Sung Tack Kwon

Three-Dimensional Pre-Bent Titanium Implant for Concomitant Orbital Floor and Medial Wall Fractures in an East Asian Population

Background The objective of this article is to evaluate clinical outcomes of combined orbital floor and medial wall fracture repair using a three-dimensional pre-bent titanium implant in an East Asian population. Methods Clinical and radiologic data were analyzed for 11 patients with concomitant orbital floor and medial wall fractures. A combined transcaruncular and inferior fornix approach with lateral canthotomy was used for the exposure of fractures. An appropriate three-dimensional preformed titanium implant was selected and inserted according to the characteristics of a given defect. Results Follow-up time ranged from 2 to 6 months (median, 4.07 months). All patients had a successful treatment outcome without any complications. Clinically significant enophthalmos was not observed after treatment. Conclusions Three-dimensional pre-bent titanium implants are appropriate for use in the East Asian population, with a high success rate of anatomic restoration of the orbital volume and prevention of enophthalmos in combined orbital floor and medial wall fracture cases.

New classification of polydactyly of the foot on the basis of syndactylism, axis deviation, and metatarsal extent of extra digit.

Background Polydactyly of the foot is one of the most frequent anomalies of the limbs. However, most classification systems are based solely on morphology and tend to be inaccurate and less relevant to surgical methods and results. The purpose of this study is to present our new classification of polydactyly of the foot, which can serve as a predictor of treatment and prognosis. Methods To find a correlation between the various morphologic traits of polydactyly of the foot and the treatment plan and outcomes, we reviewed 532 cases of polydactyly of the foot in 431 patients treated in our hospital, expanding on our previous study that described polydactyly based on the importance of metatarsal bone status and varus deformity. The records of patients were evaluated and compared with previous studies at other centers. Results Unsatisfactory results were seen in 36 cases, which included 5 cases of incomplete separation due to syndactylism, 23 cases of axis deviation, and 8 cases of remnants of extra-digit metatarsal bones. The locus of the polydactyly, or the digit which was involved, did not seem to affect the final postoperative outcomes in our study. Three factors-syndactylism, axis deviation, and metatarsal extension-are the major factors related to treatment strategy and prognosis. Therefore, we developed a new classification system using three characters (S, A, M) followed by three groups (0, 1, 2), to describe the complexity of polydactyly of the foot, such as S1A2M2. Conclusions Our new classification could provide a communicable description to help determine the surgical plan and predict outcomes.

Foot Syndactyly: A Clinical and Demographic Analysis

Background Syndactyly of the foot is the second most common congenital foot anomaly. In East Asia, however, no large case study has been reported regarding the clinical features of isolated foot syndactyly. In this study, we report a review of 118 patients during the last 25 years. Methods We conducted a chart review of patients who underwent surgical correction for foot syndactyly between January 1990 and December 2014. Operations were performed with a dorsal triangular flap and a full-thickness skin graft. The demographics of included patients and their clinical features were evaluated. Surgical outcomes and complications were analyzed. Results Among 118 patients with 194 webs (155 feet), 111 patients showed nonsyndromic cases and 7 patients showed syndromic cases. In 80 unilateral cases (72.1%), the second web was the most frequently involved (37.5%), followed by the fourth (30%), the first (15%), the third (15%), the first and second in combination (1.3%), and the second and third in combination (1.3%). Among 31 bilateral cases, 2 cases were asymmetric. Among the remaining 29 symmetric bilateral cases, the second web was the most frequently involved (45.2%), followed by the first (22.6%), and the fourth (6.5%). No specific postoperative complications were observed, except in the case of 1 patient (0.51%) who required a secondary operation to correct web creep. Conclusions This retrospective clinical study of 118 patients with both unilateral and bilateral foot syndactyly revealed that the second web was the most frequently involved. In addition, complete division and tension-free wound closure with a full-thickness skin graft of sufficient size showed good postoperative results.

Medial and lateral canthal reconstruction with an orbicularis oculi myocutaneous island flap.

Background The eyelid and canthal areas are common locations for cutaneous tumors. The medial canthus includes, among many other apparatuses, the canthal tendon and lacrimal canaliculi, and its characteristic thin and supple skin is hard to mimic and restore using tissue from other regions. Accordingly, reconstruction of the canthal area can prove challenging for surgeons. Although various methods, such as skin grafts and local flaps from adjacent regions, have been utilized for reconstructive purposes, they present known disadvantages. However, we were able to successfully reconstruct both lateral and medial canthal area defects by using orbicularis oculi myocutaneous island flaps. Methods Our study included seven patients who underwent medial or lateral canthal region reconstruction, using orbicularis oculi myocutaneous island flaps, between 2011 and 2014, following either cutaneous tumor excision or traumatic avulsion injury. Results Five patients had basal cell carcinoma, one had squamous cell carcinoma of the eyelid, and one had sustained a traumatic avulsion injury of the eyelid and canthal area. Entire flap loss was not observed in any patient, but one-a heavy smoker-showed partial flap loss, which healed with secondary intention and yielded acceptable results. Donor site morbidity was not observed, and all patients were satisfied with their surgical outcomes. Conclusions The canthal regions can be successfully reconstructed with orbicularis oculi myocutaneous island flaps. These flaps offer several key advantages, including similarity in texture, color, and thickness to the recipient site and a negligible incidence of donor site morbidity.

Nerve Regeneration and Functional Recovery With Neurorrhaphy Performed at the Early Distraction Osteogenesis: An Experimental Study

Abstract Distraction osteogenesis is widely used in many clinical situations, but distraction in cases accompanying nerve injury has been avoided due to concern of unfavorable effect on nerve regeneration by traction. This study evaluated the feasibility of early distraction lengthening after neurorrhaphy. Thirty-six rats were evenly distributed into 3 groups (12 rats in each group); neurorrhaphy and distraction (group I), neurorrhaphy and osteotomy without distraction (group II), and only distraction without neurorrhaphy (group III), respectively. After osteotomy on the right tibia, distraction started after 1 week and was continued for 40 days with 0.25 mm per day. Histological evaluation was carried out to identify nerve regeneration at 4, 8, and 12 weeks after surgery. Walking tract analysis was performed to assess the functional recovery preoperatively and 1, 4, 8, and 12 weeks postoperatively. Histologically, axon number ratio was significantly impaired in group I (0.48 ± 0.14) and group II (0.53 ± 0.13) compared with group III (0.88 ± 0.04) at 4 weeks (P = 0.020). There was no significant difference at both 8 and 12 weeks. Walking tract analysis showed significant differences between groups I and III (−40.5 ± 4.3), and groups II and III (−35.5 ± 5.0) at 1 week (P = 0.001), but no difference was observed at 8 and 12 weeks. Distraction osteogenesis in early stage after nerve repair is safe and effective, when performed at a rate of 0.25 mm per day in rats.

Basaloid Squamous Cell Carcinoma on the Skin of the Hand.

Basaloid squamous cell carcinoma (BSCC), an uncommon tumor with a predilection for the upper aerodigestive tract, is considered a distinct variant of squamous carcinoma due to its unique histological features and aggressive clinical behavior [1,2]. To the best of our knowledge, BSCC with a primary origin in the skin is extremely rare, although metastatic deposits of this type of cancer have been reported on the skin [3,4]. In this report, we present an unusual case of primary BSCC of the skin of the hand. An 89-year-old female presented with an exophytic mass on the dorsum of the proximal phalanx of the right third finger that had exhibited rapid growth. The mass was grossly measured to be approximately 1.5 cm×1.5 cm, with irregularly protruding and ulcerative features (Fig. 1). A punch biopsy was performed by a dermatologist, and the pathology report found malignancy with skin surface necrosis and multifocal tumor cell necrosis. Chest computed tomography and positron emission tomography were performed as part of a metastatic work-up, but no evidence of metastasis was observed. A wide excision was made, with a 1.5-cm peripheral margin, and the sheath of the extensor tendon was removed to ensure the complete removal of the tumor along the deep margin (Fig. 2). All frozen biopsies from the surgical margin were found to be negative, and a venous free flap with a 6-cm×3.5-cm skin paddle was harvested from the ipsilateral forearm. One proximal vein was anastomosed to the distal end of the digital artery, and the other three veins were anastomosed to the digital veins in a retrograde pattern (Fig. 3). No adjuvant chemotherapy or radiation was administered, and the patient was discharged seven days postoperatively. Pathological examination found that the tumor had a basaloid component, with lobules of small closely packed basaloid cells showing unique peripheral palisading and central comedonecrosis. The exaggerated nuclear-to-cytoplasmic ratio of the tumor nests accounted for their basaloid appearance, which suggested a histological diagnosis of BSCC (Fig. 4). When a diagnosis of BSCC is suspected, it is important to evaluate the differential diagnosis with other diseases that have similar pathological or clinical features. A pathologist therefore performed an immunochemical evaluation. Immunohistochemistry, which played a substantive role in the diagnosis, showed a positive response for Ki-67 and p63. Ki-67 is a nuclear protein found during the active phase of the cell cycle, while p63 enables BSCC to be distinguished from adenoid cystic carcinoma [5]. Moreover, other possible diagnoses were excluded through tests for MOC-31, chromogranin, cytokeratin 20, and synaptophysin. MOC-31 is useful in diagnosing adenocarcinoma, and chromogranin is a protein found in endocrine tumors. Cytokeratin 20 and synaptophysin show that a cell is from gastric/intestinal mucosa cells or neuroendocrine cells, respectively. Fig. 1 Photograph of primary basaloid squamous cell carcinoma on the skin of the dorsal side of the right third finger. Fig. 2 Intraoperative photograph after wide excision of the tumor. Fig. 3 Schematic view of venous free flap harvest from the ipsilateral forearm. Fig. 4 Hematoxylin and eosin-stained section, showing a mixture of superficial squamous cells and deep basaloid cells with a more aggressive tendency towards infiltration. The flap healed well, without any postoperative complications, and resulted in a natural contour of the dorsal finger (Fig. 5). During two years of subsequent follow-up, no local recurrence was observed. No signs of metastasis, such as the abnormal hypertrophy of a lymph node, were found. Fig. 5 Postoperative photograph at a two-month follow-up visit. BSCC is recognized to be an aggressive variant of squamous cell carcinoma. It is most frequently found in the head and neck area, especially the upper aerodigestive tract, in areas such as the supraglottic larynx, the base of the tongue, the palate, and the buccal cavity. However, BSCC has also been reported in the esophagus, thymus, anus, and cervix [1]. The differential diagnosis for BSCC includes adenoid cystic carcinoma and small cell carcinoma. Distinguishing BSCC from adenoid cystic carcinoma can be difficult. Immunohistochemical staining is a useful method of distinguishing these two malignancies [5]. Early detection and treatment with a generous safety margin is paramount to reduce the risk of local recurrence and metastasis. After surgical treatment, careful follow-up is important. We report a rare case of primary BSCC on the skin of the hand. BSCC is an uncommon, histologically distinct, high-grade variant of squamous cell carcinoma. This case adds to our knowledge of the clinical presentation and treatment of BSCC.