Autologous Fat Graft in the Reconstructed Breast: Fat Absorption Rate and Safety based on Sonographic Identification

BACKGROUND: Autologous fat graft has become a useful technique for correction of acquired contour deformity in reconstructed breasts. However, there remains controversial regarding the efficacy and safety of the practice for reconstructive breast surgery. METHODS: A retrospective review was performed on 102 patients who had secondary fat grafting after breast reconstruction. Fat harvest, refinement and injection were done by Coleman's technique. All patients were followed up postoperatively within 1 month and after 6 months including physical examination and ultrasonography. In 38 patients, the reabsorption rate was calculated by serial changes of thickness between skin and pectoral fascia in the ultrasonic finding. Locoregional recurrence rate was compared with control group of 449 patients who had breast reconstruction without fat graft in the same time period. RESULTS: Average 49.3 mL fat was injected into each breast. The most common location of fat graft was upper pole, followed by axilla, lower and medial breasts. During 28.7 months of average follow-up period, 2.9% of total patients had symptoms of palpable mass on fat graft side and ultrasonography identified fat necrosis and cyst formation in 17.6% of the patients. Calculated fat reabsorption rate was 32.9%. Locoregional recurrence was occurred in 1 patient (0.9%) and the rate was not different significantly with control group (2%). CONCLUSIONS: Although further studies are required to provide surgeons with definitive guidelines for the implementation of fat grafting, we propose autologous fat graft is an efficient and safe technique for secondary breast reconstruction.

Effectiveness of Helmet Cranial Remodeling in Older Infants with Positional Plagiocephaly

BACKGROUND: Management of positional plagiocephaly by wearing a cranial molding helmet has become a matter of growing medical interest. Some research studies reported that starting helmet therapy early (age 5 to 6 months) is important and leads to a significantly better outcome in a shorter treatment time. The aim of the present study was to evaluate the effectiveness of cranial remodeling treatment with wearing helmet for older infants (> or =18 months). METHODS: We conducted a retrospective study of 27 infants with positional plagiocephaly without synostosis, who were started from 2008 to 2012. Every child underwent a computerized tomography (CT) before starting helmet therapy to exclude synostosis of the cranial sutures and had CT performed once again after satisfactory completion of therapy. Anthropometric measurements were taken on using spreading calipers in every child. The treatment effect was compared using cranial vault asymmetry (CVA) and the cranial vault asymmetry index (CVAI), which were obtained from diagonal measurements before and after therapy. RESULTS: The discrepancy of CVA and CVAI of all the patients significantly decreased after cranial molding helmet treatment in older infants (> or =18 months) 7.6 mm from 15.6 mm to 8 mm and 4.51% from 9.42% to 4.91%. Six patients had confirmed successful outcome, and all subjects were good compliance patients. The treatment lasted an average of 16.4 months, was well tolerated, and had no complication. Additionally, the rate of the successful treatment (final CVA < or =5 mm) significantly decreased when the wearing time per was shorter. CONCLUSION: This study showed that treatment by cranial remodeling orthosis was effective if the patient could wear the helmet longer and treatment duration was somewhat longer than in younger patients, well tolerated in older infants and had no morbidity. This therapeutic option is available and indicated in these older infants before other cranial remodeling surgery.

Effectiveness of Helmet Cranial Remodeling in Older Infants with Positional Plagiocephaly

BACKGROUND: Management of positional plagiocephaly by wearing a cranial molding helmet has become a matter of growing medical interest. Some research studies reported that starting helmet therapy early (age 5 to 6 months) is important and leads to a significantly better outcome in a shorter treatment time. The aim of the present study was to evaluate the effectiveness of cranial remodeling treatment with wearing helmet for older infants (> or =18 months). METHODS: We conducted a retrospective study of 27 infants with positional plagiocephaly without synostosis, who were started from 2008 to 2012. Every child underwent a computerized tomography (CT) before starting helmet therapy to exclude synostosis of the cranial sutures and had CT performed once again after satisfactory completion of therapy. Anthropometric measurements were taken on using spreading calipers in every child. The treatment effect was compared using cranial vault asymmetry (CVA) and the cranial vault asymmetry index (CVAI), which were obtained from diagonal measurements before and after therapy. RESULTS: The discrepancy of CVA and CVAI of all the patients significantly decreased after cranial molding helmet treatment in older infants (> or =18 months) 7.6 mm from 15.6 mm to 8 mm and 4.51% from 9.42% to 4.91%. Six patients had confirmed successful outcome, and all subjects were good compliance patients. The treatment lasted an average of 16.4 months, was well tolerated, and had no complication. Additionally, the rate of the successful treatment (final CVA < or =5 mm) significantly decreased when the wearing time per was shorter. CONCLUSION: This study showed that treatment by cranial remodeling orthosis was effective if the patient could wear the helmet longer and treatment duration was somewhat longer than in younger patients, well tolerated in older infants and had no morbidity. This therapeutic option is available and indicated in these older infants before other cranial remodeling surgery.

Palatal Mucoperiosteal Island Flaps for Palate Reconstruction

BACKGROUND: Many options are available to cover a palatal defect, including local or free flaps. The objective of this study was to evaluate the usefulness of palatal mucoperiosteal island flap in covering a palatal defect after tumor excision. METHODS: Between October 2006 and July 2013, we identified 19 patients who underwent palatal reconstruction using a palatal mucoperiosteal island flap after tumor excision. All cases were retrospectively analyzed by defect location, size, tumor pathology, type of reconstruction, and functional outcomes. Speech and swallowing functions were evaluated using a 7-point visual analog scale (VAS) score. RESULTS: Among the 19 patients, there were 7 men and 12 women with an age range of 25 to 74 years (mean, 52.5+/-14.3 years). The size of flaps was 2-16 cm2 (mean, 9.4+/-4.2 cm2). Either unilateral or bilateral palatal island flaps were used depending on the size of defect. During the follow-up period (mean, 32.7+/-21.4 months), four patients developed a temporary oronasal fistula, which healed without subsequent operative. The donor sites were well re-epithelized. Speech and swallowing function scores were 6.63+/-0.5 and 6.58+/-0.69 on the 7-point VAS, indicating the ability to eat solid foods and communicate verbally without significant disability. CONCLUSION: The palatal mucoperiosteal island flap is a good reconstruction modality for palatal defects if used under appropriate indications. The complication rates and donor site morbidity are low, with good functional outcomes.

Palatal Mucoperiosteal Island Flaps for Palate Reconstruction

BACKGROUND: Many options are available to cover a palatal defect, including local or free flaps. The objective of this study was to evaluate the usefulness of palatal mucoperiosteal island flap in covering a palatal defect after tumor excision. METHODS: Between October 2006 and July 2013, we identified 19 patients who underwent palatal reconstruction using a palatal mucoperiosteal island flap after tumor excision. All cases were retrospectively analyzed by defect location, size, tumor pathology, type of reconstruction, and functional outcomes. Speech and swallowing functions were evaluated using a 7-point visual analog scale (VAS) score. RESULTS: Among the 19 patients, there were 7 men and 12 women with an age range of 25 to 74 years (mean, 52.5+/-14.3 years). The size of flaps was 2-16 cm2 (mean, 9.4+/-4.2 cm2). Either unilateral or bilateral palatal island flaps were used depending on the size of defect. During the follow-up period (mean, 32.7+/-21.4 months), four patients developed a temporary oronasal fistula, which healed without subsequent operative. The donor sites were well re-epithelized. Speech and swallowing function scores were 6.63+/-0.5 and 6.58+/-0.69 on the 7-point VAS, indicating the ability to eat solid foods and communicate verbally without significant disability. CONCLUSION: The palatal mucoperiosteal island flap is a good reconstruction modality for palatal defects if used under appropriate indications. The complication rates and donor site morbidity are low, with good functional outcomes.

Crush Syndrome Resulting from the Use of a Tourniquet: A case report / 대한마취과학회지

Although tourniquet application is a widely accepted adjuvant technique in the field of extremity surgery, its complication may be neglected. A 37-year-old healthy male underwent arthroscopic surgery for left posterior cruciate ligament reconstruction under a combination of spinal and epidural anesthesia. During the eleven hour operation, a tourniquet was applied four times in nine hours on the left thigh. The pressure reached 450 millimeters of mercury. Compartment syndrome developed with muscle ischemia and edema postoperatively. On the first day of the operation, a fasciotomy was performed to prevent the development of crush syndrome. However, bleeding due to vascular injury during the fasciotomy continued and crush syndrome including myoglobinemic renal failure, hyperkalemia, hypovolemic shock, and cardiac arrhythmia developed. On the second day, sudden cardiac arrest occurred during artery ligation. The patient was immediately resuscitated; he recovered, but his mental state was stuporous. Thereafter, the patient was cared intensively for eight days with fluid and electrolyte therapy, ventilatory care, hemodialysis, antibiotics for crush syndrome and renal failure, but the result was unsuccessful.

Facial Nerve Paralysis after General Anesthesia: A case report / 대한마취과학회지

A 42-year-old male was scheduled for left fronto-temporo-parietal craniotomy and subdural hematoma removal under general anesthesia. The past history was diabetes mellitus, hypertension, and chronic alcoholism. He was moderately obese, short neck, and deep drowsy. After rapid sequence induction with fentanyl, thiopental sodium and succinylcholine, anesthesia was maintained with nitrous oxide-oxygen-isoflurane. His head was fixed on horseshoe head rest with right side tilted. Throughout the 4 hours of anesthesia, cardiovascular and respiratory variables remained within normal limit. After extubation, upper respiratory obstruction developed, presumably as the result of the tongue's falling back against the posterior pharyngeal wall. This was only partly corrected by insertion of a rubber oral airway, but it was fully relieved when the lower jaw was lifted forward by bilateral digital pressure applied behind the angles of the mandible about ten minutes. At the intensive care unit, left partial facial nerve paresis developed with mild weakness of the right corner of the mouth, and striking right parotid swelling and tenderness. The parotid swelling receded over 2 weeks, and the paresis resolved over 3 weeks to complete recovery.

Efficacy of a Simulated Epidural Test Dose in Isoflurane-Anesthetized Adults / 대한마취과학회지

BACKGROUND: An epidural test dose containing epinephrine may be incomplete marker of incidental intravenous injection or migration of the epidural catheter in adult patients under general anesthesia. This study tests the hypothesis that the efficacy of simulated epidural test doses in anesthetized adult can be used to predict the adequacy of correct catheter placement. METHODS: Seventy-five healthy adult patients were randomly assigned to inject intravenously one of 5 solutions, either 2% lidocaine 3ml and epinephrine 15 microgram(Group E15, n=15) or epinephrine 20 microgram (Group E20. n=15) or isoproterenol 3microgram (Group I3, n=15) or isoproterenol 5microgram (Group I5, n=15) and 0.9% saline(Group NS, n=15), which was anesthetized with isoflurane and nitrous oxide. After the injection, a blinded observer recorded systolic blood pressure(SBP) and heart rate(HR) every 30seconds for 4minutes and the changes were analyzed. RESULTS: Although none in the saline group developed a HR increase> or20bpm, 6, 10, 12 and 15 patients elicited positive reponses in group E15, I3, E20, and I5(40%, 67%, 80% and 100% sensitivities), respectively. Meanwhile, none in the saline group developed a SBP increase> or15mmHg and 11, 1, 14 and 4 patients elicited positive reponses in E15, I3, E20, and I5(73%, 7%, 93% and 27% sensitivities), respectively. CONCLUSIONS: We conclude that under isoflurane anesthesia, (a) epinephrine 15 microgram or isoproterenol 3microgram is not reliable marker for incidental intravenous injection or migration of the epidural catheter, (b) epinephrine 20 microgram is applicable on SBP criterion and, (c) isoproterenol 5 microgram is applicable on HR criterion.

The Effects of Single Epidural Triamcinolone Injection on the Blood ACTH and Cortisol Level / 대한마취과학회지

BACKGROUND: Epidural steroids injections are often used for the treatment of low back pain but their effects on the endocrine system have not been determined. Few studies have quantified the degree or duration of the suppression of the hypothalamic-pituitary-adrenal (HPA) axis in humans given epidural triamcinolone injection (ETI) for low back pain. The evaluation of the blood adrenocorticotropic hormone (ACTH) and cortisol was undertaken to determine the extent of suppression of the HPA axis in patients given ETI. METHODS: Lumbar epidural triamcinolone injections were performed on the painful lumbar intervertebral space with patients in the lateral decubitus position. The injection consisted of 40 mg of triamcinolone acetonide diluted in 10 mL of 1% lidocaine. Patients remained in the lateral position for 10 min after the procedure. Basal blood sampling was performed at 30 min before ETI and tested blood sampling was obtained at 7 days, 10 days, and 14 days after ETI. RESULTS: The blood cortisol level was significantly decreased at 7 days and 10 days but at 14 days was not significantly decreased and the blood ACTH level was not significantly decreased at 7 days, 10 days, and 14 days. CONCLUSIONS: Above results demonstrate that blood ACTH and cortisol level normalize 7 days and 14 days, respectively, after epidural triamcinolone 40 mg injection.

The Ventilatory and Cardiovascular Changes during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Laparoscopic cholecystectomy has emerged rapidly as a popular alternative to tradidonal laparotomy and cholecystectomy in the management of cholelithiasis. The advantages of shorter hospital stay, more rapid return to normal activities are combined with less pain associated with the small limited incisions. But it has some disadvantages related to insufflation of a large amount of carbon dioxide into peritoneal cavity. METHODS: To investigate ventilatory and hemodynamic changes during laparoscopic cholecystectomy, we observed the changes in blood pressure (systole, diastole, mean), heart rate, end-tidal carbon dioxide tension (PerCO2), arterial carbon dioxide tension(PaCO2), and arterial oxygen tension(PaO2) at intervals during general anesthesia with controlled ventilation (tidal volume: 10 mg/kg, ventilatory rate: 10 breaths/min). RESULTS: Mean arterial pressure was increased significantly until 30 minutes after carbon dioxide insufflation(p<0.05). Heart rate was not changed significantly throughout the operation. End-tidal carbon dioxide tension and arterial carbon dioxide tension were increased significantly during carbon dioxide insufflation(p<0.01), but arterial oxygen tension was not decreased significantly throughout the operation. CONCLUSIONS: This study described 19 patients who underwent laparoscopic cholecystectomy and analyzed the changes in hemodynamic and ventilatory parameters. It is important for anesthesiologist to monitor ventilation and hemodynamics carefully because the patients with cardiac or pulmonary diseases may be adversely affected by the hypercarbia associated with carbon dioxide insufflation.

Effect of Pre-vs. Post-incisional Lidocaine Infiltration on Postoperative Pain after Inguinal Herniorrhaphy / 대한마취과학회지

BACKGROUND: Recently many studies reported that the postoperative pain was prevented or decreased from preoperative regional anesthesia by preventing the establishment of central sensitization(pre-emptive analgesia). Therefore, we evaluated the efficacy of preincisional lidocaine infiltration on the postoperative pain. METHODS: We conducted a study to compare preinfiltrating group with 1% lidocaine (30 ml), postinfiltrating group with 1% lidocaine (30 ml) and non-infiltrating group in 45 patients scheduled for elective inguinal herniorrhaphy. During operation, all patients received a general anesthesia with thiopental, isoflurane and nitrous oxide in oxygen. Postoperatively, pain scores on visual analogue scale (VAS) and on verbal rating scale(VRS) at rest, coughing and movement from supine into sitting position were assessed. Also the time to first request for an on-demand postoperative analgesics and the total dose of postoperative analgesics were assessed. And the number of patients who didn't require any analgesics during postoperative period was assessed. RESULTS: The VAS and VRS at rest, coughing, movement were low in preinfiltrating group than in non-infiltrating group and postinfiltrating group postoperatively, but it was statistically significant only in early postoperative period. The time to first request for an on-demand postoperative analgesics occurred later in preinfiltrating group than in non-infiltrating group and in postinfiltrating group and the total dose of supplemental analgesics (ketorolac) was smaller in the preinfiltrating group than in non-infiltrating group and postinfiltrating group, and the patients without analgesic treatment was less in the preinfiltrating group than in non-infiltrating group and postinfiltrating group, but it was not statistically significant. CONCLUSIONS: In patients with inguinal herniorrhaphy, we can not support the pre-emptive analgesia clinically with preincisional lidocaine infiltration.

Anesthetic Experience of Adrenalectomy with Primary Aldosteronism / 대한마취과학회지

Primary aldosteronism is a clinical syndrome referring to increased and inappropriate production of aldosterone from adrenal gland due to a solitery adenoma, bilateral hyperplasia or an adrenal carcinoma and this syndrome is characterized by hypertension, hyporeninemia, and hypokalemia and its manifestations. Under the general anesthesia, operation was performed on a 34-year-old male, who was diagnosed as primary aldosteronism caused by aldosterone producing adenoma and we have experienced the anesthetic management of unilateral adrenalectomy during perioperative periods.

The Effect of Labetalol on the Hemodynamic Response to Endotracheal Intubation / 대한마취과학회지

Transient increases in blood pressure and heart rate following laryngoscopy and endotra- cheal intubation are common. These stress responses are greatly exaggerated in patients with hypertension and cardiovascular diseases and can lead to cardiac arrhythmia, pulmo- nary edema, and cerebral hemorrhsge. Many approaches have been tried to attenuate these potentially adverse circulatory responses but none has been satisfactory. This study was made to evaluate the hemodynamic responses to tracheal intubation using combined alpha-and beta-adrenoreceptor blocking agent, labetalol. We intravenously administered labetalol or placebo prior to laryngoscopy and tracheal intubation in adult patients with ASA class 1, or 2. Sixty patients were randomly assigned to one of three treatment groups. Group 1 patients (control group,n=20) received normal saline 3ml, Group 2 patients (n=20) received labetalol 0.3mg/kg, and Group 3 patients (n= 20) received labetalol 0.6mg/kg intravenously. These drugs were injected 3 minutes before induction with thiopental sodium (5mg/kg). Succinylcholine chloride 1.0mg/kg i.v. was used to facilitate endotracheal intubation. After the completion of intubation, nitrous oxide/oxygen with enflurane or isoflurane was administered. The blood pressure and heart rate were measured upon arrival in the operating room (baseline), immediately before intubation, immediately after intubation, 1 minutes after intubation and at 2, 3, 5, 7, 10 minutes after intubation. There were no significant differences in preinduction values of blood pressure and heart rate. A significant reduction in heart rate was observed in the group 3, group 2 in that order compared with the group 1. Similarly, systolic, diastolic and mean arterial pressure de- creased in labetalol groups, but was not significantly different in all groups. None of the patients experienced any untoward side effects, such as hypotension, aignificant bradycardia, bronchospasm or electrocardiographic ehanges. In conclusion, in patients with no history of hypertension or significant cardiac disease, labetalol 0.3 or 0.6mg/kg i.v. is better suited to blunting tachycardia than to blunting hypertension to laryngoscopy and intubation.

Changes in End Tidal CO2 before and After Release of Tourniquet / 대한마취과학회지

In 24 healthy adult patients having orthopedic surgical procedures requiring the use of a tourniquet under general anesthesia with controlled mechanieal ventilation, we have deter- mined ehanges in end tidal CO2(PetCO2) and arterial blood gas values before and after release of tourniquet. After deflation of tourniguet, PETCO and PaCO2 increased significantly with the maximal elevation occuring within two minutes. The pH level decreased significantly and maximally within three minutes. There was statistically significant linear correlation between PCO and PaCO2 Sugesting prediction of the PaCO2, level by monitoring the PetCO2 level. On these findings, hyperventilation may be indicated to facilitate the return of PaCO2 and pH to baseline just before and for several minutes after tourniquet release, especially in patients with increased intracranial pressure. In conclusion, we recommend noninvasive monitoring of the PetCO2 level instead of invasive measure-ment of the PaCO2 level.

Severe Bradycardia & Hypotension during Spinal Anesthesia / 대한마취과학회지

Spinal anesthesia has been widely used for operations performed in the lower abdomen, inguinal regions, lower extremities, and perineum. When patient have aevere systemic disease and a full . stomach, spinal anesthesia is may be more safe than general aneethesia. Bradycardia and hypotension have been accepted to be the most common complications in cardio-vascular system during spinal anesthesia. The mechanisms are a decrease in total peripheral vascular resistance, a decrease in cardiac output or a combination of both. Accessory factors include bradycardia resulting from block of accelerator impulses to the heart or decrease in endogeneous release of norepinephrine from sympathetic nerve endings, thereby reducing myocardial contractility. We report 2 cases of sudden extreme bradycardia and hypotension in patients who had received spinal anestesia. Although the exact pathophysiology of this phenomenon is unknown, the etiology is probably vagal effect. Thus the patient who receives spinal anestbesia should be required constant monitoring and vigilance throughout all procedures.

The Comparison of Vecuronium with Succinylcholine for Endotracheal Intubation / 대한마취과학회지

Depolarizing muscle relaxant, succinylcholine, has a rapid onset of action, allowing early endotracheal intubation. Succinylcholine, however, has a number of undesirable side effects. Therefore, some methods using nondepolarizing muscle relaxants for rapid endotracheal intubation have been tried, i.e. single large bolus, priming principle, timing principle, but their results were not enough to satisfy. In this study, there were administered vecuronium prior to anesthetic induction in order to shorten the intubation time, and compared intubation time and intubating condition in succinylcholine and vecuronium groups respectively. Sixty adult patients were adminstered succinylcholine 1mg/kg(group 1, 30 patients) or vecuronium 0.15 mg/kg(group 2, 30 patients), and measured intubation time and intubating condition. As a result, intubation time and intubation condition was not different in both groups significantly. It is concluded that vecuronium administered prior to induction agent for the endotracheal intubation is a reliable alternative in cases where succinylcholine is contraindicated.

The Comparison of Vecuronium with Succinylcholine for Endotracheal Intubation / 대한마취과학회지

Depolarizing muscle relaxant, succinylcholine, has a rapid onset of action, allowing early endotracheal intubation. Succinylcholine, however, has a number of undesirable side effects. Therefore, some methods using nondepolarizing muscle relaxants for rapid endotracheal intubation have been tried, i.e. single large bolus, priming principle, timing principle, but their results were not enough to satisfy. In this study, there were administered vecuronium prior to anesthetic induction in order to shorten the intubation time, and compared intubation time and intubating condition in succinylcholine and vecuronium groups respectively. Sixty adult patients were adminstered succinylcholine 1mg/kg(group 1, 30 patients) or vecuronium 0.15 mg/kg(group 2, 30 patients), and measured intubation time and intubating condition. As a result, intubation time and intubation condition was not different in both groups significantly. It is concluded that vecuronium administered prior to induction agent for the endotracheal intubation is a reliable alternative in cases where succinylcholine is contraindicated.

Anesthesia for Thymectomy in Patient with Myasthenia Gravis - Two cases report / 대한마취과학회지

Malignant hyperthermia is an inherited disorder of skeletal muscle, characterized by temperature elevation, muscle destruction, muscle rigidity and high oxygen consumption, etc. It is triggered by anesthetic agents, usually potent inhalation anesthetics and succinylcholine. It is fatal in the majority of cases unless early diagnosis andtreatment are performed. We experienced a case of malignant hyperthermia after general anesthesia with succinylcholine and halothane. The case is presented of an 11 year old male weighing 35.5kg. He had developed the strabismus one year prior, but he was relatively healthy and had no considerable past or family history. He underwent surgery for correction of the strabismus under N2O-O2-halothane anesthesia with induction by thiopental and succinycholine. Approximtely 25 minutes after induction tachycardia developed, followed by severe arrhythmia with unstable BP, temperature elevation and cyanosis. About 30 minutes after induction, anesthesia was stopped and aggressive emergency management was performed. Unfortunately, the patient died 4 hours and 30 minutes after induction. We discuss this case and review the history, incidence, etiology, pathophysiology, symptoms, diagnosis, pervention and treatment.

Retrograde Endotracheal Intubation Using Epidural Catheter / 대한마취과학회지

Since in 1963 Waters first described the techniques of guiede blind tracheal intubation to solve the problem of difficult in airway maintenance in patients who have deformity of the upper jaw, several methods are recommended to overcome a difficult intubation. We experienced successful retrograde endotracheal intubation without significant complications as follows. Using loca anethesia, 16G Tuohy needle was passed through the anterior wall of the trachea 1.5 to 2.0 cm below the cricoid cartilage in the midline. The needle was directd upward foward the larynx and the epidural catheter was insertedc through it and advanced retrograde between the vocal cords and into mouth or nose. The endotracheal tube was threaded over the catheter and the proximal end of the catheter was clamps by kelly forceps. By keeping the catheter taut and coincidently pulling back, the tube was adnvanced in to trachea.

Retrograde Endotracheal Intubation Using Epidural Catheter / 대한마취과학회지

Since in 1963 Waters first described the techniques of guiede blind tracheal intubation to solve the problem of difficult in airway maintenance in patients who have deformity of the upper jaw, several methods are recommended to overcome a difficult intubation. We experienced successful retrograde endotracheal intubation without significant complications as follows. Using loca anethesia, 16G Tuohy needle was passed through the anterior wall of the trachea 1.5 to 2.0 cm below the cricoid cartilage in the midline. The needle was directd upward foward the larynx and the epidural catheter was insertedc through it and advanced retrograde between the vocal cords and into mouth or nose. The endotracheal tube was threaded over the catheter and the proximal end of the catheter was clamps by kelly forceps. By keeping the catheter taut and coincidently pulling back, the tube was adnvanced in to trachea.