Ki-Taik Han

Gluteal fold V-Y advancement flap for vulvar and vaginal reconstruction: a new flap.

Background: Soft-tissue reconstruction following vulvar cancer resection is a difficult challenge because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages. Methods: The authors introduce the gluteal fold fasciocutaneous V-Y advancement flap for vulvovaginoperineal reconstruction after vulva cancer resection. This flap is supplied by underlying fascial plexus derived from perforators of the internal pudendal artery and musculocutaneous perforators of underlying muscle. The sensory supply of this flap comes from the posterior cutaneous nerve of the thigh and the pudendal nerve. An axis of V-shaped triangular flap is aligned to the gluteal fold. A total of 17 flaps were performed in nine patients. Results: All flaps survived completely, with no complications except for small perineal wound disruption in three patients. Conclusions: This flap is thin, reliable, sensate, easy to perform, and has matched local skin quality and concealed donor-site scar on the gluteal fold. In addition, it can cover large vulvovaginal defects because it can be advanced farther as a result of the character of the gluteal fold area. In our experience, the gluteal fold fasciocutaneous V-Y advancement flap has proven very useful for vulvar reconstruction, especially at the point of donor-site scar, flap thickness, and degree of flap advancement.

Ankyloglossia correction: Z-plasty combined with genioglossus myotomy.

AbstractAnkyloglossia or tongue-tie is a disease in which the tongue has a mobility disorder because the lingual frenulum is short and tight, and as a result, the tongue tip is tied up. It may be asymptomatic or may cause various problems such as articulation disorder. Surgical treatment is required in many of the patients, and conventional methods release only the mucosal layer of the frenulum. However, conventional method alone is not as effective; therefore, the authors studied the addition of a partial myotomy of the genioglossus muscle along with mucosal layer release for treatment.The authors performed the surgery on 106 patients from 2005 to 2010, and during the surgery, the mucosal layer was released through Z-plasty after myotomy was performed on the contracted genioglossus muscle.During the follow-up, none of the patients showed signs and symptoms of tongue mobility impairment or articulation disorder caused by the partial myotomy of the genioglossus muscle, and a satisfactory outcome was obtained in achieving mobility of the tongue tip.Because tongue mobility disorder in ankyloglossia is accompanied by the contracture and shortening of the genioglossus muscle, an improved outcome is expected in the projection and mobility of the tongue tip from the combined application of conventional Z-plasty and genioglossus muscle release.

Unusally Huge Metastatic Cutaneous Renal Cell Carcinoma to the Right Buttock: Case Report and Review of the Literature

Jung-Ho Lee, MD, Paik-Kwon Lee, MD, PHD, Sang-Tae Ahn, MD, PHD, Deuk-Young Oh, MD, Jong-Won Rhie, MD, PHD, and Ki-Taik Han, MD, PHD, have indicated no significant interest with commercial supporters.

Giant Extrapleural Solitary Fibrous Tumor of the Thigh.

A solitary fibrous tumor (SFT) is an uncommon tumor that arises from primitive fibroblast-like cells in the connective tissue [1]. It characteristically shows a mixture of fibrous tissue, cellular components, and highly vascularized areas consisting of numerous, closely packed small to medium-sized blood vessels [2,3]. They usually affect adults between the fourth and the seventh decades of life (median, 50 years). Histological findings including immunohistochemistry are required for the diagnosis of SFT. Although SFTs are generally benign, well-circumscribed soft tissue tumors, 10%-15% of SFTs will recur and/or metastasize [4]. SFTs are usually located in the pleura or other serosal surfaces. Despite the fact that they are seldom located in extrapleural soft tissue, this tumor has been reported in a variety of extraserosal sites. The known extrapleural locations of SFT are as follows: the lumbar extradural space, intrameningeal space, cervical spine, deep soft tissue of the neck, orbital space, pelvic space, retroperitoneal space, vagina, thyroid gland, mammary gland, prostate, nasal mucosa, liver, renal pelvis, and extremities. The orbits and the soft tissues of the extremities are the most commonly reported extrapleural sites [1]. SFTs of extremities, particularly in the thighs, are known to have malignant potential [4]. To treat benign SFT, resection with an intact tumor capsule is required for full recovery of the patient. Reviewing the literature, we found no confirmed reasons for a wide resection [4,5]. Here, we report a case of an extrapleural SFT that occurred in the inner thigh area. A 76-year-old female presented at our department with a left inner thigh soft tissue mass. Physical examination revealed a huge mass measuring 15 cm×13 cm (Fig. 1). Preoperative magnetic resonance imaging (MRI) revealed a large (about 12.4 cm×10 cm), lobulated soft tissue mass with a diffuse hypointense signal on T2-weighted imaging in the subcutaneous fat layer with a bulging contour and peripheral heterogeneous enhancement, which was consistent with a hypervascular tumor (Fig. 2). Total body scan revealed no distant metastasis. The mass was located in the subfascial layer of the inner thigh, and surgical treatment was carried out. The whole tumor was totally excised and submitted for histopathological study. The excised specimen was about 15 cm×13 cm in size, encapsulated, and well circumscribed, with a firm, rubbery texture and a tan-brown color (Fig. 3). The initial histopathological findings revealed an acellular spindle-cell tumor with nuclear pleomorphism and cellular atypia. They also revealed the proliferation of capillaries surrounded by masses of round or spindle-shaped cells. The cellularity varied considerably in different areas with a predominance of hypercellular areas. However, increased mitotic activity, nuclear pleomorphism, or any foci of coagulative necrosis were not observed in this case. Further, immunohistochemistry was performed for the differential diagnosis. It revealed that CD-34 was positive and S-100 protein was negative (Fig. 4). The final histopathological diagnosis was a benign extrapleural SFT. The patient did not receive further radiotherapy or chemotherapy. No recurrence was found 12 months after surgery. Fig. 1 A 76-year-old woman presented with a huge, protruding, firm, and fixed mass measuring 15 cm×13 cm on her left inner thigh. Fig. 2 Coronal contrast-enhanced T2-weighted magnetic resonance imaging scan shows a large (about 12.4 cm×10 cm) lobulated soft tissue mass in the subcutaneous fat layer (red arrow). It shows a predominantly hyperdense mass with heterogeneous regions ... Fig. 3 The specimen after total excision: an encapsulated, well-circumscribed mass measuring 12 cm×10 cm and having, a firm, rubbery texture and brownish color. Fig. 4 (A) The hematoxylin and eosin (H&E)-stained slide shows the typical histopathology of a benign solitary fibrous tumor, including spindle-shaped fibroblasts in a collagenous matrix, with some interspersed focal areas of organized fibrosis without ... An SFT is a rare neoplasm that derives from mesenchymal cells. The differential diagnosis of an SFT in an extremity includes neoplasms such as fibrosarcoma, fibrous histiocytoma, desmoid tumor, dermatofibrosarcoma protuberans, hemangiopericytoma, neurofibroma, and malignant peripheral nerve sheath tumor [1]. Because of the tumors rarity, it usually takes a long time to reach the diagnosis of SFT. Imaging studies like plain radiography and ultrasound are non-specific and not suitable for the differential diagnosis. On MRI, the diagnosis of SFT is suggested by a well-circumscribed mass with smooth margins, and a focal or diffuse hypointense signal on T2-weighted imaging due to the fibrous content in the tumor. An SFT also demonstrates strong focal or diffuse contrast enhancement due to the highly vascularized areas in the tumor [1]. Malignant SFTs are usually demonstrated as hemorrhage, cystic degeneration, and central necrosis on MRI. However, in our case, there was no such evidence suggestive of malignancy. Radiological findings alone cannot definitely determine whether the tumor is benign or malignant [3]. To confirm a diagnosis and to differentiate it from other soft tissue tumors, an immunohistochemical analysis is required. SFTs are a well-circumscribed tumors. Histologically, they consist of a proliferation of capillaries surrounded by masses of spindle-shaped cells. SFT cells are separated by thick bands of collagen, demonstrating foci of keloid-like hyalinization. Prominent vascularity showing a hemangiopericytoma-like vascular pattern and thick, hyalinized vessel walls are seen. Immunohistochemically, SFTs are negative for cytokeratin, S-100 protein, desmin, and alpha-smooth muscle actin, while positive for vimentin and CD34 [2,3]. In our case, immunohistochemical staining was positive for CD34 and negative for S-100 protein, which satisfied the diagnostic criteria for SFTs. Patients with a benign SFT are usually treated with complete surgical excision. The prognosis of this tumor is good and the local recurrence rate is very low in the case of benign SFTs. However, other studies have reported that SFTs in the extremities are more likely to be malignant [4]. Further, immunohistochemical patterns are used for therapeutic decision making. With mitotic activity, increased cellularity, necrotic areas, and nuclear pleomorphism, there is a possibility of malignant SFT. Thus, if there is evidence suggestive of malignant potential, a further wide resection, a long-term follow-up, and regular MRI are proposed. Otherwise, simple excision with an intact tumor capsule is the optimal treatment of benign SFTs [4,5]. In our case, mitotic activity, nuclear pleomorphism, and central necrosis were not observed. Therefore, simple excision rather than wide excision was sufficient, and there was no evidence of recurrence over the 1 year follow-up period. In conclusion, although these tumors are an uncommon entity, the possibility of SFTs should be kept in mind during the evaluation of any huge soft tissue mass occurring in the extremities, so that the physician may examine the appropriate differential markers, arrive at an accurate diagnosis, and administer appropriate treatment.

Leiomyosarcoma of the Face

Leiomyosarcoma is a rare form of soft tissue neoplasm, with only 1% to 5% occurring in the head and neck region. Current recommended treatment suggests surgical excision with a wide lateral margin, but no definite guidelines regarding excisional margin have been established yet. Recently, complete excision with a narrow surgical margin has been recommended, and the authors present a case of cutaneous leiomyosarcoma on the face that was successfully managed by complete removal with a narrow excisional margin. A 74-year-old woman presented with a 3 cm sized, rapidly growing cutaneous mass on her right preauricular area. Preoperative biopsy of the skin lesion suggested a cutaneous leiomyosarcoma. The authors performed complete surgical excision with a 1 cm lateral margin, and the resulting skin defect was repaired with bilateral V-Y advancement local flaps. Histopathology and immunohistochemistry evaluation confirmed a moderately differentiated cutaneous leiomyosarcoma, with negative margin involvement. The patient refused of any additional treatment, but showed no locoregional recurrence during the 1.5 years of postoperative follow-up period. With a regular postoperative follow-up, cutaneous leiomyosarcomas may be successfully treated with a narrow surgical margin.

A Simple and Reproducible Surgical Technique for the Management of Preauricular Sinuses

Preauricular sinus is a relatively common congenital anomaly that mainly exists on the anterior aspect of the anterior limb of the ascending helix. Although many surgical techniques have been developed, extirpation of the sinus is not easy because of the ramifications of the sinus, remnants of the sinus wall, and infection with or without formation of abscesses, which can all lead to disease recurrence. In our institution, we have surgically treated a total of 141 cases of congenital preauricular sinuses. Instead of using the conventional lacrimal probe and methylene blue method, we used a gentian violet–soaked Cottonoid, which has antibacterial effects against the main pathogen responsible for causing infection of the preauricular sinus. Results have been very favorable, with a zero recurrence rate. We present here a simple and reproducible surgical technique using a gentian violet–soaked Cottonoid that even beginning surgeons can easily follow.

Jeopardized Digital Circulation From a Closed Phalangeal Fracture

Closed phalangeal fractures that accompany concomitant vascular injuries are not common. The mechanism of such vessel injuries vary, from direct vascular trauma by fractured bone segment, increased compartmental pressure or unintentional vascular traction during reduction procedures. Acute digital ischemia requires appropriate surgical intervention(s) to minimize complications. The authors present a case of a closed phalangeal fracture with concomitant digital artery injury, and a brief review of the related literature.

Recurrent Pleomorphic Adenoma of the Parotid Gland

Pleomorphic adenoma is the most common type of salivary gland tumor and the most common tumor of the parotid gland. Because of its propensity for invasion, pleomorphic adenoma of the parotid requires superficial parotidectomy or total parotidectomy to minimize the risk of tumor recurrence. We report a case of pleomorphic adenoma of the parotid gland with repeated recurrences. A 23-year-old male patient presented with a protruding neck mass. Six years prior to this presentation, the patient had undergone superficial parotidectomy for the removal of pleomorphic adenoma of the right parotid gland at our institution. The patient experienced recurrence at 17 months after the initial resection, which required a total parotidectomy with partial resection of the facial nerve. Pathologic examination revealed histologic findings consistent with pleomorphic adenoma across the surgical specimen from all three of the operations. The patient suffered from facial nerve paralysis, with facial expressions partially recovered over a year.

Follicular hybrid cyst on the cheek: A combination of infundibular, isthmic, and pilomatrical differentiation

A hybrid cyst is a rare condition which includes any type of cyst arising from the various parts of the pilosebaceous unit. We report a case of hybrid cyst with infundibular, isthmic, and pilomatrical differentiation. A 12-year-old boy presented with a mass on the right cheek. The physical examination revealed an oval-shaped, dark-gray protruding mass with dimensions of 0.9 cm×0.6 cm that was non-tender to palpation. The mass was totally excised. The diagnosis of a hybrid cyst was confirmed by histological evaluation. It was a well-encapsulated mass and showed combined histologic features of infundibular, isthmus, and pilomatrical differentiation. The hybrid cyst is a follicular cyst that includes two or more components of a cystic lesion arising from the pilosebaceous unit. Occasionally, there have been reports of hybrid cysts consisting of two components in differentiation, but those showing more than two components of differentiation have been extremely rare. The pathogenesis of this unusual disease is not yet known.