Objectives: Treatment of congenital facial paralysis is often postponed because patients exhibit only mild dysfunction and inconspicuous facial asymmetry at rest. Surgical facilitation of smiling has significant implications for the quality of life and the physical and mental development of patients. We describe facial reanimation using modified lengthening temporalis myoplasty (LTM) in patients with congenital incomplete facial nerve palsy who first presented to our institution after the age of 10 years.

Methods: Three patients (age, 12-26 years; two males and one female) underwent facial reanimation with modified LTM using an extended S-shaped incision. In two cases, T-shaped fascial grafts were simultaneously applied to the lower lip. Evaluation was conducted using a simple and objective method to assess smile symmetry.

Results: The postoperative follow-up period ranged from one to nine years. Postoperatively, the oral commissure remained symmetrical at rest in all three cases. Good symmetry was observed during voluntary smiling in all three cases and during spontaneous smiling in two cases.

Conclusions: Modified LTM, a technique that does not require microsurgery and leaves no facial scarring, is a useful option for smile reconstruction in patients with congenital incomplete facial nerve paralysis.

An external dental fistula is a skin perforation caused by spontaneous drainage of pus from odontogenic lesions and is often misdiagnosed due to its resemblance to other conditions. This report describes an 84-year-old man who presented with left cheek swelling and pus drainage. Although an external dental fistula was initially suspected, the diagnosis was delayed due to the edentulous state of the left maxilla. After multiple referrals to various specialties and several misdiagnoses, a computed tomography scan revealed a fistulous tract linked to a retained tooth fragment. The dental fragment was surgically removed, leading to resolution of the abscess and closure of the fistula. This case highlights the importance of considering external dental fistulas even in edentulous patients, as a retained tooth fragment can be the underlying cause.

The palm is prone to skin contractures due to Dupuytren's contractures or trauma. To cover skin defects after contracture release and prevent re-contracture, surgeons prefer flaps to skin grafts. The perforator propeller flap is one of the best local flaps; however, there are few reports on this method. In a perforator mapping study in healthy volunteers, color Doppler ultrasonography showed that the perforator vessels were located around the metacarpophalangeal joints. Five patients with Dupuytren's contracture and one with post-traumatic scar contracture underwent novel perforator propeller flap reconstruction using perforator vessels around the metacarpophalangeal joint in the second, third, or fourth intermetacarpal spaces. Flap sizes ranged from 11 × 22 to 16 × 50 mm², and all flaps survived completely. Our propeller flap is useful for the reconstruction of distal palmar skin defects, especially those less than 16 mm in width.

Electrical injury refers to sustained trauma to the skin or internal organs caused by direct contact with an electric current. Progressive necrosis caused by vascular endothelial damage is a defining feature of electrical injuries. Given this endothelial damage, careful attention is required during reconstruction after such injuries. We present a case of upper extremity reconstruction following an ultra-high-voltage electrical injury (275,000 volts), using an abdominal distant flap with planned vascular anastomosis. Many cases of electrical injury require extremities amputation; however, we were able to salvage the upper extremity. Therefore, this reconstruction method can be an effective technique for managing high-voltage electrical injuries.

A comprehensive apocrine glandectomy with a high certainty of treating axillary osmidrosis is described. Two semicircular subcutaneous disks that include all glands are dissected, starting with the backside. By deftly using every finger, the entire procedure can be performed alone. In the dissected specimens, the completely removed apocrine glands are prominent as elastic, reddish granules surrounded by loose, light-yellow fat tissue.

This is a rare case report in which a third free flap was used to restore metachronous mandibular defects. Significant functional and aesthetic losses may result from segmental mandibular excision in cases of oral cancer. The fibula flap is the gold standard for reconstructing these defects, which is essential for regaining shape and function. Reconstruction attempts become more complex when individuals experience metachronous malignancies or recurrence. We present a rare instance in which a third free flap was required for restoration following 2 metachronous mandibular defects. Mandibular continuity was effectively restored using a free chimeric scapular with latissimus dorsi myocutaneous flap, yielding positive functional and cosmetic results. This case report shows that even after prior reconstruction, patients can successfully undergo an additional free flap procedure, improving their quality of life. It further underscores the adaptability and effectiveness of this reconstructive technique in correcting complex mandibular defects.

A Spigelian hernia is a rare abdominal wall herniation that occurs within the Spigelian fascia, located between the semilunar line and the outer border of the rectus abdominis muscle. A 2-year-old boy was brought to our medical facility because of a longstanding bulge in his right lower abdominal quadrant. Computed tomography revealed the presence of a spinal hernia, right undescended testicle, and right kidney defect. Given the potential association of Spigelian hernias with an undescended testis, a comprehensive examination of the scrotal region at the time of diagnosis is warranted. In the absence of intestinal obstruction or hernia abruption, surgical intervention is recommended on a standby basis. Furthermore, concurrent treatment of any undescended testicle is advised to alleviate patient burden.

This case report presents a rare instance of distal sciatic nerve injury caused by bone fragments from a blast injury. It provides valuable insight for plastic reconstructive surgeons, offering guidance on the management of complex sciatic nerve injuries. Sciatic nerve injuries often have a poor prognosis and require long-term management. Due to limited research and established guidelines, management can vary based on surgeon expertise. Initial treatment focused on limb salvage, with the nerve injury initially overlooked. Nerve conduction studies confirmed the extent and level of the nerve injury, leading to surgical exploration, removal of bone fragments within the nerve, neurolysis, and neurorrhaphy.

Hemifacial microsomia has been reported as the second most common congenital craniofacial malformation. The aim is to present a representative case of a patient who underwent both surgical procedures for the integrated care of hemifacial microsomia. The surgical technique for dynamic facial reanimation was a two-stage procedure due to masseter function impairment. The first one consisted of a cross-facial nerve graft, which was coapted to the masseteric nerve on the contralateral side, and the second stage consisted of a gracilis muscle transfer, in which the obturator nerve was coapted to the masseteric nerve on the ipsilateral side (a dual-innervated free functional gracilis flap). Mandibular distraction was performed a year after the second stage of facial reanimation. At the five-year follow-up, the patient had sustained a satisfactory, aesthetic, and pleasant result. No further secondary or revision procedures have been needed. Objectively, we observed bite-force enhancement, as demonstrated by electromyography. In our experience, we recommend performing microsurgical facial reanimation first, followed by mandibular distraction, and finally, autologous ear reconstruction.

Objectives: To evaluate the effect of resonance tube therapy (RTT) for velopharyngeal inadequacy (VPI) of patients with cleft palate (CP± L), submucous cleft palate (SMCP), and congenital velopharyngeal incompetence (CVPI).

Methods: Thirteen patients were diagnosed with mild or moderate VPI due to either repaired CP± L (7), repaired SMCP (1), or CVPI (5) who had articulation errors. We trained these 13 patients in RTT and performed cephalometry before and after training. Roentgen lateral cephalograms during phonation were used to measure the velar height (mm) and the distance of the narrowest segment of the velopharynx (mm).

Results: After RTT, the velum was significantly elevated, and the velopharynx was narrowed during phonation of /a/ (p< 0.01). Additionally, the velum was significantly elevated, and the velopharynx was more markedly narrowed during phonation of /ɯ/ with tube (tube phonation /ɯ/) than during phonation of /a/ (p < 0.01). The velopharyngeal function (VPF) of all 13 patients was improved by RTT. Ten of 13 showed improved speech and velopharyngeal function. Our findings suggest that RTT is effective in improving velar mobility and velopharyngeal function.

Conclusions: The use of roentgen lateral cephalography during phonation provides quantitative objective findings that distinguish between velar mobility before and after RTT. We propose that RTT is effective for improving velar mobility and velopharyngeal function in patients with and without cleft palate (CP).

Minocycline has caused hyperpigmentation on various body parts, including the skin and mucosa, as a side effect. This is the first report of hyperpigmentation in transplanted free flaps. We present three head and neck reconstruction cases in two males and one female. The primary diseases were two cases of tongue cancer and one case of buccal mucosa cancer. Two anterolateral thigh flaps and one rectus abdominis musculocutaneous flap were transplanted after tumor resection with skin paddles placed intraorally. Minocycline was administered to prevent acneiform rash, which is a side effect of cetuximab during postoperative chemotherapy. The intraoral skin paddles turned blue 2 weeks to 1 month after administration. Minocycline causes hyperpigmentation by chelating the hemosiderin deposited in the skin due to capillary hemorrhage. Intraorally transplanted free flaps may be susceptible to minocycline-induced hyperpigmentation owing to vascular congestion, inflammation, and the intraoral environment.

Neonatal purpura fulminans, often caused by congenital protein C deficiency, presents with rapid onset of skin necrosis and microvascular thrombosis and can progress to disseminated intravascular coagulation. Therefore, early diagnosis and intervention are crucial for patient survival. We report a case of a neonate who developed purpura fulminans within hours after birth and presented with skin lesions on the right lower leg and abnormal coagulation markers. Treatment with fresh frozen plasma and heparin was promptly initiated, leading to significant improvement. Conservative management with ointments and wound dressings was also administered to treat the skin lesions. Genetic testing confirmed a compound heterozygous PROC mutation. Despite severe ocular complications that resulted in blindness, limb function was preserved. This case highlights the importance of early recognition, genetic testing, and aggressive treatment in managing neonatal purpura fulminans caused by congenital protein C deficiency to improve outcomes and prevent severe sequelae.

Objectives: Plastic surgeons often harvest fascia from the upper thigh or gluteal area of the patient to transplant to other parts of the body. The thickness of the fascia differs depending on its position within the two areas. This anatomical study elucidates the positional variation fascia thickness presents within the two areas.

Methods: 21 upper thighs of 12 cadavers of Japanese persons were included in the study. The gluteal maximum muscle (GM), the iliotibial tract (IT), the biceps femoris muscle (BF), the vastus lateralis muscle (VL), and the rectus femoris muscle (RF) were identified. The thicknesses of the fascia were measured for each of these regions and were compared between the regions belonging to the same area.

Results: Gluteal Area: Fascia thickness presents no statistical differences between the GM and IT regions. Upper Thigh Area: The fascia is thickest in the IT region, followed by the BF region. The fascia is thin in the VL and RF regions.

Conclusions: Fascia thicknesses present regional differences. The fascia of the gluteal area is evenly thick, with 1 mm thickness or more. Hence, the gluteal region is suited as a donor site for harvesting a large-sized, thick graft sheet. In the upper thigh area, the iliotibial tract region is the thickest, with thicknesses of 1 mm or more. The fascia is relatively thick in the posterior regions (0.5-0.6 mm), but thin in the anterior regions (0.2-0.3 mm).

Plastic surgery includes both reconstructive and aesthetic procedures, with residency programs designed to provide comprehensive training. However, practical experience in aesthetic surgeries is often limited because these procedures are not typically covered by public health systems. Body contouring surgeries for patients who have experienced massive weight loss offer a training opportunity, as they are technically similar to aesthetic procedures and are publicly funded. This study surveyed recent graduates from a plastic surgery residency program to assess their perceived competence and autonomy in aesthetic surgery. The survey focused on experiences with post-bariatric procedures such as abdominoplasty, breast surgery, thigh dermolipectomy, brachioplasty, and liposuction. The results indicated that residents felt confident in preoperative consultations and basic surgical skills but felt less prepared in theoretical knowledge, technique comparison, and the use of prostheses. Surgical autonomy was highest in abdominoplasty and lowest in inguinocrural dermolipectomy. The study also emphasized the crucial role of the assistant surgeon progressing toward full surgical autonomy. The findings suggest a need for improved training in aesthetic procedures, as well as in commercial and medicolegal aspects. Incorporating these elements into residency curricula can better prepare future plastic surgeons for comprehensive practice and enhance patient outcomes.

Risk-reducing mastectomy and risk-reducing salpingo-oophorectomy (RRSO) for patients with hereditary breast and ovarian cancer with a BRCA gene mutation can be performed with simultaneous breast reconstruction. In this report, we present a rare case of umbilical necrosis in bilateral deep inferior epigastric artery perforator flap breast reconstruction with concomitant risk-reducing mastectomy and RRSO. Both deep inferior epigastric artery flaps were elevated based on the perforators cranial to the umbilicus, which may have completely ceased the blood supply from the deep inferior epigastric arteries and caused umbilical necrosis. The supra-umbilical port was used for RRSO, which may have caused damage to the ligamentum teres hepatis, located cranial to the umbilicus. In the preoperative enhanced computed tomography, the ligamentum teres appeared to be a vein. Damage to the ligamentum teres through the supra-umbilical port might have caused umbilical necrosis due to venous congestion. Perforators and port positions might have contributed to the umbilical necrosis.

Breast augmentation using copolyamide fillers, such as Aquafilling^®, is associated with various complications, leading to an increasing consensus against their use. However, the occurrence of breast cancer in patients who have undergone augmentation with fillers has been rarely reported. The management of such cases, particularly in terms of breast reconstruction, presents unique challenges owing to the presence of filler materials. We report the case of a patient with breast cancer who underwent immediate two-stage implant-based breast reconstruction after breast augmentation with Aquafilling^®. No capsular formation was observed around the tissue expander during the second reconstruction procedure. To prevent implant migration, the normal tissue of the marginal pocket was identified and sutured. However, caudal migration of the implant still occurred. This case highlights the need for improved surgical techniques to stabilize silicone breast implants effectively. Further research is warranted to understand the long-term implications of copolyamide fillers on breast reconstruction outcomes.

The upper eyelid fistula caused by intracranial infection is rare. We present a rare case of an upper eyelid fistula caused by a chronic infection of the artificial dura mater, the bone flap, and the absorbable fixation materials following epilepsy surgery in a 13-year-old male. After surgery for left frontal lobe epilepsy, the patient developed a purulent discharge from the left upper eyelid. Imaging studies revealed a bone defect in the cranial bone flap, with the infection extending to the upper eyelid. Pseudomonas aeruginosa was identified as the causative agent. Surgical intervention, including removal of the infected artificial dura mater, bone flap, and fixation materials, was performed, followed by reconstruction of the dura mater using fascia lata. Postoperatively, the upper eyelid fistula healed completely without recurrence. This case underscores the importance of considering cranial bone and dura mater infections as potential causes of upper eyelid fistulas, especially in patients with a history of neurosurgery.

Objectives: Free flap transplantation is a fundamental technique in reconstructive surgery, and the free fibular flap presents a unique challenge owing to its composite tissue nature. Despite the difficulty of this procedure, there is a lack of research on the learning curve associated with free fibular flap harvesting.

Methods: This study, conducted between April 2011 and March 2023, aimed to calculate the learning curve for fibular flap elevation on the basis of the experience of a single surgeon. The power-law approximation formula was used to model the learning curve, with the flap elevation time as the key parameter.

Results: The average tourniquet time for 36 cases in which the first author performed as the primary surgeon was 72.8 minutes, with a range of 32 minutes to 178 minutes. The power-law approximation formula, derived using Python, was y = 187.76x^-0.376, indicating a strong correlation (maximal information coefficient = 0.870) between the formula and actual elevation times. The target elevation time was set at a single tourniquet time of 90 minutes, requiring experience with seven to eight cases.

Conclusions: This study suggests that mastering the elevation of the fibular flap requires experience with seven to eight cases, within the duration of a single tourniquet application. The findings contribute to understanding the learning curve associated with fibular flap transplantation and provide valuable insights for surgical training.

Objectives: This study aimed to elucidate the incidence of anterolateral thigh (ALT) flap failures attributable to perforator complications, distinct from issues with microvascular anastomoses or proximal vascular pedicles.

Methods: A retrospective chart review was conducted for 663 free ALT flap transfers for head and neck reconstruction between 1995 and 2024. Data on failed flaps were analyzed.

Results: There were 41 flap failures, generating an overall success rate of 93.8%. Of these, 18 (43.9%) were due to perforator compromise, whereas the remaining 23 (56.1%) stemmed from anastomotic or proximal pedicle complications. The 18 perforator-related failures predominantly occurred after hemiglossectomy (7 cases) and marginal mandibulectomy (5 cases). Flaps in 14 cases were harvested with the vastus lateralis muscle; 13 involved a single skin perforator, and others contained 2 skin perforators. Perforator skeletonization was performed in 12 cases.

Conclusions: Perforator compromise is a major cause of ALT flap failure in addition to problems with microvascular anastomoses or proximal vascular pedicles. Countermeasures such as avoiding perforator skeletonization and including multiple perforators in the skin paddle may be effective in preventing these complications.

Myelomeningocele is the most common congenital abnormality of the central nervous system. We present our experience and review the postoperative outcomes and complications by conducting a retrospective observational study. Medical records of 48 patients who underwent surgical closure of myelomeningocele from September 2013 to December 2023 were reviewed and analyzed. Overall, 28 cases were closed with direct skin repair, while 20 cases required local skin flaps. Five cases of wound dehiscence, 6 cases of cerebrospinal fluid leak, 2 cases of surgical site infection, and 1 case of flap tip necrosis occurred. Management of myelomeningoceles requires a multidisciplinary approach. Most myelomeningocele defects can be closed primarily. However, other methods can be utilized if necessary. Complications are difficult to avoid but outcomes can be optimized if the necessary steps are deployed.

Objectives: Bromelain-based enzymatic debridement has gained significant attention for its potential advantages in treating burn wounds. However, no previous meta-analyses have been conducted to provide concise evidence of bromelain's efficacy. Therefore, this study aims to conduct a systematic review and meta-analysis focusing on the comparison of bromelain use versus standard care in patients undergoing burn debridement.

Methods: Systematic searches were conducted in PubMed, Embase, and the Cochrane Library databases to identify relevant studies. Data synthesis was performed using random-effects models, with findings presented as mean differences (MDs) and weighted odds ratios, accompanied by their corresponding 95% confidence intervals.

Results: The review analyzed 10 studies, including three randomized controlled trials, two clinical trials, and four observational studies, involving 596 burn patients with an average age of 38 years and a mean total body surface area (TBSA) of 16%. Of the participants, 49% received a topical bromelain mixture, while 51% received standard care. Bromelain was linked to faster debridement (MD -3.92; p < 0.00001) and a higher rate of spontaneous healing (MD 71.00; p < 0.00001). Surgical excision and autograft procedures were less common in the bromelain group, with odds ratios of 0.08 (p < 0.0002) and 0.10 (p = 0.0001). No significant differences were observed in wound closure time, infection rates, blood transfusion needs, Modified Vancouver Scar Scale scores, or hospital stays.

Conclusions: The evidence from this study suggests that the administration of bromelain-based enzymatic debridement significantly reduces the time required to complete debridement, increases the chances of spontaneous healing of burn wounds, and decreases the need for further surgical excisions and autograft procedures.

Depressed scars may develop from subcutaneous fat damage after facial trauma. For cases without visible scars on the skin surface, a non-incisional approach is preferred. We treated a depressed scar on the mandible with string-shaped dermal fat grafts. Using an 18-gauge needle, the scar was released from the underlying tissue. A dermal fat graft, harvested from the postauricular area and cut into strings, was inserted through the needle hole. The depression improved with satisfactory aesthetic results, requiring no special equipment and avoiding new visible scars on the exposed areas of the face.

Objectives: Patients with sarcomas involving the femoral vessels have been treated with wide tumor resection and reconstruction using great saphenous vein (GSV) grafts. Several studies have reported on the application of fibrin glue (FG) at microvascular anastomosis sites. This study aimed to evaluate the effectiveness of autologous FG (AFG) in femoral vessel reconstruction using GSV grafts.

Methods: Five male patients with lower extremity sarcomas underwent revascularization using harvested GSV grafts, each 1.5 times longer than the resected femoral artery. Anastomoses were sutured using 8-0 nylon under a microscope. AFG was applied to the anastomosis sites and along the length of the grafts. Approximately 10 mL of AFG (excluding thrombin solution) was available and consequently used. Operative details and postoperative complications requiring re-exploration were assessed.

Results: The mean tumor size was 10.2 cm, the mean vessel defect length was 11.1 cm, and the mean graft-to-defect ratio was 1.56. Among the patients, two underwent revascularization of the artery and vein, while three underwent arterial revascularization. One patient experienced distal-side necrosis due to arterial insufficiency based on severe size discrepancies.

Conclusions: The large volume, high fibrinogen content, and growth factors in AFG suggest its potential to support external vein grafts, prevent graft overdistention, enhance graft thickness, and minimize minor leakage from vein graft branches.

Objectives: Submucous cleft palate (SMCP) is a subtle and occult subtype of cleft palate. Diagnosis is often delayed due to inconspicuous clinical features of the SMCP. This study aims to investigate the demography of SMCP patients, to determine when SMCP patients are operated on, and to analyze the surgical technique applied to correct SMCP in our center.

Methods: Medical records in Hospital Pakar Universiti Sains Malaysia (HPUSM) from 1999 to 2023 were retrospectively reviewed. Patients diagnosed with SMCP who were operated on were identified. The variables extracted from the records include gender, ethnicity, age at diagnosis, age at surgery, antenatal history, genetic study, associated signs and symptoms, other conditions and anomalies, associated syndromes, surgical techniques, and complications.

Results: A total of 21 SMCP patients who underwent repair were identified. However, only 15 complete medical records were obtained. The mean age of surgery is 68.4 months, ranging from 5 to 212 months. The majority of patients at 47.6% underwent Bardach's two-flap palatoplasty. Other techniques identified were Veau-Wardill-Kilner palatoplasty, Von Langenbeck palatoplasty, Furlow double-opposing Z-palatoplasty, and intravelar veloplasty.

Conclusions: This retrospective case series reported that SMCP patients were operated at a later age. The higher average age of surgery is multifactorial and likely includes delayed diagnosis. Various surgical techniques may be used to repair the SMCP. A high level of suspicion of SMCP is paramount when the clinical features of cleft palate are subtle, but patients exhibit other suspicious signs such as recurrent episodes of otitis media, nasal regurgitation, or speech impediments.

A 15-year-old male patient was referred to our hospital with a congenital elevated lesion in the sacrococcygeal region, which measured 8 × 5 cm. Six months prior to presentation, the patient developed redness and pain in the lesion during cycling. Computed tomography revealed dorsal angulation of the 5th sacral segment (S5) and the 1st coccygeal segment (Cy1) and ventral angulation of Cy2 to 4th coccygeal segment (Cy4). Under general anesthesia, Cy1 to Cy4 were resected and S5 was flattened. Soft tissue and overlying tissue of the coccyx were not resected. At the 18-month follow-up, the patient exhibited no recurrence of the coccygeal pad (CCP) or associated pain. Pathologically, CCP consists of connective tissue. However, the coccyx deformity can cause subjective symptoms. This case suggests that coccygectomy without skin or soft tissue resection can be an effective treatment for CCP.

Objectives: Cellulitis is a significant prognostic factor for lymphedema, rendering its prevention and prediction critical for effective lymphedema management. Given the influence of climatic conditions on abdominal aortic aneurysm rupture and considering that the lymphatic system is part of the circulatory system, we hypothesized that lymphedema may be classified as a meteoropathy. Therefore, we aimed to investigate the correlation between climatic conditions and the onset of cellulitis in lymphedema-affected limbs.

Methods: The clinical records of patients with lymphedema admitted for cellulitis to our institute between January 2007 and December 2017 were reviewed. Forty patients were identified, with 25 residing in the same geographic area (Yokohama City). The association between the frequency of patient admissions according to season and the meteorological data obtained from the Japan Meteorological Agency database was analyzed.

Results: The mean age of the 40 participants was 56.1 (range, 15-79) years, of whom 7 were men and 33 were women. Among the 25 patients who lived in Yokohama City, 13 were admitted in summer, whereas only one patient was admitted in winter. In summer, the temperature was higher (p = 0.0016), while the atmospheric pressure was lower (p = 0.0018) compared with the other seasons. Notably, higher temperatures and lower atmospheric pressure around the day of admission were associated with the occurrence of cellulitis.

Conclusions: Lymphedema may be considered a meteoropathic disease, as climatic conditions were found to be associated with cellulitis in lymphedema-affected limbs.

Lower limb reconstruction, particularly in the distal third, is challenging due to limited local flap options, poor skin laxity, and the direct exposure of critical structures such as bone and tendons due to the thin skin in the region. For larger defects, a microvascular free flap transfer is often required. For small to medium defects, the distally based peroneus brevis muscle flap is a viable option, though it may risk distal flap necrosis over the critical defect area. This study presents the authors' experience using this flap in 9 patients at a Singapore health care center. Key considerations include (1) modifications in situations where a perforator-based propeller flap is considered as an alternative option, (2) the use of intraoperative Indocyanine Green Near-Infrared Video Angiography to reduce necrosis risk, (3) employing negative pressure wound therapy, and (4) determining the optimal immobilization duration.

Background: In Japan, resection of basal cell carcinoma (BCC) with a margin of at least 4 mm is recommended by guidelines.

Objectives: This study aimed to investigate the effectiveness of surgical margins for well-defined pigmented BCC in Japanese patients.

Methods: Between 2010 and 2017, 25 cases of well-defined nodular pigmented BCC measuring 20 mm or less on the face were surgically resected with a margin of 4 to 5 mm, and pathological measurements were performed at the National Hospital Organization Nagasaki Medical Center. The measurement item was subclinical extension of the tumor, which is the difference in distance between the actual tumor border confirmed under a microscope and apparent tumor border determined clinically from the outside.

Results: Subclinical extension of the tumors ranged from 0 to 3.5 mm, with a mean of 1.0 mm, standard deviation of 1.0 mm, and 95% confidence interval of 0.7 to 1.6 mm. Regardless of the malignancy grade, resection with a 3-mm margin for nodular pigmented BCC with a clear border and long diameter of 20 mm or less was effective, with a complete resection rate of 96%.

Conclusions: Surgical excision with a 3-mm margin is reliable treatment for well-defined, primary pigmented BCC, with a complete removal rate of 96%. These results suggest that resection margins recommended in guidelines can be narrowed in Japanese patients with BCC.

We report the usefulness of the parallelogram skin graft harvest method, using a device that facilitates direct donor site closure by harvesting the skin in a parallelogram shape. The skin graft was designed as a parallelogram, and an electric dermatome was used to slide across the area at an oblique angle to the direction of travel. The donor site was then sutured directly. Early (hematoma, infection, and wound dehiscence) and late (pain and itching of the scar) donor site complications were also investigated. Twenty-seven patients were included in the study. Twelve patients were 75 years old or older, and two were consuming prednisolone. The maximum size of the harvested skin was 150 cm² (5 cm× 30 cm). None of the patients experienced donor site complications. The parallelogram skin graft harvest method is effective for the direct closure of the split skin graft donor site to promote healing.

We report a rare case of a 25-year-old man with paraplegia and hemodialysis dependency due to traumatic spinal cord injury and renal infarction. Ischial and severe sacral pressure ulcers complicated by an urethrocutaneous fistula developed in the patient. A multidisciplinary approach was implemented, including percutaneous cystostomy, negative pressure wound therapy, and musculocutaneous flap surgery. This strategy successfully preserved urethral integrity, a significant achievement in such complex cases. After complete ulcer closure and meticulous follow-up, the patient successfully underwent living donor kidney transplantation with preserved urethral function.

This case highlights the efficacy of a multidisciplinary approach in managing severe pressure ulcers with a urethrocutaneous fistula while maintaining urethral integrity. It also underscores the importance of achieving complete ulcer healing and preventing recurrence before kidney transplantation. Long-term follow-up and development of standardized treatment protocols for such complex cases are warranted, particularly focusing on urethral preservation strategies.

Three patients with severe facial injuries and with history of attack by a single bear were simultaneously admitted to our hospital. With the rapid industrialization and overpopulation of India, there is an increased pressure on the available land, leading to increased human-animal conflicts. Fortunately, all three patients survived. The prolonged hospitalization needed and the tumultuous course in the hospitalization punctuated by multiple complications will tax medical practitioners. This study describes the clinical course of these patients in detail and the treatment particulars to help similarly placed physicians. We would like to stress the importance of early debridement, primary closure of wounds, and early skin grafting for raw areas even in patients with suboptimal physical status, along with appropriate anti-rabies prophylaxis, as key in managing these patients.

Bifid scrotum and penoscrotal transposition are rare congenital scrotal anomalies. Cases diagnosed without hypospadias and chordee are uncommon. We present a rare case of bifid scrotum and incomplete penoscrotal transposition without hypospadias and chordee in a 10-year-old patient. Examination revealed an incomplete transposition of the external genitalia, with the scrotum bifid along the scrotal raphe. The hypoplastic penis was buried at the midpoint of the scrotum. Intraoperatively, no hypospadias or chordee was identified. Single-stage scrotal reconstruction was performed with the modified Glenn-Anderson technique. Post-operatively, the patient recuperated well, with minimal edema. Bifid scrotum and penoscrotal transposition may exhibit broad clinical variations. Different surgical techniques with single- or multiple-stage reconstruction may be performed to achieve good functional and cosmetic outcomes. The modified Glenn-Anderson technique is a feasible single-stage scrotal reconstruction procedure that enables the repair of hypospadias and chordee in the same setting. The post-operative swelling and aesthetic results are acceptable.

Apert syndrome is one of the most challenging congenital hand disorders to treat due to the absence of skin and soft tissues and the complex osseous fusion morphology. In addition, hypoplasia of the digital arteries and abnormal bifurcations are also known, so it is not recommended to create all interdigital spaces in a single operation. Multiple surgeries are usually required. In this report, a two-stage interdigital reconstruction using adipose flaps was performed for syndactyly with Apert syndrome. The osseous fusion of the complex syndactyly was dissected and covered with adipose flaps simultaneously with the interdigital reconstruction of the simple syndactyly at the primary surgery. Six months later, the interdigital reconstruction of the complex syndactyly was performed. This method is considered to be easy to perform and useful for ensuring sufficient soft tissue thickness in the lateral nail fold and secure skin grafting.

Pollicization surgery for thumb reconstruction has a long-standing history. However, advancements in microsurgery and the widespread use of free tissue transplants from the toe for the surgical treatment of traumatic thumb defects have narrowed the indications of pollicization in thumb reconstruction. Despite this, pollicization offers certain advantages over free flap transfer in specific cases. Literature on cases requiring multiple-digit amputations or bilateral thumb reconstruction is sparse, and the indications for pollicization remain controversial. Here, we present a case of a 31-year-old man who lost multiple fingers, including both thumbs, in an industrial accident. He underwent pollicization surgeries on both hands. At 3 years and 9 months post-surgery, his postoperative course and hand function were assessed as good. In an era where microsurgery is prevalent, pollicization remains a viable option for patients with multiple-digit amputations, including index finger and bilateral thumb loss, provided the functional thenar muscles remain intact.

A 15-year-old male patient presented with an enlargement of his right thumb. The thumb had an atypical morphology characterized by a hypertrophic tip and a concave pulp. His parents had noticed this deformity since he was an infant. As the patient grew older, he began to feel tenderness in the hypertrophic region. We thought that this condition could be congenital and attributed the origin of the tenderness to decreased fat tissue in the pulp. We planned surgery to excise the skin on the concave part and augment the bulk there with a flap from the distal hypertrophic part. Intraoperatively, a solid subcutaneous tumor was found in the distal hypertrophic region. Pathological examination confirmed that the tumor was a schwannoma. Postoperatively, the tenderness resolved and the appearance of the thumb improved. This case is very atypical; information on this condition is lacking in the literature.

Fournier's gangrene is a severe, rapidly progressing necrotizing fasciitis with a high capacity for compromising tissues at different levels. It primarily affects perianal and genital areas with a high mortality rate due to extensive impact. Although typically observed in adult males (incidence of 1.6 cases per 100,000 men), there exists an out-of-standard population that can be affected by the disease, becoming the window of opportunity for underdiagnosis, deterioration of prognosis, and increased mortality. The lack of standardized treatment protocols contributes to the high morbidity and mortality rates. Increased awareness and rapid intervention are essential for improving outcomes in integral medical attention. Based on the literature we report a Caucasian neonatal case of Fournier's gangrene based on the Surgical Case Report (SCARE) guidelines and complemented with the literature available. This article aims to enhance clinical understanding, encouraging standardized management strategies for special populations at risk of this life-threatening condition.

Congenital midline cervical cleft (CMCC) is a rare defect of the midline neck which is often misdiagnosed. The aim of this study is to show the efficacy and safety of a novel surgical technique for CMCC to get excellent aesthetic and functional results. We report a series of four cases, two female and two male patients, affected by midline cervical cleft who underwent surgical excision and primary reconstruction of the neck defect through a double opposing Z-plasty, at the Pediatric Plastic and Maxillo-Facial Surgery Unit of a third-level referral hospital in Rome. No complications nor recurrences were noted; cosmetic results were satisfactory in all cases with progressive scar improvement. Early and complete surgical excision is essential to ensure good aesthetical results. The double opposing Z-plasty closure allowed us to obtain an excellent functional outcome and reduce cervical contracture.

Loss of the entire extensor mechanism of the knee presents a major reconstructive challenge. We encountered a patient who was missing the patellar tendon, patella, and quadriceps tendon following a remote trauma. A prior attempt at allograft reconstruction failed due to infection and dehiscence at the allograft-muscle connection. To avoid an allograft, we reconstructed the entire knee extensor mechanism with an ipsilateral functional free gracilis transfer, maintaining the enthesis at the tibia, rerouting the muscle across the anterior knee, and attaching the origin to the fascia lata. We vascularized the muscle with the descending branch of the lateral circumflex femoral vessels and innervated the muscle with a motor branch of the femoral nerve. The transfer was successful, with the patient able to ambulate without a brace by 6 months and to perform squats by 9 months. Complications commonly seen with allograft were obviated, and functional recovery was excellent.

Intraorbital surgery, including orbital wall repair, often requires surgeons to work in a confined surgical space, obstructed by overhanging tissue and exudate. Conventional retractors, used to maintain an accessible surgical working space, are not always effective in overcoming these challenges. Moreover, excessive retraction to obtain sufficient space in the surgical field can cause oculocardial reflexes and trauma. Here, we report the effective use of silicone sheets during intraorbital procedures as a spacer to maintain sufficient surgical space and as a template to shape reconstructive materials in two illustrative cases. The use of silicone sheets served as a surgical template and spacer, resulting in smooth procedures for both case reports.

Objectives: To report our single institution multidisciplinary step-by-step management of Fournier gangrene and specifically focus on our surgical reconstructive strategy.

Methods: This was a retrospective single-arm monocentric study including all consecutive Fournier gangrene treated at our institution between May 2001 and February 2020. Data on initial management, including urological care, resuscitation in collaboration with the infectious disease unit, and reconstructive strategies based on defects location, were collected. Patient self-reported functional and aesthetical results were assessed using a 5-point Likert scale.

Results: Overall, 45 patients were included in this study. All patients had surgical debridement on admission and 26 (57.8%) required repeated surgical debridement. Additional surgical procedures were colostomy in 31 (68.9%) cases, suprapubic catheter in 5 (11.1%) cases, orchiectomy in two cases, and penectomy for one patient. Overall, 14 (31.1%) patients had septic shock and required active resuscitation. Following surgical debridement, vacuum-assisted closure was used in 19 (42.2%) patients. No patient died. Thirty-six (80%) patients had reconstructive surgery. The median time from admission to reconstruction procedure was 37.5 days (range: 11-70). According to our reconstructive algorithm, reconstruction of the penile, scrotum, medial thigh, suprapubic, and the anal area was performed in respectively 19 (52.8%), 18 (50%), 11 (30.6%), 3 (8.3%), and 2 (5.6%) cases. Aesthetic and functional results of reconstruction were reported to be satisfying or extremely satisfying by 15 (71%) of the 21 patients who could be contacted.

Conclusions: Multidisciplinary step-by-step management of Fournier gangrene including our reconstruction approach based on lesion extension can be achieved with minimal mortality and with good results for the patients.

Run-over injuries, particularly those involving burns from vehicle exhaust systems, present significant challenges due to the complexity of associated trauma. This report details two cases where enzymatic debridement using anacaulase was employed for burns sustained during run-over incidents. Both cases involved extensive injuries, including fractures and pulmonary complications, necessitating careful timing of debridement. Anacaulase facilitated early, selective removal of necrotic tissue, preserving healthy dermal layers and reducing the area for autografting. Despite initial challenges, including insufficient debridement in areas with low petechial bleeding, outcomes were favorable with minimal blood loss. The first case required a skin graft on Day 35, while the second was on Day 48, highlighting variability based on injury severity and thermal exposure. These cases suggest anacaulase as a valuable alternative to surgical debridement, especially in complex trauma cases where conventional methods are less feasible. Further research is warranted to optimize its use in burn treatment protocols.