PURPOSE: In cases of breast reconstruction with a free transverse rectus abdominis musculocutaneous(TRAM) flap after skin-sparing mastectomy with nipple-areolar complex(NAC) removal, the flat contour of the flap's skin paddle can easily look unnatural and dissatisfying. Reconstructed NAC on the flap surface lacks the elevated contour that the normal areola possesses, resulting in an unnatural final result. Therefore, we would like to introduce a novel method to improve this problem and report the satisfactory results we obtained. METHODS: Operations were conducted on 19 patients who underwent immediate breast reconstruction with a free TRAM flap and skin-sparing mastectomy from January 2009 to January 2010, with a mean follow-up of nine months. While the TRAM free flap was being inset, a purse-string suture was carried out on the dermal layer of skin flap to create a slight protrusion with Gore-Tex(R) sutures. RESULTS: The elevated mound surrounding the NAC was well maintained for an average follow-up period of nine months. Nipple projection was also well maintained. There was no complaint about breast contour or nipple height reduction. In addition, there was no reported incidence of other complications. CONCLUSION: The purse-string suture technique presents a more natural breast silhouette around the NAC and helps to maintain nipple projection. Furthermore, it does not require any supplementary incisions or complicated skills. There has been no report of additional complications using this technique.
Breast ; Female ; Follow-Up Studies ; Free Tissue Flaps ; Humans ; Incidence ; Mammaplasty ; Mastectomy ; Nipples ; Rectus Abdominis ; Skin ; Suture Techniques ; Sutures

PURPOSE: Angiosarcoma is a rare malignant neoplasm of endothelial type cells that line vessel walls. It tends to occur in aged male and the prognosis of angiosarcoma is very poor because of frequent local recurrence and early metastasis. The treatment regimen is yet to be established from its rare occurrence but the wide excision in early stage is known to be the most effective. The authors report two cases of near totally excised angiosarcoma with more than a safety margin of 5cm. METHODS: The two subjects were aged male patients, one of the two was diagnosed with angiosarcoma from our institution confirmed by the biopsy. The other one went through the wide excision with a safety margin of 2cm and split-thickness skin graft but local recurrence was observed. The two patients underwent near total excision with more than a safety margin of 5cm, leaving only the periosteum. After confirming that the angiosarcoma had not infiltrated the excision margin, reconstruction with split-thickness skin graft was performed. RESULTS: Based on 6 months and 24 months post-surgery assessment, no local recurrence or remote metastasis in the lungs, liver, bones, and lymph nodes at the neck, where remote metastasis is common, was reported by the two subjects who underwent near total excision with a safety margin of 5cm. CONCLUSION: Angiosarcoma has very poor prognosis from its frequent recurrence and metastasis. To enhance the survival rate of angiosarcoma patients, early diagnosis, timely surgical treatment, and radiotherapy after surgery are critical. In addition, authors suggest that it is necessary to further study the efficacy of wide excision using a wider safety margin as much as possible, and to apply this to more cases.
Aged ; Biopsy ; Early Diagnosis ; Glycosaminoglycans ; Hemangiosarcoma ; Humans ; Liver ; Lung ; Lymph Nodes ; Male ; Neck ; Neoplasm Metastasis ; Periosteum ; Prognosis ; Recurrence ; Scalp ; Skin ; Survival Rate ; Transplants

PURPOSE: Cardiac radiofrequency catheter ablation procedures using fluoroscopy were performed for the treatment of supraventricular and selected ventricular tachyarrhythmia. Fluoroscopy is used to localize the position of the intracardiac catheter. Fluoroscopically- guided procedures often involve high radiation doses to patient's skin, but the incidence of serious radiation injuries in these patients is rare. We reported two cases of severe postradiation skin injury on the back treated with the V-Y latissimus dorsi musculocutaneous flap. METHODS: These two patients underwent radiofrequency catheter ablation under the diagnosis of Woff Parkinson White syndrome(WPW syndrome). They had radiation- induced skin injuries on the subscapular area and these lesions represented chronic ulceration, surrounding induration, hardness, and dyspigmentation. We treated these lesions with complete excision and coverage with V-Y latissimus dorsi musculocutaneous flap. RESULTS: These two patients had no recurrence and no special complications during 20 months and 12 months follow-up periods and were satisfied aesthetically and functionally. CONCLUSION: V-Y latissimus dorsi musculocutaneous flap obtained better results functionally and aesthetically compared with conservative management and skin graft in severe radiation-induced skin injuries after cardiac radiofrequency catheter ablation procedure.
Cardiac Catheters ; Catheter Ablation ; Fluoroscopy ; Follow-Up Studies ; Hardness ; Humans ; Incidence ; Radiation Injuries ; Recurrence ; Skin ; Tachycardia ; Transplants ; Ulcer

PURPOSE: Augmentation mammoplasty by cohesive silicone gel implant is becoming more popular nowadays. Many types of complications have been reported, such as hematoma, seroma, infection, capsular contracture and etc. But there were no report of deep vein thrombosis(DVT) after augmentation mammoplasty in Korea. The authors experienced one case of DVT after augmentation mammoplasty using a cohesive silicone gel implant. METHODS: A 38-year-old woman with breast cancer underwent reconstruction by tissue expander and augmentation mammoplasty by cohesive silicone gel implant, and exchange of expander to cohesive silicone gel implant. The operation was finished without any complicating event. On 4th day after the operation, the patient complained of intermittent right lower leg pain. By doppler ultrasonography, the patient was diagnosed with acute venous thrombosis of the popliteal vein, posterior tibial vein and peroneal vein. RESULTS: Intravenous heparinization and oral warfarin were started immediately and elastic compression stocking was applied. Intravenous heparinization was continued until INR(blood coagulation unit) reached to target levels. The patient was discharged on 11th day of operation with oral warfarin. Other complication has not been reported after 10 weeks of operation. CONCLUSION: To our knowledge, this is the first report of DVT after silicone implant based breast augmentation.
Adult ; Breast ; Breast Neoplasms ; Contracture ; Female ; Hematoma ; Heparin ; Humans ; Korea ; Leg ; Mammaplasty ; Popliteal Vein ; Pulmonary Embolism ; Seroma ; Silicone Gels ; Stockings, Compression ; Tissue Expansion Devices ; Ultrasonography, Doppler ; Veins ; Venous Thrombosis ; Warfarin

PURPOSE: Nasotracheal or oral intubation procedure is widely used for facial bone fractures. However, during the operation intubated tube can interfere or obstruct the view of the operator. We authors used a modified submental intubation method in panfacial bone fracture patients for intact airway and the operation view. METHODS: After intravenous induction of anaesthesia, traditional orotracheal tubation was done. A horizontal incision was made 2cm from the midline, 2cm medial to and parallel with the mandible in the submental region.1 In order to approach to the floor of the oral cavity, a haemostat was pushed through the soft tissues. A chest tube front cover was applied to the intubation tube and the tube was inserted through the submental tunnel. Orotracheal tube was disconnected and pulled back through the soft tissue and secured with a suture. RESULTS: The procedure took about 30 minutes and there were no problems during the intubation. Intraoral manipulation and occlusal checks were free without any interference. Extubation was also easily done without any complications such as lung aspiration, infection, hematoma, or fistula. CONCLUSION: Submental endotracheal intubation is fast, safe, easy to use and free from the concern about the tube being pull back again. Conventional submental intubations are being held without any coverage of the tip. We authors applied the modified method to the trauma patients and obtained satisfactory results. From the above advantages, modified submental intubation can be widely available not only in fractured patients, but also in aesthetic or orthognathic surgeries.
Chest Tubes ; Facial Bones ; Floors and Floorcoverings ; Fractures, Bone ; Hematoma ; Humans ; Intubation ; Intubation, Intratracheal ; Lung ; Mandible ; Mouth ; Orthognathic Surgery

PURPOSE: Vaccum-assisted closure(VAC) has rapidly evolved into a widely accepted treatment of contaminated wounds, envenomations, infiltrations, and wound complications. This results in a sealed, moist environment where tissue is given the opportunity to survive as edema is removed and perfusion is increased. Many plastic surgeons now place a VAC device directly over the fasciotomy site at the time of the initial procedure. Large amounts of the fluid are withdrawn, and fasciotomies can be closed primarily sooner. This study was designed to observe the effect of VAC in preventing complications in snake bitten hands. METHODS: In our study of three cases of snake bite, three of them underwent the VAC treatment & fasciotomy of the wound in the hand. This cases, the posterior compartment of the hand was bitten for a few days, releasing incisions were made of the posterior hand and 125mmHg of continuous vacuum was applied to fasciomy incision site and the biting wound. The dressings were changed three times per week. RESULTS: Our study examining the effects of applied vacuum in preventing snake bite wounds showed that the incidence of tissue necrosis and compartment syndrome was significantly lower for vacuum-treated wounds than for conservative wounds. Serum myoglobin, CK-MB, and CPK levels measured after fasciotomy incision were significantly decreased. We obtained satisfactory results from early dorsal fasciotomy, drainage of the edema with the VAC system, and then primary closure. The postoperative course was uneventful. CONCLUSION: Envenomation is a term implying that sufficient venom has been introduced into the body to cause either local signs at the site of the bite and/or systemic signs. Use of the vacuum-assisted closure device in snake bite can result in a decreased rate of tissue necrosis, lymphatic fluid collection, hemolytic fluid collection, and edema. Early fasciotomy of the dorsal hand and VAC apply is the alternative treatment of the snake bite.
Bandages ; Bites and Stings ; Compartment Syndromes ; Drainage ; Edema ; Hand ; Hypogonadism ; Incidence ; Mitochondrial Diseases ; Myoglobin ; Necrosis ; Negative-Pressure Wound Therapy ; Ophthalmoplegia ; Perfusion ; Snake Bites ; Snakes ; Vacuum ; Venoms

PURPOSE: Carpal tunnel syndrome is the most common peripheral compressive neuropathy. Most cases are idiopathic, but rarely carpal tunnel syndrome can be associated with a ganglionic mass. We report our recently encountered experience of surgical treatment of carpal tunnel syndrome caused by a simple ganglionic mass. METHODS: A 53-year-old man presented with chief complaints of numbness and hypoesthesia of his left palm, thumb, index finger, long finger, and ring finger of one and half month duration. Physical examination revealed positive Tinnel's sign without previous trauma, infection or any other events. Electromyography showed entrapment neuropathy of the median nerve. Magnetic resonance imaging(MRI) showed an approximately 2.0cm-sized mass below the transverse carpal ligament. Upon surgical excision, a 1 x 1.5cm2 mass attached to the perineurium of the median nerve and synovial sheath of the flexor digitorum superficialis and redness and hypertrophy of the median nerve were discovered. With surgical intervention, we completely removed the ganglionic mass and performed surgical release of the transverse carpal ligament. RESULTS: The pathology report confirmed the mass to be a ganglion. The patient exhibited post-operative improvement of his symptoms and did not show any complications. CONCLUSION: We present a review of our experience with this rare case of carpal tunnel syndrome caused by a ganglionic mass and give a detailed follow-up on the patient treated by surgical exploration with carpal tunnel release.
Carpal Tunnel Syndrome ; Electromyography ; Fingers ; Follow-Up Studies ; Ganglion Cysts ; Humans ; Hypertrophy ; Hypesthesia ; Ligaments ; Magnetic Resonance Spectroscopy ; Median Nerve ; Middle Aged ; Nerve Compression Syndromes ; Peripheral Nerves ; Physical Examination ; Thumb

PURPOSE: Many fingertip injuries are associated with nail injury and it is hard to repair to original shape due to its unique characteristic. Mucosal graft is used for a defect of the nail bed injury. Hereby, we introduce a DAP flap and buccal mucosal graft, with which we could reduce the defect size of the injured fingertip and donor site morbidity at the same time, without any need for harvesting additional skin from other part of hand. Also, mucosal graft makes good cosmetic and functional outcome of nail. METHODS: This method was performed in a 56-year-old man with fingertip injury on dorsal side of left thumb due to electrical saw. First, DAP flap was performed on the injured finger to reduce the size of the defect of fingertip and cover the bone exposure. Second, nail bed part of the DAP flap was de-epithelized and buccal mucosal graft was done from left side of intraoral cavity wall. RESULTS: Flap and graft survived without any necrosis but some nail bed could not be covered with flap due to insufficient flap size. All wounds healed well and did not present any severe adversary symptoms. CONCLUSION: DAP flap with mucosal graft is an effective method that we can easily apply in reconstruction of fingertip injury. We suggest that the combination of the two procedures makes good functional and cosmetic outcome compared to the usual manner, especially in cases of nail bed injury without distal phalanx bone defect.
Arteries ; Cosmetics ; Fingers ; Hand ; Humans ; Middle Aged ; Nails ; Necrosis ; Skin ; Thumb ; Tissue Donors ; Transplants

PURPOSE: Neurofibromas may present as multiple or solitary lesions. Although there is no predilection site for solitary lesions, they are rare on the hand. In addition, solitary intramuscular neurofibromas are a very rare pathological type. Here, we report a rare solitary intramuscular neurofibroma in the hand. This paper examines the clinical characteristics of intramuscular neurofibroma arising from the lumbricalis in order to enable a correct diagnosis and treatment. METHODS: A 32-year-old male presented with a painless mass on the palm. The physical examination revealed a 3 x 2cm protruding mass that was non-tender to palpation. The vascular and sensory examinations were unremarkable, while the motor examination showed mild difficulty with flexion and extension. Magnetic resonance imaging demonstrated an enhancing solid mass between the thenar eminence and second metacarpophalangeal joint. The diagnosis of an intramuscular neurofibroma was confirmed following surgical excision and histological evaluation. RESULTS: The pathological examination was consistent with a neurofibroma, with delicate fascicles and loose fusiform cells in a fibrous stroma, with oval or spindle-shaped nuclei and scant cytoplasm. The background matrix was pale staining and had focal myxoid stroma. There was no significant nuclear pleomorphism and no mitoses. Immunohistochemistry with S-100 was slightly positive. At the 6-month follow-up, motor and sensory function were intact and the range of motion was full. CONCLUSION: A neurofibroma is a rare tumor of the hand, especially the intramuscular type. Hand surgeons should consider the diagnosis of this tumor based on the examination and imaging.
Adult ; Cytoplasm ; Follow-Up Studies ; Hand ; Humans ; Immunohistochemistry ; Magnetic Resonance Imaging ; Male ; Metacarpophalangeal Joint ; Mitosis ; Neurofibroma ; Palpation ; Physical Examination ; Range of Motion, Articular ; Sensation

PURPOSE: An extensive knowledge of the arterial anatomy of the upper extremity and its variations is indispensable to the hand surgeon. We report a patient with anomalous radial artery, superficial course of two radial arteries, encountered during the excision of volar wrist ganglion. METHODS: The patient was a 53-year-old man who had a painful mass on the left volar wrist for 1 year. Under general anesthesia, a curved incision was made around the mass. With the skin flaps retracted, the dome of the cyst was identified. Particular care was taken to identify and protect the radial artery, which was intimately attached to the wall of the ganglion. Two radial arteries completely encircled the ganglion. The pedicle was traced to the volar joint capsule, radiocarpal ligament. The joint was open and the capsular attachments were excised. RESULTS: The patient made an uneventful recovery. There were two arterial pulsations at the volar side of the wrist joint. Compressing this site revealed that the major arterial contributor to blood supply in the hand was the ulnar artery. At angioCT, an anomaly of the radial artery was found with a duplication. The pathway of this aberrant artery was superficial to the original radial artery. It changed its course subcutaneously at the level of the tendon of the brachioradialis muscle, and crossing the wrist lateral to the original radial artery and ending in the deep palmar arch. CONCLUSION: Authors experienced a case of bifurcating radial artery encountered during the excision of ganglion on the volar of the wrist. Because these duplicated radial arteries make strong contributions to the thumb and index finger as well as to the deep palmar arch, when they are present there may be probably less blood supply to the hand from the ulnar artery. If the radial artery is palpated superficially on the brachioradialis muscle, it is important to remember the kind of anomaly.
Anesthesia, General ; Arteries ; Fingers ; Ganglion Cysts ; Hand ; Humans ; Joint Capsule ; Joints ; Ligaments ; Middle Aged ; Muscles ; Radial Artery ; Skin ; Tendons ; Thumb ; Ulnar Artery ; Upper Extremity ; Wrist ; Wrist Joint