Il Jae Lee

Complete tight fibrous band release and resection in congenital muscular torticollis

Congenital muscular torticollis (CMT) is caused by shortening of the sternocleidomastoid (SCM) muscle, which may lead to neck movement limitation and craniofacial deformity. The authors retrospectively reviewed clinical experiences of CMT at their hospital from February 2007 to June 2008. During the study period, 20 CMT patients underwent complete tight fibrous band release and resection. Mean patient age was 47.6 months at operation. Eighteen of the 20 patients started a programme of physical therapy preoperatively. All patients received well-controlled postoperative physical therapy and wore a soft neck collar to correct head position for at least 3 months. At 3 months postoperatively, passive ranges of neck motion were determined, and compared with those of uninvolved sides. Eighteen patients showed a full range of motion of neck rotation and lateral flexion, but one patient showed a 10 degrees limitation in lateral flexion, and another showed 10 degrees limitations of neck rotation and lateral flexion. The authors recommended that the described operative technique involving complete fibrous band release and resection, combined with intensive postoperative physical therapy and application of a soft neck collar, provides good functional and cosmetic results.

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.

Mandibular tubercle resection: a means of maximizing the benefits of reduction mandibuloplasty.

Background: A square mandible is considered unattractive in Asia; as a result, mandibular reduction is the most common type of operation performed. The authors review the importance of mandibular tubercles in the lower margin of the parasymphysis area and introduce their resection techniques and results. Methods: From April of 2005 to September of 2009, 178 patients underwent tubercle resection in the parasymphyseal area. The procedures used were as follows: mandibular angle reduction in 139, genioplasty in 39, and mandibular angle reduction with simultaneous malar reduction in 58 patients. In the chin area, horizontal osteotomy was performed in 35 patients to reduce chin length. Other patients underwent mandibular tubercle resection and burring. Results: With the exception of one patient who developed hyperesthesia in the left lower lip 2 years after the procedure, all patients achieved satisfactory aesthetic results after mandibular tubercle resection and concurrent mandibular reduction. Conclusion: The authors consider mandibular tubercle resection, either as a single procedure or combined with mandible reduction, essential for patients who require a slimmer, more feminine lower face.

Is craniofacial asymmetry progressive in untreated congenital muscular torticollis

Background: Although craniofacial asymmetry is frequently involved in patients with congenital muscular torticollis, it has not been evaluated appropriately. The authors analyzed preoperative craniofacial asymmetry objectively and confirmed the relationship between craniofacial asymmetry and aging in congenital muscular torticollis patients who underwent surgical release. Methods: The authors retrospectively measured preoperative craniofacial asymmetry using the Cranial Vault Asymmetry Index and intercommissural angle and reviewed preoperative rotational and flexional deficit of neck movement for 123 congenital muscular torticollis patients who underwent surgical release at Ajou Medical Center from February of 2007 to February of 2011. The relationships among Cranial Vault Asymmetry Index, intercommissural angle, rotational deficit, flexional deficit, and age were analyzed. Mean values of dependent variables were compared after patients were grouped by age. Results: Mean age at operation was 82.5 months (range, 5 to 498 months). Seventy-one percent (n = 87) of patients had a significant cranial asymmetry and 87 percent (n = 107) had a significant facial asymmetry. In correlation analysis, intercommissural angle increased proportional to age (r = 0.334, p = 0.000), especially before 3 years (r = 0.42, p = 0.001). Cranial Vault Asymmetry Index was unrelated to age or rotational or flexional deficit. Rotational deficit decreased proportional to age (r = −0.229, p = 0.032). By analysis of variance test, intercommissural angle and rotational deficit between the age groups were statistically significantly different (p < 0.05). Conclusions: In congenital muscular torticollis, facial asymmetry is progressive if the contracted sternocleidomastoid muscle is not released, although cranial asymmetry is already determined in those younger than 6 months. Early correction of torticollis should be considered to prevent progression of facial asymmetry in congenital muscular torticollis patients. CLINICAL QUESTION /LEVEL OF EVIDENCE: Risk, III.

Dermofat graft after superficial parotidectomy via a modified face-lift incision to prevent Frey syndrome and depressed deformity.

Superficial parotidectomy is a well-established treatment for the early stages of tumors involving the parotid gland. However, there are 3 problems with traditional superficial parotidectomies: (1) cosmetic problems, such as scars, especially around the neck; (2) depressed deformities; and (3) Frey syndrome. A superficial parotidectomy via a modified face-lift incision with dermofat graft provides a solution for these problems and should be considered as an alternative technique in select patients.

Significance of osteoporosis in facial bone density using computed tomography.

ObjectivesThe objectives of this study were to compare the variations of bone density in the midfacial bones as measured by computed tomography (CT) scans between the osteoporosis and control groups and to evaluate the regions that facial trauma and iatrogenic problem often occur in the midface. MethodsThe 96 patients who underwent both osteomeatal unit CT scans and dual-energy x-ray absorptiometry at our hospital were included in this study retrospectively. Seven skeletal regions were chosen for evaluation: group A (orbital floor, nasal bone), group B (zygomaticomaxillary suture, zygomatic arch, zygomaticofrontal suture), and group C (anterior wall of the maxillary sinus, maxillary process). Forty-seven patients were in the osteoporosis group, and 49 patients were in the control group. On a PACS (picture archiving communication system), the region of interest was analyzed, and the Hounsfield units were measured. ResultsThere was a significant difference in the mean bone density of the midfacial bones between the osteoporosis group and the control group (P < 0.01). For both groups, each of comparison of the 7 skeletal regions was greater as group A < group B < group C in this order (P < 0.01). ConclusionsWe can see the independent effects of osteoporosis on the midfacial bones using CT scans. Estimated Hounsfield unit through CT scan is able to explain osteoporosis, which may be useful in the clinical fields in the future.

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.

Integrative analysis of congenital muscular torticollis: from gene expression to clinical significance

BackgroundCongenital muscular torticollis (CMT) is characterized by thickening and/or tightness of the unilateral sternocleidomastoid muscle (SCM), ending up with torticollis. Our aim was to identify differentially expressed genes (DEGs) and novel protein interaction network modules of CMT, and to discover the relationship between gene expressions and clinical severity of CMT.ResultsTwenty-eight sternocleidomastoid muscles (SCMs) from 23 subjects with CMT and 5 SCMs without CMT were allocated for microarray, MRI, or imunohistochemical studies. We first identified 269 genes as the DEGs in CMT. Gene ontology enrichment analysis revealed that the main function of the DEGs is for extracellular region part during developmental processes. Five CMT-related protein network modules were identified, which showed that the important pathway is fibrosis related with collagen and elastin fibrillogenesis with an evidence of DNA repair mechanism. Interestingly, the expression levels of the 8 DEGs called CMT signature genes whose mRNA expression was double-confirmed by quantitative real time PCR showed good correlation with the severity of CMT which was measured with the pre-operational MRI images (R2 ranging from 0.82 to 0.21). Moreover, the protein expressions of ELN, ASPN and CHD3 which were identified from the CMT-related protein network modules demonstrated the differential expression between the CMT and normal SCM.ConclusionsWe here provided an integrative analysis of CMT from gene expression to clinical significance, which showed good correlation with clinical severity of CMT. Furthermore, the CMT-related protein network modules were identified, which provided more in-depth understanding of pathophysiology of CMT.

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.

Role of JAK3 in myogenic differentiation

Skeletal muscle differentiation is regulated by transcription factors, including members of the myogenic regulatory factor (MRF) family and many signaling pathways. The JAK1 and JAK2 pathways are known to each have different effects on myoblast proliferation and differentiation; however, the role of JAK3 in myoblast differentiation remains unclear. In this study, we investigated the effect of JAK3 inhibition on myogenic differentiation in the C2C12 mouse myoblast cell line. During myogenic differentiation, treatment with the JAK3 inhibitor WHIp154 significantly increased the number of MHC-positive multinucleated myotubes and the expressions of myosin heavy chain (MHC), myogenin (MGN), MyoD, and myogenic enhancer factor 2 (MEF2). Knockdown of the JAK3 gene using siJAK3 also significantly increased MHC, MGN and MyoD mRNA expressions as well as insulin-like growth factor-II (IGF-II) gene expression. During differentiation, JAK3 was initially activated and later decreased. Differentiation decreased STAT1, which was further decreased by WHIp154. In contrast, STAT3 gradually was elevated during differentiation, and was increased by JAK3 inhibition. Moreover, we found that up-regulation of AKT activity and down-regulation of ERK activity cooperated to accelerate myogenic differentiation. Taken together, these data indicate that JAK3 inhibition potently facilitates myoblast differentiation through antagonistic STAT1/STAT3 activities. Additionally, JAK3 inhibition induced precocious differentiation and played important roles for terminal differentiation, including fusion, which is involved with regulation of AKT and ERK pathways.