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Skin avulsions are severe traumatic injuries, in which sections of skin and subcutaneous tissue are torn off from the body, and the surgical management and salvage of these injuries are quite challenging due to their high morbidity and mortality. The entire or partial loss of an avulsed flap is prone to occur. If this happens, scars can be particularly conspicuous, and additional surgery, such as skin grafts or local flaps or even composite grafts, might be required. A 24-year-old male patient presented to the emergency room with a severe traumatic avulsion injury on his nose. We used a combination of three therapies to minimize the loss of the distal portion of the avulsed flap: polydeoxyribonucleotide injection, continuous non-rebreather mask oxygen therapy, and chemical leeching. We achieved complete flap salvage of the avulsed wound, and the patient showed full satisfaction in both aesthetic and functional aspects. Although this report is confined to a single case of severe avulsed injury, we suggest this triple-combination therapy as a good combined modality for maximizing the salvage of an avulsed flap on the basis of this case and a literature review.

Known to be chemically inert, Aquafilling filler has been widely used in local aesthetic clinics in South Korea for breast augmentation. However, Aquafilling is only approved as a dermal filler and is not approved as an injectable filler for breast augmentation by the U.S. Food and Drug Administration or the Ministry of Food and Drug Safety. Several reports of complications following large-volume Aquafilling injections in the breast have been published. In this study, an HIV (human immunodeficiency virus)-infected transgender patient presented to the emergency room with a purulent infection of the breast and systemic fever. The patient had a history of large-volume Aquafilling injection in both breasts 3 years earlier to obtain a feminized appearance of the breasts. After using intravenous antibiotics and performing several surgical debridements over 4 weeks, the overall inflammatory response subsided. The skin defect site was covered successfully using an Integra Wound Matrix Dressing and there were no recurrent complications over 2 years of follow-up visits. Before injecting Aquafilling to augment patients’ breasts, a thorough consultation is mandatory, and doctors must notify patients that the risk of complications may be relatively high. Furthermore, any fillers including Aquafilling must not be used for unapproved purposes.

Although lipoma is a common benign tumor, it occurs relatively infrequently in the oral and maxillofacial areas, and only 31 cases of lipoma in the buccal fat pad have been reported. Herein, we present an extremely rare case of symmetric lipomas in both buccal fat pads. These masses were incidentally discovered during a facelift procedure in a 50-year-old woman with a 4-year history of tamoxifen use. during which she had gained 10 kg. The patient stated that cheek protrusion had developed concomitantly with weight gain and was exacerbated by an injection lipolysis procedure she had received 1 year previously. This case underscores the importance of paying careful attention to the patient’s medication use and surgical history when evaluating suspected cases of lipoma, and sheds light on tamoxifen use and subcutaneous injections of phosphatidylcholine and deoxycholate as potential risk factors for lipoma development.

Background: The study aimed to evaluate nasal reconstruction techniques customized for Asians. The currently available nasal reconstruction guidelines are based on Caucasian patients, and their applicability is limited in Asian patients due to differences in anatomical and structural features.Methods: A retrospective analysis was performed of the medical records of 76 patients who underwent nasal reconstruction at a single center between January 2010 and June 2020. A comprehensive evaluation was conducted of patients’ baseline demographics and clinical characteristics, including age, sex, medical history, defect size and location, reconstructive procedure, pathological diagnosis, postoperative complications, and recurrence.Results: In 59 cases (77%), nasal defects resulted from tumor ablation, and the remaining 17 cases involved post-traumatic (20%) and infection-induced (3%) tissue damage. The most common defect location was the alae, followed by the sidewalls, tip, and dorsum. Forehead flaps were the most commonly used reconstructive technique, followed by nasolabial advancement flaps, rotation flaps, and skin grafts. Each procedure was applied considering aspects of structural anatomy and healing physiology specific to Asians. Complications included nasal deformity, hypertrophic scarring, secondary infection, and partial flap necrosis, but no cases required additional surgical procedures. Tumors recurred in two cases, but tumor recurrence did not significantly affect flap integrity.Conclusion: Nasal reconstruction techniques applied considering Asians’ facial features resulted in fewer postoperative complications and higher patient satisfaction than the approaches that are currently in widespread use. Therefore, this study is expected to serve as an essential reference for establishing treatment guidelines for nasal reconstruction in Asians.

Background In patients with congenital melanocytic nevus (CMN), single-stage removal of large lesions can be difficult because the high tension created by excising and repairing a large lesion may result in scar widening. Herein, we introduce a method to effectively excise lesions while minimizing scarring and compare its outcomes to those of existing surgical methods. Methods We compared patients who underwent surgery using the anchoring technique (n=42) or the conventional elliptical technique (n=36). One side of the lesion was removed via en bloc resection up to the superficial fascia. The other side of the lesion was removed via de-epithelialization. The de-epithelialized dermal flap was then fixed by suturing it to the superficial fascia on the opposite side. The length of the lesion’s long axis and amount of scar widening were measured immediately after surgery and at 2, 6, and 12 months postoperatively. At 12 months, patients were assessed using the Patient and Observer Scar Assessment Scale. Results The lesion locations included the face, arms, legs, back, and abdomen. The anchoring method resulted in shorter and smaller scars than the conventional method. There were no cases of postoperative hematoma or wound dehiscence. Significant differences in postoperative scar widening were found in the arm and leg areas (P Conclusions The anchoring method introduced in this study can provide much better outcomes than the conventional method. The anchoring method is particularly useful for the removal of CMN around the joints or extremities, where the surgical site is subjected to high tension.

Background We have devised a novel surgical method, termed as temporalis muscle tendonperiosteum (T-P) compound surgical method, by modifying pre-existing techniques. Our method is characterized by elevation of temporalis muscle tendon and the periosteum of the mandibular ramus as a single compound. Here, we describe the concept and clinical outcomes of our method. Methods We conducted both a cadaveric study and a clinical study. First, we used four human cadavers (two males and two females) to confirm the anatomy of the temporalis muscle tendon and availability of sufficient length extension through the elevation of the T-P compound. Moreover, we obtained measurements of the mouth angle and the philtrum angle from a total of six patients (two males and four females) and compared them between preoperatively and postoperatively. Results The mean length of the periosteal portion was measured as 2.43± 0.15 cm (range, 2.2–2.6 cm). There was an improvement in the mouth angle postoperatively as compared with preoperatively (7.2°± 3.0° vs. 14.5°± 4.7°, respectively). Moreover, there was also an improvement in the philtrum angle postoperatively as compared with preoperatively (7.2°± 3.4° vs. 17.2°± 6.5°, respectively). Conclusion Our method is a simple, minimally-invasive modality that is effective in achieving good clinical outcomes. Its advantages include an ability to achieve a firm extension of the temporalis muscle tendon as well as a lack of requirement for a donor site that may cause complications.

Traumatic subcutaneous emphysema, which is the infiltration of air into subcutaneous tissues due to trauma, is caused by various factors such as chest and/or abdominal trauma, facial fractures, and barotrauma caused by mechanical ventilation. In this case report, a 32-year-old woman developed traumatic subcutaneous emphysema after undergoing abdominal liposuction at a local clinic. She was subsequently admitted to Busan Paik Hospital, and with early diagnosis and conservative treatment, she was discharged on the seventh day of hospitalization with no complications. However, because traumatic subcutaneous emphysema may accompany other injuries for various reasons, radiological examination and various tests should be performed to prevent serious complications and sequelae.

Background Epidermal cysts are benign, slow growing cysts that often develop on the head, neck, chest, and back of adults. The most common method of surgical excision involves the use of a scalpel and often leaves a scar proportional to the size of the cyst. Therefore, minimally invasive techniques are required. Among these techniques, the CO2 laser-based technique is minimally invasive and has lower complication rate, shorter recovery times, and lesser scarring. This paper aimed to compare the results and postoperative complications associated with a CO2 laser-based excision against conventional surgical excision for epidermal cysts. Methods We surveyed 120 patients, aged 16 to 65 years, with epidermal cysts on the face measuring 0.5 to 2.2 cm in diameter. Twelve months later, we compared the scar length, recurrence rate, patient satisfaction, and complications between patients treated with CO2 laser excision versus surgical excision. Results The mean scar length (12 months postoperative) after CO2 laser excision was 0.30± 0.15 cm, and that following surgical excision was 1.23± 0.43 cm (p= 0.001). The procedure time (time from incision after local anesthesia to the end of repair) was 16.15± 5.96 minutes for CO2 laser excision versus 22.38± 6.05 minutes for surgical excision (p= 0.001). The recurrence rates in the surgical excision group and CO2 laser excision group were 3.3% and 8.3%, respectively; this difference was not statistically significant (p= 0.648). Conclusion The cosmetic outcome of CO2 laser excision is excellent. For epidermal cysts measuring 2.2 cm or smaller, CO2 laser excision is recommended, especially when aesthetic outcome is considered important.

Recently, dermal fillers have been used with increasing frequency to improve facial contours for cosmetic purposes. The appreciable increase in such filler procedures has led to more adverse events and complications. Herein, we report the clinical significance and differential diagnosis of delayed multiple granulomas that occurred in a patient with a history of an injection of an unknown substance as a filler 20 years previously. She was also taking oral steroids and tacrolimus for immune suppression after a kidney transplant that she received 10 years before she presented with granulomas.

Background Nasal fracture and orbital blowout fracture often occur concurrently in cases of midface blunt trauma. Generally, these multiple fractures treatment is surgery, and typically, the nasal bone and orbit are operated on separately. However, we have found that utilizing a transconjunctival approach in patients with concurrent nasal bone fracture and orbital blowout fracture is a useful method. Methods The participants in the present study included 33 patients who visited the Plastic Surgery outpatient department between March 2014 and March 2017 and underwent surgery for nasal fracture and orbital blowout fracture. We assessed patients’ and doctors’ satisfaction with surgical outcomes after indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture with associated orbital blowout fracture. Results According to the satisfaction scores, both patients and doctors were satisfied with transconjunctival approach. Conclusion We presented here that our method enables simultaneous operation of nasal fracture accompanied by orbital blowout fracture, rather than treating the two fractures separately, and it allows precise reduction of the nasal fracture by direct visualization of the fracture site without any additional incisions or difficult surgical techniques. Also, by preventing the use of excessive force during reduction, this method can minimize damage to the nasal mucosa, thereby reducing the incidence of nasal bleeding.

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient’s clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Background A transcaruncular approach is typically used for reconstructions of medial wall fractures. However, others reported that a transconjunctival approach was conducive for securing an adequate surgical field of view. In this study, we aimed to examine the extent of repair of medial wall fracture via a transconjunctival approach. Methods We retrospectively reviewed the medical records of 50 patients diagnosed as having medial wall fracture via preoperative computed tomography and who underwent surgery between March 2011 and February 2014. The fracture location was defined by dividing each of the anterior-posterior and superior-inferior distances into three compartments. Results A transcaruncular approach was used in 7 patients, while the transconjunctival approach was performed in the remaining 43 patients. The transconjunctival approach enabled a relatively broad range of repair that partially included the front and back of the medial wall, and was successful in 86% of the entire study population. Conclusion It is known that more than 50% of total cases of the medial wall fracture occur mainly in the middle-middle portion, a majority of which can be reconstructed via a transconjunctival approach. We used a transconjunctival approach in identifying the location of the fracture on image scans except for cases including the fracture of the superior portion in patients with medial wall fracture. If it is possible to identify the location of the fracture, a transconjunctival approach would be an useful method for the reconstruction in that it causes no damages to the lacrimal system and is useful in confirming the overall status of the floor.

Nevus sebaceus is a hamartoma of the sebaceous gland that occurs congenitally, from which various secondary tumors can arise with a prevalence of 5%-6%. Benign neoplasms commonly arise from nevus sebaceous, but they have a very low malignant potential. Two neoplasms may occasionally arise within the same lesion, but it is rare for three or more neoplasms to occur in a nevus sebaceus simultaneously. A 61-year-old male patient was admitted to our hospital for a 4 cm×2.5 cm growing tumor in a verrucous form arising within a periauricular nevus sebaceus in the post auricle of the left ear that had developed 30 years earlier. The nodule was diagnosed as 3 different types of tumors: trichilemmoma, desmoplastic trichilemmoma, and basal cell carcinoma. To our knowledge, this is the first report of the coexistence of three different tumors arising from nevus sebaceous. It contain malignant neoplasm also. Surgeons should be aware of the need for close monitoring and early complete surgical excision of sebaceous nevus in order to improve patient outcomes.

Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.

Background We conducted this study to analyze the values of the key cephalometric angular measurements of the mandible using 3-dimensional (3D) computed tomography scans. Methods In the 106 enrolled patients, a 3D cephalometric analysis was performed to measure the angular variables of the mandible. These values were compared between the two sides and between the two sexes. Results The frontal measurements revealed that the mandibular body curve angle was larger on the left (Lt) side (right [Rt], 141.24±7.54; Lt, 142.68±6.94; P=0.002) and the gonial angle was larger on the right side (Rt, 134.37±8.44; Lt, 131.54±7.14; P0.05). Further, the transverse measurements revealed that the mandibular body curve angle was larger on the right side (Rt, 140.28±7.05; Lt, 137.56±6.23; P Conclusions These results provide an average of the mandibular angular measurements for the Korean population, establishing a standard for determining surgical patient groups and outcome evaluations in the field of mandible contour surgery.

Linear scleroderma en coup de sabre (LScs) is a variant of localized scleroderma. This disease typically occurs in patients in their 20s or younger individuals and predominantly occurs in the forehead area. A 26-year-old man with linear scleroderma was surgically treated at our center with Medpor (porous polyethylene) and dermal fat graft for the forehead lesion. After 26 months of postoperative follow-up, the depressed lesion that appeared scarred as well as the margins improved significantly. The surgical treatment of LScs using Medpor and dermal fat graft is an effective treatment modality that can increase patient satisfaction.

Leiomyosarcomas (LMSs) are rare malignant tumors of the smooth muscles, and superficial LMS is a type of LMS that develops on the skin. Superficial LMS of the head is exceedingly rare and represents only 1%-5% of all superficial LMS cases [1]. LMSs are classified as cutaneous or subcutaneous depending on the primary site of origin. A primary cutaneous LMS derives from the erector muscles of the hair and sweat glands in the dermis. Subcutaneous LMS is considered to arise from the muscular coat of a vessel [2]. It mostly develops in people in the age group of 40-60 years and is twice more likely to occur in women than in men. The most common sites of LMS development are the legs (50%-75%), followed by the arms (20%-30%), trunk (10%-15%), and face (1%-5%) [3]. We report a case of LMS in a 13-year-old boy. LMS developed on the face of the child. A case like this has thus far not been reported internationally, and the present study contributes to the knowledge on LMS disease characteristics. A 13-year-old boy was admitted because of a protruding and painless mass on his right jaw. The tumor size had been increasing for 10 months, and the lesion was approximately 20 mm in diameter at the time of admission (Fig. 1). There were no palpable cervical lymph nodes. Fig. 1 A preoperative photograph of the patient showing a 30-mm-sized tumor under the right jaw. A solitary oval-shaped mass with increased contrast and measuring 28 mm×18 mm was observed at the superficial masseter muscle and the mandibular ramus during preoperative contrast-enhanced computed tomography (Fig. 2). At first, hemangioma was suspected. Accordingly, a catheter was placed in the right external carotid artery through the right femoral artery, and embolization through the facial artery was performed using Gelfoam. However, instead of decreasing, the tumor size gradually increased during the 2 months of postoperative follow-up. Fig. 2 A preoperative computed tomography scan showing a hypervascular mass with increased contrast. Under general anesthesia, a pale, yellowish mass, measuring 33 mm×23 mm×20 mm, on the subcutaneous layer was resected via an intraoral incision (Fig. 3). On the postoperative biopsy, LMS involving adipose and vascular tissues accompanied by dystrophic calcification and a mitotic count of 3/10 high-power fields was observed (Figs. 4, ​,55). Fig. 3 An oval-shaped mass was revealed via an intraoral incision. Fig. 4 High-power microscopic examination revealed atypical spindle cell proliferation with a long fascicular or short bundle pattern. The red arrow denotes atypical mitosis (H&E, ×400). Fig. 5 Immunohistochemically, desmin staining (desmin immunohistochemistry, ×200) was positive. Low-power microscopic examination revealed a hypercellular solid mass without necrosis or hemorrhage and composed of spindle cells. The lesion infiltrated to the adipose tissue, probably the subcutaneous fat layer. The high-power view showed cellular atypism with frequent mitotic figures (at least one/high-power field) (Fig. 4). Immunohistochemically, desmin and actin were positive, but CD34 or cytokeratin was negative (Fig. 5). SYT/SS18 fluorescence in situ hybridization revealed no t(X;18)(p11.2;q11.2) translocation. Therefore, the pathologic diagnosis was LMS. LMSs are classified as cutaneous or subcutaneous depending on the primary site of origin. Cutaneous forms, which arise from the arrector pili muscles of the hair follicles or the dartos muscles of the genital skin, are associated with epidermal changes, such as ulceration, umbilication, and discoloration. Subcutaneous forms, which arise from the smooth muscle lining of arterioles and veins in the subcutaneous tissue, are not associated with surface changes and usually grow relatively fast [2]. Differentiation into one of these two subtypes is not always straightforward because the local growth of tumors of either type may involve invasion of the dermal and subdermal layers. However, differentiating between cutaneous and subcutaneous LMSs is important because they have different prognoses. Cutaneous LMSs have a local recurrence rate of 14%-50%, but the potential for distant metastasis is very low. In contrast, subcutaneous LMSs recur locally in 40%-60% of cases and metastasize in 20%-60% of cases [2]. The present case was determined to belong to the subcutaneous type. Clinically, the tumor did not protrude out of the skin, and no epidermal changes such as ulceration were observed. This is significant because it is difficult to identify and diagnose subcutaneous-type tumors if there are symptoms indicative of a cutaneous type. LMS is extremely rare in patients below the age of 15 years. A literature search revealed a single study by Bernstein and Roenigk [4], who reported two pediatric patients with LMS localized on the shoulder or the scalp. There is no report of LMS of the lower jaw in a pediatric patient. Although a 30-mm solitary mass with increased contrast was found on computed tomography at the time of the initial hospital admission, the correct diagnosis was delayed due to the lack of knowledge on LMS. Pain is the most common symptom of LMS, occurring in 80%-95% of patients. Pruritus, burning, and bleeding are also common [2]. In our patient, no such symptoms were observed before the histological diagnosis was established, and no physical trauma was detected. Histologically, superficial cutaneous LMSs are characterized by poorly circumscribed fascicles of spindle-shaped cells in the dermis. The tumor is highly cellular, with elongated, blunt-tipped nuclei. LMSs are characterized by co-expression of vimentin, desmin, and muscle-specific actin [2]. The recommended treatment for superficial LMS is wide local excision with a 20- to 50-mm lateral margin [5]. Routine lymphadenectomy is not indicated unless the lymph node disease is evident. There is no evidence to support the use of chemotherapy in the treatment of these tumors [1,2]. Here, we report a case of a 30-mm LMS that developed on the jaw of a pediatric patient. As this is an extremely rare facial tumor, it is difficult to diagnose in the absence of obvious symptoms. It is particularly important to differentiate a tumor of the subcutaneous type, which is not manifested by changes on the surface of the skin such as protrusion or ulceration, from a hemangioma or lymphoma. An incorrect or delayed diagnosis may lead to increased tumor size, invasion to proximal tissues, or remote metastasis. Therefore, we need to consider the possibility of LMS during the diagnosis of a facial tumor in children. We hope that this study provides useful information for clinicians and researchers investigating the biological characteristics of superficial LMS.

Due to the three-dimensional configuration of the auricle and cartilage, surgeons encounter significant challenges in the reconstruction of auricular defects in anterior regions such as the antihelix and triangular fossa. Local flaps, skin grafting, and wedge excision are currently used in these locations. Postauricular flaps are the most common of these techniques, due to their advantages that include low morbidity, a well-hidden scar, direct closure, and good color match to the ear skin [1]. However, the lack of underlying vasculature and perichondrium may lead to graft necrosis. Moreover, wedge excision cannot be performed in patients with defects of the antihelix or triangular fossa because such patients are vulnerable to severe ear deformities. We modified a flip-flop flap to reconstruct anterior defects of the ear across the antihelix and triangular fossa. Our technique is a one-stage, random-pattern island flap surgery, and allows a shorter operation time and reduced losses at the donor site, while still leading to satisfactory treatment outcomes. Here, we describe our technique and its outcome. This study was reviewed and approved by the ethics review board of the Inje University Health Center. A 70-year-old man visited us with a chief complaint of Bowen's disease in the right ear. The patient underwent excision of the tumor with adequate circumferential and deep margins, including the perichondrium. The defect, located throughout the antihelix and triangular fossa, was oval in shape and 2.0×1.8 cm in size, with exposed cartilage (Fig. 1). Fig. 1 The defect, located throughout the antihelix and triangular fossa, was oval in shape and 2.0×1.8 cm in size, with exposed cartilage. We decided to create a 30% overlap in the medial direction. Under local anesthesia, we performed preoperative marking for the skin island, based on the size of the anterior auricular defect, for which we intended a 30% overlap in the medial direction (Fig. 1). A cartilage window was then drawn at the center of the overlap between the marked area and the actual defect. Thus, we attempted to provide an entrance for skin flap placement (Fig. 2). Fig. 2 After creating a skin island, we removed a small, slender piece of cartilage to provide an entrance for the skin flap. After being drawn on the anterior auricular surface, the pattern was marked on the back and then redrawn. It was then redesigned by extending the top side by approximately 10 mm, in line with the sulcus axis, thus leaving the lower base intact. In other words, it was shaped into an elongated orb alongside the axis of the sulcus. We thus made it easier to reduce the tension in the central pedicle during rotation and to suture the donor site. We placed one third of the skin island over the mastoid area and the remaining two thirds of the skin island over the postauricular surface. After excising the designated area, we elevated the skin flap while preserving the central subcutaneous pedicle. Once the flap was observed to be sufficiently elevated, we rotated it at an angle of 120° around the long axis through the cartilage window (Fig. 3). The flap was closed using interrupted prolene 6-0 sutures, and the postauricular donor site was closed using continuous vicryl 5-0 and prolene 5-0 sutures. Fig. 3 Schematic diagram. (A) Schematic illustration of a conventional flip-flop flap. There is an exact match in surgical design between the anterior defect site and the posterior donor site. The lateral side (**) of the donor site exits anteriorly through ... The donor site was easily closed through direct repair, without other procedures. No differences were observed in the color and thickness of the skin between the flap and the anterior auricle. Moreover, the patient did not develop postoperative infections or flap loss. Furthermore, at a follow-up, the patient had no ear asymmetry or other complications, such as notable scarring (Fig. 4). Fig. 4 Five-month postoperative follow-up views. (A, B) Anterior and posterior aspects of the ear. In 1972, Masson [2] first reconstructed anterior auricular defects using subcutaneous pedicle postauricular flaps. These flaps have also been referred to as revolving or flip-flop flaps, or as posterior auricular rotation flaps, and they have been reported to be appropriate for reconstructing defects on the scapha, triangular fossa, antihelix, and conchal bowl. The advantages of this technique include the availability of well-vascularized skin for the coverage of large auricular defects and a one-stage operative procedure [3]. Since first being introduced, Masson's flap has been used by many surgeons. Due to the short length and immobilization of the subcutaneous pedicle, however, it has limitations in lowering the ear projection and the depth of the sulcus. In order to increase flap mobility, some authors have described postauricular axial pattern flaps, in which the posterior auricular artery or the superior auricular artery is used as a pedicle [4]. However, these flaps are disadvantageous in that they require careful dissection and may result in morbidity. Therefore, because they are not used frequently, other researchers have developed a de-epithelialized postauricular flap; its advantages include higher safety and mobility compared to the subcutaneous pedicle flap and lower morbidity than the axial flap. Nonetheless, it is problematic that additional procedures are required for de-epithelialization, and ear deformities may occur as a result of the increased area of the postauricular donor site. Our technique can be summarized as follows. First, we approached the postauricular donor site proximally to the sulcus in the medial direction rather than in same region as the defect. Thus, we were able to obtain a sufficient amount of postauricular skin, even in patients with defects of the outer edge of the ear, such as the antihelix or scapha. Second, we rotated the postauricular skin island at an angle of 120°, unlike conventional methods in which it is rotated at an angle of 180° through the cartilage [5]. This is useful when there is no parallel relationship between the axis of the largest defects and that of the sulcus or when the angle is approximately 90°. Aligning the maximum width of the defect to the postauricular sulcus axis, which has sufficient space, reduced the size of the defect in the donor region while simultaneously allowing a safe blood supply. Third, we did not create the cartilage window at the center of the flap island, but instead made it as small as possible in the overlapping region between the defect and the donor site. Thus, we increased the stability of the skin flap by preventing the pedicle from being entangled. We modified a postauricular island flap to reconstruct defects across the antihelix and triangular fossa. Our technique was useful not only in maintaining the contour and three-dimensional structure of the auricle, but also in shortening the operation time and recovery period.

Osteoma is a benign tumor that occurs from the proliferation of cancellous bone, compact bone, or their combination [1]. It can be classified into 3 types, namely, central, peripheral, and extraskeletal osteoma. Central osteoma occurs in the endosteum, peripheral osteoma occurs in the periosteum, and extraskeletal osteoma occurs mostly within muscles [2]. Osteoma mostly begins from the compact iliac bone but can be occasionally observed in the maxillofacial region. In the maxillofacial region, osteoma most frequently invades the sinuses, particularly the frontal sinus. It rarely occurs in the mandible [3]. Various pathogenesis of osteoma have been proposed, including the developmental theory, the neoplastic theory, and the reactive theory [4]. Most cases of osteoma are asymptomatic and do not require surgery, but because patients can be admitted to hospitals due to facial asymmetry, as in the case presented herein, clinicians must understand the clinical aspects and imaging characteristics of osteoma. A 24-year-old woman with a facial asymmetry due to hypertrophy of the left mandible presented to our department. The patient had first noticed the asymmetrically large left mandible 4 years earlier, but she had observed its progress without clinical evaluation. A mass was coincidentally detected 2 years prior to presentation during orthodontic examination on panoramic radiography, which was the reason she was aware that she had an asymmetrical left mandible. The size of the mass had gradually increased since then, so the patient was admitted to our hospital for removal of the mass and reduction angloplasty for aesthetic purposes. The patient had a history of contusion on the left mandible from a bicycle accident 12 years prior and explained that she had experienced a hematoma for several weeks at that time. No history of medication was reported, and we could not identify any abnormalities in other organs in our clinical tests. A physical examination showed that the mass was asymptomatic and had a well-defined circular shape, which was firmly fixed on the left mandibular angle region. The skin color around the lesion was normal, and the skin did not adhere to the mass (Fig. 1). As for radiological evaluation, a skull anteroposterior view was obtained, and a solitary oval, well-defined, radiopaque mass was observed (Fig. 2). Fig. 1 The patient demonstrates swelling around the left mandibular angle area (red arrow). Fig. 2 Initial panoramic radiograph showing a solitary oval, well-defined, radiopaque mass (white arrow), 13 mm×11 mm in size, abutting with the inferior border of the left angle of the mandible. Under general anesthesia reduction angloplasty was performed by performing a resection inside the mouth. Along with the left mandibular angle, the mandibular mass was removed. The mass, which was firmly attached to the mandibular angle, was a white solid lump, 15 mm×10 mm×12 mm in size, with a well-defined boundary (Fig. 3). A biopsy was immediately conducted on the sample. On the postoperative biopsy, an exophytic osteogenic tumor composed of cancellous trabecular bone was observed, and the pathologic diagnosis was osteoma (Fig. 4). Fig. 3 Surgical specimen showing a white mass on the left mandibular angle measuring 15 mm×10 mm×12 mm in size. Fig. 4 Microscopic features showing an exophytic osteogenic tumor composed of cancellous trabecular bone (H&E, ×4). The patient wore a compressive garment for 10 days. No specific side effects or complications occurred. In the final follow-up 3 years after the surgery, we observed noticeable improvement of the facial symmetry and no recurrence of the osteoma (Fig. 5). Fig. 5 The patient shows no swelling three years after the operation. Peripheral osteoma can occur in the facial region in rare cases. In this region, the mandible is rarely invaded [3]. Instead, in mandibular bone, lesions most frequently develop in the condyle, angle, and margin [4]. Peripheral osteoma can be diagnosed by using conventional imaging tests such as panoramic radiography or computed tomography. On imaging examination, the osteoma appears as a unilateral, pedicled, and well-defined oval or circular mushroom-shaped mass with radio-opacity similar to that of normal bones [1,2]. Peripheral osteoma has developmental traits such as being asymptomatic, slowly proliferating, and having few prone regions, and thereby being the easiest form to diagnose through clinical characteristics and radiography. However, the definitive evidence for its diagnosis is biopsy findings [4]. Malignant transition of peripheral osteoma has not been reported. In fact, most cases of peripheral osteoma are asymptomatic and often found coincidentally. Hence, surgery is generally not required. However, if it causes facial asymmetry, as in this case, or if it is accompanied by pain or symptoms such as impairment of mouth-opening or swallowing functions, surgical treatment is indicated [5]. The pathogenesis of peripheral osteoma has not been elucidated, but three hypotheses can be proposed according to its cause. First, the developmental theory suggests that peripheral osteomas result from developmental abnormalities, but this is not convincing because most patients have passed their growth phase. Second, the neoplastic theory contradicts the fact that osteoma proliferates extremely slowly. Third, the reactive theory can explain the case of osteoma that occurs after trauma. The subperiosteal hematic extravasation caused by the injury could have facilitated neoplastic degeneration of the injured tissues [4]. We report here a case of osteoma in the mandibular angle. As osteomas can induce clinical symptoms such as facial asymmetry and pain, clinicians must carefully conduct physical examinations during patients' preliminary medical examination. Diagnosis can be made according to the results of preoperative evaluation and appropriate imaging tests, which can be the foundation for surgical planning. Through histological examination, and regular clinical and imaging follow-up after surgery, full recovery can be achieved. We believe that this study can be helpful for clinicians and researchers investigating facial osteoma.

Background Recently, the number of thyroid surgery cases has been increasing; consequently, the number of patients who visit plastic surgery departments with a chief complaint of swallowing deformity has also increased. We performed a scar correction technique on post-thyroidectomy swallowing deformity via platysma flap with Z-plasty and obtained satisfactory aesthetic and functional outcomes. Methods The authors performed operations upon 18 patients who presented a definitive retraction on the swallowing mechanism as an objective sign of swallowing deformity, or throat or neck discomfort on swallowing mechanism such as sensation of throat traction as a subjective sign after thyoridectomy from January 2009 till June 2012. The scar tissue that adhered to the subcutaneous tissue layer was completely excised. A platysma flap as mobile interference was applied to remove the continuity of the scar adhesion, and additionally, Z-plasty for prevention of midline platysma banding was performed. Results The follow-up results of the 18 patients indicated that the definitive retraction on the swallowing mechanism was completely removed. Throat or neck discomfort on the swallowing mechanism such as sensation of throat traction also was alleviated in all 18 patients. When preoperative and postoperative Vancouver scar scales were compared to each other, the scale had decreased significantly after surgery (P Conclusions Our simple surgical method involved the formation of a platysma flap with Z-plasty as mobile interference for the correction of post-thyroidectomy swallowing deformity. This method resulted in aesthetically and functionally satisfying outcomes.

Background The purpose of this study is to analyze the current attitudes toward professionalism, the core values, and the type of professionalism among plastic surgeons in Korea to establish a code of ethics regarding the role of professionalism for plastic and reconstructive surgeons. Methods From March 9, to July 1, 2012, face-to-face and mail surveys were conducted targeting the 325 participants (256 specialists and 69 residents) who are registered members of the Korean Society of Plastic and Reconstructive Surgeons. The proportion of each response given to an item was obtained through statistical processing through frequency analysis. The Mann-Whitney U test was used to compare the differences in the responses between the resident group and the specialist group. Results The survey results on the perception of professionalism in plastic surgery showed that a high proportion (90.5%) of the respondents viewed the future of plastic surgeons as bright. Through evaluation of the importance of the value items,"professional dominance" (4.58 pts), "autonomy" (4.45 pts), "lifestyle" (4.34 pts), and "commercialism" (4.31 pts) were assessed as critical values. "Altruism" (3.84 pts), "interpersonal competence" (3.79 pts), and "social justice" (3.61 pts) were viewed as lesser values. This difference showed the characteristics of an entrepreneurial outlook. Conclusions Plastic surgeons should pursue excellence, humanism, accountability, and altruism in order to overcome the crisis of professionalism in plastic surgery. In order to develop the necessary competencies of professionals, vocational education should be arranged by the Korean Society of Plastic Surgeons, and an appropriate code of ethics should be established.

Background If a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patient's hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect. Methods From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpa's fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction. Results Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery. Conclusions Using a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle.

Stafne bone cavity is a rare mandibular defect that was first reported by Edward C. Stafne in 1942. It commonly presents with a well-demarcated, asymptomatic, unilateral radiolucency that indicates lingual invagination of the cortical bone. A 52-year-old female patient who with nasal bone fracture, visited the hospital. During facial bone computed tomography (CT) for facial area evaluation, a well-shaped cystic lesion was accidentally detected on the right side of the mandible. Compared to the left side, no swelling or deformity was observed in the right side of the oral lesion, and no signs of deformity caused by mucosal inflammation. 3D CT scans, and mandible series x-rays were performed, which showed a well-ossified radiolucent oval lesion. Axial CT image revealed a cortical defect containing soft tissue lesion, which has similar density as the submandibular gland on the lingual surface of the mandible. The fact that Stafne cavity is completely surrounded by the bone is the evidence to support the hypothesis that embryonic salivary gland is entrapped by the bone. In most cases, Stafne bone cavity does not require surgical treatment. We believe that the mechanical pressure from the salivary gland could have caused the defect.

Background Patients who have undergone enucleation during infancy due to retinoblastoma can develop microorbitalism due to the decreased growth stimulation from the eyeball and the surrounding soft tissues. Anatomically, the orbit consist of parts of the frontal bone superiorly, the maxilla inferiorly, the ethmoid bone medially, and the zygoma laterally. Considering the possibility of surgically expanding the orbit using tripod osteotomy, in this study we conducted tripod osteotomy on adult patients with microorbitalism of retinoblastoma. Methods Tripod osteotomy was conducted to expand the orbital volume in adult patients with microorbitalism due to enucleation in infancy for retinoblastoma. The orbital volume was measured using the Aquarius Workstation ver. 4.3.6 and the orbit width was measured with preoperative and postoperative 3-dimensional facial bone computed tomography (CT) imaging. Preoperative and postoperative photographs were used to visualize the difference produced by the surgery. Results The orbital volume of the affected side was 10.3 cm3 before and 12.5 cm3 after the surgery, showing an average increase in volume of 2.2 cm3 (21.4%). The increase in the obital width was confirmed by the preoperative and postoperative 3-dimensional facial CT images and aesthetic improvement was observed by the preoperative and postoperative photographs. Conclusions Tripod osteotomy, which realigns the orbital bone, zygoma, and maxilla, is used to correct posttraumatic malunion as well as non-traumatic congenital abnormalities such as that seen in facial cleft. We applied this procedure in microorbitalism secondary to enucleation for retinoblastoma to allow orbital expansion and correct asymmetry.

PURPOSE Advancement genioplasty to achieve aesthetic improvement was performed; however, the more genioplasty was advanced, the worse the depth of the labiomental fold became. Therefore, our hospital applied not only advancement of genioplasty but also rotational advancement of anterior segmental osteotomy (ASO) for satisfactory aesthetic lines. MATERIALS AND METHODS From January 2008 to March 2010, our hospital operated on 10 patients who showed not only convexity profile with posterior divergent but also small SNB and microgenia in the cephalometric analysis. Their mean age was 24.8 years, and we had them followed up for at least 6 months. The surgical technique was contrary to the ASO setback, which means a rotational advancement and an average 5-mm advancement of the ASO segment, adding an average of 6- to 7-mm advancement of genioplasty. RESULTS Postoperative results in the cephalometric analysis showed a good balance of the lower part of the face. Average SNB was increased from 69.96 to 72.88 degrees. The pogonion of the soft tissue came forward on an average of 7.18 mm and superiorly on an average of 1.93 mm. The inclination of L(1)MP was decreased from 100.00 to 91.99 degrees, but it was within the reference range. The labiomental fold was not deeper. We checked that spaces created by the anterior segmental osteotomy and advancement of genioplasty were filled with new bone through follow-up x-ray density images. CONCLUSIONS If balance of the lower part of the face with mandibular retrusion is insufficient using advancement of genioplasty, our hospital also applied rotational advancement of ASO. This operative technique not only was relatively simple and applied less pressure but also made a new B point.

Purpose The a-disintegrin-and-metalloprotease (ADAM) family proteins are widely expressed in the different layers of the retina throughout development. The effect of ADAM proteins on the epithelial-to-mesenchymal transition (EMT) in proliferative vitreoretinopathy (PVR) or AMD is yet to be elucidated. In this study we used Epstein-Barr virus (EBV)-transformed adult retinal pigment epithelial (ARPE) cells to investigate how sorafenib, a multikinase inhibitor, modulates ADAM proteins to control EMT. Methods Epithelial to mesenchymal transition and related mechanisms in EBV-infected ARPE cells were determined by RT-PCR, Western blot, invasion assay, ELISA assay, and gene silencing with siRNA. Results Mesenchymal-like ARPE/EBV cells exhibited considerably increased cellular migration and invasion compared with ARPE cells and produced EMT-related cytokines. Sorafenib significantly inhibited production of TGF-β1, VEGF, IL-6, IL-8, MCP-1, and TNF-α and blocked the activation of migration-related signaling molecules, such as HIF-1α, p-STAT3, MMP2, and Ang-1. The expression of mature ADAM10, ADAM17, and cleaved Notch 1 proteins in ARPE/EBV cells was downregulated after treatment with sorafenib through the regulatory activity of nardilysin (NRD-1). Gene silencing of NRD-1 in ARPE/EBV cells attenuated secretion of EMT-related cytokines and expression of ADAM10 and 17 and upregulated epithelial markers. Conclusions Sorafenib controls the mesenchymal characteristics of EBV-infected ARPE cells. Nardilysin and ADAM family proteins might be new targets for the prevention or control of EMT in retinal diseases.

BACKGROUND Acute auriculocephalic angle refers to an ear with helix that is spaced closely to the cranium. An increasing number of patients with acute auriculocephalic angle wish to undergo corrective operation for aesthetic purposes. However, there is a paucity of data regarding acute auriculocephalic angle. This paper proposes a treatment protocol for patients with acute auriculocephalic angle. METHODS We performed a retrospective analysis of patients undergoing acute auriculocephalic angle (4 patients, 6 ears). Patient records were reviewed for demographic data as well as auricular measurements at preoperative, immediate postoperative and final follow-up evaluations. RESULTS All of the patients were men with a mean age of 36.5 years (range, 23-52 years). The mean follow-up period was 47.5 months (range, 28-60 months). Postoperative auriculocephalic angle was close to the normal auriculocephalic angle (25°-30°) without notable scars. Moreover, the patients had minimal contractions of the skin flaps without any hematoma or relapse. CONCLUSION We propose the following three treatment protocols for patients with acute auriculocephalic angle: the posterior auricular muscle should be sufficiently released, the mastoid area should be augmented using implants, the skin should be repositioned with a superior auricular flap.

Background Lobular keloid appears to be a consequence of hypertrophic inflammation secondary to ear piercings performed under unsterile conditions. We wish to understand the pathogenesis of lobular keloids and report operative outcomes with a literature review. Methods A retrospective review identified 40 cases of lobular keloids between January, 2005 and December, 2010. Patient records were reviewed for preclinical factors such as presence of inflammation after ear piercing prior to keloid development, surgical management, and histopathologic correlation to recurrence. Results The operation had been performed by surgical core extirpation or simple excision, postoperative lobular compression, and scar ointments. Perivascular infiltration was noted in intra- and extra-keloid tissue in 70% of patients. The postoperative recurrence rate was 10%, and most of the patients satisfied with treatment outcomes. Conclusion Histological perivascular inflammation is a prominent feature of lobular keloids. Proper surgical treatment, adjuvant treatments, and persistent follow-up observation were sufficient in maintaining a relatively low rates of recurrence.

Hemangiopericytoma is rare in occurrence worldwide, including Korea. It was initially described by Stout and Murrary [1] in 1942. It is derived from a type of smooth muscle cell attached to pericytoma, capillaries also known as Zimmerman pericytes, and it is characterized by a "staghorn" shape on microscopic findings, in other words, a tumor with a diffuse pattern of branching, and dilated, thin-walled blood vessels surrounded by short spindle cells. Hemangiopericytoma has the very unusual characteristic of growing slowly, mainly in the lower extremities and pelvic retroperitoneum, but it can also be found in any part of the body such as the head and neck [1,2]. We introduce here a case of hemangiopericytoma found in the nasolabial fold because it rarely occurs in that area. Hemangiopericytomas in the head and neck are uncommon, but have been found in the neck, orbit, nasal cavity, parapharyngeal area, or tongue. A 57-year-old male with no specific underlying disease was admitted to our hospital due to an increasing mass in the nasolabial fold as the chief complaint. The mass had been growing in size for 1 year. The mass was painless, non-fixed, movable, and round in shape. The mass grew in size until the nasolabial fold was more pronounced than the opposite side. The skin and buccal mucosa area around the mass were intact, and there was no drainage (Fig. 1). The computed tomography and magnetic resonance imagining findings showed a well-defined, solid mass with isoattenuation and heterogeneous enhancement in the premaxillary area (2.4×3.4×3.5 cm3) (Fig. 2). Fig. 1 Preoperative photograph shows a mass near the right nasolabial fold. Fig. 2 T1-weighted magnetic resonance imagining findings show a solid mass enhanced in the premaxillary area (2.4×3.4×3.5 cm3). The operation was carried out under general anesthesia. The mass was large and considered to be a hemangioma or any other benign mass. However, the possibility of malignancy was not completely ruled out, and the incision was made through the nasolabial fold for minimal scarring. An approximately 5 cm incision was made along the right nasolabial fold, undermining the muscle layer. Complete excision of the mass was performed, and the mass was slightly irregular in shape and encapsulated, and was not attached to the surrounding tissues (Fig. 3). Fig. 3 Photograph of an extracted specimen after complete excision. Microscopically, the tumor was composed of variably sized ectatic vessels showing a staghorn configuration and surrounding closely packed spindle or ovoid cells (Fig. 4). The tumor cells showed a small amount of pale cytoplasm and mild nuclear atypia, but had a low mitotic rate (less than 1 mitosis in 10 high power fields [HPF]). The tumor cells were diffusely positive in CD34 and CD99 immunostains (Fig. 5). There was no evidence of a tumor in the surgical margin. Postoperative chemotherapy and radiotherapy were not performed. Fig. 4 Tumor composed of ectatic, staghorn-shaped vessels and closely packed tumor cells, showing short spindle to round cells with a small amount of pale cytoplasm (H&E, ×200). Fig. 5 The tumor cells are positive for CD34 based on the immunostain (×100). The patient did not mention any particular complaints for 3 months after surgery. There were no obvious facial changes or an awkward appearance when talking or showing emotions. The affected nasolabial fold had no significant difference from the opposite side. It seems that the dermal elasticity and subcutaneous adipose layer, which define the shape of the nasolabial fold, were not affected by the operation or the mass. Hemangiopericytoma is characterized as a slow growing painless mass. When it occurs in the head and neck, patients are admitted to the hospital with symptoms caused by the mass physically affecting the surrounding tissues. The tumor is composed of spindle or round CD34 positive cells surrounding staghornshaped vessels. However, these features are overlapped with a solitary fibrous tumor; nevertheless, a solitary fibrous tumor has more prominent collagen, less prominent vessels, and less cellular pattern than a hemangiopericytoma. The clinical features of both tumors are also similar. Recently both types of tumors are considered to be the same entity with the two ends of one process. Hemangiopericytoma has a varied spectrum of biological behavior: benign to malignant. The prediction of the clinical behavior of hemangiopericytomas is not clear. Generally, a large size (>5 cm), increased mitotic rate (>4 mitosis/10 HPF) with the presence of atypical mitosis, high cellularity, pleomorphic tumor cells, and foci of hemorrhage and necrosis predict a highly malignant course [3,4]. The main treatment of hemangiopericytoma is complete surgical excision. Preoperative embolization can be helpful for decreasing the size of the mass. Radiotherapy, chemotherapy, or a combination of both can effectively improve the survival rates when the mass is inoperable or cannot be completely removed, or metastasis occurs. Hemangiopericytoma has a varied spectrum of biological behavior: benign to malignant. Multiple articles have shown non-eventful life-long results after complete excision of hemangiopericytomas; however, it is better to consider a hemangiopericytoma to be malignant throughout a patient's lifespan because the tumor has the possibility of metastasis or recurrence. Therefore, long-term follow-up seems to be essential [4].

Squamoid eccrine ductal carcinoma (SEDC) is an exceedingly rare tumor that shows both squamous differentiation and adnexal ductal differentiation. As our review of the literature revealed, only a total of 7 cases were reported to date. We report an additional case of SEDC occurring on the scalp of a 53-year-old man. Despite complete excision by conventional technique with clear margin, the lesion recurred within a 3-month period, with regional lymph node metastasis. The tumor was completely removed, and the large scalp defect was reconstructed by using scalp rotation flap. We present a case of recurrent SEDC on the scalp, and we surgically resected this tumor. In addition, the large scalp defect was reconstructed successfully with scalp flap, and no recurrence has been observed in the patient's postoperative follow-ups.

The occurrence of congenital midline cervical cleft (CMCC) is very rare all over the world and has never been reported in Korea. The typical characteristic of CMCC is a longitudinal skin defect on the midline of the anterior neck that has a nipple-like skin tag at the cranial end, a fistula or sinus tract at the caudal end, and atrophic skin in between. It appears anywhere between the mandibular symphysis and the manubrium [1,2]. Surgical removal in early infancy is the choice of treatment in order to prevent neck extension disabilities caused by cicatricial neck contracture that may occur while aging. Complete excision of abnormal tissue and closure with single or multiple Z-plasty is usually required for functional and aesthetic purposes [1,2,3]. This report is about a 13-month-old female with the typical characteristics of CMCC, for whom we performed complete excision, platysmaplasty with Z-plasty, and skin closure with single Z-plasty. The patient was a 13-month-old girl born by a full-term vaginal delivery and whose initial crying and other activities were normal. No other abnormal finding except a vertical skin defect in the anterior neck region was reported at birth or during growth. At our hospital, we clinically examined the skin lesion on the midline of the anterior neck, noting that it had a nipple-like skin tag at the cranial end, a fistula-like skin lesion at the caudal end, and atrophic skin in between them. Further, it showed a cervical tethering cord formed by the skin lesion (Fig. 1). Fig. 1 Preoperative photograph shows typical characteristics of congenital midline cervical cleft. Neck magnetic resonance imaging and neck sonography showed a hypoechoic lesion in the subcutaneous layer of the midline of the anterior neck at the suprahyoid level with no definite evidence of a thyroglossal duct cyst or a fistula tract. The patient clinically diagnosed with CMCC was placed on the operating table in a supine position under general anesthesia. A fistula opening at the caudal end was checked under the 0.5-cm-long blind end by testing with probe insertion. The cleft and the underlying band-like subcutaneous tissue were completely excised. The cranial end was loosely adhered to the mentalis muscle, and the caudal end was extended with band-like tissue near the manubrium (Fig. 2). After complete excision, platysma flap with Z-plasty and skin closure with single Z-plasty were performed (Figs. 3, ​,44). Fig. 2 Subcutaneous band-like tissue at the caudal end; it reached nearby the manubrium. Fig. 3 Platysma flap with Z-plasty was performed for a functionally and aesthetically better prognosis. Fig. 4 Postoperative photograph. Skin closure with single Z-plasty was performed. The excised tissue was a 4.0 cm×1.1-cm tube-like tissue with a relatively smooth inner surface. Microscopically, the inner surface was covered with squamous epithelium with irregular thickness and parakeratosis. The subepithelial portion revealed a paucity of skin adnexal tissue and had haphazardly arranged skeletal muscle bundles mixed with fat tissue and seromucinous glandular tissue. Minimal scarring was expected two months after the surgery (Fig. 5). No limitation of neck extension was expected upon long-term follow-up. Fig. 5 Postoperative 2-month photograph. Minimal scarring was predicted. CMCC is very rare, and less than 100 cases of this condition have been reported worldwide. It is reported to occur sporadically, and girls have as high as twice the incidence rate as compared to boys [2,3]. The mechanism of CMCC has not yet been ascertained; however, embryologically defective fusion of the first and the second branchial arches is the most accepted hypothesis [1,2]. It is regarded as a variant of the Tessier median mandibular facial cleft and the type-30 craniofacial cleft [3]. Genetic studies are currently in progress; these studies focus on the mutation in the SIX5 gene and the deletion of the pregnancy-associated plasma protein A (PAPPA) as potential candidates, but an accurate mechanism is still unknown [4]. CMCC has three typical characteristics: 1) a nipple-like skin tag in the cranial portion, 2) a sinus tract or fistula in the caudal portion, and 3) a midline cleft resembling a skin defect in between. Subcutaneous band-like fibrosis usually appears above the platysma plane [1,2,3]. Other head and neck anomalies such as lower lip cleft, cleft tongue, cleft mandible, or hypoplasia of midline neck structures are known to be associated [1,2]. In this case, there are three typical characteristics of CMCC without any other anomalies. The characteristic pathologic findings are reported as parakeratosis in the skin, the absence of skin appendages, the presence of striated muscle tissues under the skin, and the presence of respiratory epithelium or seromucinous glands [2,3,4]. In this case, the abovementioned histologic findings were conspicuous, but skin adnexal tissues were absent or very focally dispersed. In the previously reported articles, complete excision of the cleft including the subcutaneous band and skin closure with Z-plasty (single or multiple) have been performed to prevent cicatricial neck contracture and the resulting limitation of neck motion [1,2,3]. In this report, in addition to the above treatment, we performed platysma flap with Z-plasty to prevent midline platysma banding and continuation of scar adhesion. This is expected to produce a functionally and aesthetically better prognosis [5].

Aesthetic nasal augmentation has increased in popularity among Asian populations, and nasal bone fracture is the most common type of facial bone fracture. In Asia, the frequency of nasal bone fractures is also increasing among patients who have undergone silicone augmentation rhinoplasty. The increasing prevalence of this injury presents a challenge to the surgeon. Thirty-six patients who had previously undergone augmentation rhinoplasty with silicone implant presented with nasal bone fracture from June 2007 through December 2011. The patients were grouped into three categories: patients with fractures in the high level (type I), patients with fractures in the low level (type II), and patients with fractures throughout the entire nasal bone, from base to top (type III). The largest group comprised patients with type I fractures (n = 24, 67%), followed by type II (n = 4, 11%), and Type III (n = 8, 22%) fractures. Symptoms and surgical outcomes for nasal bone fractures may be different in patients with silicone implants. A novel classification system for nasal bone fractures is required, as is a new approach to diagnosis and treatment.

Purpose Transvenous embolization has become the treatment of choice for carotid cavernous sinus fistula (CCSF). We report a case of coil embolization of CCSF using a superior ophthalmic vein (SOV) approach. Methods We have used the SOV approach on 5 patients with dural arteriovenous fistulas involving the cavernous sinus. Diagnostic facial contrast-enhanced computed tomography, brain magnetic resonance imaging, and contrast angiography and cerebral angiography revealed a CCSF. Fistula occlusion using an external SOV approach of CCSF was performed. Results Angiography performed on both sides demonstrated complete occlusion of the fistula. We had good result with coil embolization via SOV approach. We have a 100% success rate with no major complication. Conclusions The coil embolization via SOV approach is a safe and effective treatment. The SOV can be channeled by allowing the insertion of detachable coils in the fistula. We suggest that there is need to training plastic surgeon to be experienced.

PURPOSE Facial asymmetry can be produced by congenital or acquired factors, and surgical correction is one of the very important and difficult fields in plastic surgery. Zygoma plays a key role to keep facial symmetry, and diverse methods have been tried to correct asymmetric face. We used the malarplasty with tripod osteotomy to correct nontraumatic asymmetric face. METHOD From December 2008 to February 2010, 3 patients presenting with facial asymmetry and enophthalmia were selected, and their average age was 18 years. One of the patients has undergone surgeries 4 times without improvement for rare facial cleft no. 4 from other hospitals. The other 2 cases had hypoplastic zygoma complex caused by early enucleation and radiation therapies because of retinoblastoma in their childhood. Through a bicoronal approach, malarplasty and calvarial bone graft were done after tripod osteotomy including the zygomaticofrontal suture, zygomatic arch, and zygoma body. RESULTS The surgery results were evaluated by radiographic inspection and the photographs of the patients. Differences in preoperative heights of both normal and hypoplastic zygoma-orbit complex in Waters and zygomatic view were estimated. After corrective operation, the height of the zygoma complex was almost close to normal height, and orbital volume was increased, and ectropion was corrected at the same time in patients. CONCLUSIONS Using corrective malarplasty with tripod osteotomy, we achieved satisfactory results of zygoma expansion and improvement in orbital area. Therefore, malarplasty via tripod osteotomy cannot be applied only on the patients with traumatic zygoma deformation, but also on the patients with nontraumatic facial asymmetry.

The authors performed aesthetic correction of hypertrophic frontal sinus in 3 patients with protruded supraorbital region by using beveled osteotomy. Under general anesthesia, a bicoronal incision was performed followed by dissection through the subgaleal plane to the supraorbital ridge. Subsequently, the anterior wall of the frontal sinus was sectioned with a reciprocating saw and an osteotome by using the beveled osteotomy technique. Beveled osteotomy is a technique applied during sectioning of the anterior wall of the frontal sinus whereby the upper portion of the sinus remains intact and the lower portion of the sinus is changed. The technique used by the authors differed from the conventional method in that the existing shape of the outer wall of the frontal sinus was preserved when osteotomy was performed. This technique therefore preserves a more natural contour of the forehead and is advantageous in that it does not require additional interventions.

Copyright © 2012 The Korean Cleft Palate-Craniofacial Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.kcpca.or.kr ISSN 2287-1152 57 청소년기에 발견된 상구순 누공의 치험례

143 Copyright © 2012 The Korean Cleft Palate-Craniofacial Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-acfs.org pISSN 2287-1152 eISSN 2287-5603 변형된 정중옆 이마피판을 이용한 코끝 재건례