Hyung Do Kim

Heterodigital Free Flap of Index Finger Amputee for Coverage of the Long Finger Soft Tissue Defect

www.e-arms.org Since Komatsu and Tamai reported the first successful replantation of a completely severed finger of a human by using the microvascular anastomosis in 1968, the replantation of amputated fingers using microscopes has been advanced consistently. But in case that irreversible damage is accompanied, an amputated part may not be reattached to their anatomically original position. If the replantation on the original position is not possible, the amputated tissue of a hand may be used as a donor for recovering hand functions at other positions. This procedure is termed ‘heterodigital replantation’. The biggest purpose of this surgery is to minimize the functional loss of the amputated finger while to maximize the recovery of functions of the entire hand. Heterodigital free flaps have an advantage that the reconstruction can be made without additional donor site morbidity by using tissues damaged by trauma such as amputated, discarded or non functioning limbs. For successful heterodigital free flaps, it is necessary to preserve as much useful tissue as possible in the initial surgery and perform the reconstruction using the preserved tissue by deciding the priority of fingers to be replanted according to the degree of trauma and the demand of the patient. Herein, authors report a case of reconstruction which was performed on a patient using his amputated finger as a heterodigital free flap to preserve functions of other fingers since the amputated finger could not be replanted due to the severity of crushing injury.

Reduction of Nasal Bone Fracture using Ultrasound Imaging during Surgery

Background Most nasal bone fractures are corrected using non-invasive methods. Often, patients are dissatisfied with surgical outcomes following such closed approach. In this study, we compare surgical outcomes following blind closed reduction to that of ultrasound-guided reduction. Methods A single-institutional prospective study was performed for all nasal fracture patients (n=28) presenting between May 2013 and November 2013. Upon research consent, patients were randomly assigned to either the control group (n=14, blind reduction) or the experimental group (n=14, ultrasound-guided reduction). Surgical outcomes were evaluated using preoperative and 3-month postoperative X-ray images by two independent surgeons. Patient satisfaction was evaluated using a questionnaire survey. Results The experimental group consisted of 4 patients with Plane I fracture and 10 patients with Plane II fracture. The control group consisted of 3 patients with Plane I fracture and 11 patients with Plane II fracture. The mean surgical outcomes score and the mean patient dissatisfaction score were found not to differ between the experimental and the control group in Plane I fracture (p=0.755, 0.578, respectively). In a subgroup analysis consisting of Plane II fractures only, surgeons graded outcomes for ultrasound-guided reduction higher than that for the control group (p=0.007). Likewise, among the Plane II fracture patients, those who underwent ultrasound-guided reduction were less dissatisfied than those who underwent blind reduction (p=0.043). Conclusion Our study result suggests that ultrasound-guided closed reduction is superior to blind closed reduction in those patients with Plane II nasal fractures.

Clinical Analysis of Lobular Keloid after Ear Piercing

Background Lobular keloid appears to be a consequence of hypertrophic inflammation secondary to ear piercings performed under unsterile conditions. We wish to understand the pathogenesis of lobular keloids and report operative outcomes with a literature review. Methods A retrospective review identified 40 cases of lobular keloids between January, 2005 and December, 2010. Patient records were reviewed for preclinical factors such as presence of inflammation after ear piercing prior to keloid development, surgical management, and histopathologic correlation to recurrence. Results The operation had been performed by surgical core extirpation or simple excision, postoperative lobular compression, and scar ointments. Perivascular infiltration was noted in intra- and extra-keloid tissue in 70% of patients. The postoperative recurrence rate was 10%, and most of the patients satisfied with treatment outcomes. Conclusion Histological perivascular inflammation is a prominent feature of lobular keloids. Proper surgical treatment, adjuvant treatments, and persistent follow-up observation were sufficient in maintaining a relatively low rates of recurrence.

Improvement of Infraorbital Rim contour Using Medpor

Background Asymmetry of the infraorbital rim can be caused by trauma, congenital or acquired disease, or insufficient reduction during a previous operation. Such asymmetry needs to be corrected because the shape of the infraorbital rim or midfacial skeleton defines the overall midfacial contour. Methods The study included 5 cases of retruded infraorbital rim. All of the patient underwent restoration of the deficient volume using polyethylene implants between June 2005 and June 2011. The infraorbital rim was accessed through a subciliary approach, and the implants were placed in subperiosteal space. Surgical outcomes were evaluated using preoperative and postoperative computed tomography studies. Results Implant based augmentation was associated with a mean projection of 4.6 mm enhancement. No postoperative complications were noted during the 30-month follow-up period. Conclusion Because of the safeness, short recovery time, effectiveness, reliability, and potential application to a wide range of facial disproportion problems, this surgical technique can be applied to midfacial retrusion from a variety of etiologies, such as fracture involving infraorbital rim, congenital midfacial hypoplasia, lid malposition after blepharoplasty, and skeletal changes due to aging.

Soft Tissue Chondroma Presenting as a Dermal Mass in the Toe

Soft tissue chondroma is a rare benign tumor, and it mainly affects hands and feet. Its prevalence reaches the highest level in individuals aged between 30 years and 60 years. In addition, it is known that there is no sex-related difference in its incidence. Repeated microtrauma has also been reported to be responsible for its occurrence. A 72-year-old woman visited us with a chief complaint of a 3-year-history of a palpable, skin protuberance on the left third toe. The patient had a past history of taking surgical excision for skin protuberance at the department of dermatology of other hospital. Thereafter, however, the patient received resection of the skin protuberance again because of its recurrence. Nevertheless, the patient had a palpable mass at the surgical sites and complained about discomfort in the toe. Therefore, the patient visited us. On physical examination, the patient had a round, ill-defined skin protuberance with a diameter of approximately 1 cm. On palpation, it was a rather solid mass. In addition, the patient had a scratch on the skin surface (Fig. 1). On preoperative plain radiography, the patient had a calcified lesion with a diameter of <1 mm in the deep lesion of the skin mass (Fig. 2). Fig. 1 Preoperative clinical view. 72-year-old female patients visited our hospital with chief complaint of 1 cm sized round and protuberance skin lesion which had a indeterminated margin on dorsolateral aspect of third toe on left foot. Fig. 2 Preoperative radiologic finding. One calcification lesion with less then 1 mm size was shown on plain anteroposterior radiograph. After IV sedation, local anesthesia is applied and then the patient received a resection of the mass. We made an oval-shaped incision along the margin of the skin protuberance, for which we set the depth of resection at the right above the periosteum, thus attempting to sufficiently involve the subcutaneous adipose tissue. Thus, we performed a resection of the mass involving the calcified lesion identified on preoperative plain radiography. Postoperatively, the size of the resected mass was 1.0×0.8 cm. We performed histopathologic examinations (Fig. 3). Fig. 3 Including calcified lesion, 1.0×0.8 cm sized mass excision was performed. On histopathologic examinations, the patient was diagnosed with chondroma characterized by the presence of mature chondrocytes in the hyaline matrix accompanied by a mild focal cellular atypia (Fig. 4). Fig. 4 Histopathologic finding. Pathologic confirmation disclosed that mass was chondroma which includes mature chondrocyte with mild focal cellular atypia in hyaline matrix (H&E, ×100). Postoperatively, the patient presented with a mild wound dehiscence, but achieved a recovery from it through the conservative treatments. At the surgical sites, there was no further recurrence until postoperative year 1 (Fig. 5). Fig. 5 Postoperative clinical view. 1-year follow up after operation shows no other complications nor recurrence signs. Clinically, soft tissue chondroma is a rare entity. Irrespective of the sex, it mainly occurs in hands or feet of individuals aged between 30 years and 60 years. Most cases of the soft tissue sarcoma are characterized by a slowly-growing mass. There are many asymptomatic cases in the early stage of onset. Over time, however, patients with soft tissue sarcoma complain of such symptoms as local tenderness, limited joint mobility and pain on action. Clinically, its incidence is also relatively lower. Therefore, it is often missed in the early stage of onset. Its final diagnosis should be made on histopathologic examinations [1]. In the current case, a 72-year-old woman did not recognize the necessity of taking the treatment until she complained of discomfort during gait. Therefore, the patient visited after long periods of time. At the department of dermatology of other medical institution, the patient solely received a resection of the skin lesion without taking other treatments. But the patient presented with recurrent episodes. Still, little is known about the pathophysiology of soft tissue chondroma. It has been hypothesized, however, that the metaplasia of the adjacent joint or synovial membrane is responsible for its etiology [2,3]. In addition, Bahnassy and Abdul-Khalik [4] also reported that the repeated, persistent microtrauma would also trigger its occurrence. Also in the current case, the patient formed a habit of scaratching toes on a regular basis. Presumably, this might be associated with the occurrence of soft tissue sarcoma. Still, little is known about the malignant transformation of soft tissue chondroma [5]. A differential diagnosis of it from chondrosarcoma should be made. This should also be accompanied any adjuvant radiological examinations and histopathologic analysis. Also in the current case, there was a solitary calcified lesion 1 mm below the skin protuberance on preoperative plain radiography. Based on these findings, we determined that the patient had a recurrence of the skin lesion, although the patient received a resection of the skin protuberance, not because the lesion was a simple skin mass but because the mass was not removed from the deep layer of the soft tissue. We therefore perceived the necessity of performing a resection of the tumor involving the calcified lesion within the soft tissue, thus making a diagnosis of soft tissue chondroma following the surgical excision of the soft tissue tumor. Although soft tissue chondroma is a benign tumor, it shows a relatively higher rate of local recurrence of 15% to 25% [5]. Presumably, this might be because we removed only the contents within the membrane without involving the membrane covering the tumor or because we could not achieve a complete resection of the tumor during previous surgeries [1]. In the current case, the patient showed no recurrences during a 1-year period following the surgical excision of soft tissue chondroma at our medical institution. But this deserves continual, long-term follow-up studies. Soft tissue chondroma is a rare entity. Its diagnosis cannot therefore be made solely on clinical presentations. Imaging studies and histopathologic examinations are essential for making a diagnosis of it. Although it is a benign tumor, it shows a higher rate of local recurrence. Therefore, surgeons should be aware of its local recurrence in making a surgical excision of it. Even postoperatively, surgeons should perform a meticulous monitoring of clinical course for long periods of time.

Moll's Cyst Occurring in the Orbital Septum

Molls cyst is one of the apocrine sweat gland cysts that occur on the margin eyelid. Thus far, however, only a few cases of Molls cyst occurring in the orbital septum have been reported [1]. A 29-year-old woman complained of gradual swelling of the right upper eyelid. The patient had a history of undergoing blepharoplasty 7 years ago at another hospital. However, the patient had no other notable findings such as trauma. Upon physical examination, the patient was found to have a protruded mass when she had her eyes closed (Fig. 1). Ultrasonography revealed that the isoechoic mass was 1.6 cm×0.6 cm in size and had a well-defined margin and a fluid-containing lesion (Fig. 2). Under local anesthesia, we made a transverse incision along the double-eyelid line. The mass presented in the orbital septum. Through an incision of the orbital septum, we exposed the mass (Fig. 3). The mass was encapsulated by a transparent, white fibrous tissue. We carefully dissected it while paying special attention to not damage the levator aponeurosis. The patient wanted a mild blepharoptosis correction at the same time; therefore, we performed surgery on both eyes. Postoperatively, the mass contained a transparent fluid in the unilocular capsule. Histopathological examinations revealed that the tumor was composed of two layers of cuboidal epithelium. These two layers had a columnar shape (Fig. 4). Further, a 1-year follow-up revealed that the patient had no notable findings without recurrence (Fig. 5). Fig. 1 Preoperative findings: When the patients eyes are closed, the protruded mass (yellow arrow) on the right upper eyelid becomes noticeable; this mass was soft, pliable, and round. Fig. 2 Preoperative ultrasonography: 1.6 cm×0.6 cm in size, an isoechoic mass with a well-defined margin and fluid-containing lesion (yellow arrow) on the lateral side. Fig. 3 Intraoperative findings. The cystic mass was in the orbital septum, surrounded by the periorbital fat. It contained fluid and was encapsulated by transparent, white fibrous tissue. Fig. 4 Histopathological findings. The tumor was composed of two layers of cuboidal epithelium surrounded by adipose fibrous tissue. The two layers of cuboidal epithelium had a columnar shape (H&E, ×200). Fig. 5 Postoperative findings (1 year later). The patient had no notable findings without recurrence. Molls cyst may also occur in the orbital septum because of congenital factors. That is, it occurs when there are disturbances in the development of the epidermis that should have developed on Molls gland in the embryonic stage [2]. Further, it has been reported that Molls cyst may also occur as a result of the epidermal invagination of the eyelid from certain acquired causes such as trauma or other iatrogenic factors [3]. Our case developed this cyst for acquired reasons and not congenital ones. This is attributed to the following: Molls cyst occurs very rarely in the orbital septum. Concurrent deformities of the adjacent tissue may also occur during the growth to the adult stage in congenital cases of Molls cyst. The patient complained of the discomfort on the eyelid only recently. The patient had a history of blepharoplasty. Molls cyst is surrounded by a thin white wall and contains a transparent fluid. Histologically, a cuboidal epithelium composed of two layers of secretory cells forms the inner wall of the cyst, and the rest of the cyst undergoes a fibrotic change. Of the two layers of secretory cells, the inner layer is composed of columnar epithelium and protrudes into the cyst. Further, its apical portion contains an eosinophilic substance. These findings are similar to those of Molls gland [4]. In the current case, the clinical characteristics and histopathological findings were typically suggestive of Molls cyst. In other words, we witnessed a rare case of Molls cyst occurring in the orbital septum.