Purpose: Various factors such as blood velocity, turbulent flow,and intimal injury are the most basic elements in free tissue transfers. However, how blood flow is reestablished, maintained, and changed after vascular anastomosis has rarely been studied.Methods: A 54-year-old male sustained an unreplantable severe crushing injury to his right hand. The middle finger was transferred to the thumb as an ectopic replantation using an anastomosis between the radial and digital arteries. However, secondary reconstruction for the first web space defect was inevitable and an anteromedial thigh free flap procedure was performed 2 months later using the previously anastomosed vessels. During the procedures, we noted morphologic changes in the microvessels and tried to explain those phenomena by applying the principles of hemodynamics.Results: Due to the discrepancy in vascular size between the radial and digital arteries, the velocity of the blood flow in the post-anastomotic site, which was the digital artery, must have been increased by Poiseuille’s law. Supposing that the velocity through the post-anastomotic site of the digital artery was increased, the pressure exerted by that flow decreased, resulting in more shrinkage of the vessel lumen of the digital artery by Bernoulli’s principle. Pascal’s law could also be applied in confined spaces with a static flow; where there is a constant pressure, as the radius of the post-anastomotic digital artery diminishes, the tension within the digital artery’s wall also simultaneously decreases. By Laplace’s law, the post-anastomotic digital artery’s wall thickens as less tension is exerted on the wall.Conclusion: Understanding these simple flow mechanics will enable microsurgeons to better avoid the risk factors causing thrombosis, which is related to flap failure.
Low blood flow in the distal part of the diabetic foot aggravates the wound to an ischemic state, which eventually leads to amputation. However, major advancements in microvascular surgery have shown the ability to salvage the limb even in the presence of poor perfusion. Since a foot is constituted of a complex network of angiosomes, each separate territory of the foot is supplied by interconnected vessels. We report the successful salvage of a severe diabetic foot injury of a 72-year-old male patient with a heavily calcified dorsalis pedis artery (DPA). Although the proximal end of the DPA was clogged to prevent the flow of blood and was insufficient to use as a recipient vessel, reverse flow from the distal end was restored after removing multiple calcification fragments. As a result, a large soft-tissue defect on the third and fourth toe region was successfully covered by a contralateral anterolateral thigh free flap.
Hidradenitis suppurativa (HS) is a recurring and chronic inflammatory skin disease. Various medical and surgical treatments, with varying degrees of efficacy, have been applied based on the Hurley staging system. Since medical treatment cannot change the natural course of the disease and relapse is inevitable in the long-term, radical excision to reduce recurrences is considered as the only curative therapy option for patients with severe II and III stage HS. However, such methods may require intensive reconstructive surgeries and are often accompanied by intraoperative or postoperative problems, resulting in extended treatments. Several methods to detect the degree of the disease and define the resection area have been employed; coloring agents have also been recommended as an option. In this case, we focused on the use of a coloring dye to determine the precise resection margin for a patient with severe HS, as there have been no conclusive reports on the use of a coloring dye in intraoperative operations or follow-up findings. This method could help preserve more viable tissue to reduce the possibility of complications and the duration of hospitalization.
In branchial lymphoepithelial cyst (BLEC), which is also known as branchial cleft cyst, the remnants of a branchial arch develop into a cyst, causing swelling. The first case of BLEC in the parotid gland was reported by Hildebrant in 1895. Since then, BLEC in the parotid gland has continued to be reported, but in rare cases. A 45-year-old man presented to our hospital with a swelling of the left cheek of approximately 6 months’ duration. The patient underwent a superficial parotidectomy and was pathologically diagnosed with BLEC. Of note, this was the first case of non-human immunodeficiency virus (HIV)-related BLEC of the parotid gland in South Korea. BLEC is a benign condition, but its treatment depends on the presence of HIV infection. In HIV-negative patients, BLEC does not require a further work-up to evaluate metastasis. Our case report describes the diagnosis and treatment of BLEC in a patient without HIV.
Background: The anatomical structures in relation to the carpal tunnel release are the palmaris brevis muscle (PBM), transverse carpal ligament (TCL), and the recurrent motor branch of the median nerve (RMBMN). Our aim is to describe the gross morphology in the Korean population of the PBM, TCL, and RMBMN specifically looking for anomalies, and to determine the muscles encountered during a standard carpal tunnel release. Material and Methods: A total of 30 cadaveric hands were dissected. A longitudinal line drawn from the third web space to the midpoint of the distal wrist crease served as the reference line (RL). The PBM and TCL were classified according to its shape and location. The length, width, and thickness of the TCL were measured. The ratio of the lengths of PBM and TCL to RL was calculated. The course of the RMBMN was dissected specifically looking for anomalies. We also looked at the muscle fibers encountered during a standard carpal tunnel release to identify the muscle. Results: PBM was classified into three different types based on the shape. The average thickness of the PBM and TCL were 0.89 ± 0.16 mm and 1.43 ± 0.40 mm, respectively. The distal border of the TCL was thicker than the proximal border. The average ratio of the length of the PBM to the RL was 25.65 ± 8.62% and TCL to the RL was 24.00 ± 3.37%. The distribution of the RMBMN was classified into three different types. A few accessory branches of the RMBMN were also noted. And 36 muscle fibers were noted within the TCL in line with the RL. Conclusion: We clarified findings and added quantitative information about the anatomical structures surrounding carpal tunnel. A thorough knowledge of the anatomy and anomalies around the carpal tunnel is helpful for surgeons to ensure optimal surgical results.
A variety of benign and malignant neoplasms can develop in the hand, originating from skin, adipose tissue, tendons, muscles, nerves, and bones. However, most cases are benign; therefore, observation is recommended if they are small, painless and do not cause limitation of motion. When symptoms are present or a lesion is larger than 5 cm in the long axis, an excisional biopsy is required to relieve symptoms and exclude malignancy. Lipomas of the hand are quite rare and do not generally cause symptoms. Lipomas of the hand that do present with symptoms are usually giant (larger than 5 cm in diameter) or located in a deeper layer, compressing the nearby nerves and vessels. We report a rare case of a non-giant superficial lipoma of the wrist that resembled two separate masses and caused pain, limitation of motion, and neurological symptoms.
Although blast injuries have been considered a problem unique to military practice or warfare, accidental civilian blast-related injuries due to misplaced landmines have been reported in South Korea. A 71-year-old man was admitted to the emergency room due to multiple severe blast injuries after the detonation of an unknown explosive device. After shrapnel that penetrated the pericardium was removed via median sternotomy in an emergency operation, an extensive defect remained on the lower third of the anterior chest wall. After debriding the contaminated wound several times, chest wall reconstruction with a skin-paddled vertical rectus abdominis muscle (VRAM) flap was successfully performed. However, the patient presented a delayed fungal infection of the deep sternal wound 28 days postoperatively. To salvage the previous flap, antifungal agents were administered and negative-pressure wound therapy was performed between serial radical debridement. The previous flap was successfully salvaged with infection control, and the final defect was covered by re-rotating the previous flap. This case presents the successful reconstruction of a chest wall defect using a skin-paddled VRAM flap notwithstanding a delayed sternal wound infection from a rare civilian blast injury in South Korea.
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