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Background Benign tumors of the forehead are highly prevalent and can cause facial asymmetry, discomfort, and psychological issues for patients. Generally, excision is performed via an incision directly over the mass, which can produce suboptimal cosmetic outcomes. Many methods involving remote incisions have been developed to conceal scars at the hairline. This study compared patient satisfaction after remote and direct incisional approaches. Methods We retrospectively enrolled 122 patients who underwent forehead mass excision at our clinic between January 2010 and May 2019 and compared the remote and direct removal of benign forehead lesions. Data on demographics, tumor size, operative time, imaging method, the incidence of complications, and pathological results were collected. Patient satisfaction was assessed via a telephone survey. The complications monitored included hypoesthesia due to nerve injury, wound dehiscence or necrosis, hematoma or seroma, and recurrence. Results A total of 79 patients underwent direct-approach mass excision, and 43 underwent excision with a remote approach. Lipoma was the most common tumor (70 patients), followed by osteoma (26 patients). Statistical analyses with the Mann-Whitney and Fisher exact tests revealed significantly higher satisfaction among the remote-approach group than among the direct-approach group (P

Perioperative peroneal neuropathy is an uncommon complication following surgeries performed with patients positioned supine. It may be caused by various factors aside from intraoperative compression. The authors report a case of common peroneal nerve palsy in a patient who underwent total thyroidectomy with central and bilateral selective neck dissection. The patient’s body mass index was 31.3 kg/m2. She was positioned supine and the operative time was 7-h. During surgery, her mean arterial pressure intermittently dropped to 50-60 mmHg for 55 min and 61-70 mmHg for 195 min. She developed common peroneal nerve palsy on postoperative day 1. Nevertheless, the patient fully recovered without any complications within 3 weeks.

Background The scalp is an important functional and aesthetic structure that protects the cranial bone. Due to its inelastic characteristics, soft-tissue defects of the scalp make reconstruction surgery difficult. This study aims to provide an improved scalp reconstruction decision making algorithm for surgeons. Methods This study examined patients who underwent scalp reconstruction within the last 10 years. The study evaluated several factors that surgeons use to select a given reconstruction method such as etiology, defect location, size, depth, and complications. An algorithmic approach was then suggested based on an analysis of these factors. Results Ninety-four patients were selected in total and 98 cases, including revision surgery, were performed for scalp reconstruction. Scalp reconstruction was performed by primary closure (36.73%), skin graft (27.55%), local flap (17.34%), pedicled regional flap (15.30%), and free flap (3.06%). The ratio of primary closure to more complex procedure on loose scalps (51.11%) was significantly higher than on tight scalps (24.52%) (p= 0.011). The choice of scalp reconstruction method was affected significantly by the defect size (R = 0.479, p< 0.001) and depth (p< 0.001). There were five major complications which were three cases of flap necrosis and two cases of skin necrosis. Hematoma was the most common of the 29 minor complications reported, followed by skin necrosis. Conclusion There are multiple factors affecting the choice of scalp reconstruction method. We suggest an algorithm based on 10 years of experience that will help surgeons establish successful surgical management for their patients.

Background Rosenthal et al. classified female, habitual, non-suicidal wrist cutters as a group and introduced the concept of wrist-cutting syndrome. We investigated the characteristics of wrist-cutting patients at our institution in comparison with results reported previously. Methods We conducted a retrospective study involving 115 patients who had cut their wrists and been examined at the emergency department of a single hospital in Seoul, Korea, between March 2014 and August 2018. Results There were more women (73 patients; 63.5%) than men (42 patients; 36.5%), and the women (mean age, 34.42 years) were significantly younger than the men (mean age, 50.07 years). The patients who had cut their wrists repeatedly were mainly women (22 of 26 patients; 84.6%); however, men caused more severe damage than women. Substance use before a suicide attempt did not significantly increase the severity of wrist cutting. Our institution planned and implemented a suicide prevention intervention program to improve the continuity of outpatient care. The number of patients who continued psychiatric treatment increased significantly after program completion. Conclusions We confirmed that most patients were young women who were not suicidal in the true sense because their wounds were not severe. Our study showed a protective role of the barrier tendons (flexor carpi radialis, palmaris longus, flexor carpi ulnaris), and we suggest careful repair of the barrier tendons to protect neurovascular structures against subsequent cutting events. We found that it was possible to improve the continuity of patient counseling by managing patients through a psychiatric treatment program.

Authors tried to investigate the maxillomandibular morphology of Korean nationality with computerized tomography images and establish a series of cephalometric values which should be considered in orthognathic plastic surgery in Korea.The computerized tomography images of 200 patients were retrospectively reviewed with the computer workstation in Sanggye Paik Hospital, Inje University College of Medicine from 2016 to 2017.The mean distance between nasion to point A (NA) line and the maxillary central incisor was 5.07 cm. The mean distance from nasion to point B (NB) line to the mandibular central incisor was 7.11 cm. The mean angle between NA line and the long axis of the maxillary central incisor was 20.58 degree. The mean angle between NB line and the long axis of the mandibular central incisor was 26.47 degree. The mean angle between SN (sella to nasion) line and NA line was 83.18 degree. The mean angle between SN line and NB line was 78.83 degree. The mean angle between NA line and NB line was 4.35 degree. There were no any statistically significant differences between age groups. But there were statistically significant difference in the mean of angle between NB line and the long axis of the mandibular central incisor (P = 0.025, between sex groups) and in the mean of angle between NA line and the long axis of the maxillary central incisor between sex groups in the 51 to 60 age group (P = 0.045).The maxillomandibular profile of Korean adults was established which can be applied for orthognathic surgery of Korean patients.

Background Lipomas are common benign soft tissue tumors composed of mature white adipocytes, with histological features including a well-circumscribed and lobular mass covered with a thin fibrous capsule. However, lipomas that are poorly demarcated from the surrounding fat are often encountered during surgery despite a postoperative histological diagnosis. We investigated the complications associated with different types of lipomas. Methods This retrospective study included 119 patients who underwent lipoma excision and computed tomography (CT) imaging at our clinic between January 2011 and August 2018. We classified the lipomas as encapsulated or nonencapsulated according to the histology, CT findings, and clinical criteria. Nonencapsulated lipomas were defined as relatively heterogeneous without a distinct capsule, whereas encapsulated lipomas were homogeneous with a distinct capsule. The analyzed complications included delayed wound healing, which can cause prominent scarring, hematoma or seroma, and recurrence. Results Encapsulated and nonencapsulated lipomas were diagnosed in 89 (74.8%) and 30 (25.2%) patients, respectively. Encapsulated lipomas occurred most commonly on the head, whereas nonencapsulated lipomas occurred most commonly on the neck and trunk (P=0.000, P=0.002, and P=0.031, respectively). The Fisher exact test showed a significantly higher incidence of delayed wound healing for nonencapsulated than encapsulated lipomas (P=0.014). Conclusions Preoperative classification of lipomas using CT imaging is important for predicting the incidence of postoperative complications. Direct excision is adequate for removing encapsulated lipomas. However, nonencapsulated lipomas might require alternative methods, such as ultrasonic liposuction, to prevent postoperative complications. Our results will help reduce the incidence of scarring by providing guidance on surgical methods.

Trauma to the auricle is common given its prominent position, and various methods for ear reconstruction exist. Herein, we present our experience of ear reconstruction using diced autogenous cartilage. A 72-year-old woman fell from a 1-m height, damaging her ear in the process. The ear helix, which was approximately 3.5×3 cm2 in size, was amputated. The cartilage was diced into 1-mm pieces. The detached skin was made into a pocket and filled with the diced cartilage. Molding was performed with tie-over dressings on the anterior and posterior areas of the scaphoid fossa. Ten days post-surgery, the wound showed signs of successful recovery, and the contour of the ear helix was maintained. Ten months later, the cartilage in the damaged ear helix was intact. Conventional composite grafts on amputated ears have size limitations and exhibit significant resorption, and loss of anatomical structures and stability often occur. In this case, the operating time required to complete the composite graft was short, and molding the contour was not complex. The original ear structure was maintained over the long term and did not require an additional operation for aesthetic purposes. We believe that this is a useful method for the reconstruction of an amputated ear.

Background Blowout fracture is one of the most common facial fractures, and patients usually present with accompanying ocular complications. Many studies have looked into the frequency of persistent ocular symptoms, but there is no study on assault patients and related ocular symptoms. We evaluated the incidence of residual ocular symptoms in blow-out fractures between assaulted and non-assaulted patients, and sought to identify any connection among the degree of enophthalmos, defect size, and assault-related injury. Methods A retrospective review was performed for any patient who sustained a unilateral blowout fracture between January 2010 to December 2014. The collected data included information such as age, gender, etiology, and clinical ocular symptoms as examined by an ophthalmologist. This data was analyzed between patients who were injured through physical altercation and patients who were injured through other means. Results The review identified a total of 182 patients. Out of these, 74 patients (40.7%) have been struck by a fist, whereas 108 patients (59.3%) have sustained non-assault related injuries. The average age was 36.1 years, and there was a male predominance in both groups (70 patients [94.6%] in the assaulted group and 87 patients [80.6%] in the non-assault group). Diplopia and enophthalmos were more frequent in patients with assault history than in non-assaulted patients (p

Background The authors sought to compare the use of the nonabsorbable polyvinyl alcohol sponge (PVA, Merocel) and absorbable synthetic polyurethane foam (SPF, Nasopore Forte plus) as intranasal splints after closed reduction of fractured nasal bones during the hospitalization period. Methods The medical records of 111 patients who underwent closed reduction for nasal bone fracture at Sanggye Paik Hospital, Inje University College of Medicine, from 2012 to 2013 were reviewed retrospectively. PVA (group A) or SPF (group B) was packed as an internal splint after closed reduction. The efficacy of the materials was compared and statistically analyzed. Results PVA was used in 82 patients, and SPF was used in 29 patients. The patients in group B complained significantly more of nasal pain on the first day after operation than the patients in group A. Headaches on the operation day were significantly more painful in group B than in group A. Bleeding on the fourth postoperative day was significantly reduced in group B as compared to group A. The patients in group B exhibited significantly more intensive nasal obstruction on the operation day and the following day than the patients in group A. However, on the third and fourth postoperative days, the nasal obstruction in group B was less than that in group A. The pain and bleeding related to the packing material was significantly reduced in group B as compared to group A. Conclusions The use of SPF as an absorbable packing material is a reasonable substitute for the traditional nonabsorbable material.

Meningiomas are a diverse set of tumors arising from the meninges, which are the membranous layers surrounding the central nervous system. Most meningiomas grow inward toward the brain as discrete, well-defined, dural-based masses and are spherical or lobulated. The borders between the tumor and the brain are usually smooth and clear because they preserve the histologic structures, such as the tumor capsule, cerebrospinal fluid, arachnoid mater, and pia mater [1]. Considering such a growth pattern, we report a rare case of transitional meningioma misdiagnosed as a soft tissue tumor. A 60-year-old female patient presented with a hard and fixed mass that grew spontaneously on her forehead within one year (Fig. 1). There was no history of trauma or exposure to carcinogens, and she was otherwise fit and well. Computed tomography (CT) showed frontal cortical thickening and swelling suggestive of a type of soft tissue tumor. To determine the character of the tumor-like mass, excision was performed (Fig. 2). The pathologist confirmed the mass as a transitional meningioma. Magnetic resonance imaging (MRI) which was taken after primary excision revealed an intracranial mass that was 3.0 cm in size, ovoid and well enhanced (Fig. 3). Wide-excision osteoplastic craniotomy via a bicoronal approach was performed under navigation guidance by neurosurgeon. Fig. 1 Preoperative photograph showing a lesion on the right forehead. Fig. 2 Gross appearance of the specimen. Fig. 3 Brain magnetic resonance imaging (T1) showing a soft tissue mass 3.0 cm in size, ovoid and well enhanced under the skull. The mass shows a dural tail sign. Transitional meningiomas are also called as mixed meningiomas, and these tumors have transitional between those of meningothelial and fibrous meningioma and they are common tumors with meningothelial, fibrous, psammomatous, and angioblastic meningiomas. 90% of meningiomas are consisting of those five types of meningiomas. The brain mass was also established as a meningothelial-type meningioma, 2.5×2.3 cm in size. Histologically, the tumor was lobulated by intersecting collagenous fibers. Immunohistochemical staining was positive for vimentin and epithelial membrane antigen and negative for pancytokeratin. There was no recurrence of meningioma during the 6-year follow-up period. Meningiomas are estimated to constitute between 13% and 26% of primary intracranial tumors, with an annual incidence rate of approximately 6 per 100,000 population. They are the most frequently diagnosed primary brain tumor, accounting for 33.8% of all primary brain and central nervous system tumors reported in the United States between 2002 and 2006 [2]. The exact causes of most of these tumors are not known. They result from abnormal patterns of growth that are most likely due to defects in the genetic material. The exact type of genetic defect or mutation has not been conclusively identified in meningiomas. Despite the lack of definitive evidence that clearly isolates possible causes, it has been suggested that meningiomas are associated with traumatic head injury, prolonged inflammation of the meninges following injury, viral infections, radiation, certain genes, Neurofibromatosis type 2, and hormones, particularly sex hormones, including estrogen, progesterone and androgens. Excessive use of cellular phones has also been implicated as a possible cause, but the evidence to conclusively link cell phone use to meningioma development is lacking [2]. The majority of meningiomas are benign, and they are seldom invasive. Wang et al. [1] studied 7,084 cases of meningiomas and examined the female: male ratio, patient age, subtypes, and locations. The female: male ratio of all types of meningioma is 2.34, while that of transitional meningioma is 2.11. The mean age of among all cases of meningioma is 51.45 years, and that of transitional meningioma is 50.54 years; the age of the patient in this case was 60 years. In their study, there were 323 cases of transitional meningioma among 7,084 cases, accounting for 4.56% of all meningiomas. There were 3 cases of extracranial meningioma among 7,084 cases, accounting for 0.04% of the total. Extracranial extension of meningiomas is very rare, and only a few cases have been reported [1]. Panchmatia et al. [3] reported an asymptomatic forehead lump that was initially diagnosed as an osteoid osteoma. CT was suggestive of an exostosis and an enostosis associated with frontal skull thickening. The mass was excised, and its histological features were consistent with intraosseous meningioma [4]. Nadarajan et al. [4] reported a similar case of unusual meningioma. An 82-year-old man was had a large deformity over the frontal area of his scalp. CT and MRI revealed an intracranial mass that extended across the frontal lobes. The mass permeated the skull and extended through the scalp. The histologic finding of the mass suggested a benign meningioma with low mitotic activity [3]. In cases of a protruding mass on the head, clinicians tend to diagnose the tumor as osteoma or lipoma because of their high prevalence. In this case, the manifestation of the mass was more similar to another soft tissue tumor rather than extracranial meningioma. Following excision, pathology and other radiologic studies such as MRI and ultrasonography indicated that the tumor was a meningioma instead of a soft tissue tumor. The high-power view reveals many whorling epithelioid cells and admixed spindle cells (Fig. 4A). Immunohistochemical staining for epithelial membrane antigen (EMA) disclosed diffuse positivity, which was strongly supportive of meningothelial differentiation. The tumor cells were composed of oval cells with occasional intranuclear inclusion bodies (Fig. 4B). To diagnose meningioma, initial investigations should include contrast-enhanced CT and MRI. In addition, angiography is a valuable tool that allows the surgeon to elucidate the relationship of the tumor with nearby vascular structures and to determine the vascularity of the tumor [3]. Fig. 4 (A) The high-power view reveals many whorling epithelioid cells (red arrow) and admixed spindle cells. The tumor cells are composed of oval cells with occasional intranuclear inclusion bodies (blue arrow) (H&E, ×400). (B) Immunohistochemical ... The meningioma in the present case was misdiagnosed as a soft tissue tumor because of its gross manifestation, and MRI study and punch biopsy were excluded. Unfortunately, nonenhanced brain CT cannot present characteristic feature of meningioma and gives little information to diagnose. The mechanism of extracranial extension was not yet established, but there are two possible theories. One is the proliferation of perineural cells or ectopic arachnoid tissue along the cranial nerve, and the other is misplaced embryonic rests of arachnoid cells and multipotent mesenchymal cells [5]. In conclusion, even if a mass on the forehead has an obvious clinical manifestation, thorough imaging studies are required and suspicions about rare tumors should be addressed before surgery.

Background Pathogens in the nasal cavity during nasal surgery could lead to a systemic infectious condition, such as bacteremia, nosocomial infection, or toxic shock syndrome. However, there is no research about the prevalence of nasal carriage in patients with nasal bone fracture. Methods This was a prospective, double-blind, randomized study about the rate of nasal carriage in 200 patients with nasal bone fracture in Korea. Nasal secretions were taken from both the middle nasal meatus and colonized. All analyses were carried out using SPSS software. Results Pathogens were identified in 178 of the 200 cases. Coagulase-negative staphylococci (CNS) were the most cultured bacteria in 127 (66.84%) of the 190 total patients after excluding 10 cases of contaminated samples, and methicillin-resistant coagulase-negative staphylococci (MRCNS) were found in 48 (25.26%). Staphylococcus aureus was the second most identified pathogen, found in 36 (18.95%), followed by 7 cases (3.68%) of methicillin-resistant Staphylococcus aureus (MRSA). The prevalence rate of MRSA in the females was higher than that in the males (RR=4.70; 95% CI, 1.09-20.18), but other demographic factors had no effect on the prevalence rate of MRSA and MRCNS. Conclusions The prevalence rate of these pathogens in patients with nasal bone fracture in Korea was similar to other reports. However, few studies have addressed the prevalence rate of CNS and MRCNS in accordance with risk factors or the change in prevalence according to specific prophylaxis against infectious complications. Additional research is needed on the potential connections between clinical factors and microbiological data.

The simultaneous reconstruction of a skin defect and lost extensor mechanism of the knee joint is difficult. We present a 31-year-old male who lost the patella and had a 9 × 10 cm skin defect after a total patellectomy for an infected open patellar fracture. A composite anterolateral thigh (ALT) flap including vascularized skin and fascia lata (FL) was elevated. The FL was folded and sutured to the remaining patellar tendon. The skin flap covered the skin defect. The wound healed uneventfully. Thirty months later, the active range of motion of the knee joint was 0°-120° and the extension strength of the knee joint was normal. He could stand on his right leg and walk without assistance. The composite ALT flap is a valuable option in knee reconstruction after a total patellectomy.

Background The most common cutaneous malignant masses are basal cell carcinoma (BCC) and squamous cell carcinoma. The predominant site of a malignant mass is the face, which has many opportunities to be exposed to ultraviolet radiation. However the predilection sites of malignant masses have been equivocal due to the use of general regions, rather than anatomical landmarks, in surveys. A facial esthetic unit is an anatomical site classified as an area of similar facial contour characteristics that can be distinguished from other areas. The purpose of this study is to determine widely accepted anatomical landmarks using the esthetic unit. Methods We retrospectively analyzed 118 cases of malignant masses in our clinic from January 2005 to October 2012. We evaluated the patients' age, gender, and predilection site of the malignant mass by esthetic unit through pathology, medical records and patient photographs. We mapped the occurrence site of the malignant mass on schematic drawings of the esthetic units. Results Most of the malignant masses were BCC. The ratio of males to females was 1:1.41. The frequent predilection site of a malignant mass was on the nasal unit (33.1%), followed by the buccal unit (11.0%). Primary closure was the most common method of repairing a surgical defect (38.9%), followed by a local flap (35.5%). Conclusions This review described the relationship between clinical characteristics and esthetic units by proposing objective predilection sites for malignant masses, which can be used commonly as a framework in the study of malignant masses by unifying equivocal occurrence sites.

Background Isolated pure blowout fractures are clinically important because they are the main cause of serious complications such as diplopia and limitation of extraocular movement. Many reports have described the incidence of blowout fractures associated with diplopia and limitation of extraocular movement; however, no studies have statistically analyzed this relationship. The purpose of this study was to demonstrate the correlation between the location of isolated pure blowout fractures and orbital symptoms such as diplopia and limitation of extraocular movement. Methods We enrolled a total of 354 patients who had been diagnosed with isolated pure blowout fractures, based on computed tomography, from June 2008 to November 2011. Medical records were reviewed, and the prevalence of extraocular movement limitations and diplopia were determined. Results There were 14 patients with extraocular movement limitation and 58 patients complained of diplopia. Extraocular movement limitation was associated with the following findings, in decreasing order of frequency: floor fracture (7.1%), extended fracture (3.6%), and medial wall (1.7%). However, there was no significant difference among the types of fractures (P=0.60). Diplopia was more commonly associated with floor fractures (21.4%) and extended type fractures (23.6%) than medial wall fractures (10.4%). The difference was statistically significant (Bonferroni-corrected chi-squared test P Conclusions Data indicate that extended type fractures and orbital floor fractures tend to cause diplopia more commonly than medial wall fractures. However, extraocular movement limitation was not found to be dependent on the location of the orbital wall fracture.

Extraskeletal Ewing's sarcoma (EES) is a rare round cell malignant neoplasm with rapid growth and an uncharacterized mesenchymal cell origin, and it is histologically similar to Ewing's sarcoma (ES) arising from bone [1]. EES was first described as a paravertebral 'round cell' tumor morphologically resembling ES of bone by in 1969 [1,2]. In 1975, a review of 39 patients was reported about malignant soft tissue tumors not arising from bone but with histomorphologic characteristics similar to primary osseous ES [1,2]. The sites of involvement varied, yet there appeared to be a tendency to involve the paravertebral region, intercostal area, lower extremities and pelvis [1]. EES rarely occurs in the head and neck region, with only five cases reported in a series of 118 patients in the four largest series in the English literature [1,3]. Furthermore, another report indicated that only 5% to 11% of EES cases occur in the head and neck region, and the nose, eyelid, nasopharynx, parotid gland, scalp, and parapharyngeal space have been described [3,4]. However, we encountered EES on the forehead. To the best of our knowledge, there have been no reports regarding EES originating from the forehead. Two years ago, a 35-year-old male patient presented with a palpable and non-tender mass. The mass size was 2×2 cm, and there were no other problems. Excision was performed in a local clinic one year ago. After excision, he had no clinical symptoms. However, 3 months ago, a 1×1 cm mobile, protruding mass recurred on the patient's forehead (Figs. 1, ​,2).2). The patient visited our department for further evaluation and treatment. At the initial physical examination, lymph node enlargement in the neck, weight loss, tenderness and other clinical problems were not observed. Fig. 1 Preoperative photograph showing a non-tender mobile soft tissue (black arrow) mass on the forehead. Fig. 2 Photograph of the grayish brown excised mass, sized 1×1 cm. Radiologic evaluation demonstrated no invasion or any destruction of the frontal bone. X-ray examination showed a soft tissue mass with muscle tissue invasion that was without calcification or onion skin-like radiation characteristics, which are specific to osseous ES (Fig. 3). Fig. 3 Radiologic evaluation of a skull lateral X-ray showing no abnormal calcification or bony erosion. Under local anesthesia, excisional biopsy was performed. An approximately 1.0×1.0 cm tissue mass was excised. The pathologic report revealed monomorphic proliferation of small, blue, round cell tumors with scanty cytoplasm and the absence of rosette-like structures (Fig. 4). Immunohistochemical staining demonstrated that the tumor cells were positive for vimentin, CD99, CD56, and neuron-specific enolase (NSE) (Fig. 5) but negative for chromogranin, synaptophysin, myeloperoxidase, and common leukocyte antigen. Periodic acid-Schiff (PAS) staining was negative. Fig. 4 Histopathology showing monomorphic small, round, blue cells with scant cytoplasm and prominent nucleoli (H&E, ×400). Fig. 5 Immunohistochemical staining revealed weak but diffuse positivity for CD99 (×400). The tumor was finally diagnosed as EES by a pathologist. After surgical excision, the patient was required to follow-up for further evaluation. We therefore recommended additional studies, including facial computed tomography, bone scan, and magnetic resonance imaging, among others. We also recommended adjuvant chemo-radiotherapy in the oncology department to ensure the best outcome. However, the patient refused all studies and treatment. We tried to contact him with an effort, but lost contact to him because his phone number was changed. And he did not appear to our department. EES has non-specific characteristics regarding its symptoms and signs as well as a low incidence rate, and it typically has an aggressive course with a high incidence of recurrence. However, it has a high tendency to spread locally, infiltrating surrounding fascial planes and invading muscle and bone [3]. Distant metastasis is common, and most frequently occurs in the lung [4]. Therefore, an early definitive diagnosis is important. The rarity of EES and locations at uncommon sites may lead to a delay in clinical diagnosis and appropriate treatment and management. Therefore, when clinicians observe a soft tissue mass that grows rapidly within a few months, EES should be clinically suspected, with a comprehensive work-up such as radiologic and pathologic examinations necessary to confirm the diagnosis. Before the development of appropriate medical treatment, the prognosis of EES was poor. In a study, the 1-year survival rate was only 40% [1]. Therefore, various therapeutic treatment plans have been developed. In a recent study, the two-year survival rate was 65%, although 88% of the patients were treated with chemo-radiotherapy [1]. Furthermore, another report described an 82% 2-year survival rate [1]. If radical excision with adjuvant chemo-radiotherapy is received, the survival rate of EES can be increased dramatically. Although clinical and radiographic evaluations are important in the early diagnosis of EES, the definitive identification is made in conjunction with pathologic findings [2]. Therefore, the diagnosis of EES is typically made after excision. In our case, the patient refused all recommendations. Therefore, patients must be informed about further evaluation and further surgery or chemo-radiotherapy to ensure better compliance if the mass has a possibility of being EES. In our case, the pathologic report revealed monomorphic proliferation of small round cell tumors and the absence of rosette-like structures. The differential diagnosis includes small round cell tumors such as rhabdomyosarcoma, neuroblastoma, primitive peripheral neuroectodermal tumor (PNET), Merkel cell carcinoma and lymphoma [1,3,5]. Antibody staining for CD99 helps to confirm the diagnosis. PNET shows neuroectodermal differentiation, with rosette formation and positive immunohistochemical staining in the nucleus for NSE, neurofilament and synaptophysin. In our case, even NSE was positive following immunohistochemical staining, but there was no evidence of neuroectodermal differentiation. Moreover, PAS is typically positive in EES, but PAS was negative in our case [5]. Despite the histomorphologic difficulties in differentiating this tumor from other soft tissue malignancies, EES must be diagnosed earlier to allow initiation of a treatment plan to increase the survival rate. In conclusion, EES is a rare soft tissue sarcoma and has an aggressive course with a high incidence of recurrence. However, EES/PNET is sensitive to multimodal treatment. Early awareness and treatment of this rare disease and wide resection, followed by chemo-radiotherapy, might improve long-term patient survival. In our case, we could not treat the patient to this end. Therefore, before the operation, patients should be informed about further treatment and management for EES. Additionally, special consideration must be given to rapidly growing soft tissue masses that present with or without tenderness.

Background The purpose of this study was to identify the epidemiologic characteristics of hand tendon injuries in children and to compare these with those of adults. Methods This retrospective study was conducted on acute traumatic tendon injuries of the hand treated at our institution from 2005 to 2013, based on medical records and X-ray findings. Age, sex, hand injured, mechanism of injury, tendons and zones injured, number of affected digits, and comorbidities and complications were analyzed. Patients were divided into 2 groups: a pediatric group (≤15 years) and an adult group (>15 years). Results Over the 9-year study period, 533 patients were surgically treated for acute traumatic tendon injuries of the hand. In the pediatric group (n=76), being male, the right hand, the extensor tendon, complete rupture, the middle finger, and glass injury predominated in hand tendon injuries. In the adult group (n=457), results were similar, but injury to the index finger and knife injury were the most common. An accompanying fracture was more common in the adult group and complication rates were non-significantly different. Conclusions This comparative analysis revealed no significant epidemiologic intergroup differences. The belief that pediatric tendon injuries tend to be less severe is misplaced, and careful physical examination and exploration should be conducted in pediatric cases of hand injury.

Eccrine porocarcinoma (EPC) is a cutaneous malignancy that arises from the intraepidermal portion of the eccrine sweat duct (acrosyringium). The eccrine sweat gland is a major sweat gland that is found in virtually all skin. EPC accounts for 0.005% to 0.01% of all cutaneous tumors. It predominantly occurs in elderly people who are more than 60 years old and has a female predominance [1]. As far as we know, only five cases of this medical condition have occurred on the abdomen since Pinkus and Mehregan first described EPS in 1963 [1,2]. Here, we report an unusual case of a 65-year-old female patient with EPC that developed primarily on the abdomen. In 1992, a 65-year-old female patient presented with a palpable and non-tender mass. No ulceration or any discomfort was noted with respect to the lesion. The mass size was 1 cm×1 cm at the beginning, but the size changed periodically, and the lesion had an oozing serous discharge. There were no other problems. Twenty years later, in July 2012, the mass had undergone rapid enlargement, and the lesion had bloody discharge (Fig. 1). Fig. 1 A preoperative photograph shows a brownish maculopapule on the abdomen, and a palpable mass was present. The patient visited the general surgery department of our hospital. For biopsy, curettage was performed, and a grayish-brown soft tissue was obtained from the skin lesion. The tissue was diagnosed as squamous cell carcinoma. Immunohistochemical staining indicated that the tissue was positive for p63. The patient was referred to our department for appropriate therapy. Because of the metastatic potential of squamous cell carcinoma, prior to the operation, we performed a physical examination and positron emission tomography-computed tomography (PET-CT) to search for metastasis. No adjacent palpable lymph node was found in the physical examination. PET-CT indicated a hypermetabolic abnormality on the right lower abdomen (Fig. 2), and there was no evidence of metastasis. The laboratory workup and systemic examination for this patient yielded normal results. Fig. 2 A hypermetabolic abnormality was observed on the right lower abdomen in positron emission tomography-computed tomography (white arrow). Under general anesthesia, wide excision and frozen biopsy were performed. An approximately 6 cm×3 cm tissue mass was excised, applying at least a 10-mm clear margin. A 1.8-cm well-defined nodule was found within the tissue. Broad tumor free margins were confirmed, and the tumor was diagnosed as EPC by a pathologist. Therapeutic lymphadenectomy was not performed because there was no metastasis according to the PET-CT results. We performed primary repair to reconstruct the soft tissue defect. The biopsy histology indicated irregularly proliferating elongated nests composed of small, round basaloid cells and epithelium (Fig. 3), and the tumor nests contained central duct formation (Fig. 4). Immunohistochemical staining was positive for the epithelial membrane antigen (EMA) (Fig. 5), and negative for the carcinoembryonic antigen (CEA); these findings were consistent with a diagnosis of eccrine porocarcinoma [2]. Fig. 3 The right-side epithelium shows irregularly proliferating elongated nests composed of small, round basaloid cells (black arrow heads). The left-side epithelium reveals a complex structure of keratinizing squamous epithelium (black arrows) (H&E, ... Fig. 4 Some tumor nests display central duct formation (H&E, ×100). Fig. 5 An immunoperoxidase stain is positive for epithelial membrane antigen, suggesting eccrine differentiation. The patient was followed up at our department because of the high recurrence of EPC. At 7 months after the operation, there was no evidence of recurrence or metastasis. EPC has a propensity to form on the lower limbs (44%), trunk (24%), head (18%), upper limbs (11%), and neck (3%) [2]. Morphologically, the tumors vary greatly in size, from less than 1 to 10 cm [3]. A long period of clinical features is historically noted (up to 50 years) because some of these tumors can arise from a benign eccrine poroma.Local and regional lymph node metastasis are observed in approximately 20% of patients, and distant metastasis, for example, visceral and bone metastasis, arise in approximately 10% of the patients [3]. Following metastasis, the prognosis is poor, with a reported mortality rate of up to 80% [1]. Because EPC has a high metastatic potential and mortality rate, early definitive diagnosis is necessary, followed by appropriate treatment. The tumor may appear nodular, infiltrative, ulcerated, or polypoid, and these characteristics tend to indicate a malignant tumor. Multinodularity, ulceration, and rapid growth may be associated with either local recurrence or metastasis [3]. Thus, when these characteristics are observed, we need to consider the possibility of a malignant change. Because of the rarity and nonspecific appearance of EPC, a tentative clinical diagnosis will never be accurate and the condition might be misdiagnosed as squamous cell carcinoma, basal cell carcinoma, seborrheic keratosis, or metastatic adenocarcinoma [3]. In particular, as in our case, a small biopsy specimen, such as a needle or punch biopsy, can be easily misdiagnosed. Even defined EPC may present some type of basal or squamous differentiation. The presence of ductal differentiation distinguishes EPC from squamous and sebaceous cell carcinoma. The ducts are usually visible in a microscopic evaluation and can be outlined with CEA and EMA immunohistochemical markers [4]. Further, most metastatic adenocarcinomas are positive for CEA and EMA stains. However, CEA is negative in most EPCs but can be positive in tumors containing well-formed ducts [2]. To achieve a definitive diagnosis, a well-handled specimen and expert pathology and oncology departments are required. Histological findings that predict the worse prognosis are lymphovascular invasion, a mitotic index of more than 14 mitotic cells for every high power field, and a tumoral depth of more than 7 mm [2,4,5]. There is no standard therapeutic protocol for EPC. However, because of its high rate of local recurrence, wide excision with histologically clear margins is the treatment of choice. Appropriate surgical resection achieves curative outcomes in 70% to 80% of the cases, and there is 20% local recurrence and 20% distant metastasis [5]. Because of the high recurrence rate, close follow-up and a search for metastasis should be performed, and sometimes, adjuvant therapy could be performed. However, anecdotal reports show some benefits when utilizing radiation or chemotherapy [3]. EPC is curable if an accurate diagnosis is performed early and appropriate treatment is provided. EPC can be easily misdiagnosed because of a lack of particular characteristics; therefore, a careful approach is necessary. Because of its aggressive potential for metastasis and poor prognosis, a complete early definitive pathologic diagnosis of EPC should be performed along with regional lymph-node involvement assessment, such as a physical examination, and radiological tests. PET-CT can easily indicate whether metastasis is present. Thus, prior to any operation, a PET-CT scan should be performed, as it can assist in determining whether selective adjacent lymph node resection is required.

Nevus lipomatosus cutaneous superficialis (NLCS) is a relatively rare benign malformation characterized by ectopic deposition of mature adipose tissue in the collagen bundles of the dermis [1-4]. NLCS is classified into two subtypes: the multiple (classical) type and solitary type [1-3]. The multiple type usually appears within the first two decades of life, most commonly in the pelvic girdle region and consists of flesh-colored or yellow papules or nodules [3,4]. Also, its histopathological features are relatively uniform [3]. In contrast, the solitary type consists of a single nodular lesion without a favored location and it usually occurs in adults [3]. Surgical excision is a simple and adequate treatment for all lesions [2]. Recently, some authors have reported that CO2 laser is useful method of treatment for NLCS, especially in the multiple type [4]. We report here a case of multiple type NLCS on the right lower back, which recurred after CO2 laser treatment and was treated by staged surgical excisions. To the best of our knowledge, there have not been any cases of recurred NLCS after laser treatment in the literature. A 13-year-old girl presented with asymptomatic, yellow-orange papules on the right lower back measuring 14×5 cm and composed of three clusters (Fig. 1). According to her parents, the skin masses had appeared at age 5 and gradually increased in number and size as she grew. However, there was no evidence of any systemic disease and no symptoms due to her back mass. Her family history was unremarkable, with a lack of similar skin lesions. Three years earlier, the patient had been treated with CO2 laser at another clinic to avoid the inconvenience of removing her clothes. At that time, they had thought that the mass was treated well. However, a few months later, remarkably, the skin masses had recurred and increased in numbers and size very rapidly. On physical examination, there were multiple yellow-colored, non-tender, soft nodules coalescing into a plaque on her right lower back. Complete surgical excision was performed divided in three stages and covered with local advancement flaps (Fig. 2). Fig. 1 Clinical photograph of the case. A 14×4 cm nevus lipomatosus cutaneous superficialis lesion on the right flank. Initially, only the central cluster had been presented, but after CO2 laser treatment, Fig. 2 Photograph 6 months postoperatively. The lesion was completely excised and there were only wide scars remaining. Histopathologically, lobules of the mature adipocytes were located between the collagen fibers in the entire dermis. Fat lobules extending to the reticular dermis were located around the capillaries. All of these findings coincide with NLCS (Fig. 3). Fig. 3 Histopathologic findings of the case. Lobules of mature fat are diffusely scattered between collagen fibers in the dermis. Fat lobules extending to reticular dermis are located around the capillaries (H&E, ×200). NLCS is a rare idiopathic benign malformation characterized by ectopic adipose tissue in the dermis [1-3]. Generally, there are no clinical symptoms during its course, although sometimes NLCS can appear with some symptoms [2]. Now NLCS is classified into two subtypes [1-3]. The multiple type usually appears within the first two decades of life, but occasionally it can have a later onset [3]. There is no sex or genetic predilection [3]. Usually the multiple type consists of grouped, flesh-colored or yellow papules or nodules on the pelvic girdle region in a segmental pattern that coalesce to form plaques [1,3,5]. The plaque surfaces are smooth, but sometimes they have a verrucous or cerebriform appearance [4,5]. In our case, the skin lesion appeared from age 5 on the right lower back, and there were no clinical symptoms from the NLCS. It presented typical characteristics of multiple type NLCS. The pathogenesis is still unknown and several theories have been proposed [4]. One theory suggests that multiple type NCLS arises from adipose metaplasia in the course of degenerative changes in the dermal connective tissue [4]. Another theory is that the adipocytes represented a true nevus from the developmental displacement of adipose tissue [4]. A third proposal is that the mature adipocytes grow from mononuclear cells that were differentiating lipoblasts in a perivascular area [1]. The hitopathology of NLCS usually shows clusters of ectopic mature adipose tissues among the collagen bundles in the dermis, and there is no connection to the subcutaneous fat tissue [1,2]. These ectopic adipocytes contain large intracytoplasmic lipid vacuoles, often associated with vascular structures [1,4]. Many authors have reported that treatment is not necessary in most cases, other than for cosmesis [2]. However, clinicians should be aware that sometimes the masses can become a larger tumor if untreated [5]. Simple surgical excision is sufficient for treatment without recurrence in almost cases [2]. However, if surgical excision is not adequate, recurrence is possible. Recently, some authors have reported that CO2 laser treatment is effective for treating large lesions of multiple type NLCS without recurrence [4]. They argue that CO2 laser treatment is somewhat better than surgical excision. Because multiple type NLCS usually involves a large area, sometimes it requires a skin graft. These skin grafts could cause unsatisfying cosmetic results, but the study reported that patients treated with CO2 laser were pleased with the results [4]. The authors treated recurred multiple type NLCS after CO2 laser treatment with staged excisions and covered with local advancement flaps, but the patient was satisfied with the cosmetic results and there was no recurrence. Consequently, physicians should take note that insufficient treatment, including CO2 laser or any surgical excision, can cause recurrence, as in this case. We suggest that staged excision can be another treatment modality for large multiple type NLCS.

Subperiosteal orbital hematoma occurs rarely after blunt trauma. However, this is of importance, as this condition may cause ocular symptoms. The major characteristics of subperiosteal orbital hematomas are painful proptosis, downward displacement of the globe, absence of lid ecchymosis, chemosis without subconjunctival hemorrhage, and motility impairment. Visual impairment is known as a rarely presenting symptom. A 22-year-old male patient presented with right periorbital ecchymosis, swelling, and diplopia with upper lateral gaze limitation. Besides, the patient complained of lower visual field disturbance. Radiologic evaluation revealed traumatic subperiosteal orbital hematoma. The hematoma was evacuated through a lacerated wound on the right lateral eyebrow with additional incision. After the hematoma evacuation, the orbital symptoms are restored. Postoperative computed tomographic scans showed normally restored orbital space without any evidence of remnant hematoma or rebleeding. In case of subperiosteal hematoma, early detection and complete surgical evacuation is crucial for preventing possible complications and sequelae.

A 24-year-old man was assaulted and complained of vague discomfort with tenderness on the nose. Physical examination manifested pain over the nasolabial angle region aggravated by upper lip closure. Computed tomography with three-dimensional reconstruction of the facial bone revealed a fracture of the anterior nasal spine accompanying the overt displacement. The patient underwent open reduction and internal fixation. Clinical symptoms were completely resolved after the surgery. Regular diet was recommenced in 2 weeks without any complications. The purpose of this study was to emphasize the awareness of the clinical feature and the modality of treatment in case of anterior nasal spine fracture with displacement.

Background: Reduction of nasal bone fracture can be performed under general or local anesthesia. The aim of this study was to compare general anesthesia (GA) and monitored anesthetic care (MAC) with dexmedetomidine based on intraoperative vital signs, comfort of patients, surgeons and nurses and the adverse effects after closed reduction of nasal bone fractures. Methods: Sixty patients with American Society of Anesthesiologists physical status I or II were divided into a GA group (n = 30) or MAC group (n = 30). Standard monitorings were applied. In the GA group, general anesthesia was carried out with propofol-sevoflurane-N 2O. In the MAC group, dexmedetomidine and local anesthetics were administered for sedation and analgesia. Intraoperative vital signs, postoperative pain scores by visual analog scale and postoperative nausea and vomiting (PONV) were compared between the groups. Results: Intraoperatively, systolic blood pressures were significantly higher, and heart rates were lower in the MAC group compared to the GA group. There were no differences between the groups in the patient, nurse and surgeon’s satisfaction, postoperative pain scores and incidence of PONV. Conclusions: MAC with dexmedetomidine resulted in comparable satisfaction in the patients, nurses and surgeons compared to general anesthesia. The incidence of postoperative adverse effects and severity of postoperative pain were also similar between the two groups. Therefore, both anesthetic techniques can be used during the reduction of nasal bone fractures based on a patient’s preference and medical condition. (Korean J Anesthesiol 2013; 65: 209-214)