Nae-Ho Lee

Management of Defects on Lower Extremities with the Use of Matriderm and Skin Graft

Background The reconstruction of large skin and soft tissue defects on the lower extremities is challenging. The skin graft is a simple and frequently used method for covering a skin defect. However, poor skin quality and architecture are well-known problems that lead to scar contracture. The collagen-elastin matrix, Matriderm, has been used to improve the quality of skin grafts; however, no statistical and objective review of the results has been reported. Methods Thirty-four patients (23 male and 11 female) who previously received a skin graft and simultaneous application of Matriderm between January 2010 and June 2012 were included in this study. The quality of the skin graft was evaluated using Cutometer, occasionally accompanied by pathologic findings. Results All 34 patients showed good skin quality compared to a traditional skin graft and were satisfied with their results. The statistical data for the measurement of the mechanical properties of the skin were similar to those for normal skin. In addition, there was no change in the engraftment rate. Conclusions The biggest problem of a traditional skin graft is scar contracture. However, the dermal matrix presents an improvement in skin quality with elastin and collagen. Therefore, a skin graft along with a simultaneous application of Matriderm is safe and effective and leads to a significantly better outcome from the perspective of skin elasticity.

Predisposing factors for poor prognosis of angiosarcoma of the scalp and face: Systematic review and meta‐analysis

Angiosarcoma of the scalp and face is an aggressive tumor with a high rate of local recurrence. Although many previous studies have demonstrated risk factors for poor prognosis, debate remains. We identified the predisposing factors for poor prognosis through comprehensive review of selected studies with meta‐analysis.

A case report of a chemical burn due to the misuse of glacial acetic acid.

As young and elastic skin is what everyone dreams of, various measures have been implemented including chemical, laser resurfacing and dermabrasion to improve the condition of ageing skin. However, the high cost of these procedures prevents the poor from having access to treatment. Glacial acetic acid is widely used as a substitute for chemical peeling because it is readily easily available and affordable. However, its use can result in a number of serious complications. A 28-year-old female patient was admitted to our hospital with deep second-degree chemical burns on her face caused by the application of a mixture of glacial acetic acid and flour for chemical peeling. During a 6-month follow-up, hypertrophic scarring developed on the both nasolabial folds despite scar management. Glacial acetic acid is a concentrated form of the organic acid, which gives vinegar its sour taste and pungent smell, and it is also an important reagent during the production of organic compounds. Unfortunately, misleading information regarding the use of glacial acetic acid for chemical peeling is causing serious chemical burns. Furthermore, there is high possibility of a poor prognosis, which includes inflammation, hypertrophic scar formation and pigmentation associated with its misuse. Therefore, we report a case of facial chemical burning, due to the misuse of glacial acetic acid, and hope that this report leads to a better understanding regarding the use of this reagent.

A Comparison of the Effectiveness of Triamcinolone and Radiation Therapy for Ear Keloids after Surgical Excision: A Systematic Review and Meta-analysis

Background: The ear is a common site for keloid formation, usually after trauma or ear piercing. This study is a meta-analysis to identify effective treatments for ear keloids after surgical excision. Methods: A systematic literature review and meta-analysis were performed using core databases. Postoperative adjuvant treatment modalities for ear keloids and recurrence rates were extracted and analyzed. Fixed and random effect models were applied. Results: Twenty-five studies published before August of 2015 were identified. The recurrence rate after surgical excision of an ear keloid in the triamcinolone group was estimated as 15.4 percent (95 percent CI, 9.4 to 24.1 percent; p < 0.001). The recurrence rate in the radiation therapy group was estimated as 14.0 percent (95 percent CI, 9.6 to 19.9 percent; p < 0.001). Conclusion: Although a large-scale, randomized study is required for confirmation, both triamcinolone and radiation therapy provided outstanding treatment for ear keloids after surgical excision without a significant difference between the two treatments.

Radiofrequency ablation and excision of multiple cutaneous lesions in neurofibromatosis type 1.

Background Von Recklinghausen disease or neurofibromatosis type 1 is an autosomal dominant genetic disorder of chromosome 17q11.2. The most common characteristic findings of NF 1 include multiple and recurrent cutaneous neurofibromas associated with psychosocial distress. Methods Sixteen patients (9 female, 7 male; average age, 31 years; range, 16 to 67 years) with multiple cutaneous neurofibromas between March 2010 and February 2012 were included in the study. All patients were treated with radiosurgical ablation and excision under general anesthesia. Results All 16 patients were satisfied with the results, when questioned directly during the outpatient department follow-up. The only complaint from a few patients was minimal scarring, but acceptable results were obtained in the end. Conclusions The radiofrequency procedure is almost bloodless and quick, creating a smaller necrotizing zone. Therefore, instead of employing the time consuming traditional surgery, such as laser therapy and electrosurgical excision, that produces uncertain results and can affect normal adjacent tissue, treatment of neurofibromas with radiofrequency ablation and excision can be an alternative choice of treatment for patients with a large number of neurofibromas.

Versatility of the Distally-Based Sural Artery Fasciocutaneous Flap on the Lower Leg and Foot in Patients with Chronic Disease

Background A recent advancement in microsurgery, the free flap is widely used in the reconstruction of the lower leg and foot. The simple and effective methods of local flaps, including transposition and advancement flaps, have been considered for patients with chronic debilitation who are unable to endure long surgical procedures or general anesthesia. However, the location and size of the wound may restrict the clinical application of a local flap. Under these circumstances, a sural flap can be an excellent alternative, rendering satisfying clinical outcomes in chronically debilitated patients. Methods Between 2008 and 2012, 39 patients underwent soft tissue defect treatment by sural artery flap as a final method. All of the patients had at least one chronic disease or more (diabetes, hypertension, vascular disease, etc.). Also, all of the patients had a history of chronic lower extremity ulceration, which revealed no response to several months of conservative treatment. Results The results of the 39 cases had a success rate of 100% with 39 complete recoveries. Nine cases suffered complications: partial necrosis (n=4), wound dehiscence without necrosis (n=3), hematoma (n=1), and infection (n=1). Conclusions The sural artery flap is not only useful for the lower leg but also for the heel, and other various parts. Furthermore, it is a relatively simple surgical technique for reconstructing the defect area for patients with various chronic conditions with a high surgical risk or contraindications to surgery.

Ischemic Necrosis of Upper Lip, and All Fingers and Toes After Norepinephrine Use.

A 68-year-old woman with necrosis of total finger, toe, and upper lip was requested by department of internal medicine. She was diagnosed with septic shock and treated with norepinephrine 10 days ago. Norepinephrine is an often-used medicine for normalizing blood pressure in septic shock patients. Norepinephrine stimulates adrenergic receptors, causing vasoconstriction and the rise of blood pressure. These peripheral vasoconstrictions sometimes lead to ischemic changes in end organs. In this case report, the authors describe ischemic necrosis of the upper lip and all fingers and toes after norepinephrine use in a patient in the intensive care unit.

Giant maxillary mucocele occurring after reduction malarplasty.

Reduction malarplasty for patients with a prominent malar complex is a popular procedure in Asia. However, a range of complications have been reported after reduction malarplasty, such as hematoma, orbital complications, asymmetric face, and nonunion. A medially displaced fracture or bony fragment can induce sinusitis and subsequent trauma to bones in combination with chronic inflammatory processes, which can lead to chronic obstruction of mucus-secreting glands. In our case, 46-year-old man presented with a large mucocele in the maxillary sinus after malar reduction approximately 20 years ago.

Risk of major limb amputation in diabetic foot ulcer and accompanying disease: A meta-analysis

BACKGROUND Limb amputation in diabetic patients raises important issues regarding low quality of life and survival rates. This meta-analysis aimed to identify predictive factors accompanying diseases with high major amputation rates in diabetic patients. METHODS A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE and Cochrane databases. Eight variables were extracted from the included studies and evaluated according to major amputation rates. The Newcastle-Ottawa scale (NOS) was utilized to assess the quality of the studies. RESULTS The search strategy identified 101 publications. After screening, 10 articles were selected for review. Hypertension, ischemic heart disease, cerebrovascular disease, and peripheral vascular disease were identified as predictive variables of higher major amputation rates. CONCLUSIONS Although further investigation of long-term and prospective studies is needed, we identified four variables as predisposing factors for higher major amputation in diabetic patients through meta-analysis.

Clinical Experience of Morel- Lavallee Syndrome

Morel-Lavallee syndrome is closed internal degloving of subcutaneous tissue from the underlying fascia by trauma. It was first described in 1848 by French physician Victor Auguste Francosis Morel-Lavallee [1]. The cavity developed and filled with fluid such as hematoma or liquefied fat etc. It was associated with significant soft tissue injury and frequently occurred on the greater trochanter [2]. Although not common, it can be very severe with infection. The first case was a 70-year-old man who had suffered a cultivator accident. Approximately two weeks later, swelling was observed on the left lateral thigh with fluctuation. Ultrasonography and magnetic resonance imaging (MRI) (Fig. 1) were performed and fluid collection was found. It subsided with debridement and percutaneous tube drainage (PCD) and compressive dressing. The patient was treated about 45 days. The second case was a 53-year-old man who suffered a pedestrian traffic accident. MR imaging showed a pelvic bone fracture and a huge hematoma on both thighs. (Fig. 2) He was transfer to plastic surgery 4 days later from the accident. Fig. 1 Magnetic resonance imaging. Fluid collection (white arrow) was observed on left thighs. Fig. 2 Magnetic resonance imaging. Fluid collection (white arrows) was observed on both thighs. Pseudomonas aeruginosa infection was present on the necrotic tissue and necrosis spread like wildfire throughout the cavity. Massive debridement was performed and skin and soft tissue defects were observed on his lower back, sacral area, both buttocks, and lateral thighs. Surgical dressing was done daily and IV antibiotics were administered. The infection subsided and the defect was covered by split thickness skin graft and a local flap (Fig. 3). He was treated about seven months from the day of the accident. The third case was a 45-year-old man who suffered a fall from a ladder, with fluid collection on both thighs. PCD was attempted on both thighs and the symptoms subsided. However, femoral bursitis remained and was removed by simple excision (Fig. 4). Fig. 3 (A) Skin necrosis after injury. Demarcated large area of necrotic tissue was observed. (B) Local flap and split thickness skin graft. Mild contracture was observed. Fig. 4 Femoral bursitis (withe arrow). He was treated for Morel Lavallee syndrome with percutaneous drainage with compression. He underwent one more operation for removal of the bursitis. First and third cases subsided with percutaneous tube drainage and compressive dressing. But the second case, hard to relieve the infection. In this case, Morel-Lavallee syndrome was detected after infection was spread. We report on three cases of Morel-Lavallee syndrome after severe soft tissue injury. Morel-Lavellee syndrome is uncommon and diagnosis is often delayed. MR imaging is good for assessment of Morel-Lavallee syndrome [3]. Various treatment protocols could be used, such as compressive therapy, sclerosant injection, pulse lavage, and open debridement [4,5]. It could be confuse with recalcitrant bursitis of the knee, soft tissue tumors and lymphocele. Analysis of the protein contents and of the cytology of the liquid is the clue for differential diagnosis with them. We consider that the collected fluid and the cavity increased the severity. Infection is spread through the subcutaneous tissue on the internal cavity, and fluid could be a source of bacterial growth. Therefore, drainage of fluid and removal of the cavity was needed before the infection occurred. For that reason, early detection is important, and knowledge of Morel-Lavallee syndrome and a high index of suspicion are needed.