Su-Shin Lee

Endoscopic excision of benign tumors in the forehead and brow.

Twenty-five cases of benign tumor of the forehead and brow were excised successfully with endoscope-assisted surgery. The access incision was selected strategically behind the front hairline. For tumors in the middle of the forehead, the tumor was approached by subgaleal dissection. For those in the brow or temporal area, the dissection plane was just superficial to the deep temporal fascia. Patient age ranged from 3 to 59 years. The mass varied in size from 1.0 × 0.5 to 2.0 × 2.0 cm. There were 18 lipomas, 6 dermoid cysts, and 1 pilomatricoma. There was no residual mass or recurrence 1 to 24 months postoperatively. There was no paresthesia or numbness in the scalp. Patients and their families were greatly satisfied with this operation and the absence of visible scarring.

Surgical treatment of the chronic tophaceous deformity in upper extremities - the shaving technique.

BACKGROUND Tophaceous gout is frequently directly related to the duration and the severity of hyperuricaemia. Conventional surgical debridement of the tophaceous lesions carries the risk of overlying skin necrosis. Life-long urate-lowering drugs have become the mainstay of primary treatment. However, surgical intervention may be necessary when the overlying skin becomes ulcerated and wound infection develops. This has become the impetus for new surgical treatment methods with less potential for morbidity. METHODS From November 2000 to July 2006, 32 patients with chronic tophaceous deposits involving their hands or elbows were treated surgically in our hospital. In this series, a soft tissue shaver device with a mini-incision technique was used to treat upper extremity tophaceous lesions. Multiple 5-mm skin incisions were made to allow direct access to the tophaceous mass. Intra-lesion shaving was done. A tourniquet aided reduction of intraoperative blood loss. Suction and irrigation were performed simultaneously while the shaver system was operating; the chalky deposits of sodium urate were thereby removed efficiently. RESULTS No major complications were noted among these 32 patients. Using this shaver technique, each tophaceous lesion was removed in less than 15 min. Twenty-nine of these operations (80.6%) were performed for patients at the intercritical gout phase. Two patients suffered a recurrent acute attack of gouty arthritis within 12h after the operation. Symptoms were controlled by oral colchicine as well as nonsteroidal anti-inflammatory drugs (NSAID). Swelling at the operative site was usually evident for the first 10 days postoperatively, therefore posture drainage is advised. CONCLUSION The shaver technique provides another option in the surgical treatment of tophaceous lesions. It prevents poor wound healing associated with tendon or joint exposure that often occurs after conventional enucleating procedures. The tophaceous lesions can be treated surgically at the intercritical gout phase. Also, the upper extremity group has a shorter hospitalisation period when compared with our preliminary study involving treatment of tophaceous deposits in the lower extremity. The shaver technique is worthy of consideration in the treatment of upper extremity chronic tophaceous patients.

The soft-tissue shaving procedure for deformity management of chronic tophaceous gout

Gout is a condition characterized by the deposition of monosodium urate crystals in the joints or soft tissue. A gouty tophus occasionally mimics an infectious or neoplastic process. However, the conventional enucleating procedure might cause complications. In severe cases, skin necrosis and tendon or joint exposure can occur after debridements. In this series, the soft-tissue shaver is used for deformity management of the chronic tophaceous patients and the results are encouraging. From November 2000 to August 2002, 17 patients with chronic tophaceous gout were treated by the shaver technique. Suction and irrigation were performed simultaneously while the shaver was operating, and chalky deposits of sodium urate could be removed efficiently. Skin necrosis was minimized by means of proper incision planning. Also, bedside debridements and wound wet dressing were helpful for improving the outcomes. The families and patients were satisfied with the results. In conclusion, severe chronic tophaceous gout can be a surgical challenge. The soft-tissue shaving technique can be useful for cosmetic debulking of large tophi in patients with advanced chronic tophaceous gouty arthritis.

Endoscope-assisted parotidectomy for benign parotid tumors.

&NA; Sixteen cases of parotidectomy of benign tumors were performed by means of a short incision with the assistance of endoscopic surgery. The average length of the preauricular and retromandibular incision was 6.9 cm (range, 6.0‐8.1 cm). This incision provided safe dissection of the facial nerve trunk and exposed a major part of the gland to direct vision. Identification and separation of the facial nerve branches in peripheral glandular tissue was performed by means of endoscopic surgery instead of wide exposure with a long incision. Because endoscopic surgery provided good illumination and magnification on the monitor, the operation could proceed clearly and sharply in a bloodless field. Therefore, the incidence of facial nerve injury and perioperative morbidity was minimized. In this series, tumors were removed completely, without injury to the facial nerve. Patients were also satisfied with the short and inconspicuous postoperative scars. Lin S‐D, Tsai C‐C, Lai C‐S, Lee S‐S, Change K‐P. Endoscope‐assisted parotidectomy for benign parotid tumors. Ann Plast Surg 2000;45:269‐273

Autologous fat grafting alleviates burn-induced neuropathic pain in rats.

Background: The management of neuropathic pain after burn injury is a critical clinical issue. Autologous fat grafting has been shown to alleviate neuropathic pain in certain cases, but has not been shown to alleviate the pain associated with burn-induced scars. The authors assessed the effectiveness of autologous fat grafting for the management of pain in burn-induced scars. Methods: One paw of the experimental rats received a third-degree burn using a heated metal block. Neuropathic pain in the affected paw was assessed based on behavioral responses to thermal and mechanical stimuli. A graft (0.4 ml of autologous fat or a sham graft) was administered by injection to the burn scar and sham-burned paw. The animals were killed 4 weeks after the fat graft treatments; Masson trichrome stain of hind-paw skin and expression of phosphorylated p38 and OX42 in the dorsal horns of the spinal cords were examined. Result: The third-degree burns were completely healed at 4 weeks. Burn-induced scarring caused mechanical allodynia and increased the expression of phosphorylated p38 and OX42 in spinal cord dorsal horn microglial cells. Autologous fat grafting significantly alleviated mechanical allodynia (p < 0.05), and immunohistochemistry showed that the expression of phosphorylated p38 and OX42 was significantly lower in spinal cord dorsal horn microglial cells 4 weeks after fat grafting (p < 0.05). Conclusions: Autologous fat grafting is used daily in clinical practice. It is an effective treatment for the relief of burn-induced mechanical allodynia in rats. Further investigation of the clinical use of autologous fat grafting in burn patients is warranted.

Body Dysmorphic Disorder in Patients With Cosmetic Surgery

Body dysmorphic disorder (BDD) refers to a preoccupation with an imagined or grossly exaggerated minor physical defect. Those with BDD might seek medical help (cosmetic surgery) rather than attend a psychiatric clinic. Therefore, it is often underdiagnosed. To investigate the prevalence of BDD, we reviewed the medical records of 817 individuals who sought cosmetic surgery during a 3‐year period. The outcome after surgery was described for those with BDD. Our results showed that 63 (7.7%) patients had BDD, of which 54 (85.7%) were diagnosed at preoperative evaluation. However, nine (14.3%) patients went undiagnosed and all had a bad outcome after cosmetic surgery. BDD was not uncommon at the cosmetic surgery clinic. Our results support the idea that cosmetic surgery should be avoided for patients with BDD. The development of a more effective diagnostic procedure could help address this issue.

Influencing factors of outcome after lower-limb amputation: a five-year review in a plastic surgical department.

The crude major lower limb amputation procedure rate is 8.8 per 100,000 of the population per year in Taiwan. From January 2002 to October 2006, patients that received major lower limb amputation in our department were enrolled in this study. Retrospective chart reviews concerning different factors that can affect the eventual postoperative functional status were investigated. Factors that affected the length of hospital stay included duration before amputation (P < 0.001) and renal function (P = 0.045). Phantom limb pain was affected by wound healing time (P = 0.006). Factors that affected the daily prosthesis usage time were initial infection status (P = 0.021), renal function (P = 0.01), patient educational level (P = 0.016), and pretraining waiting time (P = 0.003). The duration of prosthetic training was affected by patient educational level (P = 0.004) and marital status (P = 0.024). In addition, subjective satisfaction about the usage of prosthesis was affected by pretraining waiting time (P = 0.001) and daily prosthesis usage time (P < 0.001). The daily prosthesis usage time was closely related to life quality improvement (P < 0.001) and subjective satisfaction of prosthesis usage (P < 0.001). Despite reported unchangeable factors like age, end-stage renal disease, dementia, coronary artery disease, and level of amputation, preprosthesis training waiting time significantly affected the satisfaction and daily usage time of the prosthesis. Surgeons can make some contribution to accelerate amputation wound healing and stump maturation by choosing the correct operating procedure, delicately managing the soft tissue, and ascertaining proper wound care to improve the outcome.

Alleviation of Neuropathic Scar Pain Using Autologous Fat Grafting

AbstractTraumatic wounds inflict small- and large-fiber sensory nerve damage, causing neuropathic pain in scar tissue, thus impairing patients’ quality of life and leading to the development of psychological disorders. Autologous fat grafting has been clinically shown to improve scar quality, but few studies have explored the effects of this technique on pain. The purpose of this study was to assess the effect of fat grafting on treating neuropathic scar pain. From February 2008 to January 2013, 13 patients who were identified using the Douleur Neuropathique 4 Questions (scores >4/10) were enrolled in this study. The Visual Analog Scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) were used to evaluate pain preoperatively and 1 week, 4 weeks, and 24 weeks postoperatively. The mechanism of trauma, scar location and size, duration of allodynia, fat graft volume, pharmacologic therapy duration, and total follow-up time were recorded. Thirteen patients experiencing neuropathic pain were enrolled in this study. The mean ± SD age was 33.08 ± 16.35 years. The mean duration of pain was 4.29 ± 2.85 months. The mean VAS score before treatment was 7.54 ± 1.05. The mean VAS scores decreased by 4.38 ± 1.66 after 1 week of treatment (P = 0.009), 5.38 ± 2.06 after 4 weeks of treatment, and 5.62 ± 2.18 after 24 weeks of treatment. The mean NPSI scores were 49.38 ± 13.25 before treatment, 25 ± 14.4 after 1 week of treatment (P = 0.004), 21 ± 17.78 after 4 weeks of treatment, and 14.62 ± 16.88 after 24 weeks of treatment. The 13 patients followed a mean of 24 weeks; 10 (77%) of the patients had improvement of 5 or greater on the VAS score. The mean follow-up period was 19.3 ± 12.26 months (range, 6–38 months). No surgical complications were noted in this series. In our study, both VAS and NPSI scores decreased significantly, revealing that the autologous fat grafting can alleviate neuropathic scar pain 1 week after operation and in the long term.

A review of intraoperative airway management for midface facial bone fracture patients.

In craniofacial trauma patients, oral route endotracheal intubation may thwart the accuracy of dental occlusion and nasotracheal intubation carries the risk of intracranial invasion in skull base fracture cases.Between November 2005 and June 2006, patients receiving facial bone fracture operations at Kaohsiung Medical University Hospital were enrolled in this study. Intraoperatively, the endotracheal tube was pushed to either the retromolar space or the missing tooth space and secured by two 4.0 silk stitches. Then, surgeons could perform the usual procedure to explore the fracture sites, check the occlusion and correct the deviated nose without limitation. Also, for better understanding the time needed for various intubation techniques, a time-measuring study was performed.Ninety-one patients were treated by this method. Most of them were satisfied with the result of occlusion and nasal contour. Only 2 patients received second surgery to correct nasal deformity. One hundred seventeen anesthesia procedures were checked. In average, an experienced anesthesiologist could successfully intubate a patient in less than 105 seconds. The advantages and reported complications of different intubation methods were discussed.This retromolar position and tooth fixation technique allowed surgeons to correct the dental occlusion and nasal deformity simultaneously. It has served well for zygoma fracture, maxilla fracture, and Le Fort II fracture patients. It is worthy of consideration in management of middle face trauma patients involving occlusion change and nasal deviation.

Medial epicanthoplasty based on anatomic variations

The presence of epicanthal folds is a unique appearance in the eyelids of Asians. Various medial epicanthoplasty techniques have been discussed to achieve a better aesthetic result. Owing to the complexity of the surgery, a design based on anatomic variations of the epicanthal fold is imperative. From September 2006 to November 2010, the author performed medial epicanthoplasty procedures on 86 Asian patients. The whole procedure, including discrepant Z skin incision, myotomy and the plication of the medial canthal ligament (MCL), was performed layer by layer. The inner canthal distance (ICD) was measured and calculated by software ImageJ before and 3 months after surgery. All patients were satisfied with the long-term results and there were no recurrences of the epicanthal fold. The shortening ratios of the ICD ranged from 7.2% to 13.7% (average 10.78%) in the group without the plication of the MCL (57/86). In addition, the ICD shortening ratio ranged from 9.1% to 17.7% (average 15.66%) in the group with the MCL plication (29/86). The technique we described is aimed to correct layered structures including skin, muscle and the MCL of the medial epicanthus. Satisfactory results were ideally achieved with finer scar and natural cosmetic appearance in this series.