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Blue nevi, which are characterized by collections of pigment-producing melanocytes in the dermis, have a variety of clinicopathological characteristics. Plaque-type blue nevus (PTBN) is a variant of blue nevi. PTBN presents at birth or arises in early childhood, and it shows a combination of the features found in common blue nevus and cellular blue nevus. It is typically found on the dorsal surface of the hands and feet or on the head and neck, and it is usually benign and stable over time. However, reports have occasionally described malignant melanomas developing in or associated with a PTBN. Malignant blue nevi are most commonly found on the scalp. We report the case of an 88-year-old woman with a malignant melanoma associated with a PTBN of the cheek.

Fibrin glue is a topical agent widely used for hemostasis, wound healing, and surgical adhesion. Complications of fibrin glue itself are extremely rare because it is absorbed over time, but can occur as a result of inappropriate application. We report a case of a postoperative complication caused by inappropriate application of fibrin glue in blow-out fracture surgery. A 65-year-old male patient presented with periorbital swelling and an open wound on the right infraorbital area. Computed tomography showed a right orbital floor fracture. After reduction of the herniated tissue into the orbit, an implant was inserted and fibrin glue was applied to stabilize the implant. This procedure was performed without difficulty, but the patient complained of persistent diplopia and limited eyeball movement after surgery. An imaging study showed a mass-like lesion, which was not a hematoma, in the orbital cavity. In a second operation, the mass was identified as clotted fibrin glue that had not been applied properly. After removal, the patient’s symptoms were relieved without further complications. Appropriate and careful application of fibrin glue is necessary to avoid unnecessary complications.

The soft tissue structure near the medial malleolus is an area where the bone is covered only with thin skin and subcutaneous tissue without structures like ligaments or tendons. In addition to the above anatomical features, wearing normal footwear should be considered when reconstructing the soft tissues in these areas. Therefore, it may be desirable to restore the original thickness of the soft tissue when performing a reconstruction. The authors reconstructed defects on the medial malleolus of a 50-year-old woman, after wide excision of a malignant melanoma, using only a deep fascial flap based on the posterior tibial artery-based perforator. This technique is thought to be a good option for reconstructing soft tissue defects in this area.

Background Local symptoms and signs of snake envenomation mimic the clinical features of compartment syndrome. It is important to measure the intracompartmental pressure to diagnose compartment syndrome. In this study, we present our experiences of confirming compartment syndrome and performing fasciotomy in snakebite patients based on high intracompartmental pressure findings. Methods The medical records of patients who visited the trauma center of Wonju Severance Christian Hospital from January 2010 to December 2015 for the management of venomous snakebite were retrospectively reviewed. Starting in 2014, fasciotomy was performed in patients with an intracompartmental pressure of more than 40 mmHg in addition to the clinical symptoms of compartment syndrome. Results A total of 158 patients with snakebite came to the hospital within 48 hours for treatment. Most patients (110 patients) were bitten at the upper extremities (69.6%). Since 2014, 33 out of 59 patients were suspected to have compartment syndrome, and their intracompartmental pressures were measured. Seventeen of those patients had a high intracompartmental pressure (average, 49.6 mmHg; range, 37–88 mmHg), and fasciotomy was performed. Conclusions In this study, as many as 10.8% of all cases were in need of fasciotomy when compartment syndrome was diagnosed by measuring the intracompartmental pressure. Previously, it was reported that fasciotomy was not required in many cases of compartment syndrome originating from snakebite. However, some patients may develop very severe compartment syndrome, requiring fasciotomy.

Background The alar and nasal tip are important subunits of the nose. Determining the optimal procedure for reconstructing a cutaneous defect in a nasal subunit depends on several factors including size, location, and involvement of deep underlying structures. We treated cutaneous defects after tumor ablation in the alar and nasal tip with a local flap, using an S-shaped design and a modified V-Y advancement flap with a croissant shape. Methods We analyzed 36 patients with skin tumors who underwent flap coverage after tumor ablation. Rotation flaps were used in 26 cases and croissant-shaped V-Y advancement flaps were used in 10 cases. The primary cause of the defects was skin cancer, except for one benign tumor. Results The mean patient age was 71 years. The size of the defects ranged from 0.49 cm2 to 3.5 cm2. No recurrence of skin cancer was noted and all flaps lasted until the end of follow-up. Partial desquamation of the epidermis was noted in one case. The postoperative appearance for most patients was excellent, objectively and subjectively. Conclusion For cutaneous defects of up to about 4.0 cm2 of the alar and nasal tip, local flaps using our methods offered a good cosmetic and therapeutic result. The main advantage of our flaps is the minimal dissection required compared to bilobed and other local flap methods. We believe our flaps are a suitable option for alar and nasal tip reconstruction.

Background Ablative fractional carbon dioxide laser is widely used for the treatment of various scars including burn injuries. We applied ablative fractional CO2 laser on the skin graft scar of faces. Methods Fourteen patients between 2010 and 2013 who underwent facial skin graft were included in this study. The ablative fractional CO2 laser was applied to 7 patients in the laser therapy group. It was initiated at 5th week after the skin graft. Clinical photographs were taken, and Patient Scar Assessment Score (PAS) was obtained during every visit from a patient at the outpatient clinic and 4 weeks after the last laser treatment. In the untreated control group, clinical photographs and PAS were taken at 5th and 21st weeks after the skin graft. Vancouver Scar Scale (VSS) and Observer Scar Assessment score (OAS) was rated by single independent plastic surgeon with the clinical photographs. Results In the laser therapy group, VSS, PAS, and OAS improved after fractional laser treatment. In the untreated group, VSS was also improved by the natural process of scar maturation. However, the laser treated group showed significant improvement compared with the untreated group. Conclusions The ablative fractional CO2 laser can be a viable option for the treatment of skin graft scar. Further study with sufficient patients and long term follow-up is necessary for definite conclusions.

Primary cutaneous mucinous carcinoma (PCMC) is a rare malignant tumor of eccrine origin. Clinically, the carcinoma presents as a solitary, slow growing, and painless nodule. For this reason, this tumor is often considered to be a benign mass in the preoperative setting. The lesion is, however, malignant in nature and has a tendency for local recurrence and infrequent metastasis. Wide local excision is the treatment of choice. However, few reports exist with information regarding surgical margins and clinical outcomes. Herein, we report a case of PCMC excised with a narrow surgical margin and review the relevant literature. A 49-year-old man presented with a small cutaneous nodule of the right cheek. The mass was excised without any margin, but pathologic examination revealed histology of mucinous carcinoma. Because of this, the operative site was re-excised with a 5-mm margin, and the wound was closed using a V-Y advancement flap. Systemic work-up did not reveal other potential metastatic primary, for a final diagnosis of PCMC. We report this case of PCMC, treated with relatively narrow margin in a patient with good prognostic factors.

Myopericytoma is a benign tumor that is composed of myoid-appearing oval to spindle-shaped cells with a concentric perivascular pattern of growth. The tumor is morphologically heterogeneous and can exhibit a broad histologic spectrum. We describe a case of multiple myopericytoma occurring in the head and neck skin region with involvement of the parotid gland where it is known to occur very rarely. A 40-year-old woman noticed multiple enlarging, painless, round-shaped masses on her left cheek. The patient had experienced a similar lesion of the same area 8 years earlier which was completely excised and the pathological diagnosis was spindle cell type myoepithelioma. On a computed tomographic image, one mass involved the superficial parotid gland and was well encapsulated. Excision of the facial masses and superficial parotidectomy with facial nerve preservation were performed. A diagnosis of myopericytoma was established in light of the immunohistochemical pattern with the histopathological findings. Over the 4-year follow-up period, there was no evidence of recurrence. As many perivascular myoid neoplasms share common morphologic features with myopericytoma, we should consider the differential diagnosis, and confirm the histological findings with appropriate immunohistochemical staining. After identifying myopericytoma, it should be treated with wide surgical excision to prevent local recurrence.

This paper provides an algorithm for identifying the multipoles of a meromorphic function from the boundary measurements, which can be applied to inverse source problems for a Poisson equation to reconstruct its source such as linear combination of mono and dipolar point sources. After establishing an algorithm that allows to identify the number, the locations and the moments of poles, we provide a stability estimate of the algorithm under the measurement error.

From April of 2000 to May of 2003, 28 consecutive patients with chronic osteomyelitis of the lower extremity underwent surgical debridement and reconstruction with anterolateral thigh perforator flaps (six cases were combined with vastus lateralis muscle flaps). All wounds were open for a minimum period of 6 weeks (average, 24.7 months; range, 6 weeks to 52 months). The average patient age was 42.8 years (range, 18 to 71 years), there were 21 male and seven female patients, and the average follow-up period was 18.2 months (range, 5 to 41 months). The cause of injury was an open fracture in 10 cases, secondary wound complications after reduction in eight cases, and diabetic foot in 10 cases. The surface defects ranged from 50 to 153 cm. The wounds were debrided an average of 2.5 times and then reconstructed with flap and treated with antibiotics for 6 weeks. Antibiotic beads were used in six cases and secondary bone graft procedures were performed in seven cases 3 months after the flap coverage. All 28 flaps were successful without any signs of recurrences or persistent osteomyelitis, but partial wound dehiscence was observed during early rehabilitation in two cases suspected of delayed healing caused by diabetes. These wounds healed spontaneously. All patients achieved acceptable gait function after rehabilitation. No debulking procedure was necessary in any case. Although the muscle flap is known to provide superior vascular supply, the type of flap used for coverage seems to be less critical in the final outcome, provided that total debridement and obliteration of dead spaces are achieved. A well-vascularized anterolateral thigh perforator flap was successfully used to combat infection and bring stability to wounds with chronic osteomyelitis.

The effect of hyperbaric oxygen is known to increase survival of ischemic tissue but its mechanism is not fully understood. The purpose of this study was to evaluate the effect of hyperbaric oxygen on a rat musculocutaneous flap versus ischemia-reperfusion injury, focusing on the mechanism involving the expression of adhesion molecules such as intercellular adhesion molecule-1 (ICAM-1) of endothelial cells and CD18 of neutrophils. A transverse rectus abdominis musculocutaneous (TRAM) flap (6 x 5 cm) supplied by a single superior epigastric vascular pedicle was elevated in 100 Sprague-Dawley rats. The rats were divided into 4 groups: group 0, sham (n = 10); group I, 4 hours of ischemia followed by reperfusion (n = 30); group II, 4 hours of ischemia and hyperbaric oxygen (100% oxygen, 2.5 atm absolute, during the last 90 minutes of ischemia before reperfusion) followed by reperfusion (n = 30); and group III, 4 hours of ischemia followed by reperfusion and hyperbaric oxygen (100% oxygen, 2.5 atm absolute, after reperfusion for 90 minutes; n = 30). The study consisted of gross examination for flap survival, histology, immunohistochemical staining, myeloperoxidase assay, flow cytometric study of CD18, and Northern blot analysis on ICAM-1 messenger ribonucleic acid expression. Gross measurement of the flap showed increased survival in groups II and III compared with group I (P < 0.05). The leukocytes adherent to the endothelium were counted at 24 hours and on day 5. Group I leukocytes were significantly increased compared with groups II and III (P < 0.05). The myeloperoxidase assay of TRAM flaps at 24 hours revealed a significant increase in group I compared with groups II and III (P < 0.05). The expression of CD18 was similar between groups I, II, and III. Immunohistochemical staining for ICAM-1 and Northern blot analysis on ICAM-1 messenger ribonucleic acid showed decreased expression in groups II and III compared with group I. Throughout the analysis, groups II and III did not show any significant differences. These results suggests that hyperbaric oxygen reduces the accumulation of leukocytes in the TRAM flap, but not enough to prevent adhesion of neutrophils on endothelial cells; ischemia-reperfusion injury increases the expression of CD18 and ICAM-1 and causes increased adhesion of leukocytes on the endothelium; hyperbaric oxygen does not alter the expression of CD18 but decreases the expression of ICAM-1; and the point of application for hyperbaric oxygen, whether applied before or after reperfusion, did not show any differences in outcome. In conclusion, the application of hyperbaric oxygen against ischemia-reperfusion injury increases flap survival and the beneficial effect may be explained by a protective mechanism involving downregulation of ICAM-1 on endothelial cells.

Background/Objectives: Skin rejuvenation with laser is effective method to manage the skin aging process, however, it need repetitive procedures within short period. To compensate this shortcoming of laser, thread for facial tissue fixation is an excellent alternative of laser in skin rejuvenation. In this study, we evaluated the effectiveness of cogged polydioxanone(PDO) thread in improvement the lower face line and jowl. Methods/Statistical analysis: A total of 55 consecutive patients with mild to moderate wrinkles were enrolled in the study. They underwent facial lifting with cogged thread (Secret Cog®, HyundaeMeditech, Korea) to correct lower facial line. Follow-up assessments were performed at 1 week, 4weeks and 3 months after procedure. The efficacy was rated by the two independent plastic surgeons using the Wrinkle Severity Rating Scale and patients’ satisfaction was assessed using the Visual Analog Scale. Post-operative complications were also recorded. Findings: The patients showed prominent improvements after the procedure. The numbers of patient, presented WSRS difference greater than 1 were 53 (96.4%) on the left cheek and 54 (98.2%) on the right cheek. All patients achieved symmetrical facial state at all three post-operative visits. The mean satisfaction score of the patients was 6.6±2.6 on week 12. It also improved asymmetrical facial wrinkles. Improvements/Applications: Cogged PDO is excellent alternative method in lower face rejuvenation. Although it cannot substitute the face lift surgery, however, in mild to moderate lower face wrinkle, it can improve the lower face contour with simple procedure.

Epithelioid sarcoma is an uncommon soft tissue malignancy that is usually slow growing in the dermal or subcutaneous area of the distal extremity of young adults. Epithelioid sarcoma was first characterized as a distinct clinicopathologic finding by Enzinger [1] in 1970. It accounts for less than 1% of all soft tissue sarcomas [2]. Epithelioid sarcoma of the perineum and pubic regions is rarer than in the distal extremity and has a higher rate of local recurrence and distal metastasis. Epithelioid sarcomas are classified into a "distal type" that occurs in the upper and lower extremities and a "proximal type" that appears in the trunk and pubic area [3]. There have been few reports on proximal-type epithelioid sarcomas, and in most cases the reports contained no description of the reconstructive method used for treating the pelvic defects after the wide excision. In this case, we dissected a pedicle of sufficient length and were able to reduce the passage length of the flap by passing the flap under the rectus femoris muscle. A 42-year-old woman was referred to our department for a recurred perineal area mass. Two years earlier, a general surgeon had excised a mass 2 cm in diameter from the same area. Pathology reported epithelioid sarcoma. The general surgeon recommended a wider excision margin; however, the patient refused additional surgery. At time of presentation at our department, a 7×4 cm mass (Fig. 1) at the site of the previous excision was noted. The round-shaped mass was fixed to adjacent tissues and without tenderness. The inguinal lymph nodes were not palpable. Computed tomography of the pelvic and inguinal area showed a soft tissue tumor of 2.4×2 cm diameter in the perineal area. Positron emission tomography did not reveal hypermetabolism in the internal structures of the pelvis and adjacent lymph nodes. The tumor abutted the deep fascia of the gracilis muscle, but did not involve the gracilis muscle. There was no evidence of distal metastasis. Fig. 1 (A) Preoperative findings: 4×7 cm mass was palpable in the left perineal area. (B) Positron emission tomography-computed tomography findings: mass in subcutaneous plane. We excised the mass with a 5-cm safety margin. The deep fascia of the internal compartment muscles of the thigh was preserved. After wide excision, the defect size was 17×14 cm (Fig. 2). The antero-lateral thigh flap was designed to be 18×15 cm size. The anterolateral thigh flap was elevated in the conventional method with a septocutaneous pedicle. The proximally-based flap was medially rotated and passed under the rectus femoris muscle to reach the perineal area. The flap donor site was covered with a split thickness skin graft. Additional lymph node dissection was not performed based on clinical staging. Fig. 2 (A) After wide excision, 14×17 cm soft tissue defect. (B) At follow-up 7 months after reconstruction. Pathology confirmed the diagnosis of epithelioid sarcoma with T2N0M0 staging. The histopathologic examination revealed the typical cell pattern of epithelioid sarcomas (Fig. 3). There were polygonal epithelioid cells and the cells had irregular vesicular nuclei with eosinophilic nucleoli. Fig. 3 Microscopic finding showing epithelioid cells and spindle or polygonal cell components with atypia (H&E, ×40 high power field). The wound healed uneventfully. The patient remains disease free at the time of this report (total 18 months follow-up) without any other adjuvant chemotherapy or radiation therapy. Also, no limitation of hip joint motion was noted. Epithelioid sarcoma is a rare malignant soft tissue tumor of mesenchymal origin. It accounts for less than 1% of all soft tissue sarcomas and is usually slow growing, with a peak incidence in young adult men and occurrence predominantly in the extremities [2]. The proximal subtype occurs predominantly in adults (age range, 13 to 80; median, 40), with a slight predominance in men [4,5]. Epithelioid sarcoma is difficult to diagnose histologically, because histologic findings of epithelioid sarcoma are similar to those of other malignant sarcomas such as the synovial sarcomas, malignant rhabdoid tumors, or squamous cell carcinoma [1]. Confusion and misdiagnosis of the epithelioid sarcoma may lead to time consuming treatment and tumor recurrence. Microscopically, epithelioid sarcoma is characterized by irregular nodules composed of relatively uniform, polygonal or epithelioid cell proliferation [2]. The mass is differentiated from the surrounding normal tissue with fibrous stroma and embedding spindle cells without a clear demarcation. On immunohistochemistry of epithelioid sarcoma, cytoplasmic immunoreactivity can be observed with cytokeratin and vimentin, and negative results for S100 and CD31 stainings [2]. These findings are useful for differentiating epithelioid sarcoma from other soft tissue tumors. Epithelioid sarcoma requires a wide, total surgical excision with clear margins due to its high recurrence rate. Even with wide enbloc excision or amputation of the region, the reported recurrence rate of this sarcoma is 34% to 77% and the metastasis rate is about 40% [5]. Common metastasis sites are the lungs, regional nodes, scalp, bone, and brain. Proximal-type epithelioid sarcoma is even more aggressive than the distal type. Lymph node involvement is the most important prognostic factor. Young age at first diagnosis, female sex, and small size of tumor (less than 5 cm) are better prognostic factors. In our case, the patient was a woman, the size of tumor was less than 5 cm, and there was no evidence of lymph node metastasis. In our case, we did not perform a lymph node dissection because inguinal lymph node resection is controversial. Lymph node removal is considered when it is large enough to be palpable on physical examination or appears in an imaging study to be suspiciously involved [2,5]. High-dose chemoradiotherapy may contribute to reducing the recurrence rate, but has not been proven to improve long-term survival [2]. In our patient, we did not perform any adjuvant therapy because of the many favorable prognostic factors mentioned above. There are several options for reconstructing a soft tissue perineal defect. Regional flaps are of limited use for an extensive defect. Microsurgery in this region is limited by aesthetic contours and the complexity of the recipient vessel. The pedicled anterolateral thigh flap has a wide arc of rotation and is large enough to cover perineal defects without the need for microsurgery. In this case, we dissected a pedicle of sufficient length and were able to reduce the passage length of the flap by passing the flap under the rectus femoris muscle.

Nasal bone fractures are the most common among facial fractures and are the third most common fractures in the human frame. Although many forms of treatment have been introduced, controversy regarding the optimal treatment still remains. Nasal bone fractures are complex, with significantly varying types that are often undermanaged in closed reduction procedures. The authors' experiences with nasal bone fractures have shown that the baseline for surgical intervention depends on the type of fracture and the method of maintenance after reduction, both of which have considerable impact on the final result. Therefore, it is very important and challenging to determine the proper method of reduction and maintenance. The periosteal covering plays an important role in the splinting action after closed reduction, but sagging, depression, and instability remain major complications in some cases. The authors devised a new method of accurate, firm stabilization of the fractured nasal bone by using external pins in those unfavorable fractures determined radiologically to gain optimal reduction and fixation. In the present study, fractures were grouped into favorable and unfavorable fractures, the latter being those that remained unstable or impacted even after reduction and thus needed open reduction. Unfavorable fractures were divided into four subclasses according to radiologic findings: (1) type I (frontal), including chip or tip fractures, which often depress the upper lateral cartilage and tend to sag after reduction; (2) type II (lateral), or laterally depressed segmental fractures with a lateral shift of the arch in fragments or as a unit; (3) type III (mixed), or type II with septal involvement; and (4) type IV (complex), including open or multiple comminuted fractures. After an initial evaluation to determine the fracture type, closed reduction and external fixation were performed for types I, II, and III fractures and open reduction was performed for type IV fractures 5 to 7 days after the fracture. Closed reduction with the use of external pins was done in eight cases: type I (two), type II (four), and type III (two). The mean age of the patients was 27.8 years, and the average follow-up period was 11.7 months. Functional and aesthetic results were satisfactory. This new method for support and fixation is an alternative to the conventional closed reduction and a promising way to prevent secondary deformity.

Background Management of positional plagiocephaly by wearing a cranial molding helmet has become a matter of growing medical interest. Some research studies reported that starting helmet therapy early (age 5 to 6 months) is important and leads to a significantly better outcome in a shorter treatment time. The aim of the present study was to evaluate the effectiveness of cranial remodeling treatment with wearing helmet for older infants (≥18 months). Methods We conducted a retrospective study of 27 infants with positional plagiocephaly without synostosis, who were started from 2008 to 2012. Every child underwent a computerized tomography (CT) before starting helmet therapy to exclude synostosis of the cranial sutures and had CT performed once again after satisfactory completion of therapy. Anthropometric measurements were taken on using spreading calipers in every child. The treatment effect was compared using cranial vault asymmetry (CVA) and the cranial vault asymmetry index (CVAI), which were obtained from diagonal measurements before and after therapy. Results The discrepancy of CVA and CVAI of all the patients significantly decreased after cranial molding helmet treatment in older infants (≥18 months) 7.6 mm from 15.6 mm to 8 mm and 4.51% from 9.42% to 4.91%. Six patients had confirmed successful outcome, and all subjects were good compliance patients. The treatment lasted an average of 16.4 months, was well tolerated, and had no complication. Additionally, the rate of the successful treatment (final CVA ≤5 mm) significantly decreased when the wearing time per was shorter. Conclusion This study showed that treatment by cranial remodeling orthosis was effective if the patient could wear the helmet longer and treatment duration was somewhat longer than in younger patients, well tolerated in older infants and had no morbidity. This therapeutic option is available and indicated in these older infants before other cranial remodeling surgery.

Determining the optimal method for zygoma fracture reduction is a common challenge. Numerous methods for treating zygomatic arch fractures have been suggested. However, a substantial gap exists between suggested treatment strategies and real-world practice. A general consensus of classification and treatment guidelines for zygomatic arch reduction has not yet been established. We reviewed our cases and propose a new classification of zygomatic arch fracture and a treatment algorithm for successful reduction based on the injury vectors.

The purpose of this study was twofold. To evaluate whether prostaglandin El can increase the survival of the flap, and to determine its function against ischemia-reperfusion injury in musculocutaneous flaps. Thirty-five Sprague-Dawley rats weighing 250 to 350 g were analyzed. The transverse rectus abdominis musculocutaneous flap was used in all rats. The rats were divided into three groups: group 1 (N = 15), the control group with 4-hour ischemic injury and intraflap injection of normal saline followed by reperfusion; group 2 (N = 15), prostaglandin E1 intraflap injection of 1 microg immediately after ischemic injury and reperfusion 4 hours later; and group 3 (N = 5), the sham-operated group. Analysis consisted of flap skin survival area measurements, immunohistochemical study using anti-intercellular adhesion molecule (anti-ICAM-1) monoclonal antibody, and histological evaluation including endothelium-sticking leukocytes at 24 hours and 5 days after reperfusion. The group treated with prostaglandin E1 showed immunohistochemical findings with decreased expression of ICAM-1 on the surface of the endothelium, and histology showed significant (p < 0.01) reduction of leukocyte adhesion at 24 hours and 5 days after reperfusion. These two factors were considered to play a role against ischemia-reperfusion injury, and led to improved survival of the flap. These results suggest that prostaglandin E1 may increase flap survival and may have a protective mechanism against ischemia-reperfusion injury by decreasing leukocyte-endothelial cell adhesion through decreased expression of ICAM-1.

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenging problem. These patients need not only soft tissue but also dynamic and functional reconstruction. Four cases of major defects of the Achilles tendon and overlying soft tissue after trauma are presented. In each case, the tendon and the overlying soft tissues were reconstructed using only a latissimus dorsi muscle free flap and overlying split-thickness skin graft. In conventional methods, evolved in the reconstruction of the Achilles tendon and soft tissue, the size of the defect was a limit. However, this technique can be used to reconstruct an extensive defect, including distal calf muscle to the plantar metatarsal area. In one case, the flap was harvested in a myocutaneous unit, and the skin portion was deepithelialized for the coverage and enough padding on the bony exposure area in reverse position. The purpose of the present study was to reevaluate the potential of denervated muscle flap for a force-bearing conduit as an alternative reconstructive method of the Achilles tendon. The denervated latissimus dorsi muscle in this study eventually experienced the process of atrophy and fibrosis but maintained its original length. Although there remained some atrophic muscle fibers, a fibrosis of the muscle fibers formed a tendon-like fibrous band, and so the action of the posterior calf muscle could be transmitted through the tendon-like fibrotic change of the denervated latissimus dorsi muscle. The advantages of this technique are that (1) it is a single procedure, (2) it is adaptable to a wide range of defect sizes, (3) it allows faster wound healing supported by well-vascularized tissues, (4) it produces satisfactory function of the ankle joint and a padding effect, and (5) it produces good contour of the posterior calf to the sole and an acceptable donor-site morbidity.

Five patients with segmental tibial defects whose contralateral fibula could not be used as a donor were treated with ipsilateral island fibular transfer in an antegrade or retrograde fashion. Antegrade-flow pedicled flaps based on the peroneal vessel as in the conventional free flap were used for the proximal or middle one-third tibial defects, whereas retrograde-flow pedicled flaps based on the communicating branch between the peroneal and posterior tibial vessels were used for the middle or distal one-third of the tibia. All patients had one of the following problems: a previously failed free flap, below-knee amputation of the opposite leg because of open tibia fracture, refusal to use the contralateral sound leg, or poor general condition to endure a lengthy operation. Four of the patients also had an associated fibular fracture on the same leg, which was ultimately used as one of the osteotomy sites. The follow-up period was from 31 to 48 months. Time to bony union ranged from 4 to 7 months. Time to full weight bearing was from 5 to 9 months after operation. All of the transferred fibulas showed hypertrophy after weight bearing. Nonunion occurred in two cases, which were treated with a long leg cast and cancellous bone graft, respectively. The limb was shorter by an average of 0.5 cm in three cases, longer by 1.1 cm in one case, and in the last case, it was uncheckable because the opposite limb was previously amputated. Limited arc of rotation was not a problem. Other disabling complications were not seen. We believe that these methods can be a valuable alternative to the contralateral free fibula flap in certain cases.

Background Even though the quality of medical and surgical care has improved remarkably over time, iatrogenic injuries that require surgical treatment including injuries caused by cast and elastic bandage pressure, extravasation, and dopamine-induced ischemia still frequently occur. The goal of this study was to estimate the incidence and analyze the distribution of iatrogenic injuries referred to our department. Methods A retrospective clinical review was performed from April 2006 to November 2010. In total, 196 patients (116 females and 80 males) were referred to the plastic surgery department for the treatment of iatrogenic injuries. We analyzed the types and anatomic locations of iatrogenic complications, along with therapeutic results. Results An extravasation injury (65 cases, 37.4%) was the most common iatrogenic complication in our study sample, followed by splint-induced skin ulceration, dopamine-induced necrosis, prefabricated pneumatic walking brace-related wounds and elastic bandage-induced wounds. Among these, prefabricated pneumatic walking brace-related complication incidence increased the most during the 5-year study period. Conclusions The awareness of the very common iatrogenic complications and its causes may allow physicians to reduce their occurrence and allow for earlier detection and referral to a plastic surgeon. We believe this is the first study to analyze iatrogenic complications referred to a plastic surgery department in a hospital unit.

Background The use of a V-Y advancement flap is an effective technique for the reconstruction of small facial defects. However, in some areas, the use of a conventional V-Y advancement flap is not possible because of the tension caused by size variation. In the current study, we modified this method using a croissant-shaped V-Y advancement flap and repaired intermediate-sized defects without difficulty. Materials and methods A croissant-shaped modified V-Y flap was used in 15 patients (aged 53-82 y). To completely remove masses, wide excisions were performed in all cases (nasolabial area = 7, nasojugal area = 3, medial canthal area = 1, cheek = 2, nose = 1, forehead = 1), and the average size of the defects was 2.6 × 2.5 cm. The flap was designed after confirmation of clear resection margins on frozen section. The long axis of the V-flap was 1.5 to 2 times the length of the diameter of the defect and parallel to the nasolabial or nasojugal fold. In a conventional V-Y advancement flap, the lateral limbs of the V-flap begin at the end point of the central limb. However, in our design, the incision lines of the lateral limbs of the V-flap were extended to the end point of the defect to form a more convex shape. The flap was elevated in the subcutaneous layer above the mimetic muscles. The bilateral tips of the horns of the V-flap were sutured to each other and fixed medially to cover the distal aspect of the defect. The flap was then sutured with a 6-0 nylon. Donor site closure was performed with 6-0 Vicryl and 6-0 nylon in 2 layers. A Penrose drain was inserted at the donor site. Results No complications were reported in any of the 15 cases. In 2 cases, there was minimal flap congestion immediately after surgery. However, in both cases, the congestion spontaneously resolved during the ensuing days. At follow-up (mean, 12 mo), all 15 patients demonstrated satisfactory cosmetic results. Conclusions This modified croissant-shaped V-Y flap may serve as an alternative to conventional V-Y flaps for reconstruction of soft tissue defects on the face.

Genetic instability resulting from mutations in repair genes, defects in folic acid metabolism or DNA synthesis has been reported to contribute significantly to the development of skin cancer. The enzymes 5,10-methylenetetrahydrofolate reductase (MTHFR) and thymidylate synthase (TS) are essential participants in folic acid metabolism and DNA synthesis. Thus, the present case-control study was conducted to determine whether an association exists between the MTHFR/TS polymorphisms and squamous cell carcinoma (SCC) and/or basal cell carcinoma (BCC) among Korean individuals. The study subjects comprised 95 patients with SCC, 100 patients with BCC and 207 controls with no evidence of malignancy or pre-malignant lesions. Patients with skin cancer and control samples were analyzed for polymorphisms of the MTHFR or TS genes by means of polymerase chain reaction-restriction fragment length polymorphism. The MTHFR 677C>T and MTHFR 1298A>C polymorphisms showed no significance with regard to the development of SCC and BCC. However, within the 6 bp insertion (ins)/deletion (del) polymorphism in the 3'-untranslated region (3'-UTR) of the TS gene, the BCC group showed statistical significance with a 2.8-fold increased risk of cancer development [adjusted odds ratio (AOR)=2.821] in heterozygous mutations (0 bp/6 bp), 7.5-fold (AOR=7.539) in homozygous mutations (6 bp/6 bp) and 3-fold (AOR=3.079) upon combination of heterozygous mutations and homozygous mutations (0 bp/6 bp + 6 bp/6 bp). We thus conclude that the 6 bp ins/del polymorphism in the 3'-UTR is associated with increased risk of the development of skin cancer among Korean individuals with BCC.

Symplastic glomus tumors are defined as glomus tumors with a high-grade nuclear pleomorphism in the absence of any other malignant features, such as large size, deep location, infiltrative growth, mitotic activity, or necrosis. Only 11 cases have been reported so far in the English literature. It could be a challenge for pathologists who have no experience with it because the tumor can show marked nuclear atypia and pleomorphism. Despite its high nuclear grade, a symplastic glomus tumor itself has a benign biologic behavior. Hereby, the authors report a case of a symplastic glomus tumor on the right index finger tip of a 44-year-old woman with a literature review.

Panfacial bone fracture is challenging. Even experienced surgeons find restoration of original facial architecture difficult because of the severe degree of fragmentation and loss of reference segments that could guide the start of facial reconstruction. To restore the facial contour, surgeons usually follow a general sequence for panfacial bone reduction. Among the sequences, the bottom-to-top and outside-in sequence is reported to be the most widely used in recent publications. However, a single sequence cannot be applied to all cases of panfacial fractures because of the variations in panfacial bone fracture patterns. In this article, we intend to find the reference and discuss the efficacy of inside-out sequence in facial bone fracture reconstruction.

DNA in most cells is regularly damaged by endogenous and exogenous mutagens. Unrepaired damage can result in apoptosis or may lead to unregulated cell growth and cancer. Inheritance of genetic variants at one or more loci results in reduced DNA repair capacity. This hospital-based case-control study examined whether polymorphisms in the DNA repair gene X-ray repair cross-complementing groups 1 (XRCC1) (Arg194Trp[C > T], Arg280His[G > A] and Arg399Gln[G > A]) play a role in susceptibility to skin cancer. We genotyped these polymorphisms for 212 histopathologically confirmed skin cancer cases (n = 114 basal cell carcinoma, n = 98 squamous cell carcinoma) and 207 age- and sex-matched healthy control cases in Korea. We found that individuals with the Arg/Gln and Arg/Gln + Gln/Gln genotypes at XRCC1 Arg399Gln(G > A) had an approximately 2-fold increased risk of basal cell carcinoma compared to individuals with the Arg/Arg genotype (adjusted odds ratio [AOR] = 2.812, 95% confidence interval [CI] 1.32–5.98, and AOR = 2.324, 95% CI 1.11–4.86). However, we observed that the 194Trp allele of the Arg194Trp(C > T) polymorphism was inversely associated with squamous cell carcinoma risk (Trp/Trp, AOR = 0.06, 95% CI 0.006–0.63). Our data suggest that the Arg194Trp and Arg399Gln polymorphisms may be differentially associated with skin cancer risk. (Cancer Sci 2007; 98: 716–720)

Finger amputation with bone exposure when replantation is not feasible requires a procedure for closure and padding of the stump. To preserve the length and provide adequate coverage, various flaps are used. A situation may occur in which local flaps are not sufficient and distant flaps are preferred. However, distant flaps often require a two-stage procedure, prolonged immobilization, and skin grafts. Thus, a simpler approach for fingertip or stump reconstruction while maintaining the padding effect of a flap was designed. The composite of glabrous skin and subcutaneous fat provided such padding, was performed in a single stage, and the donor site morbidity was negligible. During a 5-year period from 1996 to September 2002, 15 cases of finger stumps were reconstructed using the hypothenar composite graft. The age of the patients ranged from 1 to 63 years (average, 30 years). The average follow-up was 35 months. The donor sites were closed primarily and there were no marked complications related to this site. The graft showed relatively good contour and color match to the adjacent field, with an average two-point discrimination of 5.7 mm, indicating satisfactory reinnervation. The hypothenar composite graft for reconstruction of finger stumps can provide protective padding, maximal stump length, and minimal donor site morbidity, leading to satisfactory aesthetic and functional recovery.

The coverage of soft-tissue defects around the knee joint presents a difficult challenge to the reconstructive surgeon. Various reconstructive choices are available depending on the location, size, and depth of the defect relative to the knee joint. However, the knee joint frequently accompanies injuries to the lower leg that may limit the use of muscle flaps, especially the gastrocnemius muscle. The use of a free flap is preferred for reconstruction involving obliteration of large-cavity defects, but the isolation of recipient pedicle can be difficult because of the extent of injury zone and in cases of chronic infection around the knee. To provide muscle bulk with a reliable vascular supply, the distally based, prefabricated sartorius muscle flap was used as a last resort to reconstruct difficult wounds with chronic osteomyelitis around the knee joint in 6 patients from June 1995 to May 2001. This method is a two-stage procedure. First, the sartorius muscle is prefabricated by denervation and vascular delay. Silicone sheets are used to increase the vascularity and dimension of the flap. Second, after 3 weeks, the muscle is transposed based on a distal pedicle to reconstruct the soft-tissue defect around the knee. The prefabricated sartorius muscle can provide efficient bulk to obliterate the dead space and to cover moderate-size soft-tissue defects around the knee joint. This method can be considered to reconstruct the soft tissue around the knee joint when local muscle flaps and free flaps are not feasible.

The reconstruction of the posterior heel including a wide defect of the Achilles tendon is difficult as a result of complicated infection, deficient soft tissue for coverage, and functional aspects and defects of the tendon itself. As a single-stage procedure, various methods of tendon transfer and tendon graft have been reported along with details of local flaps or island flaps for coverage. With advances in microsurgical techniques and subsequent refinements, several free composite flaps, including tendon, fascia, or nerve, have been used to reconstruct large defects in this area without further damaging the traumatized leg. The authors report such a single-stage reconstruction of a composite Achilles tendon defect using the extensor digitorum longus tendon of the second to fourth toe in combination with a dorsalis pedis flap innervated by the superficial peroneal nerve. The follow-up of this case has proved a satisfactory outcome to date.

Solitary fibrous tumour is a rare mesenchymal neoplasm that most commonly involves the pleura. The diagnosis of solitary fibrous tumour is primarily histological. It consists of histological and positive immunohistochemical findings of CD-34 and vimentin. Recently, solitary fibrous tumour has been reported to occur in extrapleural soft tissues, such as the orbit, nasal cavity, abdominal cavity, parotid gland, scalp and neck. In an extensive review of the literature, we found no reports of solitary fibrous tumour arising in the facial soft tissue, other than in the parotid gland. This rare location of an uncommon lesion can lead to a confusing diagnosis. We report a case of solitary fibrous tumour originating in the temporal region of the face, and call for awareness of this tumour among plastic surgeons.

The coverage of soft-tissue defects of the sole needs special consideration because of the forces of weight bearing on the reconstruction. A variety of free tissue transfers have been advocated for soft-tissue replacement of the weight-bearing portions. However, there is no doubt that the ideal tissue for resurfacing the sole is the plantar tissue itself. The authors present a case of reconstructing the sole with the combined medial plantar and medialis pedis free flap that involves approximately 70% of the weight-bearing portion. This contralateral, combined fasciocutaneous free flap based on the posterior tibial-medial plantar vascular system is a good alternative in covering extensive sole injuries.

The foot plays a vital role in standing and gait. Its function results from harmonious interaction of bones, joints, and soft tissue. An imbalance or a defect in these structures can result in problems. The cuneiform bone of the foot consists of three bones: medial, intermediate, and lateral. Its structure plays an important role in maintaining the skeletal arch and it supports the body's weight. A defect or dislocation can disrupt the distribution of the weight-bearing complex of the foot and can lead to difficult gait.