Is It Necessary to Use Dextran in Free Flap Surgery?

PURPOSE: Low-molecular-weight dextran is one of the most frequently used antithrombotic agents in microvascular surgery, but there is controversy whether it has the real benefit in the clinical aspects or not. The purpose of this study is to evaluate the effect associated with postoperative use of low-molecula-weight dextran in breast reconstruction by free TRAM flap patients. METHODS: From January 2002 to October 2008, we reconstructed 88 cases of postmastectomy deformity using the free TRAM flap. They were divided into two groups: a group with no use of dextran(66 patients, control group, Group A) and a postoperative low-molecular weight dextran loaded group(22 patients, Group B). We assessed number of flap survival, rate of complication like hematoma or seroma, total amount of drainage from operative wound, duration of drainage, and amount of transfusion in each group. RESULTS: There was no total flap loss and every flap was survived. Total amount of drainage on post-operative 5 days were 857mL in group A and 1101mL in group B. Drain was kept for average of 7.3 days in group A and 8.7 days in group B. Packed red cell transfusions were made in average of 3.3 units for group A and 3.0 units for group B. Group B showed significantly higher values in former 2 comparative parameters than group A. CONCLUSION: There was no definitive advantage of anticoagulants in elective free-flap surgery in terms of success rate. However, groups with using anticoagulants had the increased bleeding tendency in immediate postoperative period. The routine use of anticoagulants in elective free-flap surgery should be reconsidered with postoperatively less bleeding and early recovery.

Case Report of Kimura's Disease Treated by Radical Resection and Post Operative Steroid Therapy

PURPOSE: Kimura's disease is a relatively rare head and neck tumor that frequently occurs in young orientals accompanied by eosinophila. We shared our experience of two cases of Kimura's disease, treated by radical resection and post operative steroid therapy, so we report the correlation of eosinophil counts and disease progression. METHODS: A 25 years old male came to the clinic with a mass localized to the right cheek inferior to the right auricle. We could not resect the mass totally. During the follow up period, we checked the eosinophil counts, and steroid therapy was started 7 months after the surgery. A 34 year old female came to the clinic with a mass localized inferior to the left auricle reaching from the posterior portion of the auricle to the left temporal portion. We tried to remove as much tumor as possible, save the temporal region, in regard to the impairment of blood supply to the auricle. After the operation, steroid therapy was started. RESULTS: In the first case, the tumor was easily approachable, and radical resection of the tumor with post operative steroid therapy was an effective treatment. In tumors located at difficult regions to remove, as in the second case, optimal debulking and post operative steroid therapy was also effective in treating Kimura's. There were no recurrences in both cases. Eosinophil counts were always reduced after surgery and steroid therapy, and during the period with low eosinophil counts, there was no recurrence of Kimura's disease. CONCLUSION: Surgery and post operative steroid therapy were effective in treatment of Kimura's disease, and we could assume eosinophil counts as a good indicator for evaluation of the prognosis of Kimura's disease during the follow up period

Consideration on Flap Surgery in Vegetative Patients Having Nosocomial Infection

PURPOSE: The vegetative state is a clinical condition with complete unawareness of self and environment, but with preservation of brain-stem functions. Vegetative patients may have nosocomial infections in their wounds, such as pressure sores and infected craniums after cranioplasties. Flap surgery is usually necessary for those wounds, but decision of undergoing surgery is difficult because of various adverse conditions of vegetative patients. We share our experience of several successful flap surgeries in vegetative patients, and evaluate obstacles and requirements to obtain satisfactory results. METHODS: From December 2005 to September 2008, a total of 4 vegetative patients underwent surgeries. In case of 2 patients with infected artificial craniums, scalp reconstructions with free flaps were performed. In case of other 2 patients with huge pressure sores with sepsis, island flap coverage of wounds was performed. Retrospective study was made of hospitalization period, vegetative period, number of surgeries performed, underlying diseases, causative bacteria, and contents of informed consent. RESULTS: Mean hospital day was 14 months and mean vegetative period was 17.5 months. Patients underwent average of 4.5 surgeries under general anesthesia. There were several underlying diseases like hypertension, DM, CHF and chronic anemia. MRSA (Methicilinresistant Staphylococcus aureus) was cultured from every patient's wounds. Informed consent included a warning for high mortality and a need of attentive familial cooperation. CONCLUSION: There are three requirements for doing flap surgeries in vegetative patients. First, to prevent aggravation of brain damage and underlying diseases by general anesthesia, multidisciplinary team approach is needed. Second, operation should be beneficial for prolonging patient's lifespan. Third, because postoperative care is very difficult and long hospitalization is needed, detailed informed consent and highly cooperative attitude of family should be confirmed before operation.

Case Reports of Patients having Intermediate Soft Tissue Tumors

PURPOSE: Malignant soft tissue tumors, known as sarcomas, are well known to be locally aggressive, frequently metastatic, and highly recurrent. In other hands, intermediate soft tissue tumors often recur locally with adjacent tissue infiltration so the clinical management is difficult as sarcoma. In the present study, we evaluate the clinical course of the intermediate soft tissue tumors and consider the management plan for those. METHODS: From March, 1998 to April 2008, total 3 patients of intermediate soft tissue tumors underwent operations. A patient with fibrohistiocytic neoplasm, a free flap reconstruction was performed, and he underwent several more operations because of recurrences. Other patients with desmoids-type fibromatosis showed local invasion and adhesion, and one of them underwent reoperation due to local recurrence. RESULTS: Two of 3 patients underwent recurrences of tumors and reoperations were performed. In case of the other patient with no recurrence, follow-up period was just 5 months, so there may be recurrence of tumor in long term follow-up. CONCLUSION: The clinical course of intermediate soft tissue tumors shows high recurrence rate. So clinically, intermediate soft tissue tumors should be considered as sarcomas. The successful management requires wide resection, carefully planned reconstruction, and close follow up with radiologic evaluation