Objectives: Despite the limited validity of the Sunnybrook grading index, it is routinely used for the clinical evaluation of facial palsy. This study aimed to assess the dynamic asymmetry in unilateral facial palsy and mathematically validate a modified version of the Sunnybrook facial grading system.

Methods: The Sunnybrook facial grading system was modified to provide more descriptions of the measured parameters of the distorted facial expression in unilateral facial paralysis. This correlation study was conducted on 16 patients with unilateral facial palsy and a matched control group. Three-dimensional video recordings of six facial expressions - rest, maximum smile, cheek puff, lip purse, eyebrow raising, and eye closure - were used for each case in the analysis. Advanced geometric morphometrics were applied to quantify facial asymmetry and morphology throughout the course of each expression. Seven professional assessors graded facial asymmetry for the 16 cases, twice, using the modified Sunnybrook index. Cross-correlations between the objective mathematical measurements and the subjective clinical grades were calculated.

Results: The inter- and intra-observer reproducibility of the modified Sunnybrook index was high (r = −0.8). Significant positive correlations were detected between the clinical grading of facial palsy and the mathematical measurements at rest, maximum smile, lip purse, and raising of eyebrows. The correlations between the modified Sunnybrook index and mathematical measurements were poor for cheek puff and forceful eye closure.

Conclusions: The modified Sunnybrook grading index proved reproducible and mathematically valid for the grading of unilateral facial paralysis in most facial expressions, except for cheek puff and forceful eye closure.

Objectives: The umbilicus is often used as a port insertion site during laparoscopic surgery because the wound is invisible after the surgery. However, its concave shape makes postoperative treatment difficult, resulting in umbilical keloids due to infection. Current study reports four cases of the excision of umbilical keloids with satisfactory results following full-thickness skin grafts and postoperative radiation therapy.

Methods: Umbilical keloids were excised and the skin grafts were taken from the lower abdomen. The grafts were anchored at the bottom of the umbilicus and implanted along the umbilical cavity. All skin grafts were irradiated at a dose of 4 Gy for 5 days from the first postoperative day.

Results: No recurrence has been observed in any of the patients at 6 months after surgery, the shapes of the umbilicus were favorable, and normal scarring was observed at the donor skin sites. Generally, all patients are satisfied with the results.

Conclusions: Simple suture or local flap reconstruction after keloid excision may result in some cosmetic problems, e.g., flatted umbilicus, because of the concave shapes of the umbilicus. The treatment of umbilical keloids using skin grafts and electron beam irradiation can reproduce the concave shapes of the umbilical cavities and provide sufficient decompression of the umbilical region, which is useful both in terms of cosmetic appearance and risk reduction of recurrence. Accordingly, careful follow-up is necessary because of the risks of necrosis of the skin grafts due to electron beam irradiation.

A parotid fistula is a rare symptom, caused by abnormal canal between the skin and the salivary duct or gland, leading to salivary discharge from skin. A 53-year-old man suffered a severe facial, neck, and precordial flame burn, which was treated by multiple debridement and split-thickness-skin-grafts. After the release of cervical scar contracture with a distant flap, saliva discharge from small fistula became evident, following him coming to the authors' hospital for treatment of the scar contracture of the face and neck. The apertures of the fistula were located 2 cm cephalad. Computed tomography with contrast injected into the fistula revealed extension to the left parotid gland. Following from this, the site was covered with a free groin flap. Over two years after surgery, no recurrence of parotid fistula was observed.

Vaginoplasty is a gender-affirming surgery (GAS) for transwomen that laid its foundation in the 1950s and continues to be widely practiced worldwide. We present here a case of a 70-year-old transwoman who underwent lower anterior resection for rectal cancer 12 years after vaginoplasty. The preoperative diagnosis was rectal cancer (Rb-Ra, type 2, cT2N0M0, stage 1). All imaging studies showed a cord-like structure between the prostate and the anterior wall of the rectum, which was thought to be the neovagina. Careful dissection of the anterior rectal wall was required because the distance between the neovagina and the rectum was only 1.5 mm. The role of hormonal therapy and GAS in cancer development in transwomen is unclear. It is important to have regular check-ups for malignancies in patients who have undergone GAS, and if surgical procedures are needed, they should be treated by physicians who are familiar with the procedure.

A human tail complicated by Crouzon syndrome is extremely rare, with only eight reported cases of human tails associated with Crouzon syndrome. A human tail is defined as a true human tail or a pseudo-human tail according to the presence or absence of the bone tissue. A 4-year-old boy had a true caudal sacral protrusion from birth and was also diagnosed with Crouzon syndrome. There were no neurological symptoms or vesico-rectal disturbances. The patient underwent a human tail resection at 4 years and 7 months. The postoperative course was uneventful, and there was no recurrence at 6 months postoperatively.

Some reports suggested that Crouzon syndrome and the human tail are associated with FGFR2 gene mutation, but the details are currently unknown. Further genetic searches for cases of the combined human tail and Crouzon syndrome in the future are likely to reveal further associations.

Cold burn injury is a relatively uncommon type of burn and is especially rare in the tropics. We present an unusual case of cold burn injury secondary to prolonged contact with a cold surface in a tropical country. Failure of conservative treatment required early excision and reconstruction with free tissue transfer and dermal substitute grafting. To the best of our knowledge, this is the first case of such nature and severity described in a tropical setting. We discuss the differences in managing cold burn injuries compared to thermal burns, including considerations specific to warm climates.

"Non-tuberculous mycobacteria" (NTM) is a general term for pathogenic mycobacteria other than Mycobacterium tuberculosis and Mycobacterium leprae. Non-tuberculous mycobacteria are widely present in the natural environment, including soil and water, with over 150 reported species. Mycobacterium abscessus is rare among Non-tuberculous mycobacteria, and there are few reports of extrapulmonary lesions due to Mycobacterium abscessus. We describe a case of osteomyelitis in an adult woman's left first toe caused by Mycobacterium abscessus. The osteomyelitis developed due to an injury in a public bathing facility. A combination of surgical debridement and multidrug therapy was effective. When antimicrobial agents are ineffective in trauma linked to water or soil, mycobacterial infections, including Non-tuberculous mycobacteria, should be considered as differential diagnoses, and laboratory culture targeted to mycobacteria would be recommended.

We introduced a new, simple, reliable method for monitoring a free jejunal graft transfer by assessing visual signs and arterial blood flow in an exteriorized flap. In this retrospective study, all patients that underwent free jejunal graft transfers in hypopharyngeal reconstruction microsurgery between January 2013 and March 2020 were included. We monitored exteriorized flaps by assessing either visual signs only (n = 176) or both visual signs and arterial sound, detected using a hand-held Doppler (n = 164). Postoperative arterial insufficiency occurred in five flaps monitored with visual signs only. None of these flaps could be rescued. Postoperative arterial insufficiency occurred in four flaps monitored with both visual signs and a hand-held Doppler. Of these, two flaps were rescued. The new method led to satisfying results. The combination of visual signs and a hand-held Doppler provided a simple, reliable method for monitoring free jejunal graft transfers.