Ung Sik Jin

Outcomes of Surgical Management of Xanthelasma Palpebrarum

Background Xanthelasma palpebrarum (XP) is a benign disorder manifesting as yellowish cholesterol-laden plaques on the eyelids. This paper presents the outcomes in patients with XP who have undergone surgical excision as the main modality of treatment. Methods A retrospective review of patients who received surgery for xanthelasma palpebrarum from March 2007 to March 2011 was conducted. Patients were classified into four grades according to the location and extent of the lesion, with grade I being the mildest and grade IV being the most diffuse. Simple excision was performed in grade I and II lesions, while local flaps and skin grafts were performed in the more advanced grades. Results Ninety-five cases from March 2007 to March 2011 were included in this study. 66 cases (70%), were treated by simple excision. Twenty-four cases (25%) and 5 cases (5%) were treated by simple excision in combination with or without local flaps and skin grafts. In approximately 1/4 of the patients, orbicularis oris muscle involvement was observed. 4 patients (4.2%) developed scar contracture postoperatively, which required a secondary procedure. Recurrence was reported in 3 patients (3.1%). Otherwise. There were no other reports of major complications or disfigurement. Conclusions We found that for lesions involving the deep dermis and/or muscle, surgical excision was the most appropriate therapeutic option.

Oncologic Safety of Immediate Breast Reconstruction for Invasive Breast Cancer Patients: A Matched Case Control Study

Purpose The purpose of this study was to compare locoregional recurrence-free survival (LRFS) and disease-free survival (DFS) between patients undergoing mastectomy and immediate breast reconstruction (IBR) and those undergoing mastectomy alone. Methods A retrospective review of patients who underwent mastectomy and immediate breast reconstruction for resectable invasive breast cancer between 2002 and 2010 at a single center was conducted. These cases were matched to patients who underwent mastectomy alone in the same time period, performed by 1:2 matching. Matching control variables included age, tumor size, axillary lymph node metastasis, and estrogen receptor status. Overall, 189 patients were identified in the IBR group, and 362 patients were matched to this group. Results In the IBR group, 75 patients (39.7%) underwent conventional total mastectomy, 78 (41.3%) underwent skin-sparing mastectomy (SSM), and 36 (19.0%) underwent nipple-sparing mastectomy (NSM). The IBR group was significantly younger than the control group (41.9 and 45.1 years, respectively) (p=0.032), in spite of matching between three age groups. The DFS rates were similar between the IBR group and mastectomy alone group, at 92.0% and 89.9%, respectively, at 5-year follow-up (log-rank test, p=0.496). The 5-year LRFS was 96.2% in the IBR group and 96.4% in the mastectomy alone group (log-rank test, p=0.704), similar to data from previous reports. Subgroup analyses for SSM or NSM patients showed no differences in LRFS and DFS between the two groups. Additionally, in stage III patients, IBR did not cause an increase in recurrence. Conclusion IBR after mastectomy, including both SSM and NSM, had no negative impact on recurrence or patient survival, even in patients with advanced disease.

Treatment of Atypical Pyoderma Gangrenosum on the Face

Pyoderma gangrenosum is a rare destructive cutaneous disease characterized by a painful, progressive, and necrotizing wound. Pathologically, pyoderma gangrenosum is a noninfectious neutrophilic dermatitis that usually starts with a sterile pustule, which rapidly progresses to a large painful ulcer with undermined violaceous borders [1]. The treatment of pyoderma gangrenosum has been well reviewed but not established. Conservative management utilizing prolonged, high-dose systemic corticosteroids and other immunosuppressive agents, in addition to gentle local wound care, characterizes traditional treatment of pyoderma gangrenosum. Surgical treatment of pyoderma gangrenosum patients in the reconstruction field is very challenging due to the systemic immunologic condition of this disease. Surgical treatment, itself, could initiate other loci of disease with the development of new lesions at the areas of surgical trauma. Notably, the microvascular free flap reconstruction, despite its advantages in soft tissue volume replacement, has not been generally performed. The objective of this paper is to 1) present a rare case of refractory facial ulcerative lesion presented as pyoderma gangrenosum, 2) emphasize the exact diagnosis of this disease, and 3) recommend active surgical intervention like free flap reconstruction in conjunction with medical therapy as a treatment option for similar patients in the future. A 27-year-old female patient was referred from the dermatologic clinic with a 6 cm×5.5 cm painful, ulcerative, and necrotic lesion in the left temporal area. Her lesion began with a small pustule and progressed to a widening, painful ulcerative lesion (Fig. 1). Repeated cultural studies and biopsies of the affected area were performed at the dermatologic clinic. The findings were nonspecific. The lesion progressed despite dermatologic management, including local wound care. Fig. 1 Atypical pyoderma gangrenosum on the face. (A) Multiple ulcerative lesions around a reddish-purple margin. (B) Rapidly progressive lesion with ulceration, following serial surgical debridement. When we met her in our clinic, we suspected some information was missing. Through complete history taking, we found out that she had been previously diagnosed with Crohns disease. We clinically suspected and diagnosed her with pyoderma gangrenosum. We referred her to an internal medicine physician for her medical treatment. Through a thorough medical examination, including colonoscopy and blood testing, we determined that she had been in the active stage of pyoderma gangrenosum. According to the recommendation from the Department of Internal Medicine, we started steroid therapy (prednisolone 0.5 g/kg per day for 5 days, initially) for her and tapered it progressively. Slight improvement was noticed after 1 week and became obvious after 2 weeks (Fig. 2). It was decided to discontinue the steroid treatment after 3 weeks. The pain subsided and healthy granulation tissue grew. We then performed a groin free flap on her skin and subcutaneous defect and facial deformity. The pedicles of the harvested groin flap used were from the superficial circumflex iliac artery and superficial circumflex iliac vein. The recipient vessels were the superficial temporal artery and superficial temporal vein. The facial contour showed aesthetically satisfactory results after the surgery, and the volume deficiency of her face was restored (Fig. 3). Fig. 2 Importance of conjunction with medical treatment. Ten days following the commencement of prednisolone. Stabilized wound following surgical debridement and steroid therapy. Fig. 3 Photograph of the patient two years after the operation. Unlike a split-thickness skin graft, which is known to be commonly used in surgical management of pyoderma gangrenosum, through a well-designed groin free flap reconstruction, we observed satisfactory patient outcomes, including rapid wound closure and a favorable cosmetic appearance. We were able to maintain her facial contour with the groin free flap reconstruction. We were also able to decrease the wound healing time and hospital stay by a combination of active medical and surgical therapy. No recurrence of the disease has been noted. Although pyoderma gangrenosum is rare, it usually occurs in the lower limbs. More than 70% of patients have involvement of the lower limbs. Facial involvement of pyoderma gangrenosum such as this case is very rare. Pyoderma gangrenosum on the upper extremities, head, or neck, as a more superficial lesion, is classified as atypical pyoderma gangrenosum. Pyoderma gangrenosum is diagnosed clinically. It involves the exclusion of other diseases like infection or cellulitis. A patients history of possible underlying disease, and specific investigations based on that background, are necessary. In as many as 70% of cases, pyoderma gangrenosum may be associated with a variety of diseases, including inflammatory bowel disease and rheumatoid arthritis. A high index of suspicion is essential to clinically diagnose this condition. Failure to recognize this disease could lead to large tissue defects in the lesions and hazardous results. Although the histopathologic findings are not specific or diagnostic of pyoderma gangrenosum, a biopsy of the affected area and tissue culture allowed us to exclude other diseases (Fig. 4) [2]. Fig. 4 Histologic examination. The vasculitis: mixed lymphocytic and neutrophilic perivascular infiltrations and focal fibrinoid necrosis of the vascular wall with no observable evidence of bacterial or fungal organisms (H&E, ×200). Management of pyoderma gangrenosum includes local wound care, topical therapy, and systemic therapy. Many patients respond initially to systemic glucocorticoids. In a chronic course, immunosuppressive agents, such as cyclosporine, are usually added due to several side effects of the prolonged use of steroids. Reconstruction of tissue defects in pyoderma gangrenosum patients is challenging in several respects. Pathergy, the development of cutaneous lesions at the sites of trauma, is known to be a common feature of pyoderma gangrenosum. Surgery, itself, may be a trigger factor initiating other lesions. Split skin grafts have been used as a surgical option for pyoderma gangrenosum in some reported cases [3,4]. The important limitation of this option is a lack of bulk to maintain the patients contour. In our case also, we would not have been able to maintain this patients facial contour if we had perform a skin graft for the skin and subcutaneous defect. Many surgeons, having the distorted view that free flap reconstruction will hinder wound healing in pyoderma gangrenosum, choose a simpler method, such as split skin grafts. Although treatment for these patients is more complex because they require close consultation with the department of internal medicine for combination therapy with steroids or immunosuppressive agents, we should not be afraid to initiate active surgical intervention, like free flap reconstruction. As plastic surgeons, we should always consider aesthetic outcomes in addition to the recovery of patient status. In this paper, we presented a successful case of reconstruction with a free flap in an atypical case of pyoderma gangrenosum in the face, an area requiring contour maintenance to ensure the best aesthetic results.

The Superficial Inferior Epigastric Artery Flap and its Relevant Vascular Anatomy in Korean Women

Background Lower abdominal soft tissue transfer is the standard procedure for breast reconstruction. However, abdominal wall weakness and herniation commonly occur postoperatively at the donor site. To reduce the morbidities of the donor site, the superficial inferior epigastric artery (SIEA) flap was introduced, but inconsistent anatomy of the SIEA has reduced its utility. In the present study, the anatomy of the superficial inferior epigastric vessels in Korean women was determined with regards to breast reconstructive surgery. Methods The vascular anatomies of the SIEA and superficial inferior epigastric vein (SIEV) were evaluated on 32 breast cancer patients receiving free transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy. The existence, pulsation, location, external diameter, and depth of the SIEA and SIEV were measured at the lower abdominal incision level. Results SIEA and SIEV were present in 48/64 (75.00%) and 63/64 (98.44%) hemi-abdomens, respectively. Pulsation of the SIEA was found in 44/48 (91.67%) cases. The mean locations of SIEA and SIEV were +5.79 (±12.87) mm, and -8.14 (±15.24) mm from the midpoint between the anterior superior iliac spine and symphysis pubis, respectively. The mean external diameters of SIEA and SIEV were 1.20 (±0.39) mm and 1.37 (±0.33) mm, and they were found at a mean depth of 9.75 (±2.67) mm and 8.33 (±2.65) mm, respectively. Conclusions The SIEA was absent in 25% of Korean women and had a relatively small caliber. Therefore, careful preoperative assessment of the lower abdominal vasculature is required to achieve successful breast reconstruction using SIEA flaps.

Wide Local Excision for Dermatofibrosarcoma Protuberans: A Single-Center Series of 90 Patients

Background. Dermatofibrosarcoma protuberans (DFSP), a rare low-grade sarcoma of fibroblast origin, tends to extend in a finger-like fashion beyond macroscopic tumor margins. Therefore, incomplete removal and subsequent recurrence are common. This study aimed to determine the efficacy of wide local excision (WLE) for controlling local recurrence of DFSP. Methods. The medical records of 90 DFSP patients who received WLE at our hospital between June 1992 and January 2015 were retrospectively reviewed. WLE was conducted including a 3 cm (range, 1 to 5 cm) safety margin according to tumor size, location, and recurrence status. Clinical and tumor characteristics and surgical methods were evaluated for risk factor analysis and local recurrence-free survival. Results. DFSP occurred most often in patients in their 30s (30%) and on the trunk (51.1%). Five patients (5.5%) experienced local recurrence during the 43.4-month follow-up period. Recurrence was found at a mean of 10.8 months after WLE. Although no factors were significantly associated with recurrence, recurrences were more frequent in head and neck. Recurrence-free survival was 87% in 6 years and 77% in 7 years. Conclusions. WLE with adequate lateral and deep margins can effectively control local recurrence rate and is a simple and effective method to treat DFSP.

Living donor liver transplantation for an infant with osteogenesis imperfecta and intrahepatic cholestasis: Report of a case

Osteogenesis imperfecta (OI) is a group of genetic disorders characterized by bone fragility and connective tissue manifestations. We report a successful liver transplantation (LT) in an 8-month-old boy with OI and cholestatic biliary cirrhosis. After 4 cycles of intravenous pamidronate, LT was performed under intravenous anesthesia using a left lateral section from his mother without mechanical retractors. The operation time was 420 min and estimated blood loss was 520 mL requiring one unit of RBC transfusion. He was discharged without surgical complications. Therefore, LT should be considered for patients with end stage liver disease and OI under organic multidisciplinary cooperation. Graphical Abstract

Inhibition Mechanism of Acellular Dermal Matrix on Capsule Formation in Expander–Implant Breast Reconstruction After Postmastectomy Radiotherapy

BackgroundCapsular contracture is one of the most common complications of expander–implant breast reconstruction. Recently, clinical reports have shown that use of an acellular dermal matrix (ADM) to cover breast implants decreases incidence of capsular contracture, but the underlying mechanism is unclear. Here, we examine how ADM reduces capsular formation in expander–implant breast reconstruction and identify cellular and molecular mechanisms of ADM-mediated reduction of capsular contracture in nonirradiated and irradiated patients.MethodsThirty patients who underwent immediate two-stage implant-based breast reconstruction were included; 15 received radiotherapy. While the tissue expander was changed to permanent silicone implant, biopsies of the subpectoral capsule and ADM capsule were performed. Capsule thickness, immunohistochemistry of α-smooth muscle actin (αSMA), vimentin, CD31, F4/80 expression, αSMA and CD31 coexpression, and relative gene expression levels of transforming growth factor (TGF)-β1 and platelet-derived growth factor (PDGF)-B were investigated.ResultsIrradiated submuscular capsules were thicker than nonirradiated submuscular capsules, but the thickness of ADM capsules did not significantly differ between nonirradiated and irradiated groups. Levels of myofibroblasts, fibroblasts, vascularity, EndoMT, and macrophages were significantly lower in ADM capsules than in submuscular capsules. With the exception of EndoMT, all others were increased in irradiated submuscular capsules compared with nonirradiated submuscular capsule, while none significantly differed between nonirradiated and irradiated ADM capsules.ConclusionsUse of ADM reduced myofibroblasts, vascularity, fibroblasts, and EndoMT in capsule tissues. Moreover, ADM use decreased macrophages, a key regulator of tissue fibrosis, as well as TGF-β1 and PDGF-B expression. We hope that these results provide basic concepts important for prevention of capsular contracture.

Use of a Y-Shaped Plate for Intermaxillary Fixation

Maxillomandibular fractures usually require intermaxillary fixation as a means to immobilize and stabilize the fracture and to re-establish proper occlusion. Arch bars or intermaxillary fixation screws cannot be used for edentulous patients or for patients who have poor dental health. Here, we present a case of repeated intermaxillary fixation failure in a patient weak alveolar rigidity secondary to multiple dental implants. Because single-point fixation screws were not strong enough to maintain proper occlusion, we have used Y-shaped plates to provide more rigid anchoring points for the intermaxillary wires. We suggest that this method should be considered for patients in whom conventional fixation methods are inappropriate or have failed.

The rate of hepatic artery complications is higher in pediatric liver transplant recipients with metabolic liver diseases than with biliary atresia

BACKGROUND Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA. BASIC PROCEDURES Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed. MAIN FINDINGS Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P < 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014). PRINCIPAL CONCLUSION Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications. TYPE OF SUBMISSION Original article, Case control study, Retrospective. EVIDENCE LEVEL III.

Effectiveness of small monitoring skin paddle in free muscle flap for scalp reconstruction

Monitoring free muscle flaps with skin grafts is difficult. To intensify the monitoring process for this type of flap, a small skin paddle was included in the flap and analyzed its effects.