Dong Ha Park

SUBUNGUAL GLOMUS TUMOURS OF THE HAND: DIAGNOSIS AND OUTCOME OF THE TRANSUNGUAL APPROACH

We report 17 patients with a subungual glomus tumour. All complained of pain and tenderness when touched, and nine patients experienced severe pain in the cold. A transungual approach with nail plate avulsion on one side was used in all cases. A surgical microscope was used to localise and dissect the tumour and to repair the nail bed and matrix. This method has produced good results, without local recurrence or postoperative nail plate deformity.

Sepsis With Multiple Abscesses After Massive Autologous Fat Grafting for Augmentation Mammoplasty: A Case Report

BackgroundAutologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting.MethodsA 42-year-old woman presented to the authors’ emergency department reporting tenderness, swelling, and a sensation of heat in both breasts. The patient had undergone augmentation mammoplasty by autologous fat grafting 7xa0days previously. Abscess formation was suspected based on the patient’s history, physical examination, laboratory findings, and image study.ResultsIncision and drainage were performed immediately with the patient under general anesthesia, and 500xa0ml of a foul, brown, turbid, purulent fluid containing necrotic fat debris was drained from each breast. Empiric antibiotics were started on the first hospital day, and betadine and saline-irrigation were administered daily for 2xa0weeks. Incisions were closed on hospital day 19 when laboratory data and local infection signs had improved. At the patient’s 9-month follow-up assessment, breast contours were found to be well preserved, and scarring was minimal.ConclusionImmediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.

Successful lower extremity salvage with free flap after endovascular angioplasty in peripheral arterial occlusive disease

OBJECTIVEnMost patients with peripheral arterial occlusive disease undergo lower limb amputation due to complex wounds on their lower extremities. We have taken the challenging approach of combining angioplasty and free tissue transfer for limb salvage.nnnMETHODSnBetween October 2011 and December 2013, 11 patients (average age of 56.8 years; ranged from 43-72 years old) with peripheral arterial occlusive disease of main tibioperoneal arteries underwent preoperative angioplasty. Afterward, free tissue transfers (nine anterolateral thigh free flaps, one vastus lateralis muscle free flap, and one deep femoral artery perforator flap) were performed on these patients for lower extremity salvage and reconstruction.nnnRESULTSnAll 11 free tissue transfers after angioplasty were successful without operative mortality or major complications. Minimal wound dehiscence was seen in one case, and partial flap necrosis was seen in the other cases. During the follow-up period, all of the patients had their wounds healed completely and achieved acceptable contour and quality of gait.nnnCONCLUSIONnThe preoperative angioplasty provides well-vascularized tissue that both controls infection and helps free flaps to survive. Therefore, the patients due to receive leg amputation in spite of the free tissue transfer can achieve limb salvage by using the additional technique of angioplasty. This combined approach was successful in preserving the functional aspects along with the aesthetic results for the lower limb reconstruction.

Role of Muscle Free Flap in the Salvage of Complicated Scalp Wounds and Infected Prosthetic Dura

Background The prosthetic dura is an essential element in the protection of the cranial parenchyma and prevention of cerebrospinal fluid leakage. Although prosthetic dura are widely used in neurosurgery, they occasionally provoke infection, which can be a major concern after neurosurgical treatment. However, removal of the prosthetic dura carries a risk of brain parenchyma injury and cerebrospinal fluid leakage. The salvage of infected prosthetic dural material has not been adequately addressed in the literature. In this study, we demonstrate the value of the combination of a meticulous surgical debridement of necrotic tissue and simultaneous muscle free flap for intractable postoperative epidural abscess without removal of the infected prosthetic dura. Methods Between 2010 and 2012, we reviewed the data of 11 patients with persistent infection on the prosthetic dura. The epidural infections each occurred after a neurosurgical procedure, and there was soft tissue necrosis with the disclosure of the underlying prosthetic dura and dead bone around the scalp wound. To salvage the infected prosthetic dura, meticulous debridement and a muscle free flap were performed. Results All 11 patients experienced complete recovery from the complicated wound problem without the need for further surgical intervention. No signs of prosthetic dural infection were observed during the mean follow-up period of 11 months. Conclusions The combination of a meticulous surgical debridement and coverage with a muscle free flap is an effective treatment for salvage of infected prosthetic dura.

Immediate Debridement and Reconstruction with a Pectoralis Major Muscle Flap for Poststernotomy Mediastinitis

Background Poststernotomy mediastinitis is a rare, but life-threatening complication, thus early diagnosis and proper management is essential for poststernotomy mediastinitis. The main treatment for mediastinitis is aggressive debridement. Several options exist for reconstruction of defects after debridement. The efficacy of immediate debridement and reconstruction with a pectoralis major muscle flap designed for the defect immediately after the diagnosis of poststernotomy mediastinitis is demonstrated. Methods Between September 2009 and June 2011, 6 patients were referred to the Department of Plastic and Reconstructive Surgery and the Department of Thoracic and Cardiovascular Surgery of Ajou University Hospital for poststernotomy mediastinitis. All of the patients underwent extensive debridement and reconstruction with pectoralis major muscle flaps, advanced based on the pedicle of the thoracoacromial artery as soon as possible following diagnosis. A retrospective review of the 6 cases was performed to evaluate infection control, postoperative morbidity, and mortality. Results All patients had complete wound closures and reduced severity of infections based on the erythrocyte sedimentation rate and C-reactive protein levels and a reduction in poststernal fluid collection on computed tomography an average of 6 days postoperatively. A lack of growth of organisms in the wound culture was demonstrated after 3 weeks. There were no major wound morbidities, such as hematomas, but one minor complication required a skin graft caused by skin flap necrosis. No patient expired after definitive surgery. Conclusions Immediate debridement and reconstruction using a pectoralis major muscle flap is a safe technique for managing infections associated with poststernotomy mediastinitis, and is associated with minimal morbidity and mortality.

Prediction of the development of late enophthalmos in pure blowout fractures: delayed orbital tissue atrophy plays a major role.

Purpose To retrospectively evaluate the risk factors for the development of late enophthalmos in pure blowout fractures. Methods We reviewed 49 cases of pure blowout fractures diagnosed in Ajou University Hospital, South Korea, from January 2005 to June 2015. We assumed that several factors influence the development of late enophthalmos, including bony defect size, volume of displaced soft tissue, number of fracture sites, involvement of floor, soft tissue incarceration through the bony defect, and patient age. Results Twenty-one patients were diagnosed with late enophthalmos (group 1) while 28 patients were not (group 2). Soft tissue incarceration, presumably causing the soft tissue injury, was the only factor that increased the risk for late enophthalmos in this study (p = 0.04, odds ratio 4.5). In contrast with previous studies, there were no meaningful correlation between bony defect size or volume of displaced soft tissue and development of late enophthalmos. Number of fracture sites, involvement of floor, and patient age did not increase the risk for late enophthalmos. Conclusions We suggest that the delayed orbital tissue atrophy due to soft tissue injury plays a more important role than other hypotheses in the development of late enophthalmos. It is necessary to overcorrect to some extent if there is soft tissue incarceration through the bony defect in the initial computed tomography, and clinicians should warn patients about the development of late enophthalmos despite orbital reconstructive surgery.

Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions

In our hospital, an adverse event reporting system was initiated that alerts the plastic surgery department immediately after suspecting contrast media extravasation injury. This system is particularly important for a large volume of extravasation during power injector use. Between March 2011 and May 2015, a retrospective chart review was performed on all patients experiencing contrast media extravasation while being treated at our hospital. Immediate treatment by squeezing with multiple slit incisions was conducted for a portion of these patients. Eighty cases of extravasation were reported from approximately 218 000 computed tomography scans. The expected extravasation volume was larger than 50 ml, or severe pressure was felt on the affected limb in 23 patients. They were treated with multiple slit incisions followed by squeezing. Oedema of the affected limb disappeared after 1–2 hours after treatment, and the skin incisions healed within a week. We propose a set of guidelines for the initial management of contrast media extravasation injuries for a timely intervention. For large‐volume extravasation cases, immediate management with multiple slit incisions is safe and effective in reducing the swelling quickly, preventing patient discomfort and decreasing skin and soft tissue problems.

A new modality for treating congenital melanocytic nevus: "cogwheel pattern" serial excision method.

Congenital melanocytic nevus consists of congregations of nevomelanocytes. It is found in approximately 1% of new born infants. Congenital melanocytic nevus needs to be excised before it transforms into a malignant lesion. Many strategies have been attempted for the removal and reconstruction of the nevus. Serial excision enables wound closure to be accomplished with a shorter scar than if the original lesion was elliptically excised in a single stage and reorientation of the scar closer to the relaxed skin lines. The routine utilization of an elliptical serial excision as a standard method of closure often leads to the formation of elongated scars and waste of skin. The Cogwheel pattern serial excision is a new technique for reducing the size of the nevus efficiently. Reducing the final scar length, distributing the tension over many directions, and having the chance of decrease in operation numbers are ultimately achieved with the use of the Cogwheel pattern serial excision.

Knee and Ankle Reconstruction With Reverse Anterolateral Thigh and Free Anterolateral Thigh Flap From One Donor Site

Traditionally, the anterolateral thigh (ALT) free flap is used in distal lower extremity reconstruction. Reverse ALT flap has become one of the most popular choices for knee joint soft tissue defects. A 53-year-old man sustained a degloving injury in the right lateral side of the lower extremity from the lateral malleolar area to the knee joint area. The contamination was severe, necessitating serial debridement and negative pressure wound therapy. After 4 weeks, no more soft tissue necrosis was evident. No more microorganism growth was confirmed by swab culture. ALT free flap using proximal perforator was planned for lateral malleolar area reconstruction and reverse ALT flap using distal perforator was planned to cover knee joint after confirming the pedicle length was sufficient for simultaneous knee and lateral malleolar area reconstruction.

Huge Radicular Cyst of the Maxilla Treated with Complete Resection and Immediate Reconstruction by Rib Bone Graft

Radicular cysts are the most common odontogenic cystic lesions that occur in jaws. They rarely become problematic and are incidentally found on routine dental radiographs. As they appear to reach a considerable size prior to medical attention due to their insidious and destructive growth characteristics during the intraosseous stage, treatment often requires extensive cystectomy and skeletal reconstruction. Here we present the case of an 18-year-old man who was sent to our department, because of a huge, bulging mass in his left cheek. Surgery consisted of complete removal of the cyst and immediate reconstruction of the midfacial buttress using an autologous rib graft in a tongue-and-groove fashion. Histopathological examination of the lesion confirmed the diagnosis of a maxillary radicular cyst. This case underscores the nature of the frequently asymptomatic and long-term evolution of maxillary radicular cysts, with their growth causing massive bone destruction for which skeletal reconstruction is required.