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.

Objectives: This study aimed to compare the quality of scarring of DERMABOND PRINEO (Ethicon, Inc., Somerville, NJ, USA) ^® by conducting a half-side test on the same wound to determine its superiority. If the utility of DERMABOND PRINEO^® is established, its use can be expanded for more cases and higher quality medical care can be provided.

Methods: Patients who underwent two-stage breast reconstruction were included. The first surgery was half closed with DERMABOND PRINEO^® and nylon threads, and the time was measured. At the second surgery, all scars were removed, and a histopathological examination was done. Scars were evaluated with the Vancouver Scar Scale (VSS) and visual analogue scale (VAS), and statistical analysis was performed.

Results: Time to closure was significantly shorter in the DERMABOND PRINEO^® group. Postoperative VSS scores for pliability were significantly lower in the suture group, and the total VSS score was significantly lower in the suture group from 3 to 6 months postoperatively. Patients rated postoperative wound pain, itching, appearance, and satisfaction with the VAS, but no significant differences were observed between the two groups. The scars were compared with hematoxylin-eosin staining and Elastica van Gieson staining. Differences were seen in the increase of elastic fibers in the dermal reticular layer, a characteristic difference between the two groups.

Conclusions: The use of DERMABOND PRINEO^® leads to a reduction in operative time and impacts the maturity of the scar. It is expected that the indications for DERMABOND PRINEO^® can be further expanded in the future.

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.

Herein, we describe the case of a 33-year-old woman with a rare 16-mm congenital midline upper lip fistula with a broad, cystic lumen. No connection with the oral cavity was observed. Congenital midline upper lip fistulas are not clearly associated with hereditary factors or sex. Sinus computed tomography revealed an inner ear malformation; however, no associations between external and inner ear malformations and upper lip fistulas have been reported. Because the developmental processes of the upper lip and inner ear are different, each develops independently, as in the current case. The standard treatment for congenital upper labial fistula is surgical excision. Shallow fistulas are often approached through a fusiform incision around the fistula. For deep fistulas, expanding the surgical field via a small skin incision is difficult, with a high possibility of a large incision. However, an incision through the oral mucosa minimises the incision size around the fistula.

Objectives: Remote medical care is becoming popular worldwide, but not as much has yet been done in plastic surgery. We provided online treatment related to plastic surgery using a 5G system. This study aimed to investigate the usefulness and future of online telemedicine in plastic surgery.

Methods: A plastic surgeon alternated between face-to-face and telemedicine. The interval between consultations was 1 week. Specifically, local doctors and staff provided medical care to patients at the suburban hospital, and the plastic surgeon remotely observed patients and provided instructions and guidance on procedures to the local doctors and staff. In this study, we evaluated the patients who were treated under telemedicine with respect to their age, use, and effectiveness. The study encompassed the period from August 2021 to October 2022.

Results: Thirty-five patients were treated via online telemedicine (mean age, 73.0 years). Twenty-one (60%) of the postoperative procedures were related to surgeries performed by a plastic surgeon. Consultation for simple wound care was performed in 8 (22.9%) patients. Guidance on pocket incision surgery for pressure ulcers was given to one patient. As for the quality of communication, images were clear, no delays were encountered, and no cases interfered with medical care.

Conclusions: Our system was primarily useful as a postoperative management tool. The high image quality and low-latency communication allowed for real-time instruction during complex postoperative procedures and surgical techniques. Even in hospitals with infrequent visits from plastic surgeon, telemedicine has the potential to make surgery safer and more proactive.

Objectives: Many reconstruction techniques exist for full-thickness defects of the lower lip, which all have advantages and disadvantages. We performed lower-lip reconstruction using the Japanese Fusuma sliding flap method and obtained good results. Here, we introduce this method and report on its results, including long-term follow-up, and its details.

Methods: A lateral advancement flap from the cheek, pedicled on the facial artery, reconstructs the lower lip. If needed, a subcutaneous flap from the cranial nasolabial fold reconstructs the donor site of the first flap. We retrospectively examined nine patients with full-thickness, full-width lower-lip defects who underwent reconstructive surgery using the Fusuma sliding flap method between 2006 and 2021. The postoperative evaluation items were as follows: (1) survival of skin flaps, (2) appearance, (3) eating function, (4) perception, and (5) presence or absence of revision surgery.

Results: Regardless of the form or extent of defects, the flaps survived successfully in all cases, and their appearance, feeding function, and sensation were good. However, revision surgery was required for cases where defects exceeded the commissure.

Conclusions: Although the number of cases was small, and issues that the need to be addressed remain, this procedure is simple, highly versatile, and provides stable results.

A 39-year-old woman diagnosed with persistent congenital tibial pseudoarthrosis until adulthood presented with a right leg angular deformity, associated pain, and significant limb length discrepancy. Over a 17-year period, the case was closely monitored and treated through excision of the pseudarthrosis, vascularised fibular graft with bone marrow-derived and cultured mesenchymal cells, combined with highly purified β-tricalcium phosphates, internal fixation, and the application of a ring Ilizarov fixator. The successful union of bones and correction of deformities was achieved through consideration of both mechanical and biological aspects.

Basal cell carcinoma (BCC) usually occurs as a solitary lesion but occasionally presents as multiple lesions. The proportion of multiple BCCs is 5.9%-7.1% in Asian patients. We conducted BCC screening in April 2021, focusing on the presence or absence of multiple lesions. Patients examined between April 2021 and March 2022 (161 lesions in 136 patients) were classified as the screening group (SG) and those examined between April 2020 and March 2021 (111 lesions in 103 patients) were classified as the non-screening group (NSG). The proportion of patients with multiple BCCs was significantly higher in the SG than in the NSG (15.4% and 6.8%, p = 0.04). We provisionally classified the head and neck gaze region into the 'central region' and 'peripheral region' based on gaze patterns. In the SG, the proportion of lesions in the peripheral region was higher in patients with multiple BCCs (32.6%) than in patients with a solitary BCC (14.8%). We speculate that we missed recognizing tumours in different areas, especially peripheral areas of the head and neck. Our results indicate that the increase in multiple lesion cases through screening occurred owing to more conscious observation of different regions, especially head and neck regions, thereby overcoming human gaze patterns.

A subcutaneous rheumatoid nodule is a superficial soft tissue lesion that generally affects areas of frequent mechanical contact, such as the extensor aspect of the extremities, occiput, and sacrum. Rheumatoid nodules of the foot are rare, occurring in only 1% of cases. Herein, we present a case of a rheumatoid nodule on the plantar side of the left hallux in a 65-year-old woman with rheumatoid arthritis. The tumor was a 15 × 10 mm, dome-shaped, nontender, elastic hard mass in the plantar aspect of the left hallux. The discovery of rheumatoid nodules provides crucial information for the treatment and management of rheumatoid arthritis. Giant cell tumors may cause symptoms similar to those of rheumatoid nodules. Furthermore, difficulties are associated with differentiating rheumatoid nodules from giant cell tumors using imaging modalities. Therefore, the identification of these tumors requires careful observation.

We report a case of a 1-year 7-month-old boy who had resection of a divided nevus and skin grafting that resulted in the disappearance of residual nevi, graying of eyelashes, and depigmentation at the donor site of the skin graft and around the lips. The nevus partially remained on the lid margins, although resected as much as possible from the upper and lower eyelids. Nevus cell nevus was the histopathological diagnosis of the resected lesion. Approximately 3 years after surgery, the pigmentation of the nevus remaining on the lid margins started to regress, and the eyelashes at the same sites became gray. Vitiligo gradually developed on the skin grafted from the clavicular region. Approximately 5 years after surgery, the findings remain similar. In this patient, immune responses against nevus cells were established, followed by Sutton's phenomenon accompanied by the destruction of epidermal melanocytes.

Atypical Spitz tumors are one type of the Spitzoid melanocytic lesion, characterized by one or more atypical features, and often demonstrate indeterminate biological potential. Atypical Spitz tumors pose challenges in both clinical and pathological diagnoses. Herein, we report a case of a 1-year-old Japanese girl who presented with a rapidly enlarging lesion mimicking a pyogenic granuloma. The patient was ultimately diagnosed with an atypical Spitz tumor. The challenging clinical nature and diagnostic complexity of atypical Spitz tumors underscore their significance as crucial considerations in pediatric skin tumor differential diagnosis. Consistent consideration of atypical Spitz tumors within the diagnostic framework of pediatric cutaneous neoplasms is essential for timely and accurate assessment, thereby ensuring optimal patient care.

Necrotizing fasciitis is a rare, severe, life-threatening, and rapidly progressing infection characterized by necrosis of the fascia and subcutaneous tissue with systemic toxicity. In this study, we report a male patient with only controlled hypertension who was diagnosed with necrotizing fasciitis of his middle finger after sustaining a kitchen knife injury. Successful treatment involved amputating the third finger at the level of the medial proximal phalanx due to the severe and rapid progression of symptoms and the elevated risk of Vibrio spp. and Staphylococcus spp. causing necrotizing fasciitis, considering the patient's profession as a cook and his being immunocompetent. The patient was able to resume a working life after a short hospitalization without any severe complications. This is a reminder that even a minor injury can result in a life-threatening infection. Early surgical intervention saved the patient's life, eliminated the need for reoperation, and shortened the hospitalization.