Kwang-Ryeol Lim

Superficial Acral Fibromyxoma on the Second Toe

Superficial acral fibromyxoma (SAF) was first reported by Fetsch et al. [1] in 2001; they described the distinctive soft tissue tumor, which had common clinical, histopathologic, and immunohistochemical features, in 37 patients [1-5]. To date, however, few cases of SAF have been described in the literature. A 54-year-old man presented with a 1-year history of a slowly growing lesion on the volar surface of the left second toe and complained of tenderness when walking. On physical examination, the patient had a skin-colored quadrangular mass, measured as approximately 4 cm×4 cm×2 cm in size (Fig. 1A). It was a nodular lesion with a well-defined margin, but had no erosion, eschar, or bleeding. In addition, it did not invade the periungual or subungual region. Furthermore, it had a soft surface with soft tissue adhesion. There were no notable findings on radiography nor a family history. However, the patient did have a several-year history of tinea pedis. The patient scratched the itching area, resulting in alternating wound healing and scarring. The patient was tentatively diagnosed with hypertrophic scar or keloid, for which we performed a complete resection of the mass (Fig. 1B). On histopathology, the mass was located underneath the hyperkeratinized epidermis, and it extended into the dermal and subcutaneous layer. Its cross-section showed a yellowish-white, jelly-like substance. Its histopathologic findings included a fascicular or storiform arrangement of spindle-shaped or stellate-shaped tumor cells in the myxocollagenous matrix (Fig. 2A). These findings were suggestive of proliferative fibroblasts. Accentuated microvasculature was present in the matrix, accompanied by the overall presence of mast cells throughout the lesion. However, there was no marked presence of other inflammatory cells. Moreover, there was no dysplasia or hyperplasia of the tumor cells. On immunohistochemistry, the tumor cells were positive for CD34 and negative for desmin, S100, and epithelial membrane antigen (EMA) (Fig. 2B). The patient was eventually diagnosed with SAF. At a 12-month follow-up, there were no notable complications or recurrence (Fig. 3). Fig. 1 Preoperative and intraoperative clinical photos. (A) Preoperative clinical photo showing a 4 cm×4 cm×2 cm solitary skin-colored mass on the volar side of the left second toe. (B) Resected specimen. Fig. 2 Findings of histopathologic and immunohistochemical stains. (A) Collection of spindle-shaped fibroblasts in a myxocollagenous matrix that blend into primarily myxoid areas of fibrous stroma (H&E, ×200). (B) Immunohistochemical stains (×200) ... Fig. 3 Postoperative view. Good cosmetic results were achieved without recurrence (12 months later). SAF is a solitary, nodular, slowly-growing, asymptomatic soft-tissue tumor with a well-defined margin. It is a rare tumor entity that mainly affects the soft tissue of the extremities and commonly occurs as a small nodule in the periungual or subungual regions of the fingers or toes. It has a predilection for middle-aged adults, showing a male predilection with a male-to-female ratio of 2:1. In addition, the mean age of onset is estimated at 43 years. It can take 3 months to 30 years until a diagnosis of SAF is confirmed. SAF is known to invade the nail, but causes no bone destruction on radiography. Grossly, the tumor has a semispherical polypoid or a verrucous shape. It also contains a grayish-white or yellowish-white jelly-like substance on cross-sections [1-5]. Histopathologically, SAF is a non-encapsulated, well-circumscribed tumor. It commonly occurs in the dermis and sometimes extends into the subcutaneous layer. In the myxoid or myxocollagenous matrix, spindle-shaped or stellate-shaped fibroblast-like cells undergo a proliferation of moderate degree. There is an irregular, loose, fascicular or storiform arrangement of the tumor cells accompanied by the overall presence of mast cells. It has no other inflammatory cells [1-5]. The myxoid matrix of the lesion is highlighted by alcian blue (pH 2.5) stain. On immunohistochemistry, it is positive for CD34, CD99, and vimentin but negative for S-100 protein, α-smooth muscle actin, glial fibrillary acidic protein, keratin, and human melanoma black-45. There is variability in the immunoreactivity for CD10 and EMA [1-5]. Differential diagnoses of SAF include tumors with myxoid lesions (myxoid fibrous histiocytoma, superficial angiomyxoma, myxoid dermatofibrosarcoma protuberans, low-grade myxofibrosarcoma, and myxoid neurofibroma) and those mainly affecting the fingers and nails (sclerosing perineurioma, acquired digital fibrokeratoma, and periungual fibroma) [1-5]. Immunohistochemistry plays a particularly important role in the differential diagnosis of myxoid lesions with similar histopathologic features. Myxoid fibrous histiocytoma is negative for CD34 and positive for factor XIIIa. Superficial angiomyxoma is positive for CD34 and is negative for S100, which is similar to the immunohistochemical findings of SAF, but it is negative for both SMA and muscle specific actin. Myxoid dermatofibrosarcoma protuberans is positive for CD34 and vimentin, and is negative for EMA, desmin, and XIIIa. Low-grade myxofibrosarcoma is positive for vimentin, but it is negative for CD34 and desmin. Myxoid neurofibroma is a tumor of neural origin, showing positive immunohistochemistry for S100, which is of help in making a differential diagnosis of SAF [1-5]. It is known that SAF has a benign natural course, for which the standard treatment modality is complete surgical removal. Incomplete surgical removal might cause a recurrence. Patients with SAF should be under regular follow-up. Prescott et al. reported that SAF had nuclear pleomorphism or mitotic activity showing malignant potential, but its malignant transformation or metastasis has not been described [1-5].

Toe Tissue Transfer for Reconstruction of Damaged Digits due to Electrical Burns

Background Electrical burns are one of the most devastating types of injuries, and can be characterized by the conduction of electric current through the deeper soft tissue such as vessels, nerves, muscles, and bones. For that reason, the extent of an electric burn is very frequently underestimated on initial impression. Methods From July 1999 to June 2006, we performed 15 cases of toe tissue transfer for the reconstruction of finger defects caused by electrical burns. We performed preoperative range of motion exercise, early excision, and coverage of the digital defect with toe tissue transfer. Results We obtained satisfactory results in both functional and aesthetic aspects in all 15 cases without specific complications. Static two-point discrimination results in the transferred toe cases ranged from 8 to 11 mm, with an average of 9.5 mm. The mean range of motion of the transferred toe was 20° to 36° in the distal interphalangeal joint, 16° to 45° in the proximal interphalangeal joint, and 15° to 35° in the metacarpophalangeal joint. All of the patients were relatively satisfied with the function and appearance of their new digits. Conclusions The strategic management of electrical injury to the hands can be both challenging and complex. Because the optimal surgical method is free tissue transfer, maintenance of vascular integrity among various physiological changes works as a determining factor for the postoperative outcome following the reconstruction.

Recurrent Auricular Keloids during Pregnancy.

A keloid is one of the most frustrating clinical problems in wound healing. Keloids form following dermal injury and exhibit exuberant and indefinite growth of collagen. Many theories have been propounded in trying to explain some of the vagaries of keloids. From one of the theories, keloid scars may develop at any age; patients between 10 and 30 years of age (reproductive age) are the most affected population, and there may be a hormonal influence because keloid scars tend to grow during puberty and pregnancy, and resolve during menopause [1]. In our experience, pregnancy-related recurrent keloids have arisen from the ear, despite the patients successful completion of our treatment. The case presented here illustrates the possible connection between keloid formation and hormonal changes during pregnancy. A 27-year-old pregnant female visited our clinic due to progressive growth of her left auricular keloid. Three years prior to the visit, she had developed a scar on her left auricle after treatment for acute inflammation caused by an ear piercing procedure at a non-medical institute. She showed no other particular medical history. She also reported that the lesions appeared and became larger after the first trimester of pregnancy (Fig. 1). On physical examination, the left auricle showed a keloid of nearly circular appearance, approximately 2.2 cm in diameter, with a mean thickness of about 1.5 cm, extending from the superior pole of the auricle down to the middle ear. The skin surface of the keloid was irregular and showed dispersed minute superficial ulcer with itching sensation. Fig. 1 Preoperative photo showing a keloid after the first pregnancy. Because of pregnancy, we waited to perform a core extirpation of the keloid until 6 months after delivery. Compression on the auricle was performed postoperatively in combination with the application of scar care ointment. Even after 1 month, the clinical result remained obviously acceptable where the core extirpation had been performed. Two years later, the patient returned with a huge enlargement of the left auricular keloid. Similar to the previous keloid, it appeared and became bigger (2.2×1.7 cm) simultaneously with child bearing. She remembered that the keloid started to enlarge rapidly in her first trimester of her second pregnancy, with mild itching and redness. She was asked to return after her delivery (Fig. 2). Fig. 2 Preoperative photo showing a keloid after the second pregnancy. Accordingly, she underwent core extirpation 6 months after her second delivery, and compression treatment was performed postoperatively in combination with the application of scar care ointment. The patient was satisfied with the results at postoperative 4 months. The scar tissues, sized at 2.0×1.5 cm and 2.0×1.0 cm, were excised over repeated core extirpations. In both histopathologic reports, no flattening of the overlying epidermis, presence of keloidal collagen, or a prominent fascia-like fibrous band occurred, which confirms the diagnosis of keloid (Fig. 3). Fig. 3 (A) First pregnancy. Histopathologic photograph showing thepresence of keloidal collagen and a prominent fascia-like fibrous band, which confirms the diagnosis of keloid (H&E, ×100). (B) Second pregnancy. Histopathologic photograph showing ... Up to the present, the clinical outcome has shown a clean and satisfactory auricle. The patient has not undergone another pregnancy nor presented any additional keloid growth; specifically, she has reported that her lobular keloid remains inactive. In most known series of keloids, there is a higher incidence in women, with an apparent peak in the immediate post-pubertal years. Lane et al. [2] reported in his study that those who had ear piercings at 11 years of age or above were more likely to develop keloids (80%) than were those who had ear piercings under 11 years of age (23.5%). Because of this observation, the possibility of a female hormonal influence on keloid formation has been advanced. In a study of connective tissue tumors, Geschichter and Lewis [3], bioassayed a single keloid of an ear that had been preserved in formalin; they reported that this keloid tissue contained large amounts of estrogen and gonadotropic substances. However, no confirmation of their work has appeared in the literature. Jacobsson [4] reported a case of a woman whose 4-year-old scar became hypertrophic during pregnancy. Reviewing the different actions of pregnancy hormones, it appears that estrogens are the hormones most likely involved in the keloidal tendency that may accompany pregnancy [5]. The ovaries and adrenal cortex of mature women produce estrogens. In pregnancy, the major site of production is the placenta. Our patient noted rapid enlargement and irritation of her keloid, which began in the first trimester of pregnancy. This supports our view on the effect of hormonal influence in scar or keloidal tissue during pregnancy, and agrees with the concept that regression of symptoms occurs after delivery. It is known that auricular and lobular keloids appear on account of inflammation caused by an unhygienic ear piercing procedure. However, we report our treatment experience in a case with recurrent keloids during pregnancy after showing no particular change at the time of treating the inflammation. We conclude that pregnancy is the strongest risk factor for keloid recurrence in addition to the three clinical risk factors identified through a review of the literature: treatment history, timing of keloid growth, and timing of regression.

The Efficacy of Coblator in Turbinoplasty

Background Turbinate hypertrophy is one of the common causes of chronic nasal obstruction. In principle, therapeutic guidelines recommend medical treatment. Failure to treat turbinate thickening despite drug therapy may indicate the need for surgery. The main aim of this study was to determine the effect of radiofrequency surgery, among various other surgical procedures, on people with both nasal septal deviation and turbinate hypertrophy. Methods Among people with nasal deviation who visited the subject hospital between July 2008 to July 2014, 21 people with nasal septal deviation and severe turbinate hypertrophy before their surgery had undergone septoplasty with turbinoplasty using radiofrequency combined with septoplasty. The degree of the turbinates hypertrophy was appraised in all the patients before and after the surgery using the rhinoscopy, and acoustic rhinometry was objectively carried out. The subjective effect of the turbinoplasty using radiofrequency was explored through the visual analog scale (VAS) score. Results The degree of contraction of the nasal mucosa after the rhinoscopy changed from Grades 3 and 4 (100%) to Grades 1 and 2 (95.2%) and Grades 3 (4.8%). The minimal cross-sectional area significantly increased from 0.44±0.07 to 0.70±0.07 cm2 (p<0.05). The nasal cavity volume increased from 4.79±0.49 to 6.76±0.55 cm2 (p<0.05). The subjective symptoms evaluated with VAS score a year after the surgery significantly improved (p<0.05). Conclusion Turbinoplasty using Coblator with septoplasty is an effective treatment method because it expands nasal cavity, has a low incidence of complications, subjectively improves symptoms, and has short treatment duration.