Thiam Chye Lim

Cervicofacial, Retropharyngeal and Mediastinal Emphysema: A Complication of Orbital Fracture

Retropharyngeal and mediastinal emphysema is associated with traumatic aerodigestive tract injury, and may be associated with potentially severe and even life-threatening complications. Retropharyngeal emphysema or pneumomediastinum, in the absence of severe trauma to the visceral organs, is rare following facial fractures. We report a case of extensive subcutaneous emphysema extending to the retropharyngeal space and mediastinum following an orbitozygomatic fracture.

Mydriasis during Orbital Floor Fracture Reconstruction: A Novel Diagnostic and Treatment Algorithm

Orbital floor fractures are the most commonly encountered traumatic fractures in the facial skeleton. Mydriasis that is detected during orbital floor fracture reconstruction may cause significant distress to surgeons, as it may be associated with sinister events such as visual loss. It is not an uncommon problem; previous studies have shown the incidence of mydriasis to be 2.1%. The combination of careful preoperative evaluation and planning, as well as specific intraoperative investigations when mydriasis is encountered, can be immensely valuable in allaying surgeons’ anxiety during orbital floor fracture reconstruction. In this review article, the authors discuss the common causes of mydriasis and present a novel systematic approach to its diagnostic evaluation devised by our unit that has been successfully implemented since 2008.

A Protocol to Reduce Interobserver Variability in the Computed Tomography Measurement of Orbital Floor Fractures.

Orbital fracture detection and size determination from computed tomography (CT) scans affect the decision to operate, the type of surgical implant used, and postoperative outcomes. However, the lack of standardization of radiological signs often leads to the false-positive detection of orbital fractures, while nonstandardized landmarks lead to inaccurate defect measurements. We aim to design a novel protocol for CT measurement of orbital floor fractures and evaluate the interobserver variability on CT scan images. Qualitative aspects of this protocol include identifying direct and indirect signs of orbital fractures on CT scan images. Quantitative aspects of this protocol include measuring the surface area of pure orbital floor fractures using computer software. In this study, 15 independent observers without clinical experience in orbital fracture detection and measurement measured the orbital floor fractures of three randomly selected patients following the protocol. The time required for each measurement was recorded. The intraclass correlation coefficient of the surface area measurements is 0.999 (0.997–1.000) with p-value < 0.001. This suggests that any observer measuring the surface area will obtain a similar estimation of the fractured surface area. The maximum error limit was 0.901 cm2 which is less than the margin of error of 1 cm2 in mesh trimming for orbital reconstruction. The average duration required for each measurement was 3 minutes 19 seconds (ranging from 1 minute 35 seconds to 5 minutes). Measurements performed with our novel protocol resulted in minimal interobserver variability. This protocol is effective and generated reproducible results, is easy to teach and utilize, and its findings can be interpreted easily.

Toxic Epidermal Necrolysis Associated with TS-1 in a Patient with Gastric Cancer

A 64-year-old female who has undergone D2 total gastrectomy was started on adjuvant treatment with TS-1. Four weeks after initiation of TS-1, the patient developed a rare complication of life-threatening toxic epidermal necrolysis. TS-1 was discontinued and the patient received treatment with intravenous immunoglobulin and supportive care with resolution of toxic epidermal necrolysis. TS-1 has been used for the treatment of gastric cancer, both in the adjuvant and metastatic setting, and is increasingly being used in other malignancies such as colon, pancreatic and non-small cell lung cancer. TS-1 is generally well tolerated. To our knowledge, this is the first reported case of toxic epidermal necrolysis associated with the usage of TS-1.

A novel technique with aesthetic considerations in female-to-male transsexuals nipple areola complex reconstruction

Transsexuality is a condition in which the person recognizes the innate need to be the opposite sex to which they were born as. The female-to-male transsexuals (FT) undergo a myriad of procedures in order to fulfil the above goals. FTs, compared to male-to-female transsexuals (MTs), are the ones who undergo the greater number of surgeries. The most common and foremost surgery is subcutaneous mastectomy. FTs define their masculinity by being able to expose their bare chest, without the stigma of having feminine breasts. There are many methods for this subcutaneous mastectomy and the aim is to create a small NAC that resembles a male chest characteristic.

Rare Cause of Facial Palsy: Case Report of Tick Paralysis by Ixodes Holocyclus Imported by a Patient Travelling into Singapore from Australia

BACKGROUND Ticks are blood-sucking arachnids that feed on all classes of vertebrates, including humans. Ixodes holocyclus, also known as the Australian Paralysis Tick, is capable of causing a myriad of clinical issues in humans and companion animals, including the transmission of infectious agents, toxin-mediated paralysis, allergic and inflammatory reactions, and mammalian meat allergies in humans. The Australian Paralysis Tick is endemic to Australia, and only two other exported cases have been reported in the literature. CASE REPORT We report the third exported case of tick paralysis caused by I. holocyclus, which was imported on a patient into Singapore. We also discuss the clinical course of the patient, the salient points of management, and the proper removal of this tick species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing air travel, emergency physicians need to be aware of and to identify imported cases of tick paralysis to institute proper management and advice to the patient. We also describe the tick identification features and proper method of removal of this tick species.

Innovative intraoperative titanium mesh preparation for safer implantation.

Titanium meshes have been extensively used in craniomaxillofacial surgery. The benefits of these titanium implants include being inert, stable, and radiopaque and having good drainage properties. The titanium mesh is cut to shape and bent before implantation, which may give rise to the cut edges being jagged and sharp. This can lead to soft tissue being caught or lacerated by these sharp ends. A change in technique to cut and shape the implant may reduce this problem. The implant should be cut right at the end of the bars flush with the remaining parts of the implant. We present a new and simple method for smoothing these troublesome edges. We use the diathermy scratch pad or tip cleaner, a tool used frequently in every major surgery. This scratch pad can be used as a rasp to smoothen the edges of the titanium mesh once it is cut into shape.

A novel technique in full thickness lower eyelid reconstruction: the pedicled reverse-flow chondrocutaneous superior helix flap

The most common cause of eyelid injury is work-related trauma [1, 2]. While the majority of eyelid lacerations do not cause defects requiring reconstruction, avulsion and degloving types of injury may result in larger defects that prove to be a reconstructive conundrum. In addition, severe eye injuries can be associated with facial trauma and brain injury. A multidisciplinary approach is essential in the management of such cases, with referral to an experienced trauma surgeon, ophthalmologist, plastic surgeon and/or neurosurgeon. After the initial resuscitation and stabilization of the patient, a complete assessment of the eyelid injuries is done in a controlled operating room setting. Assessment of the injury and defect and initial debridement, with the view to preserve all viable tissue, are of utmost importance. Conservative surgical debridement in facial injuries is the rule due to the superior healing characteristics in this area, which is attributed to its excellent blood supply. In severe crush, avulsion or degloving injuries, where the viability of the tissues is not immediately evident, it would be imperative to preserve these as seemingly devitalized tissues frequently may regain perfusion once anatomical restoration is achieved. The size of the defect, the involvement of one or both lamellae [3, 4] and/or the lid margin will determine the type of reconstruction required. Trauma to the eye region may also involve the surrounding skin. This larger zone of injury would render local flap options unsuitable due to compromised vascularity, thus providing further indication for pedicled or free flaps. The helical root provides a good pedicle flap option for lower eyelid reconstruction because it has good colour and contour match, as well as the fact that it is located at the fringes of the face, thus preventing additional facial scars due to local flaps. The superior helix flap or ascending auricular free flap was described by Parkhouse and Evans in 1985, followed shortly by Pribaz and Falco in 1993 for microvascular reconstruction of nasal defects [5, 6]. The availability of cartilage and its curvature allow for cosmetically acceptable outcomes. Pedicled superior helix flap based on the superficial temporal artery has also been described. We present a case of reverse-flow flap based on the frontal branch of the superficial temporal artery.

A Safe and Accurate Method of Assessing the Size of Implants Required in Orbital Floor Reconstruction

Many methods to determine the size of an orbital floor implant depend on trial and error. However, this technique is imprecise and the repeated insertion and removal of the implant leads to soft tissue trauma and swelling. A method of measuring orbital floor dimensions intraoperatively using a waterproof paper ruler is presented in this study. This technique has the advantage of being simple, precise, safe, and expedient.