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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.

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.

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.

Background We conducted this study to identify the correlation between the time to surgery and that to recovery from postoperative diplopia. Methods In the current single-center, retrospective study, we enrolled a total of 11 patients (n=11) who were diagnosed with white-eyed blowout fracture and underwent surgical operation at our institution between January 2009 and January 2013. To identify the correlation between the time to surgery and that to recovery from postoperative diplopia, we divided our patients into the three groups: the group A (time to surgery, Results In our series, mean age at the onset of trauma was nine years (range, 5-16 years); the mean time to surgery was 30 days (range, 2-60 days); and the mean follow-up period was one year (range, 6 months-2 years). Our results showed that the time to recovery was shorter in the patients with a shorter time to surgery. Conclusions We found that the degree of recovery from impaired ocular motility and diplopia was the highest in the patients undergoing surgical operations within 48 hours of the onset of trauma with the reconstruction of the fracture sites using implant materials.

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 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.

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].

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