and at 12-month follow-up for the second case, the patients are asymptomatic and the cosmetic outcomes are being preserved. With radiologic intervention, the authors gained satisfactory results in the above-mentioned situations. Using this, with only local anaesthesia and the absence of incisions, a precise approach with immediate treatment to the haemorrhaging site is possible. This can be an excellent solution for arterial bleeding that is difficult to access anatomically after aesthetic surgeries, and in selected cases. Furthermore, this procedure is less disfiguring and preserves the aesthetic surgery outcomes.