SuRak Eo

Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release.

Background: Carpal tunnel release is one of the most frequently performed hand operations. However, persistent, recurrent, or completely new symptoms following carpal tunnel release remain a difficult problem. Methods: A retrospective review of the surgical findings and outcomes of 50 consecutive patients who had undergone 55 revision carpal tunnel operations was performed. Results: The initial carpal tunnel release was an endoscopic technique in 34 hands and an open technique in 21 hands. Thirty-four hands continued to have persistent symptoms, 18 hands had recurrent symptoms, and three hands had completely new symptoms. Reexploration revealed incomplete release in 32 patients. Circumferential fibrosis around the median nerve was found in all patients. Forty-six percent of patients with recurrent symptoms had slight palmar subluxation of the median nerve. External neurolysis was performed in 41, epineurectomy was performed in 15, synovial or hypothenar fat flap coverage was performed in eight, and radial forearm adipofascial flap coverage was performed in three hands. Symptomatic improvement following revision surgery after open carpal tunnel release was slightly better (90 percent) compared with after endoscopic carpal tunnel release (76 percent), but complete relief of symptoms following revision surgery was similar after open (57 percent) or endoscopic (56 percent) techniques. Ten patients (20 percent) showed no improvement and five patients required a third operation. Conclusions: A small number of patients (1) continue to have persistent symptoms after carpal tunnel release because of incorrect diagnosis or incomplete release of the transverse carpal ligament; (2) develop recurrent symptoms caused by circumferential fibrosis; or (3) develop completely new symptoms, which usually implies iatrogenic injury to branches of the median nerve. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nipple Reconstruction with C-V Flap Using Dermofat Graft

Aesthetically satisfying nipple restoration plays an important role in postmastectomy breast reconstruction. Many techniques, such as the skate flap, star flap, C-V flap, S-flap, and double-opposing tab flaps are currently employed in nipple reconstruction. Recent additions to the repertoire of nipple reconstruction include a spiral flap made of residual scar tissue and tissue engineering. These last 2 procedures have an added advantage of minimizing donor-site morbidity. The ideal method for nipple reconstruction would maintain long-term nipple projection, texture, color, and shape and have minimal donor-site morbidity. Despite the plethora of techniques available, a simple and reliable method that maintains nipple projection remains elusive. In this paper, we outline a simple technique that maintains long-term nipple projection. To this end, we have performed local C-V flaps augmented with autologous dermofat grafts harvested from excised breast tissues during breast mound revision.

Vacuum-assisted closure improves the incorporation of artificial dermis in soft tissue defects: Terudermis(®) and Pelnac(®).

As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue regeneration through infiltration of cells and neovascularisation. However, they show not only rather lower take rates compared to autologous skin grafts alone, but they also require more time for sufficient vascular ingrowth to overlay the skin graft. To accelerate this overlaying, we applied vacuum‐assisted closure negative‐pressure settings over the artificial dermis: Terudermis® and Pelnac® grafts. Fourteen patients with complex tissue defects were treated, including bone exposure in two cases, tendon exposure in seven cases and soft tissue defects in five cases. Nine cases had combined wound infections. The time interval between the first artificial dermis graft and the second split‐thickness skin graft over it was 7·64 days on average. Dermal substitutes took place completely in all cases and there were no graft failures.

Microsurgical reconstruction for canalicular laceration using Monostent and Mini-Monoka.

Many surgical techniques are available for repairing a lacerated canaliculus, such as, Worst pigtail probing, and monocanalicular or bicanalicular procedures involving silicone intubation. Despite this, controversy still exists regarding the best surgical method in terms of subjective and objective outcomes. We report the experience of microscopic canalicular repair using monocanalicular stents; Monostent (Eagle Vision Inc., Memphis, TN) and Mini-Monoka stents (FCI Ophthalmics, Marshfield Hills, MA) and compare these 2 products. Seventeen cases of canalicular lacerations in 15 consecutive patients underwent microscopic canalicular repair using a monocanalicular procedure with either a Monostent (Eagle Vision Inc.) (5 cases) or a Mini-Monoka stent (FCI Ophthalmics) (12 cases). Microscopic anastomosis of the canalicular mucosa was performed following the placement of a juxta canalicular suture to reduce tension. Subjective and objective flows of repaired lacrimal drainage systems were checked by saline injection using a Healon needle (Advanced Medical Optics, Inc., Santa Ana, CA) and dacryocystogram. Patent lacrimal drainage systems were achieved in 16 of the 17 cases, and mild epiphora was acceptable in 14 patients during follow-up. No cases of spontaneous punctal plug migration, stent displacement, eyeball irritation or inflammation, or granuloma formation were encountered. However, in one case, a Mini-Monoka stent (FCI Ophthalmics) was repeatedly extruded or clogged internally and replaced by Monostent (Eagle Vision Inc.). Although the latter had a larger conduit diameter, it was more flexible and had potentially folded on itself in the lacrimal sac, thus, obstructing flow in this case. Microscopic canalicular reconstruction using a Monostent (Eagle Vision Inc.) or Mini-Monoka stent (FCI Ophthalmics) offers a safe, effective, and straightforward means of acute lacrimal system injury treatment.

Successful composite graft for fingertip amputations using ice-cooling and lipo-prostaglandin E1

In distal fingertip amputations where microanastomosis may not be possible, composite grafting might offer the possibility of maintaining digital length and function using the patients own tissue. Many trials such as ice-cooling, pharmacologic enhancement and hyperbaric oxygenation have been reported to improve the survival rate of the composite graft. Twenty-four cases of unreplantable fingertip amputation were classified as types I to III according to the level of injury. We performed the composite grafting followed by immediate ice-cooling for 2 weeks and intravenous lipo-prostaglandin E(1) (lipo-PGE(1)) injection for 8.8 days each on average. Twenty-two fingertips in 24 patients survived completely with acceptable appearance and sensibility over the 8 month follow-up period. Confirming that therapeutic angiogenesis using ice-cooling and lipo-PGE(1) can increase the survival rate of the composite graft in unreplantable fingertip amputation, we describe the procedures and postoperative care in detail.

A new crease fixation technique for double eyelidplasty using mini-flaps derived from pretarsal levator tissues.

Background: Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that induces adhesion. Although incision method provides a significant supratarsal fold, it has the disadvantage of causing a visible depression or scarring when eyes are closed in downward gaze. Methods: The authors elevated multiple comblike mini-flaps from upper eyelid pretarsal levator tissues under loupe magnification. Flap bases were anchored on the tarsus using 7-0 nylon sutures, and distal flap portions were pulled out to the skin through a separate incision line and then interposed between edges of orbicularis muscle using absorbable microsutures to achieve a complete myocutaneous layer-by-layer repair. Results: Five hundred twenty-two double eyelidplasties were performed by the senior surgeon (Y.C.) using the described miniflap method. Patients were followed for 6 to 38 months (mean, 26 months). Seven palpebral fold failures were encountered, especially on the medial side, and 12 cases of fold asymmetry occurred because of inappropriate anchoring of miniflaps; all 12 were revised secondarily. No granuloma formation or scar hypertrophy occurred on upper lids. Although mild erythematous skin changes inevitably occurred during the early postoperative period, patients were satisfied with the palpebral folds, which showed no scars during downward gaze at 2 years postoperatively. Conclusions: The authors introduce a modified double eyelidplasty involving the interposition of multiple comblike mini-flaps derived from the pretarsal levator tissue of the upper eyelid. The procedure not only allows clean repair of the upper eyelid without disrupting tissue layer continuity but also enables double eyelidplasty with minimal scar formation.

Two-dimensional analysis of palpebral opening in blepharoptosis: visual iris-pupil complex percentage by digital photography.

AbstractThe vertical dimension of the palpebral fissure and the marginal reflex distance are conventionally used to assess the amount or degree of blepharoptosis, and levator function is assessed by measuring total upper lid excursion between the extremes of down-gaze and up-gaze. However, these are 1-dimensional measures obtained with a ruler, and the results obtained are dependent on examiner skill. Digital photographs were obtained of 692 patients before and after upper blepharoplasty. Visual iris-pupil complex percentage (VIP) was measured in the 1,305 eyes by digital calculation using Adobe Photoshop CS3 (Adobe Systems, Inc). Perioperative eye images in primary gaze were evaluated independently by 2 surgeons, 2 nurses, and a graphic designer, and after excluding 50 eyes which were nonconcordant and 29 eyes which revealed retracted upper lids, the remaining 1,305 eyes were classified into 4 major groups, that is, into excellent (n = 415), good (n = 435), subclinical (n = 270), and prominent ptosis (n = 185) groups. In addition, eyes were subdivided into 5 types according to the iris-pupil complex position within the palpebral fissure. Visual iris-pupil complex percentages were from 85% to 94% in the excellent, from 78% to 84% in the good, from 70% to 77% in the subclinical ptosis, and below 70% in the prominent ptosis group. Patients in the subclinical or prominent ptosis eye group required surgery for blepharoptosis. Iris-pupil complex relation to the palpebral opening was classified into 5 eye types, namely, standard (n = 961), scleral (n = 266), sinking (n = 151), retracted (n = 3), and fish (n = 3). The authors devised a new prospective measurement method for assessing blepharoptosis in a clinical setting. Graphical comparisons between the devised method of measuring VIP and mathematical estimations showed that the devised method is easier, more practical, and more precise for measuring degree of blepharoptosis from general population trends, and that VIP also provides a useful objective index for evaluating the postoperative results of blepharoptosis.

The Surgical Release of Dupuytren's Contracture Using Multiple Transverse Incisions

Dupuytrens contracture is a condition commonly encountered by hand surgeons, although it is rare in the Asian population. Various surgical procedures for Dupuytrens contracture have been reported, and the outcomes vary according to the treatment modalities. We report the treatment results of segmental fasciectomies with multiple transverse incisions for patients with Dupuytrens contracture. The cases of seven patients who underwent multiple segmental fasciectomies with multiple transverse incisions for Dupuytrens contracture from 2006 to 2011 were reviewed retrospectively. Multiple transverse incisions to the severe contracture sites were performed initially, and additional incisions to the metacarpophalangeal (MCP) joints, and the proximal interphalangeal (PIP) joints were performed if necessary. Segmental fasciectomies by removing the fibromatous nodules or cords between the incision lines were performed and the wound margins were approximated. The mean range of motion of the involved MCP joints and PIP joints was fully recovered. During the follow-up periods, there was no evidence of recurrence or progression of disease. Multiple transverse incisions for Dupuytrens contracture are technically challenging, and require a high skill level of hand surgeons. However, we achieved excellent correction of contractures with no associated complications. Therefore, segmental fasciectomies with multiple transverse incisions can be a good treatment option for Dupuytrens contracture.

Outer Fascia of Orbicularis Oculi Muscle as an Anchoring Target Tissue in Double Eyelid Surgery.

Background:Natural adhesion between the levator aponeurosis and the subcutaneous layer in the upper lid is essential for an aesthetically pleasing double eyelid. The study aims to emphasize the outer fascia of orbicularis oculi muscle (OFOOM) as a fixation point on the double eyelid surgery. Methods:The authors examined the detailed anatomy of the anterior lamella microscopically during 28 cases of primary double eyelid surgery. Three cadaveric dissections were performed adjunctively to compare the dynamic status in the upper lids. Subdermal tissue components and tissue changes in the upper lids were observed in 64 eyelids from secondary revisional cases who had performed an incisional technique previously. The authors also compared the locations of threads in the anterior lamella in 36 eyelids on which a nonincisional surgery technique had previously been used. Results:At the preferred crease zone in the upper lid, a definite anatomic structure, OFOOM was found between the skin and the orbicularis oculi muscle (OOM). The supratarsal creases created by the incisional technique showed that all of the anterior lamella components were fused tightly together by scar tissue. Examination of the 36 supratarsal creases created by the nonincisional technique showed that threads did not exist in the dermal layer, but were mainly within the OFOOM in 20 eyelids and mainly within the OOM layer in 16 eyelids. Conclusions:To produce satisfactory results during double eyelid surgery, the authors recommend direct suture fixation of the levator aponeurosis to the OFOOM, and not to the dermis or OOM.

A Ganglion Cyst of the Temporomandibular Joint

Ganglion cyst, although its precise etiology is not determined, is generally considered a degeneration of the mucoid connective tissue, collagen in specific, and was reported for the first time by Ledderhose in 1893 [1]. It is a benign soft-tissue tumor that usually appears near joints such as the hand, wrist, or foot. A ganglion cyst of the temporomandibular joint (TMJ) is a rare disease, and few cases of this condition have been reported in the English language literature. It may develop from a myxoid decay of the collagenous tissue of the TMJ capsule, without an epithelial or endothelial lining. Unconnected with the joint cavity, this cyst arises from the capsule of the joint. The cyst is filled with a gelatinous material and lined with a fibrous connective tissue wall without cells [2]. We present important aspects of the clinical findings, histologic features, and therapeutic options of a rare case of a ganglion cyst of TMJ with a review of the previous articles. A 48-year-old man was admitted at the Department of Head and Neck Surgery at our hospital for an acute spinning type of dizziness lasting a week. An otolaryngologists first impression was vestibular neuritis, and magnetic resonance imaging (MRI) was performed for further evaluation. The MRI revealed chronic otomastoiditis and a cystic mass in the left pre-auricular region (Fig. 1). The otolaryngologist prescribed medications for vestibular neuritis. Because the otolaryngologist and a radiologist regarded the patients preauricular mass to be a simple subcutaneous benign mass, the patient was also referred to the Plastic and Reconstructive Department for mass removal. Preoperatively, the patient had no typical symptoms and signs such as malocclusion, trismus, a clicking sound, or TMJ tenderness except for the mild swelling at the preauricular area. Physical examination revealed a 1-cm round, slightly mobile mass in front of the right tragus. As the junior author regarded the mass to be a simple subcutaneous cyst such as a lipoma or an epidermal cyst, he performed a surgical excision of the tumor under local anesthesia. The surgeon injected local anesthetics (2% lidocaine with 1:80,000 epinephrine) very superficially into the subcutaneous layer. Then, he made a direct vertical small incision in front of the right tragus over the protruding mass and performed dissection with a pair of blunt Metzenbaum scissors. During dissection around the mass, he inadvertently found that the mass penetrated into the depth of the temporalis fascia, and he started to use a nerve stimulator. After retraction of the superficial temporal vessels anteriorly with the skin flap, with the aid of a nerve stimulator, the surgeon made an oblique incision parallel to the frontal branch of the facial nerve, through a superficial layer of the temporalis fascia above the zygomatic arch. Then, he inserted the periosteal elevator beneath the superficial layer of the temporalis fascia and stripped the periosteum off the lateral zygomatic arch. Dissection was carried out inferiorly to expose the capsule of the TMJ. Intraoperatively, a cystic mass sized 10 mm in diameter was found. Its surface was soft, round, and translucent. The cystic mass was filled with a jelly-like material and connected with the lateral surface of the TMJ capsule by a short, narrow stalk. The tumor was successfully extirpated without injury to the facial nerves (Fig. 2). Histopathologic examination confirmed a ganglion cyst (Fig. 3). There was no sign of recurrence 8 months postoperatively, and the patients symptom of dizziness disappeared. Fig. 1 (A) Preoperative axial T2-weighted magnetic resonance image. (B) Coronal T1-weighted magnetic resonance image shows a cystic lesion (white arrows) lateral to the left condyle. Fig. 2 Intraoperative photograph showing the ganglion cyst in the lateral aspect of the temporomandibular joint capsule. Fig. 3 (A) Histopathologic photomicrographs show a cystic wall of fibroconnective tissue with H&E, ×40. (B) Cystic wall consisted of a myxoid degeneration of the collagenous tissue (black arrow), ×200. The ganglion cyst of the TMJ is more frequently seen in middle-aged women than in men or women of other ages and usually presents as a parotid or preauricular mass because of its anatomical region [3]. Because a ganglion cyst in the TMJ is not common, an accurate preoperative diagnosis is not easily made. The differential diagnosis of the preauricular mass has extensive lists. A variety of conditions or diseases must be considered in the differential diagnosis of a ganglion cyst at the TMJ, such as parotid tumor, parotid cyst, retention cyst, sebaceous cyst, branchial cleft cyst, vascular tumor, and lymphangioma. Besides, rare TMJ lesions, such as synovial chondromatosis, osteochondroma, osteoma, pigmented villonodular synovitis, bone cyst, Langerhans cell histiocytosis, plasma cell myeloma, and sarcoma, must also be considered. Among the most commonly used radiological modalities, that is, sonography, computed tomography, and MRI, MRI remains the best diagnostic imaging technique to determine TMJ pathology [2] as MRI usually reveals the location, size, and density of the lesion, as well as its connection with the surrounding structures [1]. Despite their distinct entities, ganglion cysts and synovial cysts are often mistakenly used alternatively in the literature. Although ganglion cysts and synovial cysts seem similar clinically, synovial cysts are true cysts filled with synovial fluid and lined with endothelial cells because they are produced by the movement and herniation of the synovial lining due to an increased pressure in the associated joint. On the other hand, ganglion cysts, which are not connected to the joint cavity, appear to be developed from a myxoid degeneration of the collagenous tissue of the joint capsule. They are not true cysts because they lack a cellular lining and are made of a gelatinous, viscous material and surrounded by fibrous connective tissue [2]. These two kinds of cysts can be clearly differentiated from each other only through histological examination. The treatment options of the ganglion cyst vary from conservative treatment to surgical removal. The surgical excision of symptomatic ganglion cysts of the TMJ remains the mainstay of the treatment, with the most common complication being recurrence due to incomplete excision. Surgical excision has usually been performed by using a preauricular approach and is considered to be the procedure of choice. Although there is a case establishing facial nerve palsy and intracranial extension, patients with asymptomatic lesions may undergo some period of conservative management, because there are some cases of spontaneous regression [4]. We emphasize that if a patient has a mass adjacent to the TMJ and shows concomitant vague symptoms related to TMJ disorders such as headache, otalgia, TMJ sounds or crepitus, dizziness or vertigo, fullness of the ear, and tinnitus, surgeons must consider the possibility of a ganglion cyst of the TMJ [5]. We expect our rare case to be helpful to surgeons for making an early diagnosis and planning a treatment strategy for the ganglion cyst of the TMJ.