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region containing bony defects of approximately 2 × 3cm using a regraft from amputated soft tissue of the forehead. Thus, we obtained a good treatment out-come without using previously reported treatment methods such as a tie-over dressing although vascular anastomosis could not be performed in our case. Here, we report on our treatment outcomes. In July 2009, a 52-year-old woman visited an emer-gency room with a chief complaint of a soft tissue de-fect of 4 × 7 cm containing bony dede-fects approximate-ly 2 × 3 cm in size extending over the forehead and scalp because the patient sustained an injury from a deadly metal weapon by her husband (Fig. 1A). The injury resulted in the amputation of soft tissue of the forehead and scalp. At the time of the emergency room visit, the patient also presented with a small bowel perforation due to a stab injury in the abdo-men. After undergoing an emergency laparotomy in the Department of Surgery for approximately 3 hours and receiving treatment at an intensive care unit, the patient was referred to us for further evaluation and treatment.
At the time of referral to us, the patient had not presented with the amputated tissue. Therefore, fol-lowing conservative treatment, it was decided that a skin graft or flap surgery would be performed once granulation tissue had formed. During the monitor-ing of the clinical course, the patient’s caregiver found the amputated soft tissue of the forehead region, ap-proximately 7 hours after the injury at the location where the patient sustained the injury (Fig. 2). We had attempted to perform a microvascular anastomosis, but we could not because the anesthe-siologist judged that the patient could not undergo general anesthesia again.
However, if treatment were further delayed, the patient would have been at risk of increased damage. Therefore, we performed the regraft of the amputated
Regraft from Amputated
Forehead Tissue of a 4×7 cm
Skin Defect Containing Bony
Defects
Hyun Jun Yoon, Jin Woo Song, Jin Hyo Lee, Young Jun You
Department of Plastic and Reconstructive Surgery, Seoul Paik Hospital, Inje University Medical Center, Seoul, Korea
Correspondence: Young Jun You
Department of Plastic and Reconstructive Surgery, Seoul Paik Hospital, Inje University Medical Center, 9 Mareunnae-ro, Jung-gu, Seoul 100-032, Korea Tel: +82-2-2270-0900, Fax: +82-2-2275-5663
E-mail: operetta70@gmail.com
No potential conflict of interest relevant to this article was reported.
Received: 15 Jun 2012 • Revised: 8 Aug 2012 • Accepted: 9 Aug 2012
pISSN: 2234-6163• eISSN: 2234-6171
http://dx.doi.org/10.5999/aps.2012.39.5.576• Arch Plast Surg 2012;39:576-578 Copyright 2012 The Korean Society of Plastic and Reconstructive Surgeons 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.
It is well established that the diameter of skin defects should not exceed 1 cm for the survival of the com-posite tissue graft [1,2], and that central necrosis is unavoidable if the diameter of the defects is greater than 2 cm. In addition, it is recommended that the composite tissue graft be performed no later than within four hours after the onset of injury [1,2]. This is also accompanied by the use of such methods as a pressure dressing with a tie-over for successful en-graftment. Cryotherapy is also used to lower the met-abolic rate [3]. It has also been reported that vascular anastomosis can be an effective treatment modality if the size of a skin defect exceeds 2 cm [1,2].
We treated a 4 × 7 cm skin defect on the frontal
Fig. 1.
(A) At the time of onset of injury, the patient had a skin defect of 4 × 7 cm containing a bony defect of 2 × 3 cm. In the center of the bony defect, the medulla was exposed. (B) Approximately 21 months postoperatively, during an outpatient visit, the patient showed results of such a successful engraftment of the graft tissue that some hairs even grew at the site of transplantation. In addition, the skin color at the site of transplantation showed no notable differences from the adjacent tissue. Furthermore, the patient had
no notable complications. A B
Vol. 39 / No. 5 / September 2012
577
Fig. 2.
Amputated forehead and scalp soft tissue. The amputated tissue was severely contaminated.
Fig. 3.
On postoperative day 10, the recipient tissue gradually began to take on a pink color
Fig. 4.
On postoperative day 12, the stitches were removed.
tissue under local anesthesia 2 hours later. The size of the amputated tissue was huge, but vascular anastomosis was impossible; therefore, we decided to remove the bone chips from the ampu-tated tissue and perform massive defatting to reduce the metabolic rate.
Efforts were made to accurately fit the dermal layer between the skin defects as accurately as possible us-ing Prolene 6-0 sutures. Immediately after transplan-tation, we did not perform a tie-over or compression dressing. However, we performed simple dressing changes 3 times a day to closely monitor the status of the flap, and thereby ensured that blood clots did not form on the incision line to prevent hematoma. From postoperative day 6 on, a pink color began to gradually appear at the transplantation site. This was followed by suture removal without any notable ag-gravation to the patient’s condition (Figs. 3, 4). In general, a successful engraftment cannot be pre-dicted if the diameter of a skin defect is greater than 1 cm. It is known that a successful engraftment
can-not be achieved if at least 4 hours has elapsed from the time of injury without any specific preservation processes such as freezing the amputated tissue fol-lowing the onset of injury [1,2]. Furthermore, there are recommended methods for increasing the likeli-hood of engraftment success such as a compression dressing with a tie-over dressing and cryotherapy that lowers the metabolic rate [3].
In our case, the skin defect had a size of approxi-mately 4 × 7 cm, and this was accompanied by the presence of bony defects with a size of approximately 2 × 3 cm. Besides, approximately 7 hours had elapsed from the onset of injury until the amputated soft tis-sue of the forehead region was found, and the tistis-sue was severely contaminated.
Additionally, the patient had a poor systemic status following an emergency laparotomy in the Depart-ment of Surgery for the manageDepart-ment of small bowel perforation, and was receiving treatment in the inten-sive care unit. Vascular anastomosis could not be per-formed for surgical management due to the patient’s condition. Therefore, we attempted to accurately fit the dermal layer between the skin defects, and thus attempted to induce angiogenesis as promptly as pos-sible within the dermal plexus.
578
(Fig. 1B).
This case shows that even though the skin defect was greater than 1 cm, a substantial period of time elapsed prior to the surgery, and the period of ischemic condition was prolonged, we were able to perform a regraft from the amputated tissue instead of vessel anastomosis. We obtained such a successful treatment outcome that entire engraftment of the amputated tissue as achieved without partial necrosis.
References
1. Haas AF, Glogau RG. A variation of composite grafting for reconstruction of full-thickness nasal alar defects. Arch Dermatol 1994;130:978-80.
2. Ratner D, Katz A, Grande DJ. An interlocking auricular composite graft. Dermatol Surg 1995;21:789-92. 3. Kim MG, Ko RY, Im TK, et al. Clinical cases of composite
graft for reconstruction of finger tip amputations using combination procedure of tie-over dressing and drain. J Korean Soc Plast Reconstr Surg 2002;29:994-9.
Primary Adenocarcinoma of
the Lacrimal Gland
Sang-Oon Baek, Yoon-Jae Lee, Suk-Ho Moon, Young-Jin Kim, Young-Joon Jun
Department of Plastic and Reconstructive Surgery, Bucheon St. Mary’s Hospital, The Catholic University of Korea, Bucheon, Korea
Correspondence: Young-Joon Jun
Department of Plastic Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, 327 beon-gil, Wonmi-gu, Bucheon 420-717, Korea
Tel: +82-32-340-2095, Fax: +82-32-340-2666 E-mail: psdoc@korea.com
No potential conflict of interest relevant to this article was reported.
Received: 26 Jun 2012 • Revised: 12 Aug 2012 • Accepted: 14 Aug 2012
pISSN: 2234-6163• eISSN: 2234-6171
http://dx.doi.org/10.5999/aps.2012.39.5.578• Arch Plast Surg 2012;39:578-580 Copyright 2012 The Korean Society of Plastic and Reconstructive Surgeons 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.
Tumors originating from the lacrimal gland account for approximately 10% of orbital tumors and have a large diversity of anatomic and pathological types. Among these, malignant epithelial tumors of the
lac-rimal gland are extremely rare, constituting less than 5% of all orbital lesions [1]. Adenocarcinoma of the lacrimal gland arises in the upper eyelid and usually presents as a mass accompanied by symptoms such as pseudoptosis, exophthalmos, dystopia, pain, and reduced visual acuity [1]. However, patients with this disease are often symptomless, leading them to be diagnosed at the advanced stage. Moreover, on radio-logic examination, it frequently presents as a cystic mass and is often misdiagnosed as a benign tumor. In this report, we present a case of a patient with rare disease of primary adenocarcinoma originating from the lacrimal gland.
A 50-year-old male patient was transferred from the ophthalmology department to plastic surgery department for blepharoptosis, hypotropia, and exophthalmos of his right eye. These symptoms had developed progressively over the previous 6 months. Initially, the patient complained of no pain, while the ophthalmologic and laboratory tests revealed no definite abnormalities. On physical examination, we observed proptosis, dystopia, and ptosis of his right eye (Fig. 1).
An MRI scan of the ocular space revealed a 2.3 × 2.2 cm benign cystic tumor on the right side of the lacrimal gland (Fig. 2). With the impression of a benign tumor, an excisional biopsy was carried out through the subbrow excision and a well demarcated cystic mass was observed intraoperatively. The mass was confirmed to be primary adenocarcinoma on pathologic examination (Fig. 3).
On immunohistochemistry examination, cytoker-atin 7 was positive, whereas cytokercytoker-atin 20 turned out to be negative. These results were adequate enough to conclude that the malignant epithelial tumor had
Fig. 1.
Initial photograph shows right blepharoptosis, hypotropia, and exopthalmos.
