Pretransfer tissue expansion of a scalp free flap for burn alopecia reconstruction in a child: a case report

A nine-year-old boy who sustained severe grease-fire burns over his right scalp, face, neck, and trunk 14 months previously, presented with extensive alopecia over the right frontotemporoparietal scalp. Near complete coverage of the scalp defect was obtained with pretransfer expansion of the left temporoparietal scalp, followed by free-flap transfer of the expanded tissue to the defect. Pretransfer tissue expansion has the advantages of increasing flap surface area and minimizing donor site deformity. This case illustrates the applicability of pretransfer tissue expansion of free flaps, and demonstrates the excellent results achievable with free-flap scalp transfers.     

Keloid formation occurring in the distribution of a congenital vascular malformation

A 35-year-old African American man presented with complaints of malodorous drainage from hypertrophic lesions on his occipital scalp (Figure 1, inset). The patient had no family history of keloid formation and no other keloids on his body. The hypertrophic mass on his scalp had been present for 10 years and had not been a result of any type of mechanical, surgical, or laser treatment. It corresponded to the distribution of a large vascular malformation over the occiput (Figure 1). The vascular malformation extended from the occipital scalp to the right parietal scalp, the right side of the face, neck, upper chest, and right arm, with varicosities and hypertrophy of the right upper extremity (Figure 2). The vascular malformation over the right parietal scalp and ear was characterized by bleb formation and hypertrophy of the right ear. The patient reported that no manipulation, including laser treatment, of the vascular malformation had been previously performed. He did state that a previous dermatologist had attempted serial surgical excision of the cerebriform nodules but retired during the course of treatment. He stated that the appearance of his keloid formation and port-wine stain had not changed during the past 10 years. A previous biopsy of a hypertrophic lesion showed histologic findings consistent with folliculitis keloidalis nuchae. Cephalexin 500 mg 4 times daily for 14 days was prescribed for the purulent drainage. A Doppler ultrasound was ordered of the right upper extremity to evaluate for an arteriovenous malformation and showed no evidence of venous thrombosis or arteriovenous malformation. On a second visit 2 weeks later, the hypertrophic lesions continued to show drainage. Clindamycin gel to be applied twice daily to the scalp was added. The patient also had magnetic resonance imaging with and without gadolinium contrast (Figure 3) ordered, which showed a large hypertrophic giant scalp keloid overlying the occipital and suboccipital region measuring 12x 19 cm. There was soft tissue thickening involving the right external ear, extending inferior to the right ear, overlying an intact parotid gland. There was no evidence of muscular or skull invasion.     

Pneumocephalus and subcutaneous scalp emphysema in a neonate on a low-flow nasal cannula

A 15-day-old boy after intracardiac repair was discharged from the intensive care unit with a low-flow nasal cannula for oxygen administration. The cannula was a 4-Fr multi-purpose tube with a side hole that was inserted into his left nostril. Next day, he suddenly developed pneumocephalus emerging from the right periorbital swelling and extending to his face and subcutaneous scalp over the next 6 h. A computed tomography (CT) scan revealed massive air pockets in the orbit, subdural space, subcutaneous scalp, and face. The nasal cannula was found to have been inserted deeper than we thought and was thus presumed to be the source of the air pockets. We immediately removed the cannula. Follow-up CTs revealed rapid resolution of the intracranial and subcutaneous air. The subcutaneous emphysema completely disappeared over the next 4 days, and he was discharged without any incident.     

On the report of the first successful surgical treatment of brain abscess in the Ottoman Empire by Dr. Cemil Topuzlu in 1891

IN 1891, Dr. Cemil Topuzlu operated on a brain abscess that originated as a complication of a depression fracture of the cranial inner table. The patient presented with Jacksonian seizures on his left side after a sharp trauma resulting in a 15 cm-long scalp laceration and underlying linear cranial fracture in the right parietal bone. Dr. Topuzlu attributed Jacksonian epilepsy to the fracture irritating the motor area in the right hemisphere and attempted a craniotomy based on his measurements to localize the Rolandic fissure. The operation was complicated by a brain abscess, and Dr. Topuzlu reoperated to drain the abscess. He successfully treated the brain abscess and Jacksonian seizures and then presented this case in the Royal Society of Medicine of the Ottoman Empire and in the International Surgery Congress in Lyon in 1894. The case report was published in his surgery book in 1905. The case was not only the first case of brain abscess to be treated successfully with surgical intervention in the Ottoman Empire, it was also one of the first cases of neurological surgery performed using contemporary anesthesiological and surgical techniques, which reveals the importance of neurological examination and cerebral localization techniques in the era before x-rays. Dr. Topuzlu was the founder of modern surgery in the Ottoman Empire and deserves to be credited for his novel applications in the 19th century.     

内窥镜下额颞部除皱术

目的：探讨内窥镜下额、颞部除皱术的临床应用效果。方法：从2003年到2004年，施行内窥镜下额、颞部除皱术28例。采用额部小切口，在帽状腱膜下和骨膜下平面剥离，用缝线和螺钉固定后推的头皮和额部皮肤。结果：28例患者术后效果满意，且脱发、感觉减退和出血等手术并发症少。结论：内窥镜下额、颞部除皱术同传统面部除皱手术相比具有很多优点，可以推广使用。     

First successful replantation of face and scalp with single-artery repair: model for face and scalp transplantation

Successful replantation of the scalp with microanastomosis of a single artery and vein has been reported to produce reliable results. In fact, there have been several reports of scalp replantations based on one-artery and vein repair. There has been a face and scalp replantation reported in the literature, but this was as two separate parts and was based on several arterial and venous repairs. The authors performed the first successful replantation of a face and scalp with repair of a single artery and, of course, two veins. A 21-year-old man presented after his face and scalp were completely severed. The patient's long hair was caught in a conveyor belt at work. The face and scalp underwent replantation, with repair of the right superficial temporal artery with an interposition vein graft. A multiteam approach allowed for minimization of overall ischemic time and simultaneous preparation of the vessels on the patient and amputated part as well as vein graft harvest from the arm. Also critical to the success of the procedure, the small portions of the vessels of the amputated part were sent for frozen section to differentiate artery from vein. Initially, only the right superficial temporal vein was repaired. One week after replantation, the patient returned for treatment of venous congestion of an area to the opposite side of the forehead partial transection, with repair of the left superficial temporal vein, also. This saved the entire part that underwent replantation, and the entire part survived. The face and scalp can undergo replantation based on single-artery repair.     

Meningioma following irradiation for vascular nevus. A case report

A case of meningioma that developed 37 years after irradiation therapy for vascular nevus of the scalp over the right frontoparietal region was reported. A 49-year-old male was admitted to the hospital of Gifu University on October 26, 1979, because of a generalized seizure. He had been born with a vascular nevus affecting the right frontoparietal scalp, for which he began receiving local irradiation at the age of 12. The total dose was not known because the only source of information regarding this treatment was the patient's memory. From the age of 17, the suffered from occasional attacks of dysesthesia in the left side of his body without consciousness disorder. He otherwise remained well for the intervening 37 years. Upon admission, he had a vascular nevus remaining with post irradiation skin changes over the right frontoparietal region. General and neurological examination were not remarkable. Right carotid angiogram and CT scan disclosed the presence of a right frontal tumor. A right frontotemporal craniotomy was performed on December 4, 1979 and a hard tumor was found firmly attached to the dura and bone at the right site. All visible tumor and involved bone were completely removed without difficulty. Histological examination of the surgical specimen showed the characteristic features of a transitional meningioma. There was no evidence of malignancy in the sections examined. Since Mann et al reported a malignant meningioma following irradiation therapy for optic nerve glioma, there have been many reports, over seventy cases of so-called radiation-induced meningioma. However, a meningioma following irradiation therapy for vascular nevus of scalp or face is exceedingly rare.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiple arteriovenous malformations located in the cerebellum, posterior fossa, spinal cord, dura, and scalp with associated port-wine stain and supratentorial venous anomaly.

Multiple arteriovenous malformations involving the left cerebellum and extra-axial posterior fossa with associated calcified cyst, spinal cord, dura, and scalp were present in a 7-year-old girl, who became symptomatic after a cerebellar hemorrhage. A large port-wine stain was noted on the right temporoparietal scalp, consistent with the scalp arteriovenous malformation area, as demonstrated by angiogram. In addition to the multiple arteriovenous malformations, nonfilling of the superior sagittal sinus and tortuous, irregular cortical veins were recognized.     

Hair growth following scalp microvascular flap transfer for baldness due to burn injury.

A female patient, 8 years of age, presented with baldness of the right scalp following deep scalds from boiling soup landing on the head, neck, and chest. The depth of the burn was severe enough to cause baldness. She was primarily advised to wear a wig to address the problem of baldness on one side. Surgery was planned to use uninjured scalp skin to offer hairy skin coverage of the bald site. A left scalp skin flap (2.5 by 7 cm) based on the superficial temporal artery and vein was transferred to the bald area, with microvascular anastomosis to the superficial temporal vessels on the right side. There was complete survival of the flap with uneventful recovery and satisfactory growth of hair. Hair growth from the flap was comparatively thicker than from the rest of the scalp. This microvascular flap has produced sufficient hair to cover the entire area of the baldness and the patient does not need to wear a wig.     

Three cases of scalp arteriovenous malformations

Three cases of scalp arteriovenous malformation (AVM) are presented and the pertinent literature is reviewed. Case 1 was a 50-year-old male who was admitted to hospital with a pulsatile mass involving the right parietal region. Selective angiography revealed a scalp AVM fed by bilateral superficial temporal and right occipital arteries. The AVM was embolized with Gelfoam pieces through catheterization and there was no evidence of recurrence of the lesion after follow-up period of three years. Case 2 was a 25-year-old male who was noticed to have a birth mark in the left occipito-parietal region and was hospitalized with a pulsatile gradually expanding mass after an episode of minor trauma in the same region. Selective angiography revealed a cirsoid type scalp AVM fed by bilateral superficial temporal and occipital arteries, and the authors performed a total resection of the mass because of selective Gelfoam embolization was not successful. Case 3 was a 49-year-old male who was hospitalized with the chief complaints of left tinnitus and pulsatile left supra-auricular mass. There was no history of trauma. Selective angiography revealed a scalp AVM fed by the left superficial temporal and occipital arteries and the authors performed a selective Gelfoam embolization and this was successful, but three months later, the AVM recurred and mainly fed by instead this was the left posterior auricular artery. Preoperative selective Gelfoam embolization followed by a total resection of the AMV with minimal blood loss.(ABSTRACT TRUNCATED AT 250 WORDS)     

额颞部小切口多层次剥离除皱术

目的 探讨一种矫正额颞部老化征象简单而有效的方法。方法 采用额、颞部头皮发际内小切口、多层次(额部：骨膜下，额肌与皮肤间；颞部：颞浅筋膜眼轮匝肌与颞深筋膜间，颞浅筋膜眼轮匝肌与皮肤间)剥离，向上提紧额肌骨膜瓣和颞浅筋膜眼轮匝肌瓣，采用折叠缝合内固定(额部缝合固定于骨膜；颞部缝合固定于颞深筋膜表面)。不去除头皮，待其自然收缩恢复。结果 从2000年1月至2003年12月于临床应用20例，既获得满意的额颞部年轻化效果，又避免了冠状切口的并发症。结论 小切口多层次剥离是一种安全有效的额、颞部除皱术，既可单独应用于额部或颞部，也可额颞部同时进行手术。本方法具有时间短，损伤小，康复快，效果可靠等优点，同时避免冠状切口的并发症。     

后置切口式颞部除皱术

目的：探讨一种单一切口、能减轻手术后瘢痕性脱发和鬓角不对称的颞部除皱方法。方法：将手术切口设计在颅后中线上，从帽状腱膜深层钝性分离，进入颞区在颞浅筋膜深分离至眶外侧，充分上提颞部组织后切除多余头皮组织，最后分层缝合。结果：经手术后1～12月的观察，患者的眉、外眦上提效果明显，减少瘢痕性秃发和鬓角不对称并发症出现。结论：后置切口式颞部除皱术是一种有效的颞部除皱方式。     

Chronic granulomatous disease: two members of a single family with different dermatologic manifestations

Case 1: A 33-year-old man with a 14-year history of localized skin disease on the face and scalp was evaluated at the department of dermatology. The physical examination revealed plaques with papules, pustules, and a golden yellow crusting on the forehead, cheeks, upper lip, and chin (Figure 1). The scalp presented fine, whitish scales. At the beginning of his disease, the patient presented large red and painful purulent boils. The 14-year clinical course of these lesions was characterized by partial remissions and recurrences, but he did not specify any treatment related to improvement. The clinical diagnosis given for the scalp lesions was seborrheic dermatitis. For the facial lesions, many differential diagnoses were considered, among them: seborrheic dermatitis, acneiform dermatitis, impetigo, folliculitis, seborrheic pemphigus, and demodicidosis. The histopathologic study of a biopsy taken from the cheek (Figure 2) showed superficial spongiform dermatitis with neutrophils and folliculitis that are compatible with the diagnosis of seborrheic dermatitis. Both Gram and periodic acid-Schiff stains were negative. Follow-up of the patient was not possible since he did not come back. The disease in this patient initially manifested at age five by the presence of recurrent ganglionic abscesses. At age 15, he presented a pulmonary abscess of a left lobule that was surgically removed; at this point the diagnosis of chronic granulomatous disease was established. At age 28, an exploratory laparotomy was performed due to peritonitis and multiple hepatic abscesses. At that time, he was treated with antibiotics (mainly trimethoprim-sulfamethoxazole) and interferon-g. The patient had two brothers who died due to complications of chronic granulomatous disease. In addition, both his mother and sister presented a history of discoid lupus-like lesions. Case 2: Coincidentally, his 27-year-old sister was seen in our department of dermatology 5 years before, presenting infiltrated and erythematous plaques with fine scales (Figure 3) on the right side of the nose and the left annular finger. No other cutaneous or mucous lesions were seen. She referred onset in childhood with similar lesions on sun-exposed areas that disappeared without scarring. A biopsy was performed and the results were compatible with the diagnosis of discoid lupus erythematosus (Figure 4). Direct immunofluorescence was not available. At that time, she did not mention the family history of chronic granulomatous disease. Clinical follow-up was not possible, but his brother referred that she afforded complete remission only with sun protection.     

Multiple Marjolin's ulcers arising from irradiated post-burn hypertrophic scars: A case report

Marjolin's ulcer is an aggressive ulcerating cutaneous malignancy that may arise in chronically inflamed or traumatized skin. Frequently overlooked, this rare condition is classically associated with burn scars, with the process of malignant degeneration typically occurring over two to three decades. The most common histopathological pattern is squamous cell carcinoma; however, compared to typical squamous cell carcinomas, Marjolin's ulcers have an increased rate of metastasis. The correlation between radiotherapy for benign hypertrophic scarring and carcinogenesis is controversial, with few reports in the literature. We present a unique case of a 61 year old Caucasian male who was burned by scald at age 4, received radiotherapy for his post-burn hypertrophic scars, and later developed multiple Marjolin's ulcers on his left arm, chest, and right temporal scalp.     

Cross-hand replantation: Preliminary case report

A 38-year-old man had his left hand avulsed and the middle third of his right upper extremity irretrievably injured in a mine accident. The right hand was replanted onto the left forearm. The operative procedure is summarized and problems associated with such a procedure are briefly discussed.     

False lateralization of mesial temporal lobe epilepsy by noninvasive neurophysiological examinations

Mesial temporal lobe epilepsy (mTLE) is the most common form of symptomatic localization-related epilepsy and is surgically remediable. Lateralization of the seizure onset is particularly important to determine from a surgical perspective. A 39-year-old woman with intractable mTLE first exhibited seizure at the age of 3 years. She experienced epigastric sensation and placed her right hand on her abdomen before falling backward. Although interictal scalp electroencephalography (EEG), sphenoidal scalp ictal EEG, and magnetoencephalography showed right temporal side focus, computed tomography and magnetic resonance imaging showed atrophy of the left cerebral hemisphere. Single photon emission computed tomography with technetium-99m ethyl cysteinate dimmer and I-123 iomazenil showed obscure focus on the left side. As a discrepancy existed between the results of neurophysiological examinations and imaging, we performed subdural electrode implantation on the bilateral temporal lobe. Although a bemegride-induced seizure arose from the right side during the subdural recording, the onset of 5 habitual seizures was observed in the left hippocampus. On the basis of these results, the seizure was diagnosed as left mTLE, and left anterior temporal lobectomy and amygdalohippocampectomy were performed. The patient has been free from the seizures for more than 1.5 years of follow up. Bilateral subdural electrode measurement of habitual seizures is indispensable for clarifying the actual focus when a discrepancy exists between neuroimaging and noninvasive neurophysiological examinations.     

Traumatic ventricular septal defect following a stab wound to the chest

A 51-year-old man who had been suffering from depression stabbed himself in the chest with an ice pick. At presentation, an ice pick lodged in the left fifth intercostal space was moving synchronously with his heartbeat. Echocardiography revealed that the tip was penetrating the anterior wall of the right ventricle. Because the patient was tamponading, an emergency operation was carried out. The ice pick was removed following the establishment of a cardiopulmonary bypass and pericardiotomy. The perforation of the right ventricle was closed with a pledget-reinforced mattress stitch. On postoperative day 12, a holosystolic murmur was detected on auscultation. Transthoracic echocardiography revealed a ventricular septal defect 5 mm in diameter located near the apex. The pulmonary-tosystemic flow ratio was 1.1 by echocardiographic measurement. No sign of heart failure was present. Although it was agreed to manage the ventricular septal defect conservatively, careful echocardiographic follow-up is mandatory.     

Cranial-bone defects with depression deformity treated with ceramic implants and free-flap transfers.

Hydroxyapatite ceramic has many advantages in the treatment of cranial-bone defects. However, for large skull defects with severe depression deformities, it may be risky to use ceramic implants because an extradural dead space will be left and the overlying scalp will have to be closed under tension. In these cases microvascular free-flap transfers are a good solution. We have treated three patients for large skull defects with severe depression deformities after repeated local infections and several operations or irradiation. A latissimus dorsi myocutaneous flap was combined with a serratus anterior muscle flap to fill the extradural space under the ceramic implant in the first patient. A latissimus dorsi muscle flap was inserted under the ceramic implant in an irradiated site and a combined small serratus anterior muscle flap was used as a monitor in the second patient. A latissimus dorsi myocutaneous flap was used to cover the ceramic implant and fill the scalp defect in the third patient. The follow-up periods varied from 12 to 35 months (mean: 20.7 months). The clinical courses of all three patients were uneventful and no flap was lost. The extradural space can be reduced to some extent by making the ceramic implant slightly flatter or thicker, but in patients with severe depression deformities, whose brain expansion cannot be expected, a muscle flap should be transferred into the space.     

A case of multiple superficial temporal artery pseudoaneurysms following craniotomy

A case of multiple superficial temporal artery (STA) pseudoaneurysms following craniotomy is reported and a review of the literature is made. The patient was a 17-year-old male who was hospitalized as he developed right hemiparesis 4 hours after golf ball injury to the left temporal region. He had been diagnosed as hemophilia A one year prior to the injury. CT scan showed right parietal intracranial hematoma with mass effect when he was submitted to emergency craniotomy. At surgery a linear scalp incision was made over the left temporal area after high factor VIII concentrates (con-VIII), 2,000 units, were administered. His postoperative course was uneventful and hemiparesis improved substantially, however two pulsatile masses along the incision scar over the scalp were noticed some 40 days after the hematoma removal. There was another pulsating mass in the left wrist where an arterial cannulation was made at the time of craniotomy. Selective angiograms showed two left STA pseudoaneurysms and left radial pseudoaneurysm was also demonstrated. The left STA was embolized with Gelfoam pieces through catheterization after administration of con-VIII, and the radial artery aneurysm was surgically resected. There was no evidence of recurrence of these lesions during the follow-up period of eight months. Among over 130 cases of STA pseudoaneurysms reported, there was no case with hemophilia and also no such a case described which developed after craniotomy on reviewing the literature. And it was proved that con-VIII has enabled a patient to tolerate embolization procedure through catheterization.