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Surgical treatment of extensive and multiple skin cancers via excision and reconstruction using multiple flaps: a case report

Dianne Dong Un LEE ; Kyeong Tae LEE

Archives of hand and microsurgery.2024;29(2):116-121. doi:10.12790/ahm.23.0058

A 47-year-old male patient presented with multiple squamous and basal cell carcinomas on the anterior chest, back, and left cheek. The patient experienced odorous discharge from the tumors. Surgical excision was planned, beginning with the anterior chest squamous cell carcinoma. An extensive 32×30 cm cutaneous defect was created, which was covered by a bilateral deep inferior epigastric perforator and pedicled latissimus dorsi myocutaneous flaps. The basal cell carcinomas on the back and squamous cell carcinoma on the left cheek were serially excised, after which the left cheek wound required flap coverage. Postoperative complications such as venous thrombosis and infection led to several reoperations, yet the extensive defect was successfully reconstructed. No local recurrence developed during 31 months of follow-up. We report this case to demonstrate that although the wide excision of very large skin cancers may result in extensive and challenging defects as large as 5.8% of the total body surface area, coverage with appropriate flaps may lead to successful oncologic outcomes and improve the patient’s quality of life.

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Nail growth disorder in multiple fingers following harvesting of radial forearm free flap for phalloplasty in gender-affirming surgery: a case report

Soyeon JUNG ; Jiwon JEONG ; Kuylhee KIM

Archives of hand and microsurgery.2024;29(2):122-126. doi:10.12790/ahm.24.0004

Nail growth disturbance commonly takes place after trauma or relevant diseases, such as infections and tumors. However, abnormal growth of the nail plate sometimes occurs without an obvious causative factor. This report presents the case of a patient who underwent male genital reconstruction with a radial forearm free flap for gender affirmation. Although the entire process was smooth, with no accidental events, the second, third, and fourth phalangeal nail plates of the hand from which the flap was harvested showed no evident growth of the fingernail 2 months postoperatively. Nail production was preserved in the remaining fingernails. Typical symptoms, such as redness, swelling, and tenderness, were noted upon clinical observation. Eventually, nail production restarted 5 months after surgery. Steroid and antibiotic treatment was attempted to reduce periungual inflammation. Additionally, close observation with psychological support was conducted.

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Reconstruction methods for large cranial-nasal communications: surgeons’ concerns about proper anterior skull base reconstruction

Kong Srey NUCH ; Jong Won HONG

Archives of hand and microsurgery.2024;29(2):110-115. doi:10.12790/ahm.24.0017

Purpose: Skull base reconstruction is one of the most difficult reconstructive surgical procedures. Due to its complexity, most surgeons have modified the reconstruction methods to minimize the postoperative complications and mortality rate. In the past, flap surgery was not usually performed, but it has recently become more common due to advances in medicine. In this study, we analyzed successful flap surgery methods in skull base reconstruction for large cranial-nasal communications. Methods: Patients who underwent skull base reconstruction from April 2015 to January 2024 were eligible for this study. Of these patients, we included those who underwent reconstruction using a volumetric flap. Reconstructions that only used the conventional galeal flap, allograft skin, or bone substitute were excluded. The reconstruction methods used local flaps and free flaps. Results: In total, 22 patients underwent skull base reconstruction. The most frequently used local flap was the bilateral reverse temporalis muscle flap (seven of 11 cases), and the most frequent free flap was the anterior lateral thigh flap (10 of 11 cases). Other local flap operations used the modified temporalis muscle flap and scalp flap. A rectus myocutaneous flap was also used. There were no cases of flap necrosis. Conclusion Flap surgery is needed for skull base reconstruction in patients with large cranial-nasal communications. As long as the flap volume is large enough to block and fill the defect, either a local flap or a free flap can be used for reconstruction.

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Effects of distal ulnar morphology on symptomatic extensor carpi ulnaris (ECU) subluxation and the clinical outcomes of anatomic ECU subsheath reconstruction: a retrospective observational study

Sung Jin KANG ; Ji Nam KIM ; Yun Seop KIM ; Seoung Joon LEE

Archives of hand and microsurgery.2024;29(2):75-81. doi:10.12790/ahm.23.0043

Purpose: This study aimed to evaluate the association between distal ulnar morphology and symptomatic extensor carpi ulnaris (ECU) subluxation and assess the results of anatomic ECU subsheath reconstruction. Methods: To investigate the effects of distal ulnar morphology on symptomatic ECU subluxation, we compared distal ulnar morphology using magnetic resonance imaging among three groups: group 1 (symptomatic ECU subluxation, 12 cases), group 2 (non-symptomatic ECU subluxation, 24 cases), and group 3 (no ECU subluxation, 24 cases). Distal ulnar morphology was evaluated using ulnar variance, ulnar styloid length, and ECU groove depth. Clinical outcomes were evaluated using the Patient-Related Wrist Evaluation (PRWE) score, the Disabilities of the Arm, Shoulder, Hand (DASH) score, grip strength, and the range of motion of the wrist joint. Results: Ulnar variance showed a statistically significant difference between groups 1 and 2, and ECU groove depth showed statistically significant differences between groups 1 and 2 and between groups 2 and 3. Ulnar styloid length showed no statistically significant between-group differences. In patients with symptomatic ECU subluxation, there was a significant increase in the range of motion in supination and grip strength, and a significant decrease in the DASH score (from 40 to 9) and PRWE score (from 48 to 12). Conclusion Negative ulnar variance was associated with symptomatic ECU subluxation, and shallow ECU groove depth was correlated to asymptomatic ECU subluxation, but unrelated to symptoms. Anatomic ECU tendon sheath reconstruction was identified as an effective surgical method.

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A comparative analysis of antegrade and retrograde Kirschner wire fixation for proximal phalanx base fractures

Sung Hoon KOH ; Yeon Wook KIM ; Jin Soo KIM ; Dong Chul LEE ; Si Young ROH ; Kyung Jin LEE

Archives of hand and microsurgery.2024;29(2):82-89. doi:10.12790/ahm.24.0009

Purpose: We aimed to determine whether the clinical outcomes of antegrade and retrograde extra-articular Kirschner wire (K-wire) pinning differed in proximal phalanx base fractures. Methods: This retrospective study investigated 73 patients aged ≥18 years with extra-articular proximal phalanx base fractures that were treated by closed K-wire pinning between January 2014 and June 2023. Patients were analyzed according to whether the K-wire fixation was antegrade or retrograde. We analyzed demographics, injury characteristics, the number of K-wires applied, surgical duration, the interval before implant removal, and when physical therapy was started. Radiological outcomes included the amount of time required for radiographically confirmed bone union. Clinical outcomes consisted of complications, total active motion (TAM), and the Michigan Hand Outcomes Questionnaire (MHQ). Results: We treated 29 and 44 patients using antegrade and retrograde K-wire fixation, respectively. The overall complication rate was higher in the antegrade group than in the retrograde group (13.8% vs. 9.1%), although this difference was not statistically significant. Similarly, no significant between-group differences were detected in the length of time required for bone union and implant removal, TAM, and MHQ scores. Conclusion Proximal phalanx base fractures were equally and effectively treated by antegrade and retrograde K-wire fixation. Therefore, the direction of K-wire fixation can be chosen based on surgeons’ preferences and experience.

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Changes in force generation by two-finger striking methods: an experimental study

Seon Mi YUN ; Hun KIM ; Kun HWANG ; Sung Gyun JUNG ; Young Joong HWANG

Archives of hand and microsurgery.2024;29(2):65-74. doi:10.12790/ahm.24.0007

Purpose: Acute sagittal injury in boxer’s knuckle causes extensor tendon subluxation. We analyzed anatomical measurements for posture-related hand parts and measured the force generated when striking the fingers. Methods: In 120 healthy adults (55 males, 65 females), the palm area, finger length, finger length, finger circumference, and wrist circumference were measured. Using a digital force gauge, the force generated by striking with finger flexion (FFF) performed by the middle finger was measured. The forces generated during extension flicking (FEFs) by the index and ring fingers were also measured. The forces exerted by the hand and fingers was measured using a grip force meter. The relationships of measured values with sex and age were statistically analyzed. Results: The FFF of the middle finger was 12.9±7.0 N, and the FEFs of the index and ring fingers were 6.8±2.5 N and 5.8±2.3 N, respectively. The grip force was 343.3±134.7 N in the four fingers excluding the thumb, 108.4±41.6 N in the index finger, 110.5±45.4 N in the middle finger, and 83.6±36.5 N in the ring finger. Males had higher FFF for the middle finger (17.9±6.6 N) than females (8.6±3.9 N) (p<0.001), and greater FEFs for the index (8.5±2.0 N) and ring fingers (7.1±2.2 N) compared to females (5.3±1.7 N and 4.7±.8 N, respectively) (p<0.001). Cross-analysis results showed differences by sex and age. The circumference of the index finger exceeded that of the ring finger. Conclusion The study findings shed light on the relationship between the forces generated in the process of finger flicking.

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The Zitelli bilobed flap for soft tissue coverage after mucoid cyst resection: a retrospective cohort study

Sangho OH ; Jaein CHUNG ; Daegu SON

Archives of hand and microsurgery.2024;29(2):90-95. doi:10.12790/ahm.24.0014

Purpose: Digital mucoid cysts are frequently found at the distal interphalangeal (DIP) joint in patients with degenerative osteoarthritis. In complicated cases, surgical treatment with mucoid cyst resection is considered, and soft tissue is covered with one of various local flap techniques. Among these, bilobed flaps are reliable and aesthetically favorable, with primary healing of the donor site. In this study, we investigated a case series of bilobed flaps for digital mucoid cysts. Methods: We retrospectively reviewed our electronic medical records and found 26 digital mucoid cysts treated with bilobed flaps at our facility between July 2022 and February 2024. We extracted data from the records of these patients on sex; age; time to surgery; clinical findings including nail ridging, the presence of osteophytes, cyst size and location, and additional procedures (arthrodesis); and follow-up data including the occurrence of complications, such as delayed wound healing, infection, stiffness, and recurrence. Results: Among the 26 patients in our sample, 19 were female and seven were male. The average age was 62.2 years, and the average time to surgery was 10.8 months. Preoperatively, the average cyst measured 6.9×8.3 mm. Nail ridging was found in 19 patients (73.1%) and osteophytes in 22 patients (84.6%). The most commonly affected digit was the middle finger, which accounted for 10 cases (38.5%). All the flaps totally survived, without major complications. Conclusion Based on our series, a bilobed flap for soft tissue coverage after mucoid cyst excision can achieve high-quality surgical results.

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Neglected very large ancient schwannoma of the distal wrist: a case report and literature review

Hyun Rok LEE ; Yeongsik YUN ; Hyoung Jong KWAK ; Jae Hoon KANG

Archives of hand and microsurgery.2024;29(2):105-109. doi:10.12790/ahm.24.0006

Ancient schwannoma is a variant of schwannoma characterized by slow progression, degenerative changes, and a higher incidence in older adults. There have been two prior reported cases of ancient schwannoma arising from the distal ulnar nerve at the wrist level, but neither were longstanding or very large. Herein, we report an ancient schwannoma found in the ulnar nerve of the distal forearm that was found to be clinically meaningful in size. A 61-year-old man presented with complaints of tingling sensation of the fourth and fifth fingers and bulging of the ulnar side of the wrist. The patient reported that the mass in his wrist had grown very slowly, starting about 10 years ago, and that he had started experiencing a tingling sensation in his fourth and fifth fingers about 3 years prior, which had become worse in the past year. Based on the results of the preoperative examination, a benign nerve sheath tumor was suspected. As it was thought that the possibility of malignancy was not high, we elected to perform a marginal excision. Pathological examination confirmed ancient schwannoma. At his most recent visit, 3 years after surgery, he reported no recurrence and that he felt better than before surgery, but some tingling sensations remained. As with small ancient schwannoma in the distal wrist, most cases of large ancient schwannoma can be treated without special complications based on an accurate preoperative diagnosis.

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Improved flap perfusion and hemostasis after postoperative embolization in free flap surgery: a case report

Junghee KIM ; Hyeokjae KWON ; Sunje KIM ; Seung Han SONG ; Sang-Ha OH ; Yooseok HA

Archives of hand and microsurgery.2024;29(2):127-131. doi:10.12790/ahm.24.0005

This study aims to present a novel use of coil embolization in managing postoperative bleeding after free flap surgery, a technique typically reserved for other medical complications. We report the case of a 77-year-old female patient who underwent muscle-sparing latissimus dorsi free flap surgery for recurrent myxofibrosarcoma on her left thigh. Although hemostasis was achieved hemostasis during surgery, the patient experienced postoperative bleeding, which was initially managed with compression and blood transfusions. Upon a critical drop in the hemoglobin level, coil embolization was performed at the proximal segment of the descending branch of the lateral circumflex femoral artery. Coil embolization successfully controlled bleeding, while preserving blood flow to the flap. The patient’s hemoglobin levels stabilized, and the flap’s perfusion improved post-procedure. This approach proved effective in managing bleeding in areas other than the anastomosis site, with the patient showing a satisfactory recovery and no significant complications in the 30-day postoperative period. Coil embolization, a method commonly used for gastrointestinal bleeding and other vascular issues, can be a viable and effective option for controlling postoperative bleeding after free flap surgery. This case demonstrates its potential as a lifesaving intervention while preserving flap viability. However, further research with more cases is needed to evaluate the generalizability and long-term outcomes of this technique in similar surgical contexts.

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Arthrodesis for Eaton-Littler stage III degenerative trapeziometacarpal arthritis: a retrospective comparative study of fixation methods

Jun-Ku LEE ; Chi-Hoon OH ; Woo Yeol AHN ; Sung Woo LEE ; Seungyeon KANG ; Soo-Hong HAN

Archives of hand and microsurgery.2024;29(2):96-104. doi:10.12790/ahm.24.0011

Purpose: This study compared clinical outcomes depending on the fixation modality in patients who underwent arthrodesis surgery for Eaton-Littler stage III trapeziometacarpal (TM) joint arthritis between 2009 and 2022. Methods: In total, 39 patients with 44 hands (five patients had surgery on both hands) were selected. Depending on the operative fixation instruments, patients were divided into two groups: group 1, surgery with 25-gauge interosseous wiring and Kirschner wire or headless screw fixation; group 2, surgery with only multiple headless screws for fixation. Bone union was achieved at 62 days after surgery in group 1 and 75 days in group 2 (p=0.165). Results: The preoperative mean visual analogue scores improved during the postoperative outpatient follow-up period in both groups (group 1, from 4.0 preoperatively to 1.0 at the final follow-up; group 2, from 5.0 preoperatively to 2.0 at the final follow-up). Mean grip strength and pinch strength increased after surgery. One patient (4.8%) experienced nonunion in group 1, whereas nonunion occurred in four patients (17.4%) in group 2. This difference was not statistically significant. Four patients in group 1 and no patients in group 2 underwent fixation instrument removal after sound union. Conclusion Adequate stability can be achieved during arthrodesis by combining interosseous wiring and other implants or multiple headless compression screws, resulting in successful outcomes for patients with Eaton-Littler stage III degenerative TM arthritis.

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