Seum Chung

Histologic change of arteriovenous malformations of the face and scalp after free flap transfer.

In three patients with long-standing vascular malformations of the face and scalp, radial forearm free flaps were transferred after a near-total excision of the lesion. All patients had typical high-flow malformations with thrill and bruit. The onset and progression of the malformations were analyzed through clinical and histologic studies. After free flap transfer, the vascular malformations were followed up grossly and histologically for between 4 and 9 years. There was no recurrence of arteriovenous malformation after free flap transfer. The portion of the residual lesion adjacent to the transferred free flap disappeared, and the remaining discoloration also vanished grossly. Histologic comparison of immediate postoperative and 4-month postoperative specimens from the margin and residual lesion using Victoria blue staining showed that the typical preoperative findings for arteriovenous malformation-an intermingling of thick-walled vessels with abundant elastic fibers and thin-walled vessels without elastic fibers-had undergone change, resulting in the disappearance of the thick-walled vessels and leaving only homogeneous, thin-walled vasculature. The highly vascularized free flap, which does not contain abnormal fistulas, impacted the histologic change of the arteriovenous malformation by blocking the vicious cycle of ischemia and anatomic replacement of disfigured skin and subcutaneous tissues.

Skin flap prefabrication using acellular dermal matrix and cultured keratinocytes in a porcine model.

&NA; In an effort to minimize the amount of autogenous tissue that is sacrificed in using a random skin flap, the authors, in a porcine model, implanted 3.0 × 7.0‐cm (median thickness, 1 mm) sheets of commercially available nonmeshed acellular dermal matrix (AlloDerm) subcutaneously. After a vascularization period of 2 weeks, the implants were elevated and used as turnover dermal flaps to cover adjacent 3.0 × 3.0‐cm full‐thickness skin defects. Sheets of autogenous cultured keratinocytes were used for epithelium. The AlloDerm‐cultured keratinocyte complex flaps healed without any complications. Measurements for percent contraction of the wound to determine the suitability of AlloDerm as a dermal flap showed that the wounds had contracted an average of 18 ± 3.6% at 24 weeks. Histological evaluation revealed multilayered keratinocytes and indurations between the cultured keratinocytes and AlloDerm. Fibroblast infiltration and the presence of luminal spaces surrounded by capillary endothelium characteristic of neovascularization of the matrix were also noted. This preliminary study may form the basis for developing other types of prefabricated flaps using AlloDerm and cultured keratinocytes. Tark K‐C, Chung S, Shin K‐S, Park B‐Y. Skin flap prefabrication using acellular dermal matrix and cultured keratinocytes in a porcine model. Ann Plast Surg 2000;44:392‐397

A Retrospective Review of Iatrogenic Skin and Soft Tissue Injuries

Background Even though the quality of medical and surgical care has improved remarkably over time, iatrogenic injuries that require surgical treatment including injuries caused by cast and elastic bandage pressure, extravasation, and dopamine-induced ischemia still frequently occur. The goal of this study was to estimate the incidence and analyze the distribution of iatrogenic injuries referred to our department. Methods A retrospective clinical review was performed from April 2006 to November 2010. In total, 196 patients (116 females and 80 males) were referred to the plastic surgery department for the treatment of iatrogenic injuries. We analyzed the types and anatomic locations of iatrogenic complications, along with therapeutic results. Results An extravasation injury (65 cases, 37.4%) was the most common iatrogenic complication in our study sample, followed by splint-induced skin ulceration, dopamine-induced necrosis, prefabricated pneumatic walking brace-related wounds and elastic bandage-induced wounds. Among these, prefabricated pneumatic walking brace-related complication incidence increased the most during the 5-year study period. Conclusions The awareness of the very common iatrogenic complications and its causes may allow physicians to reduce their occurrence and allow for earlier detection and referral to a plastic surgeon. We believe this is the first study to analyze iatrogenic complications referred to a plastic surgery department in a hospital unit.

Reduction mammaplasty by central pedicle flap with short submammary scar

Reduction mammaplasty was performed in 30 patients by combining the central pedicle flap method with the short submammary scar (3-S) technique to avoid the common drawbacks of currently popular dermoglandular procedures. Reduction was accomplished by using perforating vascular branches from the pectoralis major muscle and its fascia supplying the nipple and breast parenchyme instead of the subdermal plexus. The central vascular pedicle supplying the nipple-areola complex was preserved. Only the periphery of the breast parenchyme was resected circumferentially, with the exception of the inferolateral portion, so as not to injure the sensory nerve. The remaining breast parenchyme was preserved in an inverted cone shape. The nipple-areola complex was safely transposed with great freedom, and the amount of resection was accurately adjusted for symmetry. No cases of nipple-areola complex sensory change occurred postoperatively, and lactation is possible because of preservation of the lactiferous ducts. The length of postoperative scars was reduced by using the short submammary scar technique. We believe this combined method is ideal in patients requiring resections ranging from 200 to 600 g per breast with good skin elasticity and moderate degree of ptosis.

Multiple Myopericytoma of the Face and Parotid Gland

Myopericytoma is a benign tumor that is composed of myoid-appearing oval to spindle-shaped cells with a concentric perivascular pattern of growth. The tumor is morphologically heterogeneous and can exhibit a broad histologic spectrum. We describe a case of multiple myopericytoma occurring in the head and neck skin region with involvement of the parotid gland where it is known to occur very rarely. A 40-year-old woman noticed multiple enlarging, painless, round-shaped masses on her left cheek. The patient had experienced a similar lesion of the same area 8 years earlier which was completely excised and the pathological diagnosis was spindle cell type myoepithelioma. On a computed tomographic image, one mass involved the superficial parotid gland and was well encapsulated. Excision of the facial masses and superficial parotidectomy with facial nerve preservation were performed. A diagnosis of myopericytoma was established in light of the immunohistochemical pattern with the histopathological findings. Over the 4-year follow-up period, there was no evidence of recurrence. As many perivascular myoid neoplasms share common morphologic features with myopericytoma, we should consider the differential diagnosis, and confirm the histological findings with appropriate immunohistochemical staining. After identifying myopericytoma, it should be treated with wide surgical excision to prevent local recurrence.

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.

Rapidly developed squamous cell carcinoma after laser therapy used to treat chemical burn wound: a case report.

BackgroundIn chronic wounds, especially burn scars, malignant tumors can arise. However, it is rare for a subacute burn injury to change to a malignant lesion within one month. Moreover, a case of squamous cell carcinoma arising from HeNe laser therapy after a chemical burn has never been reported.Case reportIn this report, we examine a rare case of squamous cell carcinoma arising from HeNe laser therapy after a chemical burn. Because pathologic investigations were made from the first operation, both early detection of the squamous cell carcinoma and consideration of the HeNe laser therapy as a risk factor for the skin cancer were possible. The cancer was completely removed and reconstruction of the defect was successfully achieved in a timely manner.ConclusionAlthough there has as yet been no reported case of squamous cell carcinoma induced by laser therapy, it is important for clinicians to recognize both the possibility of laser-induced cancer and the rapid change of cancer, so they can provide appropriate and timely treatment.

Gemella morbillorum Infection after Acupuncture Therapy.

Gemella morbillorum (G. morbillorum) is a part of the normal human flora and is an extremely rare cause of infection [1]. However, Gemellae are also classified as opportunistic pathogens that are able to cause severe localized and generalized infections [2]. In this case report, we describe an infection of G. morbillorum on the chest wall after acupuncture therapy. Our patient was a 74-year-old male who had a thoracic wall contusion because of a bicycle accident. Initially, there were no open wounds or specific symptoms besides bruising and mild pain. The patient underwent acupuncture therapy before the trauma event due to back pain, at a private Korean traditional oriental medicine clinic on a regular basis; he had undergone a total of four acupuncture treatments, every three days starting from the third post-traumatic day. On the 18th day after injury, he visited the orthopedic surgery department for lumbar spinal stenosis and was transferred to the thoracic surgery department due to swelling and erythema of the anterior chest wall. In the physical examination, an abscess was observed in the anterior thoracic wall. A simple X-ray study revealed a sternal fracture. After bacterial culture and debridement of the wound (Fig. 1), we observed mediastinitis involving the sternal bone defect and confirmed surrounding soft tissue infection that disseminated to the pericardium (Fig. 2). Although a blood culture study showed no growth of bacteria, in the wound culture study, G. morbillorum was confirmed, and appropriate antibiotics (ampicillin/sulbactam) according to the susceptibility test were injected into the patient. IV antibiotics were administered for 5 weeks and oral antibiotics (amoxicillin/clavulanate) for 3 weeks. After abscess removal, daily debridement and irrigation were performed for 1 month. A wound culture study was conducted every four days, and after confirmation of four consecutive results of negative growth, we planned to reconstruct the thoracic wall with an internal mammary artery perforator flap (IMAP flap). The patients preoperative computed tomography (CT) angiography confirmed a left first internal mammary artery perforator. We designed a fasciocutaneous flap on the left side of the sternum based on this perforator (Fig. 3). We incised the upper border of the design and confirmed the pulse of the left first internal mammary artery, and then completely elevated the fasciocutaneous flap and covered the defect successfully. The flap showed a nice contour. There were no complications of the surgical site at the one-month follow-up (Fig. 4). Follow-ups were done at 3 months and 6 months after operation in the outpatient clinic and showed good results (Fig. 5). In Eastern countries, many patients receive acupuncture therapy on blunt trauma areas. Acupuncture therapy is also increasingly used in the West. The most common complication of acupuncture therapy is infection, and the most common pathogen isolated from the wound is Mycobacterium [3]. Our case report shows that G. morbillorum, which rarely causes soft tissue infection, can cause severe mediastinal infection or endocarditis under conditions of non-sterile acupuncture therapy in a patient with a missed sternal fracture. In the present case in particular, osteomyelitis was also present. After the patient received blunt trauma on the sternum area, no external wound was observed, and he underwent acupuncture therapy due to continuous pain. Intravenous drug abuse, alcoholism, cardiovascular disease, renal disease, and poor oral hygiene are known as the predisposing factors of a Gemella infection [2]. This patient did not have the aforementioned factors, and since the patient had no open wound upon trauma, erythema and swelling after acupuncture therapy, it is plausible that the infection was caused by acupuncture therapy rather than a hematogenous infection. The treatment of primary sternal osteomyelitis is appropriate antibiotics and debridement of the infected tissue including bone [4]. The defect after debridement can be covered with a myocutaneous flap [4]. In our case, the organism was successfully eradicated with appropriate antibiotic medication, and the defect of the anterior chest wall was reconstructed with an IMAP flap. The IMAP flap has not been widely used for the reconstruction of the chest wall, particularly in the case of an infected wound. However, we used an IMAP flap by confirming infection control in culture studies and considering donor morbidity. The IMAP flap is a good modality due to its quick, ease of flap elevation, and lack of muscle insult. Due to the limited number of published reports regarding a severe G. morbillorum infection after acupuncture therapy, early recognition and treatment is difficult. In such patients who received acupuncture therapy after traumatic injury, severe infection including osteomyelitis should be considered. In our patient, with appropriate antibiotic therapy and timely surgical management, the result was good without complication. Fig. 1 Intraoperative sternal wound. Fig. 2 After debridement, a thoracic wall defect including sternum and mediastinitis is observed in the computed tomography. Fig. 3 Flap design. Fig. 4 Postoperative 1-month view. The reconstructed thorax shows a nice contour, and the donor site scar is acceptable. Fig. 5 Postoperative 3-month view.

Rhomboid design for tubed inguinal flap in fingertip reconstruction

The authors present a rhomboid design for the tubed inguinal flap mainly nourished by the superficial circumflex iliac vessels and the superficial inferior epigastric vessels. The length and width of the flap are mathematically determined based on the perimeter and length of the fingertip soft-tissue defect, respectively. The rhomboid tubed inguinal flap was used in the treatment of 21 patients with a variety of fingertip injuries. The thumb was involved in 12 patients and other digits in 9 patients. A complication, flap necrosis, occurred in one obese female patient and osteomyelitis of an amputated phalangeal bone developed in another. In all other patients, the rhomboid tubed inguinal flap healed uneventfully and provided satisfying results with minimal donor site morbidity. As a secondary procedure in thumb injuries, four neurovascular island flaps and one wraparound flap from the great toe were done for improved sensation. The precisely tailored rhomboid flap, with a safe and abundant vascular pedicle, allows for effective reconstruction of the fingertip with easy primary closure and minimal morbidity of the donor site.

Primary extracranial meningioma presenting as a forehead mass

Meningioma originates from arachnoid cap cells and is the second most common intracranial tumor; however, it can also be found in an extracranial location. A very rare primary extracranial meningioma without the presence of an intracranial component has also been reported. Primary extracranial meningiomas have been found in the skin, scalp, middle ear, and nasal cavity. A computerized tomography or magnetic resonance imaging scan is necessary to determine the presence or absence of an intracranial meningioma, and a biopsy is essential for diagnosis. We report a case of primary extracranial meningioma located in the forehead skin of a 51-year-old male.