Si Gyun Roh

Innervated Cross-Finger Pulp Flap for Reconstruction of the Fingertip

Background Fingertip injuries involving subtotal or total loss of the digital pulp are common types of hand injuries and require reconstruction that is able to provide stable padding and sensory recovery. There are various techniques used for reconstruction of fingertip injuries, but the most effective method is functionally and aesthetically controversial. Despite some disadvantages, cross-finger pulp flap is a relatively simple procedure without significant complications or requiring special techniques. Methods This study included 90 patients with fingertip defects who underwent cross-finger pulp flap between September 1998 and March 2010. In 69 cases, neurorrhaphy was performed between the pulp branch from the proper digital nerve and the recipients sensory nerve for good sensibility of the injured fingertip. In order to evaluate the outcome of our surgical method, we observed two-point discrimination in the early (3 months) and late (12 to 40 months) postoperative periods. Results Most of the cases had cosmetically and functionally acceptable outcomes. The average defect size was 1.7×1.5 cm. Sensory return began 3 months after flap application. The two-point discrimination was measured at 4.6 mm (range, 3 to 6 mm) in our method and 7.2 mm (range, 4 to 9 mm) in non-innervated cross-finger pulp flaps. Conclusions The innervated cross-finger pulp flap is a safe and reliable procedure for lateral oblique, volar oblique, and transverse fingertip amputations. Our procedure is simple to perform under local anesthesia, and is able to provide both mechanical stability and sensory recovery. We recommend this method for reconstruction of fingertip injuries.

A Rare Case of Pulmonary Epithelioid Hemangioendothelioma Presenting with Skin Metastasis

Epithelioid hemangioendothelioma (EHE) is a well-differentiated and rare vascular tumor. Systemic metastases are uncommon. Herein, we present a patient with skin metastasis of pulmonary EHE (PEH) that was treated by wide excision. A 76-year-old male was evaluated due to pulmonary thromboembolism and a solitary pulmonary nodule. A biopsy was performed and pathological examination of the mass confirmed EHE. No metastasis was observed. The patient returned to care approximately two years later due to a painful nodule in the right lower leg. A skin biopsy showed metastatic EHE from the lung. We used a safety margin of 1 cm based on clinical experience, because no prior case had been reported regarding the resection margin appropriate for primary cutaneous EHE and skin metastases of PEH. At four months after surgery, the patient recovered without complications or recurrence. Skin metastasis of PEH is extremely rare, and only two cases have been reported in the literature. In this case, we report a rare case of PEH with histologically diagnosed skin metastasis that was successfully treated by curative resection. It is expected that this case report will provide a helpful contribution to the extant data regarding PEH metastases.

Congenital Insensitivity to Pain and Anhidrosis

Hereditary sensory and autonomic neuropathy (HSAN) or hereditary sensory neuropathy has five different clinical subtypes. Congenital insensitivity to pain and anhidrosis (CIPA) is HSAN type IV. CIPA is a rare disease with an autosomal recessive inheritance. Recurrent episodes of fever, no sweating, insensitivity to pain, and self-injury are symptoms of CIPA. In addition, most patients suffering from CIPA experience mental retardation [1]. CIPA has been reported to occur with a genetic mutation of the neurotrophic tyrosine kinase 1 (NTRK1) gene [2]. This gene is encoded in the tyrosine kinase receptor, which is responsible for nerve growth factor. Thus, the signals for pain, heat, and cold cannot be transmitted to the brain. A previous study reported that approximately 20% of patients with CIPA die due to hyperpraxia before the age of 3 years [3]. Here, we report on a 33-month-old female with CIPA who presented with a pathognomonic clinical feature. This 33-month-old female child visited our department. Both her hands were crusted, with yellowish discharge, swelling, redness, and heating sensation on her right index finger (Fig. 1). On the X-ray, the distal phalanx of the right index finger had disappeared and the distal phalanx of the contralateral index finger was destructed (Fig. 2). The patient was diagnosed with cellulitis and osteomyelitis. She sucked and bit her fingers even though her fingers had a large number of open wounds. Therefore, we applied an elastic bandage on both of her hands in order to stop the sucking. Antibiotic treatment was also administered. During follow-up, swelling was observed on the left dorsum of the foot with no pain. She was diagnosed with a fracture of the first metatarsal bone (Fig. 3). She visited the orthopedic surgery department, and a splint was applied. Two days later, she was transferred to our department because of a splint sore. At this time, we realized that she could not feel the pain. She did not sweat easily and therefore had recurrent fever and did not wear clothes well for fever control. She had repeated oral ulcers and injuries to the hands and feet, such as contact burns. The Sequenced Language Scale for Infants showed delayed mental age at 13 months and low IQ at 66 points. Fig. 1 (A) Right hand. On the right index finger, an erythematous swelling was observed. There was yellowish discharge and a heating sensation. Further, multiple crusts and scars were observed. (B) Left hand. On the left hand, multiple crusts and scars were ... Fig. 2 X-ray of the right-hand oblique view. Distal phalangeal bone of the right index finger had disappeared. Fig. 3 X-ray of left foot. Fracture of the first metatarsal bone was observed. Because of the elastic bandage, the patient was no longer able to suck and bite her fingers. Thereafter, the symptoms (yellowish discharge, swelling, redness, and heating sensation) were relieved. The patient was discharged after a total hospital stay of 16 days. A weak steroid ointment was applied on her fingers. This ointment has a bitter taste; thus, the patients sucking behavior decreased. The fracture of the first metatarsal bone healed with union achieved by maintaining the splint in place. The sore also healed with the dressing. We recommended nerve biopsy to confirm the diagnosis; however, the patients parents did not give their consent for the procedure. CIPA is a rare disease with a short life expectancy. It is a hereditary disorder, but it could present with sporadic occurrence [4]. Specific treatment of CIPA is not known. Nevertheless, proper training is needed for prevention of injury. Patients suffering from CIPA usually visit the pediatrics department complaining of high fever. However, they may also visit a plastic surgeon due to recurrent wounds on the hands and feet. If the plastic surgeon is aware of CIPA, proper management could be administered in order to extend the patients life expectancy.

Squamous Cell Carcinoma Arising from an Epidermal Inclusion Cyst

Epidermal inclusion cysts are commonly encountered benign cystic lesions that can occur anywhere in the body. However, malignant changes are rare, and only a few cases of malignant change have previously been reported [1,2].