Aesthetic Microsurgical Reconstruction of Extremities

The aim of extremity reconstruction has focused on early wound coverage and functional recovery but rarely aesthetics. As the quality of life improves, however, the request for aesthetics has been growing. The authors has conducted retrospective reviews on the 86 cases that had extremity reconstruction using free flap, considering the characteristics of parts that had been assessed in primary operation between May 1996 and December 2010. Aesthetic grading was performed in four categories; color, texture, contour and marginal scar. Recipient sites were 42 hands, 19 feet, 14 lower extremities excluding feet and 10 upper extremities apart from the hand. Types of free flap were 16 latissimus dorsi free flaps, 13 anterolateral thigh free flaps, 12 dorsalis pedis free flaps, 8 transvers rectus abdominis free flaps, 7 gracillis free flaps, and 5 superficial temporal fascia free flaps. Total flap necrosis was seen in 8 cases(9.3%) and partial necrosis in 5 cases(5.8%). Secondary revision was done in 24 cases(27.9%) and the most common revision, debulking was done in 14 cases(16.3%). The authors has considered cosmetic aspects along with wound coverage and functional recovery in primary reconstruction. The results of aesthetic grading was 16.2 out of 20, and the secondary revision rate was reduced.

Correction of Secondary Cleft Lip Deformities by Scar Excision and Abbe Flap Coverage: Photogrammetric Analysis

PURPOSE: The Abbe flap procedure has been used to correct disharmony of the upper and lower lips as well as for making a philtrum for patients with secondary cleft lip deformities. But the Abbe flap procedure adds two scars in addition to the prior operative scar on the upper lip. This study was conducted to determine the treatment outcomes of esthetic subunit excision of the scar on the philtrum and Abbe flap coverage for correction of cleft lip deformities with photogrammetric analysis. METHODS: This study investigated a total of 11 patients with cleft lip deformities who underwent scar excision with Abbe flap coverage, and the patients were followed up for at least 6 months. Under general anesthesia, a mushroom- shaped Abbe flap was drawn on the lower lip with a width of 8 mm and a height 1~2mm longer than that of the philtral midline. The epidermis and dermis of the scar on the upper lip were excised. In the cases with alar base depression, the orbicularis oris muscle was split vertically and transposed to the alar base. The Abbe flap was harvested as a pedicled flap containing a small amount of muscle and this was rotated 180-degree to be inserted into the upper lip. Mucosa, muscle, subcutaneous tissue and skin were closed in layers. The flap was divided at the 7~14 postoperative day. The postoperative outcomes were evaluated by using photogrammetric analysis. Three indices were measured from the standard clinical photographs taken before and after the surgery. For anthroposcopic assessment, observers described the postoperative outcomes using an ordinary scale method. RESULTS: The postoperative values obtained in the photogrammetric analysis showed improvement as compared with the preoperative ones. Improved anthroposcopic outcomes were also noted. CONCLUSION: Scar excision and Abbe flap coverage were proven to be effective in improving protrusion and the height of the upper lip, the scar of the upper lip and the symmetry of Cupid's bow and the philtral column, as well as formation of the philtral dimple.

The Importance of Septoplasty in The Treatment of Nasal Bone and Grade I Septal Fracture: Estimation with Acoustic Rhinometry

PURPOSE: Nasal bone fractures are often classified as minor injury. However, the incidence of posttraumatic nasal deformity remains alarmingly high. It is because of unnoticed septal fracture. This study was conducted to determine the necessity of septoplasty for patients with nasal bone fracture accompanying grade I septal fractures. METHODS: Among 105 patients with nasal bone fractures, 52 who had grade I septal fracture were diagnosed based on physical examination and computed tomography. Patients' age ranged from 14 to 65 years (mean 29.25 years), and 35 were male and 17 female. Patients were divided into 2 groups according to surgical treatment METHODS: patients who underwent closed reduction only (group 1, n=28) and those who underwent simultaneous closed reduction and septoplasty (group 2, n=24). The treatment outcomes were evaluated by comparing changes in nasal airway volume measured by acoustic rhinometry before the surgery, 3 months and 6 months after the surgery according to the timing of surgical repair and surgical treatment methods. RESULTS: Nasal airway volume increased after the surgery by 17.8% in 3 months after the surgery, 25.2% in 6 months in group 1 and by 22.7% in 3 months, 35.8% in 6 months in group 2. The increase in airway volume after the surgery by 26.3% in 3 months after the surgery, 34.2% in 6 months after the surgery in operation within 1 week after trauma and by 12.1% in 3 months, 22.2% in 6 months after the operation later 1 week after trauma. The difference was statistically significant. Three patients in group 1 complained of intermittent nasal obstruction, two of whom showed a decrease in nasal airway volume by acoustic rhinometry. CONCLUSION: Most patients with nasal bone fractures accompanying grade I septal fractures have been treated with closed reduction in clinical settings. However, the results of this study suggest that septoplasty be performed after a correct diagnosis of septal fracture is made through comprehensive physical examination and computed tomography. Septoplasty is important to obtain more favorable outcomes and reduce complication.

Complete Septal Extension Graft using Porous High-Density Polyethylene Sheet or Septal Cartilage in Unilateral Cleft Lip Nasal Deformities: Photogrammetric Analysis

PURPOSE: Complete septal extension grafts have been widely used in rhinoplasty for effective projection of the short retruded columella in Asian patients. Autologous septal cartilages and porous high-density polyethylene sheets are frequently used as septal extension grafts. This study was conducted to compare the postoperative results of porous polyethylene sheets and septal cartilages used for correction of unilateral cleft lip nasal deformities by using photogrammetric analysis. METHODS: This study investigated a total of 49 patients with cleft lip nasal deformities who underwent corrective surgery, and were followed up for at least 6 months. Septal cartilages were used in 39 patients, and porous polyethylene sheets were used in 10 patients. In all patients, through the open rhinoplasty, complete septal extension grafts were sutured to the caudal margin of the septal cartilage, and the alar cartilage was sutured with suspension. The cleft side alar cartilage was overcorrected by approximately 3 - 5 mm. Postoperative outcomes were evaluated by using photogrammetric analysis. Five indices and 4 angles were measured on their photographs taken before and after the surgery. In patients with unilateral cleft lip nasal deformities, symmetry was also evaluated by means of columellar length index. RESULTS: The postoperative values obtained in photogrammetric analysis showed improvements in comparison with the preoperative ones. The polyethylene group produced more improved outcomes than the septal cartilage group but also resulted in more complications at the same time. CONCLUSION: The results of this study indicates that complete septal extension grafts are efficient for the correction of unilateral cleft lip nasal deformities. However, since postoperative complications occur more frequently in the polyethylene group than in the septal cartilage group, caution is advised in using porous high-density polyethylene sheets in patients with cleft lip nasal deformities.

Comparison of Treatment Effect of the Dried Bovine Amniotic Membrane and the Cultured Allogenic Keratinocytes in the Partial Thickness Burn Management

PURPOSE: In the partial thickness burn management, despite of several advantages, the use of human amniotic membrane has been limited. The authors applied dried bovine amniotic membrane(DBAM) to overcome disadvantages of amniotic membrane for partial thickness burn and to compare the effectiveness of cultured allogenic keratinocytes(CAK) that have been recently used for the management of burn. METHODS: From August 2007 to May 2008, 16 patients with partial thickness burn were assigned to this study. The ages ranged from 12 to 59, with the average of 38. Either DBAM or CAK were applied, and the secondary dressing was removed on the following day. To compare treatment effect, time for epithelization, Vancouver scar scale and chromameteric results were evaluated. RESULTS: The time for epithelization was 10.1 days and 9.1 days in DBAM and CAK, respectively, which are shorter than the previous 2-3 weeks. At the follow up Vancouver scar scale was 2.8 in DBAM and 3.0 points in CAK, both of which showed good results. The results of chromameter showed that the L*, a*, and b* values of the area applied DBAM were 60.1, 13.6, and 13.3, respectively, and the values of the area applied CAK were 60.1, 12.4, and 12.4, respectively. It was found that the skin color of the healed area after burn was darker, the redness was higher, and the yellowness was lower. After dressing, no significant side effects were observed, and in the cases of applying CAK, it was inconvenient as the moving area had to be fixed. CONCLUSION: As CAK, DBAM has several advantages such as the shortening of the epithelization period, reduction of scar and pigmentation, and convenient application, etc., it is an effective method for the partial thickness burn management.

The Change of Burn Depth within 24 Hours after Burn in the Standardized Burn Mode

PURPOSE: In full thickness burn, the depth of burn is known to increase until around 1-3 days after the burn. However, no study on how the depth increase during the first 24 hours has been conducted. Therefore, the authors investigated how the depth of burn changes within the first 24 hours after the burn by using the standardized burn model. METHODS: A total of four experiments on pigs were carried out for this study. Experiment 1 was performed to examine how temperature affects the depth of burn. The digitally controlled aluminum thermal block was set at different temperatures-80, 90 and 100 degrees in Celsius, respectively. Then the pig was exposed to the block for 15 seconds each time. The time exposed to heat was set as a variable for the Experiment 2. The temperature was maintained at 80 degrees Celsius, and the pig was contacted with the thermal block for 5, 10 and 20 seconds, respectively. The biopsy of the tissues were performed in one hour, 6 hours, 24 hours, and 7 days after the burn. After hematoxylin and eosin staining a percentage of the depth from a basement membrane of epidermis to the deepest tissue damaged by the burn against total dermal thickness was measured. RESULTS: In Experiment 1, the depth of burn increased considerably as time passed by. At all three temperatures, differences in depths measured in 6 and 24 hours, and in 1 hour and 7 days were both significant. In addition, the depth deepened as the temperature went higher. In the case of Experiment 2, the depth of burn also increased significantly as time passed by. At all three times, differences in depth measured in 6 and 24 hours, and in 1 hour and 7 days were also significant. Moreover, the depth extended with longer contact time when it was compared according to the time. CONCLUSION: Full thickness burn progressed rapidly from 6 to 24 hours after the burn and the depth of burn was almost decided within the first 24 hours after the burn. On the other hand, partial thickness burn also advanced from 6 to 24 hours after the burn but the depth deepened at slower level.

Augmentation of Pyriform Margin Using Porous High-Density Polyethylene Sheet In Unilateral Cleft Lip Nasal Deformity

PURPOSE: The common deformity after the correction of unilateral cleft lip nasal deformity is nasal asymmetry, and it is caused by the hypoplasia of the pyriform aperture. To correct this, many procedures have been applied, but still many problems are present. Authors performed the inlay and onlay insertion of porous high density polyethylene sheet(1mm thickness Medpor(R) sheet) in the hypoplastic pyriform margin of cleft side and obtained satisfactory results. METHODS: 11 cases were performed and the mean follow up period was 15.1 months. Their mean age was 23.6 years. Under general anesthesia, bilateral pyriform margin was exposed. Medpor(R) sheets in "match stick" like shaped were inlay inserted, and kidney shaped were onlay inserted fixating with two 6mm titanium screws. After the surgery, the results was evaluated by photogrammetric analysis. On the basal view, the distance from the subalare and labiale superius' to the transverse baseline connecting the both cheilions was measured from the cleft side and the non-cleft side. Then, the postoperative symmetry was assessed by obtaining the cleft side against the non-cleft side as proportion index, defined as lateral and medial upper lip contour index. RESULTS: There were 2 infections. The cause was because the inserted implant was too long and thus protruded to the base of nasal cavity. The lateral upper lip contour index was from 95.49 to 103.27, and medial upper lip contour index was from 90.92 to 100.49, it was statistically increased, and thus the symmetry was improved. However clinically mild depression remained at nostril floor. CONCLUSION: Authors performed porous high density polyethylene sheet inlay and onlay insertion for the hypoplasia of the pyriform margin in unilateral cleft lip nasal deformity. It was found that depressed pyriform margin and upper lip were corrected effectively except for the nostril floor, for which an additional soft tissue augmentation would be necessary. The inlay insertion has risk of protrusion, thus the guideline of the use of artificial prosthesis should be observed strictly.

A Case of Primary Cutaneous Adenoid Cystic Carcinoma at the Genital Area

PURPOSE: Adenoid cystic carcinoma is a rare type of eccrine sweat gland carcinoma. Although it is mostly known as a neoplasm of the salivary gland, it could occur as a primary skin tumor. We present a patient with a primary cutaneous adenoid cystic carcinoma at the genital area. METHODS: A 60-year-old man had a slowly growing 1 cm sized single tender mass near the left scrotum and he underwent excisional biopsy at a local clinic. A diagnosis of adenoid cystic carcinoma was made and thus he was transferred to our hospital. In physical examination, other specific findings were not detected except a linear scar caused by a previous skin biopsy near the left scrotum. In CT scan, PET-CT scan and endoscopy, there was no evidence of neoplasm in other organs. It was diagnosed as the primary cutaneous adenoid cystic carcinoma and then wide excisions were performed including total 4.5cm margin of normal skin. RESULTS: Microscopic findings revealed proliferation of tumor cell islands with cribriform or tubular patterns containing several round, pseudocystic structures. The tumor cells showed basaloid cells with uniform and small nuclei. Tumor cells infiltrated into the dermis and upper portion of subcutaneous tissue. There was multifocal perineural invasion of tumor cells. In postoperative 6 months, we found no recurrence and other complications. CONCLUSION: Herein we found a rare case of primary cutaneous adenoid cystic carcinoma at the genital area.

Ultrasonographic Findings of Mild and Very Mild Carpal Tunnel Syndrome

OBJECTIVE: To assess the clinical usefulness of ultrasonography for the diagnosis of mild and very mild carpal tunnel syndrome. METHOD: Ultrasonographic evaluation was performed in 39 hands of 29 patients with mild and very mild carpal tunnel syndrome according to Bland's neurophysiologic grading scale. Controls included 41 hands of 34 subjects without electrophysiologic evidence of carpal tunnel syndrome. Ultrasonographic findings were evaluated quantitatively with regard to the cross-sectional area, the flattening ratio, the swelling ratio of the median nerve, and palmar displacement of the flexor retinaculum. The analysis of differences between controls and patients group were done by independent t-test. Cut-off values using receiver operation characteristic, were calculated. RESULTS: Patients had significantly increased cross sectional area and flattening ratio of the median nerve at proximal carpal area, palmar displacement of the flexor retinaculum at proximal carpal area. A critical value of equal or higher to 8.5 mm(2) for cross-sectional area at the pisiform level showed a sensitivity 79.5%, a specificity of 95.1%, which had most diagnostic value compared with the value of cross-sectional area at the distal radius level, flattening ratio at the pisiform level and palmar displacement. CONCLUSION: Ultrasonography was useful in the diagnosis of mild and very mild carpal tunnel syndrome.

Applied Anatomy of Pectoralis Major Muscle: Surface Anatomy Related to Female Breast

The most important factor for breast augmentation is to dissect the accurate size of implantation pockets. This study was performed to investigate the anatomical association of the pectoralis major muscle(PMM) with the female breast shape for improving the success rate of mammoplasty. This study included 60 women(120 breasts) in their twenties to thirties who were imaged by CT between September 2006 and December 2007. On reconstructed 3D CT images, 6 points in the area of the PMM were selected as fiducial points, and the PMM contour and the correlation of the PMM with the nipple were analyzed using the imaginary lines connecting individual points. As the volume increased, the lateral and inferior borders of the PMM moved to the superomedial side from the nipple. As the ptosis degree increased, the density became lower, and the lateral and inferior borders of the PMM moved to the superomedial side of the nipple. However, there was no significant correlation between age and PMM contour. The results of this study suggest that the PMM contour may change according to the volume, ptosis and density of the breast. This study can provide objective information for breast surgery, thereby increasing the success rate of mammoplasty.

Accuracy of Indirect Anthropometry on Cast Model of The Nose: Comparison with Direct Anthropometry

PURPOSE: We measured linear distances, angles and inclinations on the cast models of the noses, and compared these indirect measurements with the direct measurements obtained from the nose in order to validate the accuracy of the indirect anthropometry using the cast model. METHODS: Subjects were 50 males and 50 females, medical students in twenties(mean 27.1 years). Cast models were made from the alginate impression material and the plaster. In direct anthropometry, 16 linear, 7 angular, and 2 inclination measurements between 11 landmarks on the nose were obtained using sliding caliper, spreading caliper, and fabric tape measure. At the same time, the same measurements were obtained from the cast models of the same people. Total 25 measurements were compared, and tested by the independent t-test of SPSS. RESULTS: The standard values of Korean nose in twenties were obtained. 24 measurements except the columellar labial angle were not statistically different between the indirect anthropometry and the direct anthropometry. CONCLUSION: Indirect anthropometry on the cast model of the nose revealed no significant difference from the anthropometric measurement statistically, accounting for 24 in 25 measurements(96%). There are two possible reasons that caused the difference of columellar labial angle between direct and indirect anthropometry. First, the columellar labial angle could be decreased by protrusion of the lips which resulted from contracting mouth in which an drinking straw had been applied on the mouth corner for patients' respiration during making cast model. Second, it is generally known that the columellar labial angle could be measured larger when soft tissues were pressed by protractor in direct anthropometry. Using a drinking straw with greater diameter, and scheming respiration through the nostrils that patients don't feel discomfort, the more accurate data would be obtained from the indirect anthropometry using the cast models of the noses.

Correction of Hook Nail Deformity with Composite Graft

PURPOSE: Hook nail deformity is caused by inadequately supported nail bed due to loss of distal phalanx or lack of soft tissue, resulting in a claw-like nail form. A composite graft from the foot bencath the nail bed gives adequate restoration of tip pulp. METHODS: From September of 1999 to March of 2004, six patients were treated for hook nail deformity and monitored for long term follow up. Donor sites were the lateral side of the big toe or instep area of the foot. We examined cosmetic appearance and nail hooking and sensory test. The curved nail was measured by the picture of before and after surgery. RESULTS: In all cases, composite grafts were well taken, and hook nail deformities were corrected. The curved nail of the 4 patients after surgery were improved to average 28.7 degrees from average 55.2 degrees before surgery. The static two point discrimination average was 6.5mm and the moving two point discrimination average was 5.8mm in the sensory test. CONCLUSION: Composite graft taken from foot supports the nail bed with the tissue closely resembling the fingertip tissue, making it possible for anatomical and histological rebuilding of fingertip.

Indirect Anthropometry on Cast Model of Cleft Lip Nose: Comparison with Direct Anthropometry

PURPOSE: Anthropometry can be divided into two methods, direct anthropometry and indirect anthropometry. The most ideal and accurate method is a direct anthropometry. However, it is difficult to measure in the case of children because of poor cooperation, and it lacks re-productivity. Cast model has advantages of three dimensional featuring, inexpensive and easy fabrication. This study is conducted to find out an accuracy of indirect anthropometry on cast model by comparing it with direct anthropometry. METHODS: Total 48 cleft lip nasal deformity patients (unilateral, 40; bilateral, 8) were included in this study. Cast models were made before surgery under general anesthesia with alginate impression material and model plaster. Eleven linear measurements among 7 landmarks were taken as direct anthropometry before surgery with Castroviejo spreading caliper. At the same time, indirect anthropometry on cast model was done at the same linear distances as well. RESULTS: Of the total 11 linear measurements, both ala lengths, both columella lengths, nose width, projective distance between facial insertion points of the ala, projective distance between the alar base points, right nostril floor width, and columella width were statistically correlated between indirect anthropometry on cast model and direct anthropometry. However, the nasal tip protrusion and the left nostril floor width were not statistically correlated. CONCLUSION: Accuracy of indirect anthropometry on cast model can be influenced by cast model fabrication techniques and correct identification of landmarks. Nasal tip protrusion could be reduced by compression of the nasal tip in the process of cast model fabrication and nostril floor width can be varied by muscle relaxation of anesthetics and incorrect identification of subalare in cleft lip nasal deformity. If sufficient care is taken to make cast model and to define landmarks exactly, indirect anthropometry on cast model can be a reliable method as direct anthropometry.

Indirect Anthropometry on Cast Model of Cleft Lip Nose: Comparison with Direct Anthropometry

PURPOSE: Anthropometry can be divided into two methods, direct anthropometry and indirect anthropometry. The most ideal and accurate method is a direct anthropometry. However, it is difficult to measure in the case of children because of poor cooperation, and it lacks re-productivity. Cast model has advantages of three dimensional featuring, inexpensive and easy fabrication. This study is conducted to find out an accuracy of indirect anthropometry on cast model by comparing it with direct anthropometry. METHODS: Total 48 cleft lip nasal deformity patients (unilateral, 40; bilateral, 8) were included in this study. Cast models were made before surgery under general anesthesia with alginate impression material and model plaster. Eleven linear measurements among 7 landmarks were taken as direct anthropometry before surgery with Castroviejo spreading caliper. At the same time, indirect anthropometry on cast model was done at the same linear distances as well. RESULTS: Of the total 11 linear measurements, both ala lengths, both columella lengths, nose width, projective distance between facial insertion points of the ala, projective distance between the alar base points, right nostril floor width, and columella width were statistically correlated between indirect anthropometry on cast model and direct anthropometry. However, the nasal tip protrusion and the left nostril floor width were not statistically correlated. CONCLUSION: Accuracy of indirect anthropometry on cast model can be influenced by cast model fabrication techniques and correct identification of landmarks. Nasal tip protrusion could be reduced by compression of the nasal tip in the process of cast model fabrication and nostril floor width can be varied by muscle relaxation of anesthetics and incorrect identification of subalare in cleft lip nasal deformity. If sufficient care is taken to make cast model and to define landmarks exactly, indirect anthropometry on cast model can be a reliable method as direct anthropometry.

Photogrammetry Based on Standardized Clinical Photography using Cephalostat: Comparison with Anthropometric Analysis

PURPOSE: Direct anthropometry is an ideal method for preoperative planning and postoperative evaluation in plastic surgery, but it requires highly skilled specialty. Indirect anthropometry, especially photogrammetry, is an alternative method. In photogrammetry, standardized clinical photography is essential. Photogrammetry-based standardized clinical photography has several advantages over direct anthropometry. It is easier to measure and has less chance to make errors during measurement. Furthermore, it is possible to repeat measurements, and available for follow up study based on permanent custody. But, it is still different from actual measurement, and inherently less accurate than anthropometry. METHODS: The authors revised the standardized clinical photography and then, carried out photogrammetry using Photoshop(Adobe, U.S.A.), and compared each data with those of anthropometry. The subjects were 50 males and 50 females, undergraduate medical students in twenties. Standard head position was obtained from the wire, fixed to cephalostat which indicates the Frankfort horizontal plane. All photographs were taken at the same situation such as fixed position of light, subject and camera, etc. RESULTS: Total 96 measurements, based on 40 landmarks, consist of linear measurements, angular measurements and inclinations include 3 measurements in head, 22 in face, 15 in orbit, 28 in nose, 16 in lip and mouth, and 12 in ear. CONCLUSION: Normal photogrammetric data of face of Korean in twenties was obtained. Reliable photogrammetric measurements, not significantly different from anthropometric measurement statistically, accounted for 44 in 96 measurements(45.8%). Anthropometric values different from those of photogrammetric values were obtained by multiplying coefficient by photogrammetric value.

Photogrammetry Based on Standardized Clinical Photography using Cephalostat: Comparison with Anthropometric Analysis

PURPOSE: Direct anthropometry is an ideal method for preoperative planning and postoperative evaluation in plastic surgery, but it requires highly skilled specialty. Indirect anthropometry, especially photogrammetry, is an alternative method. In photogrammetry, standardized clinical photography is essential. Photogrammetry-based standardized clinical photography has several advantages over direct anthropometry. It is easier to measure and has less chance to make errors during measurement. Furthermore, it is possible to repeat measurements, and available for follow up study based on permanent custody. But, it is still different from actual measurement, and inherently less accurate than anthropometry. METHODS: The authors revised the standardized clinical photography and then, carried out photogrammetry using Photoshop(Adobe, U.S.A.), and compared each data with those of anthropometry. The subjects were 50 males and 50 females, undergraduate medical students in twenties. Standard head position was obtained from the wire, fixed to cephalostat which indicates the Frankfort horizontal plane. All photographs were taken at the same situation such as fixed position of light, subject and camera, etc. RESULTS: Total 96 measurements, based on 40 landmarks, consist of linear measurements, angular measurements and inclinations include 3 measurements in head, 22 in face, 15 in orbit, 28 in nose, 16 in lip and mouth, and 12 in ear. CONCLUSION: Normal photogrammetric data of face of Korean in twenties was obtained. Reliable photogrammetric measurements, not significantly different from anthropometric measurement statistically, accounted for 44 in 96 measurements(45.8%). Anthropometric values different from those of photogrammetric values were obtained by multiplying coefficient by photogrammetric value.

The Effect of Various Methods of Cross-linking in Type I Collagen Scaffold on Cartilage Regeneration

PURPOSE: Collagen is the principal structural biomolecule in cartilage extracellular matrix, which makes it a logical target for cartilage engineering. In this study, porous type I collagen scaffolds were cross-linked using dehydrothermal(DHT) treatment and/or 1-ethyl-3-(3-dimethyl aminopropyl) carbodiimide(EDC), in the presence and absence of chondroitin-6-sulfate(CS) for cartilage regeneration. METHODS: Cartilage defects were created in the proximal part of the ear of New Zealand rabbits. Four types of scaffolds(n=4) were inserted. The types included DHT cross-linked(Group 1), DHT and EDC cross- linked(Group 2), CS added DHT cross-linked(Group 3), and CS added DHT and EDC cross-linked(Group 4). Histomorphometric analysis and cartilage-specific gene expression of the reconstructed tissues were evaluated respectively 4, 8, and 12 weeks after implantation. RESULTS: The largest quantity of regenerated cartilage was found in DHT cross-linked groups 1 and 3 in the 8th week and then decreased in the 12th week, while calcification increased. Calcification was observed from the 8th week and the area increased in the 12th week. Group 4 was treated with EDC cross-linking and CS, and the matrix did not degrade in the 12th week. Cartilage-specific type II collagen mRNA expression increased with time in all groups. CONCLUSION: CS did not increase chondrogenesis in all groups. EDC cross-linking may prevent chondrocyte infiltration from the perichondrium into the collagen scaffold.

Medial Epicanthopexy Using Transverse Short Incision and Medial Canthal Tendon Shortening Procedure

The authors found that the results of severe epicanthal fold were excellent after repairing the transposition of the flap and transnasal wiring of the medial canthal tendon. Instead of using the flap transposition and transnasal wiring, we made a 4mm horizontal incision at the epicanthal region and shortened the medial canthal tendon in conjunction with double fold operation of 9 females aging from 16 to 29 (average, 20.6). Ten minutes after the injection of 1% lidocaine-1 : 100,000 epinephrine, an incision was made. Dissection of the medial canthal tendon was made in a careful and intensive manner in order to avoid injuring the angular artery. After full skeletonization of the tendon, an average of 4-6 mm of the tendon was resected and sutured with 4-0 clear nylon. Skin was sewed with two layers of 6-0 nylon. Steri-strips were applied to the wounds for a period of three months. Photogrammetric analysis of three proportional indices was carried out 6-19 months (average 6.04 months) after the surgery with the use of Photoshop. The proportional indices had intercanthal distance x 100/palpebral fissure width, and upper and lower interepicanthal distance x 100/palpebral fissure width. Postoperative proportional indices of the three levels were decreased statistically: from 159 to 150 at the medial canthus; from 168 to 164 at lower epicanthus; and from 195 to 181 at upper epicanthus. However, these indices increased slightly with time: from 143 to 150 at the medial canthus; from 152 to 164 at lower epicanthus; and from 160 to 181 at upper epicanthus. The resultant scar was short and inconspicuous except for one case which had revealed a white color. A short horizontal incision and shortening of the medial canthal tendon are supposed to be effective techniques to reduce the epicanthal fold, but not a way to completely eliminate the fold with minimal scar. The reason to why the results appeared to worsen with time was probably due to the relapse at the tendon repair. Therefore, over-resection and rigid fixation of the tendon would overcome the relaps

Various Clinical Application of the Bead Stitch Method

A double eyelid plasty is performed by an incision technique or a nonincision technique, the latter comprising a stitch method and a buried suture method. With this surgery, an appropriate design and operative technique must be selected into careful consideration of patient's desire and eyelid condition. Patients were classified into four groups according to age and upper eyelid condition and got double eyelid plasty, modified techniques based on the Shirakabe's bead stitch method by each group. From above mentioned techniques, authors obtained a relatively successful result, so authors would like to report the outcome of the modified surgery methods. In this study, bead stitch method was performed in 405 patients(402 females, 3 males, average 31.2 years) from January to December of 2001. The follow up period ranged from one month to four years. Preoperatively, considering the patient's age, skin laxity of the upper eyelid and quantity of periorbital fat, patients was divided into four groups. For the bead stitch method, the eyelid is everted by raising the eyelash, and No. 2 braided white silk suture 16 cm in length is thrust from the two third of upper tarsal rim on the conjunctival side to the anticipated point on the skin side by using No. 5 round needle. The other end of the suture is guided out at a 4 to 5 mm distance from that point in a similar manner, such a procedure is usually carried out six to seven times for each eye. Simultaneously, if necessary, defattimg, skin undermining and upper blepharoplasty was also performed. Most of our patients were satisfied except thirteen cases with minor complications(mild asymmetry: 7 cases, sunken eye: 3 cases and high fold: 3 cases). But, the post operative palpabral swelling is comparatively strong. In conclusion, Some of the positive aspects were the followings: Lowering the chance getting an infection from stitches, the prevention of loosening by the scars forming double eyelids, and the development of natural double eyelids coming from the even pressure on the upper eyelids by the glass beads. Moreover, the new method improves, by combining the bead stitch method with the blepharoplasty, the prior incision method, which was difficult to apply to eyelids with excessive skin, therefore being able to expect more successful results from all age groups.

Development of a Chronic Skin Wound Defect: A Swine Model

PURPOSE: Animal models of a chronic wound are yet to be fully developed, and animal studies on this subject has yet to take place. The purpose of this study is to create the foundation for research on chronic wound healing based on a swine model, the most similar to that of a human. METHODS: Three female 2-3 month old 'yolkshires' were used. Total of eight full thickness skin defects, 6 x 3 cm sized, were created on the back of each pigs. Three groups were created for comparison; Group I (n=4) was left as they were after full skin thickness excision, while the excised tissues of Group II (n=3) were turned inside out and sutured so that the epidermis would come in contact with the fascia. Group III (n=3) were excised full skin thickness in depth and silicone blocks were implanted in them. Dressing was not practised so that the wounds would be vulnerable to infection. RESULTS: In Group III, the skin contraction rate was the least among the three groups for each three weeks of observation respectively. Also during the three weeks, bacteral colonization was at the highest among the comparison. On the third week, inflammatory cells were still active, but the generations of epidermis and collagen synthesis were detected minimally. CONCLUSION: The Group III was relatively the most similar model of chronic wounds. and modification of the silicone blocks, could provide us with a very effective chronic skin wound model similar to human.