Jiye Kim

Zygomatic arch fracture: a new classification and treatment algorithm with epidemiologic analysis.

Abstract Determining the optimal method for zygoma fracture reduction is a common challenge. Numerous methods for treating zygomatic arch fractures have been suggested. However, a substantial gap exists between suggested treatment strategies and real-world practice. A general consensus of classification and treatment guidelines for zygomatic arch reduction has not yet been established. We reviewed our cases and propose a new classification of zygomatic arch fracture and a treatment algorithm for successful reduction based on the injury vectors.

Croissant-shaped v-y advancement flap with 2 horns for repair of small- and medium-sized facial defects.

Background: The use of a V-Y advancement flap is an effective technique for the reconstruction of small facial defects. However, in some areas, the use of a conventional V-Y advancement flap is not possible because of the tension caused by size variation. In the current study, we modified this method using a croissant-shaped V-Y advancement flap and repaired intermediate-sized defects without difficulty. Materials and Methods: A croissant-shaped modified V-Y flap was used in 15 patients (aged 53-82 y). To completely remove masses, wide excisions were performed in all cases (nasolabial area = 7, nasojugal area = 3, medial canthal area = 1, cheek = 2, nose = 1, forehead = 1), and the average size of the defects was 2.6 × 2.5 cm. The flap was designed after confirmation of clear resection margins on frozen section. The long axis of the V-flap was 1.5 to 2 times the length of the diameter of the defect and parallel to the nasolabial or nasojugal fold. In a conventional V-Y advancement flap, the lateral limbs of the V-flap begin at the end point of the central limb. However, in our design, the incision lines of the lateral limbs of the V-flap were extended to the end point of the defect to form a more convex shape. The flap was elevated in the subcutaneous layer above the mimetic muscles. The bilateral tips of the horns of the V-flap were sutured to each other and fixed medially to cover the distal aspect of the defect. The flap was then sutured with a 6-0 nylon. Donor site closure was performed with 6-0 Vicryl and 6-0 nylon in 2 layers. A Penrose drain was inserted at the donor site. Results: No complications were reported in any of the 15 cases. In 2 cases, there was minimal flap congestion immediately after surgery. However, in both cases, the congestion spontaneously resolved during the ensuing days. At follow-up (mean, 12 mo), all 15 patients demonstrated satisfactory cosmetic results. Conclusions: This modified croissant-shaped V-Y flap may serve as an alternative to conventional V-Y flaps for reconstruction of soft tissue defects on the face.

Primary Cutaneous Mucinous Carcinoma Treated with Narrow Surgical Margin

Primary cutaneous mucinous carcinoma (PCMC) is a rare malignant tumor of eccrine origin. Clinically, the carcinoma presents as a solitary, slow growing, and painless nodule. For this reason, this tumor is often considered to be a benign mass in the preoperative setting. The lesion is, however, malignant in nature and has a tendency for local recurrence and infrequent metastasis. Wide local excision is the treatment of choice. However, few reports exist with information regarding surgical margins and clinical outcomes. Herein, we report a case of PCMC excised with a narrow surgical margin and review the relevant literature. A 49-year-old man presented with a small cutaneous nodule of the right cheek. The mass was excised without any margin, but pathologic examination revealed histology of mucinous carcinoma. Because of this, the operative site was re-excised with a 5-mm margin, and the wound was closed using a V-Y advancement flap. Systemic work-up did not reveal other potential metastatic primary, for a final diagnosis of PCMC. We report this case of PCMC, treated with relatively narrow margin in a patient with good prognostic factors.

Panfacial Bone Fracture and Medial to Lateral Approach

Panfacial bone fracture is challenging. Even experienced surgeons find restoration of original facial architecture difficult because of the severe degree of fragmentation and loss of reference segments that could guide the start of facial reconstruction. To restore the facial contour, surgeons usually follow a general sequence for panfacial bone reduction. Among the sequences, the bottom-to-top and outside-in sequence is reported to be the most widely used in recent publications. However, a single sequence cannot be applied to all cases of panfacial fractures because of the variations in panfacial bone fracture patterns. In this article, we intend to find the reference and discuss the efficacy of inside-out sequence in facial bone fracture reconstruction.

Langerhans Cell Histiocytosis with Frontal Bone Indentation by an Adjoining Primary Soft Tissue Lesion in a 17-Month-Old Asian Male Child.

Langerhans cell histiocytosis (LCH) is a rare disease that represents a clonal proliferation of pathologic Langerhans cells [1]. Although its clinical manifestations range from isolated bone lesions to multisystem disease, the pathological finding is uniform irrespective of the disease manifestation. Besides their characteristic morphology, Langerhans cells are further identified histochemically by the presence of the CD1a and S-100 surface markers and electro-microscopically by the presence of Birbeck granules [2]. Pathological findings are obligatory for diagnosis. LCH usually occurs in young children with a peak from 1 to 4 years [3]. Soft tissue involvement is usually the secondary extension of an adjoining primary bone lesion, while the secondary involvement of an adjacent bone by a primary soft tissue LCH lesion is rare [4]. Here, we report the case of a 17-month-old Asian male child with a solitary primary soft tissue LCH lesion in the right forehead area with secondary bone destruction by indentation. This 17-month-old male child was referred to our institution for a forehead mass that rapidly enlarged in three weeks. This child initially presented at an outside clinic, and an ultrasonographic (US) evaluation was performed. The US revealed a soft tissue mass with a diameter of 22 mm and with bone erosion and destruction on the right forehead. LCH was suspected, and the patient was referred to our institution. Initial recognition of the mass was at three weeks before admission. Physical examination revealed a 3.0×3.0 cm tender and fixed mass over the right forehead. Computed tomography (CT), fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/CT, and skull radiography imaging studies were performed before open surgery (Figs. 1, ​,2).2). In December 2011, the mass was extirpated under general anesthesia. On the operative field, we observed an irregularly shaped firm mass measuring 2×3 cm, located in the subcutaneous layer with periosteal inflammation and thinning of the frontal bone without dural exposure. To reconstruct the thinning of the frontal bone, we performed an allograft with a demineralized bone matrix and an osteoconductive bone void filler. Pathologic findings showed that under high magnification (×400), the tumor cells were mostly large monocytes with abundant cytoplasm and occasionally central grooved nuclei, admixed with numerous eosinophils. The presence of Langerhans cells was confirmed by CD1a and S-100 immunohistochemistry (Figs. 3, ​,4).4). To identify whether the tumor origin was the soft tissue and the bone, we conducted a pathologic study of the adjoining periosteum. The histologic study revealed mild chronic inflammation with fibrosis; this result confirms the diagnosis of primary soft tissue LCH. After surgery, this child was followed-up at Samsung Medical Center every 6 months with a bone scan (Fig. 5), and the 1-year follow-ups were conducted at our institution. During the follow-up period of 3 years, no evidence of recurrence was found. LCH, previously known as histiocytosis X, is a histiocytic disorder of unknown etiology that is characterized by the clonal proliferation of dendritic cells in various organs and tissues. LCH has a variable clinical presentation and course, ranging from a solitary, often spontaneously resolving, bone lesion to a fatal multicentric and multiorgan system disease. LCH lesions can involve any organ in the body; however, bones, skin, and lungs are the most common sites of involvement. Soft tissue involvement is usually due to the extension of an adjoining primary bone lesion [4]. In our case, LCH with a soft tissue origin affected the adjoining bone by indentation. Before surgical exploration, the origin of the mass was difficult to identify on the basis of radiologic findings. To identify whether the tumor origin was the soft tissue or the bone, we conducted a pathologic study of the adjoining periosteum. The histologic study revealed mild chronic inflammation with fibrosis; this result confirmed the diagnosis of primary soft tissue LCH. There are multiple treatment modalities for LCH: solitary, easily accessible lesions can be surgically extirpated, and intralesional corticosteroid application and radiotherapy are also possible options [5]. However, clinical guidelines for the treatment of LCH are still under development. In our patient, timely surgical extirpation of the mass was performed and no evidence of recurrence was found during the 3-year follow-up period. Here, we presented the case of a 17-month-old child with a solitary primary soft tissue LCH lesion, which influenced the adjacent bone by indentation. Due to the rarity of LCH that involves both the soft tissue and the bone, it is difficult to identify the tumor origin. In this case, LCH with an ambiguous origin was completely resolved by surgical extirpation, and the primary soft tissue origin of the tumor was confirmed by a histologic study.

Effectiveness of Dual-Maneuver Using K-Wire and Dingman Elevator for the Reduction of Unstable Zygomatic Arch Fracture

Background The zygoma is the most prominent portion of the face. Almost all simple zygomatic arch fractures are treated in a closed fashion with a Dingman elevator. However, the open approach should be considered for unstable zygomatic arch fractures. The coronal approach for a zygomatic arch fracture has complications. In this study, we introduce our method to reduce a special type of unstable zygomatic fracture. Methods We retrospectively reviewed zygomatic arch view and facial bone computed tomography scans of 424 patients who visited the Wonju Severance Christian Hospital from 2007 to 2010 with zygomaticomaxillary fractures, among whom 15 patients met the inclusion criteria. Results We used a Dingman elevator and K-wire simultaneously to manage this type of zygomatic arch fracture. Simple medial rotation force usually collapses the posterior fractured segment, and the fracture becomes unstable. Thus, the posterior fracture segment must be concurrently elevated with a Dingman elevator through Keens approach with rotation force applied through the K-wire. All fractures were reduced without any instability using this method. Conclusion We were able to reduce unstable and difficult zygomatic arch fractures without an open incision or any external fixation device.