Suk Ho Moon

Treatment of sagittal synostosis: Subtotal cranial vault remodelling with right-angled Z-osteotomies

INTRODUCTIONSnSagittal synostosis is the most common type of non-syndromic craniosynostosis with fusion of the sagittal suture. Various techniques have been introduced for the treatment of this irregular calvarial deformity. However, since these methods were not suitable for patients who were aged over 1 year when they were diagnosed with sagittal synostosis, a new approach should be undertaken.nnnPATIENTS AND METHODSnBetween 2001 and 2005, five patients who were diagnosed with sagittal synostosis, after the age of 1 year, were treated with subtotal cranial vault remodelling. The procedure consisted of right-angled Z-osteotomies in the frontal and parieto-occipital bones, a shortening of the sagittal strut, and barrel-stave osteotomies in the temporal bone. They were undertaken to expand bitemporal diameter and to shorten anteroposterior diameter.nnnRESULTSnCranial index increased from 68.2 to 77.8 immediately after surgery and to 78.4 post-surgery 36 months. Cranial morphologies were satisfactory during follow-up. The main advantage of the procedure is the easy control of fixation angle according to the surgeons preference. There were no major complications including infections or relapses.nnnCONCLUSIONSnThe treatment goal of sagittal synostosis is to eliminate factors that may impede brain development by assuring an adequate cranial cavity and to maintain an aesthetically acceptable cranial morphology. We obtained functionally and aesthetically favourable results by right-angled Z-osteotomies. Further, our one-staged procedure is safe, especially in patients over the age of 1 year.

Combined V-Y Fasciocutaneous Advancement and Gluteus Maximus Muscle Rotational Flaps for Treating Sacral Sores

The sacral area is the most common site of pressure sore in bed-ridden patients. Though many treatment methods have been proposed, a musculocutaneous flap using the gluteus muscles or a fasciocutaneous flap is the most popular surgical option. Here, we propose a new method that combines the benefits of these 2 methods: combined V-Y fasciocutaneous advancement and gluteus maximus muscle rotational flaps. A retrospective review was performed for 13 patients who underwent this new procedure from March 2011 to December 2013. Patients age, sex, accompanying diseases, follow-up duration, surgical details, complications, and recurrence were documented. Computed tomography was performed postoperatively at 2 to 4 weeks and again at 4 to 6 months to identify the thickness and volume of the rotational muscle portion. After surgery, all patients healed within 1 month; 3 patients experienced minor complications. The average follow-up period was 13.6 months, during which time 1 patient had a recurrence (recurrence rate, 7.7%). Average thickness of the rotated muscle was 9.43u2009mm at 2 to 4 weeks postoperatively and 9.22u2009mm at 4 to 6 months postoperatively (p = 0.087). Muscle thickness had not decreased, and muscle volume was relatively maintained. This modified method is relatively simple and easy for reconstructing sacral sores, provides sufficient padding, and has little muscle donor-site morbidity.

A Huge Morel-Lavallée Lesion Treated Using a Quilting Suture Method: A Case Report and Review of the Literature

The Morel-Lavallée lesion is a collection of serous fluid that develops after closed degloving injuries and after surgical procedures particularly in the pelvis and abdomen. It is a persistent seroma and is usually resistant to conservative methods of treatment such as percutaneous drainage and compression. Various methods of curative treatment have been reported in the literature, such as application of fibrin sealant, doxycycline, or alcohol sclerodhesis. We present a case of a huge recurrent Morel-Lavallée lesion in the lower back and buttock region that was treated with quilting sutures, fibrin sealant, and compression, with a review of the literature.

Orbital roof reconstruction using porous polyethylene sheet with embedded titanium.

Abstract Calvarial defects, including the orbital roof defect that occurs after trauma or oncologic resection, require immediate reconstruction to avoid complications such as enophthalmos, diplopia, and transmission of the cerebral pulse to the eye. In these cases, autologous bone grafts or various alloplastic materials have been used. Between January 2010 and December 2010, 5 patients underwent surgery for orbital roof reconstruction using porous polyethylene sheet with embedded titanium, which was developed for reconstruction of inferomedial wall of the orbit. One patient underwent surgery because of tumor excision; the other patients, because of trauma. Two patients had intracranial hemorrhage and 3 patients had a defect in the supraorbital rim. We reconstructed the supraorbital rim and the orbital roof using a combination of calvarial bone graft and the porous polyethylene sheet with embedded titanium. The sheet was bended and trimmed according to the shape of the orbital defect, and it was fixed on the remaining adjacent bone using a microplate. There were no complications during the follow-up period. The patients were satisfied with the external appearance. In conclusion, the orbital roof reconstruction using porous polyethylene sheet with embedded titanium was an easy and a time-efficient procedure with satisfactory results.

Donor-site closure using absorbable dermal staple for deep inferior epigastric artery perforator flaps: its efficacy and cosmetic outcomes

BackgroundSurgeons tend to pay less attention to the donor site during breast reconstruction using deep inferior epigastric artery perforator flaps because attention is focused on microanastomosis and breast shaping. Therefore, donor site closure is typically performed by a secondary operator. We present consistently reduced operative times and improved scar quality using an absorbable dermal staple.MethodsRetrospective review was performed on 25 patients who were either standard suture controls (group I, nxa0=xa015) or received absorbable staples (group II, nxa0=xa010). Mean age, flap size, whole operative time, and length of hospital stay were collected. The donor site scar was evaluated by three plastic surgeons in a blinded manner using the modified Vancouver scar scale 6xa0months after surgery. Data were analyzed with the independent t test, and a p value ≤0.05 was considered significant.ResultsNo differences were detected between the groups for age, harvested flap size, or length of hospitalization. However, operative time was significantly longer in group I (1.07xa0±xa00.24xa0min/cm2) than that in group II (0.86xa0±xa00.16xa0min/cm2, pxa0=xa00.015). The total scar assessment score was significantly lower in group II (3.8 3xa0±xa01.30) than that in group I (5.27xa0±xa01.83, pxa0=xa00.043).ConclusionsAbsorbable dermal stapling reduced operative time, compared to that of traditional suturing. In addition, scar quality from absorbable dermal staples was superior to that resulting from traditional sutures.Level of evidenceII.

The usefulness of microsurgical pedicle lengthening in free anterolateral thigh flaps

A microsurgical pedicle‐lengthening technique can be used when a pedicle length longer than that usually provided by an anterolateral thigh (ALT) flap is required. The purpose of this report is description of pedicle lengthening method from original pedicle length for free ALT flaps and presentation of the results of application of this technique in reconstruction from a series of cases.

Intramuscular Lipoma-Induced Occipital Neuralgia on the Lesser Occipital Nerve.

Occipital neuralgia (ON) is commonly characterized by a neuralgiform headache accompanied by a paroxysmal burning sensation in the dermatome area of the greater, lesser, or third occipital nerve. The authors report a rare case of ON caused by an intramuscular lipoma originating from the lesser occipital nerve.A 52-year-old man presented with sharp pain in the left postauricular area with a 3u200a×u200a2-cm palpable mass. Computed tomography revealed a mass suspiciously resembling an intramuscular lipoma within splenius muscle. In the operation field, a protruding mass causing stretching of the lesser occipital nerve was found. After complete resection, the neuralgiform headache symptom had resolved and the intramuscular lipoma was confirmed through histopathology.Previous studies on the causes of ON have reported that variation in normal anatomic structures results in nerve compression. Occipital neuralgia, however, caused by intramuscular lipomas in splenius muscles have not been previously reported, and the dramatic resolution following surgery makes it an interesting case worth reporting.

Extravasation of a percutaneous femoral hepatic infusion device.

Using a femoral approach for inserting an intra-arterial percutaneous catheter-port device has recently been introduced for targeted treatment of hepatic tumors [1]. Unlike permanent devices that have to be implanted surgically under general anesthesia, percutaneous catheter-ports may be installed under local anesthesia, a benefit for the many cancer patients who have already undergone cancer surgery. The subclavian route is also an option; however, there exists a risk of pneumothorax, reported to be around 4%, and also other complications such as local hematoma and brain infarction [2,3]. Thus, many institutions have been compiling their experience with femoral access and have reported relatively low complication rates [1,2]. n nUnfortunately, as with any injection device, there is always the possibility of extravasation, the leakage of injection material into tissue other than that targeted. Chemotherapeutic agents are generally cytotoxic and may cause necrosis of the surrounding tissue in the thigh and groin area; therefore, this medical emergency must never be underestimated. n nA 29-year-old male patient was referred to the plastic surgery department for infection signs in his right inguinal area (Fig. 1). A hepatitis B carrier through vertical transmission, he had been diagnosed with hepatocellular carcinoma one month previously, and had received his first cycle of chemotherapy by way of a percutaneous intra-arterial catheter port device via his femoral artery. n n n nFig. 1 n nThe lesion upon consultation. There is dry eschar, edema, and skin color change in the right thigh of the patient. n n n nWhile being started on his second cycle, he reported pain in the port area, and administration of epirubicin was immediately stopped. An estimated 15 mL of epirubicin had been administered. The port function was tested, and was found to be normal. Inflammation signs increased, and the port device was removed three days later. He had developed erythema, induration, and swelling of his right medial thigh with a necrotic skin defect measuring 3 cm in diameter, and was thus referred to the plastic surgery department a week after the incident. Computed tomography revealed diffuse swelling and inflammation of the right femoral area, without any abnormal fluid collection. n nThe wound was dressed until demarcation, during which an area of erythematous induration 20×10 cm in size developed, with several points of skin necrosis. Excision of the unhealthy skin was performed, and the necrotic soft tissue was debrided until healthy pinpoint bleeding was found at the fascia level. Local flap coverage was performed and negative pressure wound therapy was applied to aid flap approximation and circulation (Fig. 2). n n n nFig. 2 n nIntraoperative views. (A) Necrotic tissue including the skin, subcutaneous layer, and part of the muscle fascia is debrided. (B) Local flap coverage is performed. n n n nThe flap took about 6 weeks to heal completely, with small areas of disruption that were closed by secondary intention (Fig. 3). The patients low levels of albumin ranging from 2.5 to 3.0 g/dL, anemia with hemoglobin concentrations ranging from 8.2 to 11.0 g/dL, and cycles of chemotherapy were all factors delaying the process of healing. His wound was otherwise uneventful until he expired just over 6 months after diagnosis due to multiorgan failure. Hepatic arterial infusion chemotherapy uses the hepatic artery catheter as a conduit to deliver antineoplastic agents in high concentrations to liver tumors. Permanent intra-arterial catheter systems have to be inserted surgically, either into the gastroduodenal artery or the common hepatic artery. To facilitate long-term administration, percutaneous implantable catheter-port devices have been developed. Herrmann reported on the use of the femoral artery for percutaneous implantation in 2000, a readily accessible method with which most radiologists are familiar [1]. The procedure may be performed under local anesthesia and provides a subcutaneous port that is available for repeated chemotherapy or prolonged parenteral nutrition. The success rate for implantation has been reported to be 90% to 100%, and the implantation technique has been constantly refined to prevent such technical complications as catheter dislocation or migration, catheter occlusion, or extrahepatic perfusion [3]. n n n nFig. 3 n nThe wound at 6 weeks follow-up. The flap healed completely. n n n nChemotherapy ports, like all other injection devices, carry a risk of extravasation, the leakage of an injection agent into untargeted surrounding tissue. The incidence of implanted port extravasation has been reported to be 0.3% to 4.7% [4]. However, this is probably lower than the actual incidence, as most cases are not reported in the literature. Femoral ports, with their many benefits, are unfortunately located in an area where there is usually an abundance of soft tissue, unlike the subclavian port, which is easily located visually. This increases the risk of missing the target, and also necessitates use of a longer needle, which may be more easily dislodged. This also increases the risk of delayed detection because a significant amount of fluid may extravasate subcutaneously before tissue pressures increase. n nExtravasation results in serious necrosis of the surrounding tissue and vasculature, and may require extensive debridement and reconstruction, as in our case. Thus, the authors suggest that several basic precautions be strictly adhered to when implanting and injecting femoral catheter ports. If possible, the port should be located in a more superficial layer so that it is visible externally. Blood withdrawal before injection and saline injection preceding the agent to check for adequate needle placement is mandatory. If in doubt, insertion of the injection needle under ultrasonographic guidance is an option. Patient education and monitoring of the medical team are needed, given the fact that thigh soft tissue is thick and therefore signs of extravasation may be more muted in this area. n nOncology patients in general, not to mention hepatic tumor patients, are in a catabolic state, and consequently have a delayed wound healing prognosis. Extravasation is a devastating medical accident that is detrimental to the patients quality of life and physical health. The patient in our case spent two months of his remaining six months of life recovering from this injury. The risk of extravasation should always be kept in mind when manipulating femoral catheter ports.