Epidermal cysts are common benign tumors typically treated through surgical excision, which may result in significant scarring. Moreover, larger cysts are associated with increased surgical invasiveness and a greater burden on the patient. This report presents a case of successful treatment of a large epidermal cyst using a small-incision technique combined with suction-assisted negative pressure. The method involved a minimal incision, aspiration of cyst contents using a suction cannula, and removal of the cyst wall. Incorporating magnetic resonance imaging into the preoperative planning further enhanced the precision of the treatment. A 16-cm cyst was completely cured without recurrence over a follow-up period exceeding 5 years. This approach minimized scarring and simplified the surgical procedure.

Objective: The objective of this study was to compare the surgical treatment of gynecomastia using circumareolar excision versus transverse skin excision.

Methods: Thirty-six male patients with unilateral or bilateral gynecomastia participated in this prospective randomized study at our institution. Participants were divided into two groups: Group A received circumareolar skin excision, and group B received transverse skin excision. Patients were evaluated for surgical and postoperative complications, patient satisfaction, and cosmetic outcomes.

Results: There were no intraoperative complications or blood transfusions. The average operative time was 150 minutes for group A and 110 minutes for group B. Hospital stays ranged from one to two days. Both groups had a 5.56% incidence of hemostasis-related issues and wound infections. Seromas appeared in 11.11% of cases and resolved spontaneously. Wound dehiscence was observed in 16.67% of group A and 5.56% of group B, with no statistically significant difference. Hypertrophic scars occurred in 16.67% of group B, while none were reported in group A (p = 0.07).

Conclusions: The circumareolar technique requires longer surgical time and may lead to a less optimal chest contour. However, it provides superior cosmetic results for the nipple-areola complex. Both techniques demonstrate comparable rates of postoperative complications.

Objectives: Necrotizing soft tissue infections (NSTIs) caused by group A streptococcus (GAS) are life-threatening diseases with high morbidity and mortality rates. Early diagnosis is of paramount importance because a delay in diagnosis results in a significant reduction in survival rates. Recent studies have shown that the use of a rapid antigen detection test for GAS (GAS-RADT) at the time of NSTI diagnosis facilitates timely identification and simplifies surgical decision-making through small incision-based interventions. This study aimed to evaluate the accuracy of rapid diagnosis using a puncture method and to describe the associated procedure.

Methods: We evaluated the accuracy and reproducibility of GAS-RADT performed using a less invasive and simpler puncture method compared to conventional sampling from small incision wounds and outlined the diagnostic procedure. The study population included 19 patients who underwent GAS-RADT using the puncture method at our hospital between 2019 and 2023.

Results: The concordance rate between GAS-RADT and wound culture was 100%; Cohen's kappa coefficient was 1.0, indicating extremely high concordance.

Conclusions: As GAS-RADT performed with puncture sampling is a minimally invasive and rapid testing method that helps determine treatment strategies, it can be considered an extremely useful diagnostic method for detecting GAS-NSTI, which has been on the rise in recent years.

Dystrophic epidermolysis bullosa (DEB) causes extensive blisters and erosions due to a genetic abnormality, significantly reducing patients' quality of life. Recently, transplantation of reversion-mutated mosaicized skin has shown promise as a radical cure. In 2019, the use of cultured epithelial autograft for DEB was approved in Japan.

Meanwhile, the Meek micrografting technique, first described in 1958 by Dr. Cicero Parker Meek in the United States of America, was reintroduced in 2019 as a new device for split-thickness skin grafting. This system can harvest skin grafts more efficiently than conventional methods.

In this case report, we report on our successful treatment of DEB using the Meek technique and cultured epithelial autografts.

Hypophosphatasia is a relatively rare congenital bone metabolic disease, occurring in approximately 1 in 100,000 to 150,000 births. It is diagnosed in infancy by low bone calcification, rickets-like symptoms visible on X-ray, and decreased serum alkaline phosphatase (ALP) levels in the blood. Prognosis varies by type, and while treatment has not been long established, ALP enzyme replacement therapy has been developed and has achieved improved outcomes since 2015. Pan-craniosynostosis, as an unfavorable side effect of this symptomatic therapy, is not well known even among experienced craniofacial surgeons, likely because it is often regarded as part of the bone transformation process, especially when the unusual discrepancy between a hard cranium and fragile limb bones is observed, or is overlooked due to poor prognosis. The author's purpose is to present rare experiences of two cases of pan-craniosynostosis considered to be iatrogenic after the therapy for hypophosphatasia. Some reports in Japan indicate that this iatrogenic complication may appear in 15.3% of cases after treatment. As craniofacial surgeons, we need to recognize this causal relationship between hypophosphatasia treatment and craniosynostosis.

The global population of older adults is expanding at an unprecedented rate, demanding greater focus on their health care needs. Older individuals are particularly susceptible to burn injuries, and complications are more likely to develop in these patients. Therefore, accurate assessment of burn severity is essential. Among the various scoring systems used worldwide to predict mortality in patients with burns, the burn index (BI) and Prognostic BI (PBI) have been routinely applied in Japan since the 1980s. However, with both overall life expectancy and healthy life expectancy steadily increasing in Japan, the PBI may now overestimate mortality risk in today's older adults. Here, we review BI, PBI, and global burn severity assessment tools to highlight their differences and discuss their applicability in older patients, drawing in part on the authors' clinical experience.

Preoperative Indocyanine Green (ICG) angiography is often used to confirm lymphatic vascular circulation; however, in advanced edema, ICG may be unable to confirm circulation. We use contrast-enhanced ultrasound to confirm the course of lymphatic vessels before lymphaticovenous anastomosis (LVA).

We performed ICG angiography and lymphatic contrast-enhanced ultrasound using perflubutane before surgery. The intraoperative detection rate of lymphatic vessels was compared between cases in which only ICG imaging was performed preoperatively and cases in which ICG and contrast-enhanced ultrasound were performed.

When comparing the use of ICG alone with the use of ICG in combination with contrast ultrasound, the detection rate of lymphatic vessels in total (72.6% vs 82.8%) and in areas exhibiting a diffuse pattern (54.5% vs 74.0%) was significantly increased.

Using this method, we will be able to perform LVA more safely, reliably, and time-efficiently, even in patients with severe lymphedema showing a diffuse pattern on ICG imaging.

Breast cancer remains a leading public health issue in low- and middle-income countries (LMICs), where 5-year survival rates range from 12% to 53%. Although post-mastectomy breast reconstruction is a key part of cancer care, its uptake remains low in LMICs. This review identifies the main barriers limiting reconstruction access to inform potential interventions. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were searched for English-language, peer-reviewed articles published between January 2013 and October 2023 on challenges to post-mastectomy breast reconstruction. Eligible studies were original research. Two reviewers extracted and categorized findings into socio-cultural, structural, and financial themes, summarized through descriptive analysis. The search identified 15 papers from 11 countries across four continents. Of the included studies, 73% (n = 11) mentioned barriers under two or more categories; 20% (n = 3) mentioned only structural barriers, and 7% (n = 1) mentioned only socio-cultural factors. Ten studies (67%) described socio-cultural barriers, with the most prevalent themes being the perception of reconstruction as purely aesthetic (47%), fear of anesthesia and recovery time (33%). Thirteen studies (87%) described structural barriers, with the most prevalent structural barrier being a lack of patient awareness, especially before mastectomy (47%). Limited numbers of practicing plastic surgeons (40%), urban-clustered tertiary treatment facilities (33%), and low surgeon referral rates (27%) reduced reconstruction utilization. Twelve studies (80%) described financial barriers with self-payment cited as the most significant limitation to reconstruction and the most significant barrier overall (60%). Reconstruction in LMICs faces intertwined socio-cultural, structural, and financial barriers that limit access and patient willingness.

Postpartum mastitis is common, but immunological changes specific to the postpartum period can exacerbate the inflammation. We report a case of methicillin-resistant Staphylococcus aureus-associated mastitis that rapidly progressed, leading to breast necrosis and symptoms resembling toxic shock syndrome. Postpartum mastitis can result in severe symptoms, so early detection and intervention are important.

A 46-year-old male patient had been undergoing treatment for hidradenitis suppurativa for over 10 years and had undergone surgical treatment 9 and 7 years before visiting our hospital and subsequently received only conservative treatment. The patient had a history of diabetes mellitus and was diagnosed with stage III hidradenitis suppurativa according to Hurley's classification. He had scars and fistulas, particularly, on the buttocks, and had severe anemia. This anemia appeared to be associated with bleeding from the lesions and chronic inflammation. A colostomy was performed, which eliminated the need for regular blood transfusions, and his hemoglobin level improved to within normal limits after two-stage excisional surgeries, followed by reconstruction with split-thickness skin grafting. Although colostomy can help manage anemia, a serious complication of hidradenitis suppurativa, aggressive surgical intervention, including colostomy, may be necessary for patients with refractory disease to prevent deterioration of their general condition.

Congenital lip sinus is known to occur in the upper lip, lower lip, or oral commissure, but a midline sinus of the upper lip is extremely rare. This report describes a 5-year-old boy who was born as a dizygotic twin at a gestational age of 33 weeks and 6 days, weighing 2,118 g. He was noted at birth to have a subcutaneous mass with an opening in the philtrum of the upper lip. Magnetic resonance imaging at 1 year of age revealed a teardrop-shaped cyst with high intensity on T2-weighted images beneath the upper lip. Surgical excision was performed due to the gradual enlargement of the mass. The sinus tract was removed using a combined intraoral and extraoral approach. Histopathology showed cystic dilation of the epithelial lining. The postoperative course was uneventful with good aesthetic results. Early diagnosis and excision are essential for the successful management of this rare congenital anomaly.

Objectives: Lymphedema is a chronic condition characterized by fluid accumulation and limb swelling, often accompanied by pain. While complete decongestive therapy may reduce pain, some patients experience persistent symptoms. Lymphaticovenous anastomosis (LVA) is a minimally invasive procedure that has shown promise in alleviating pain, but the types of pain most responsive to LVA remain unclear.

Methods: This retrospective study included 14 patients (12 women, 2 men; mean age 55.6 years) with lower limb lymphedema and pain who underwent LVA between August and December 2023. A total of 25 limbs were treated. Pain was assessed using a visual analog scale (VAS, 0-10), and pain characteristics were categorized. Limb circumference was measured at six points and summed. Preoperative and postoperative data were compared using paired t-tests. The mean follow-up duration was 268.4 days.

Results: The mean preoperative VAS score was 3.1, which improved slightly to 2.9 postoperatively (p = 0.23); 5 patients (35.7%) experienced pain reduction, 6 (42.9%) had no change, and 3 (21.4%) reported worsening pain. Limb circumference improved significantly from 205.5 cm to 200.5 cm (p < 0.01). Pain improvement showed moderate correlation with changes in limb circumference (r = 0.42) and postoperative weight loss (r = 0.49). Subgroup analysis revealed greater pain reduction in patients who described their pain as "sharp" or "throbbing," whereas all patients who experienced worsening pain reported "heaviness."

Conclusions: LVA may provide meaningful pain relief in selected patients with lower limb lymphedema, particularly those with sharp or throbbing pain. Limb volume reduction and postoperative weight loss appear to be associated with greater pain improvement.

A keloid scar is a benign fibroproliferative disorder that is characterized by excessive tissue growth beyond the original wound. The psychosocial and surgical challenges that arise can present potentially devastating long-term consequences for patients, particularly in demographics with a high incidence of keloid scar formation. Considering the high incidence of keloids with an estimated 11 million cases annually, particularly in those of Asian and African backgrounds, an understanding of their exact pathophysiology remains challenging. Piercing-induced keloids of the ear are a common cause of ear keloids, yet the exact mechanism and optimal treatments are of considerable debate. This narrative review aims to evaluate current treatment modalities for ear keloids, focusing on their association with ear piercings and the implications for management.

A systematic review of Medline, Embase, and Mendeley identified 26 studies, covering a range of surgical and non-surgical treatment methods, indicating a considerable recurrence rate, with an average of 20.3%. Surgical excision remained the primary treatment modality, which was often accompanied by adjunctive therapies such as steroid injections and radiotherapy. Fractional carbon dioxide laser therapy may also be a useful treatment modality with fewer potential complication risks.

Overall, the findings identified significant variability in treatment protocols and outcomes, underscoring the need for personalized approaches based on keloid characteristics and patient preferences. Ultimately, the review highlights the importance of further research to establish standardized treatment protocols for ear keloid scars and to understand the role of piercing-specific pathophysiology in improving patient outcomes.

We report the first case of endoscope-assisted deep inferior epigastric perforator (E-DIEP) flap breast reconstruction in Japan. A 46-year-old woman underwent skin-sparing mastectomy with immediate reconstruction using a DIEP flap. Intramuscular perforator dissection was performed using an open approach, followed by pedicle harvesting using an endoscopic totally extraperitoneal technique. Consequently, a 14-cm pedicle was successfully obtained through a 3.5-cm fascial incision. Microsurgical anastomosis was performed via a mastectomy incision. Recovery was uneventful and the patient was discharged on postoperative day six without complications. This hybrid approach combines the advantages of minimal donor site morbidity and a long pedicle length, enabling tension-free anastomosis and safety. E-DIEP flap harvesting may serve as a practical and less-invasive alternative to robot-assisted techniques, particularly, in facilities where robotic systems are unavailable. This case demonstrated the feasibility and potential benefits of E-DIEP flap for clinical breast reconstruction.

Parotid gland arteriovenous malformation (AVM) may present as a parotid mass. Most parotid masses are benign, and the majority of these are pleomorphic adenomas; therefore, the initial diagnosis of vascular malformations can be challenging without the pathognomonic turkey-wattle sign. We present a case of a parotid gland AVM that was initially misdiagnosed as a parotid gland cyst. The clinical and radiological findings are also discussed here. The AVM was managed with surgical intervention and sent for histopathological study to confirm the diagnosis.

Extensive pelvic resection often results in complications, making flap reconstruction essential for managing pelvic defects. We report a case of successful reconstruction using a pedicled vastus lateralis myocutaneous flap following abdominoperineal resection for anal canal cancer. The flap was transferred through an intermuscular and subcutaneous tunnel into the pelvic cavity. Its anteroposterior extensibility allowed effective filling of the defect. Advancement of the posterior portion of the muscle into the deep pelvis compensated for the limited pedicle length. Preservation of the motor nerve may have helped maintain muscle volume, particularly on the intrapelvic side, with minimal postoperative atrophy observed. These technical strategies demonstrate that the pedicled vastus lateralis myocutaneous flap provides adequate volume, reach, and durability, and may represent a valuable option for extensive pelvic floor reconstruction, especially when motor innervation is preserved.

Smith-Magenis syndrome (SMS) is caused by a deletion in the 17p11.2 region or abnormalities in the RAI1 gene. Clinically, it is characterized by distinctive facial features, sleep disturbances, and neurobehavioral traits such as self-injurious behaviors and developmental delays. It may also be accompanied by ophthalmologic, ear, nose, and throat (ENT), and cardiovascular abnormalities. The prevalence of cleft lip and palate in SMS is reported to range from 0% to 25%; however, there are no detailed reports on speech therapy or speech evaluations following surgery in such patients. Given the significant individual variability in developmental delays among patients with SMS, careful consideration is necessary when determining surgical indications for cleft palate. We conducted regular language assessments, including evaluations of mental development, with a speech therapist, and determined that the patient was a candidate for cleft palate surgery when pre-linguistic speech with meaningful elements was confirmed. Herein, we report a case of SMS in which palatoplasty was performed.

We report the first case of penile sensory reconstruction in a patient with spina bifida in Japan. A 27-year-old man presented with congenital sensory loss in the perineal region owing to spina bifida. His myelomeningocele was repaired immediately after birth. He was unable to recognize bladder fullness and required urinary self-catheterization. Emotional erection and ejaculation were possible, and his gait was normal. We elected to perform the TOMAX procedure (i.e., TO MAXimize sensation, sexuality, and quality of life) to reconstruct penile sensation. Microsurgical sensory nerve anastomosis between the ilioinguinal nerve and the dorsal nerve of the penis was performed bilaterally under general anesthesia. No complications occurred. Penile sensation was noted 3 months after surgery. At the 1-year follow-up, the patient could detect the blue filament on Semmes-Weinstein testing. The TOMAX procedure can provide sensory recovery in patients with spina bifida and improve their quality of life.

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: 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.

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.

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.