Personal technique for definite repair of complete unilateral cleft lip: modified Millard technique

BACKGROUND: Millard’s rotation-advancement repair, which is used by many surgeons, can make a natural philtral column, but most surgeons use a modification of the rotation-advancement flap. The purpose of this article is to introduce a modification utilized by the authors and to provide detailed surgical procedure. METHODS: We retrospectively reviewed 82 patients’ medical records and presented surgical technique and outcomes. The main features of the authors’ strategy are emphasizing horizontal length of the lip, orbicularis oris muscle duplication for improving the definition of the philtral column, overcorrection of domal portion than the non-cleft side in order to compensate for the recurrence during growth. Two judges rated two times the appearance of the patients’ nose and lip using Asher-McDade aesthetic index. Intra- and interobserver reliabilities were determined using Cohen’s kappa statistics. RESULTS: All patients recovered eventually after surgery; however, two patients have a minor complications (wound infection in one patient, wound disruption due to trauma in the other patient). The improvement of the aesthetic results can be achieved with this modified Millard technique. Total mean scores of the Asher-McDade index was 2.08, fair to good appearance. The intraobserver reliabilities were substantial to almost perfect agreement and the interobserver reliabilities were moderate to almost perfect agreement. CONCLUSION: We modified Millard method for repair of complete unilateral cleft lip. The surgical outcomes were favorable in long-term follow-up. We hope our technique will serve as a guide for those new to the procedure.

Anatomical and Functional Recovery of Neurotized Remnant Rectus Abdominis Muscle in Muscle-Sparing Pedicled Transverse Rectus Abdominis Musculocutaneous Flap

BACKGROUND: Pedicled transverse rectus abdominis musculocutaneous flaps typically sacrifice the entire muscle. In our experience, the lateral strip of the rectus abdominis muscle can be spared in an attempt to maintain function and reduce morbidity. When the intercostal nerves are injured, muscle atrophy appears with time. The severed intercostal nerve was reinserted into the remnant lateral strip of the rectus abdominis muscle to reduce muscle atrophy. METHODS: The authors retrospectively reviewed 9 neurotized cases and 10 non-neurotized cases. Abdominal computed tomography was performed to determine the area of the rectus muscles. Electromyography (EMG) was performed to check contractile function of the remnant muscle. A single investigator measured the mean areas of randomly selected locations (second lumbar spine) using ImageJ software in a series of 10 cross-sectional slices. We compared the Hounsfield unit (HU) pre- and postoperatively to evaluate regeneration quality. RESULTS: In the neurotization group, 7 of 9 cases maintained the mass of remnant muscle. However, in the non-neurotization group, 8 of 10 lost their mass. The number of totally atrophied muscles in each of the two groups was significantly different (P=0.027). All of the remnant muscles showed contractile function on EMG. The 9 remaining remnant rectus abdominis muscles showed declined the HU value after surgery but also within a normal range of muscle. CONCLUSIONS: Neurotization was found to be effective in maintaining the mass of remnant muscle. Neurotized remnant muscle had contractile function on EMG and no fatty degeneration by HU value.

Treatment of Diabetic Foot Ulcer Using Matriderm In Comparison with a Skin Graft

BACKGROUND: For patients with neuropathy, vasculopathy, and impairment of wound healing, treatment of a diabetic foot ulcer poses many challenges. A large number of dermal analogues have been invented in an effort to overcome these challenges. Matriderm, a dermal analogue, is made from bovine collagen and elastin. This study was conducted in order to evaluate the effectiveness of Matriderm for treatment of diabetic foot ulcers, in comparison with skin grafting. METHODS: Sixty patients with diabetic foot ulcer were included in this prospective study. The average age of the patients, who had type II diabetes mellitus, was 58 years old. The patients were allocated to an experimental or control group with their consents. The patients were selected with their consent for inclusion in an experimental group and a control group. Patients in the experimental group received a Matriderm appliance and a split-thickness skin graft, while those in the control group received only a split-thickness skin graft. RESULTS: A shorter hospitalization period (7.52 weeks) was observed in the experimental group than in the control group (9.22 weeks), and a shorter period of time (8.61 weeks) was required for complete healing, compared with the control group (12.94 weeks), with statistical significance (P<0.05). A higher elasticity ratio of the affected side to the non-affected side was observed in the experimental group, compared with the control group (P<0.01). CONCLUSIONS: Matriderm enables effective healing and improves elasticity in treatment of patients with diabetic foot ulcer.

Evaluation of an Amniotic Membrane-Collagen Dermal Substitute in the Management of Full-Thickness Skin Defects in a Pig

BACKGROUND: To minimize the inflammatory reaction and improve healing, a new modified dermal substitute composed of an atelocollagen, chondroitin-6-sulfate, and amniotic membrane (AM) was applied to full-thickness skin defects in a pig. Atelocollagen was extracted from bovine skin, and two modified dermal substitutes were generated according to the cross-linking type. METHODS: The AM-collagen dermal substitutes were characterized and compared with currently used dermal substitutes in a pig skin defect model. There were five experimental groups: dehydrothermal (DHT) cross-linking atelocollagen with the AM on the top (AM-DHT), DHT and chemical cross-linking atelocollagen with the AM on the top (AM-DHT/chemical), Terudermis, Integra, and AlloDerm. After 3x3 cm full-thickness skin defects on the back of a pig were created, each dermal substitutes dermal substitutes was randomly grafted on the defects. Two weeks after grafting, autologous partial-thickness skin was over-grafted on the neodermis. The take rate of the dermal substitutes, skin, and histological sections were all assessed at 1, 2, and 4 weeks postoperatively. RESULTS: More rapid healing and a higher take rate were evident in the AM-DHT and Terudermis groups. Histological examination revealed fewer inflammatory cells and more fibroblast hyperplasia in these two groups. Four weeks after surgery, the amount of newly formed collagen was significantly more appropriate in the AM-DHT group. CONCLUSIONS: These observations provide supporting evidence that a newly developed amniotic-collagen dermal substitute may inhibit inflammatory reactions and promote wound healing.

Finger Tip Composite Grafting Managed with Moist-Exposed Dressing

PURPOSE: The purpose of this study was to determine whether keeping the wound moist improves the results of composite grafting of amputated fingertip. MATERIALS AND METHODS: Between 1997 and 2010, 93 patients with traumatic amputation of 100 digits have undergone composite finger tip graft. The hand was kept elevated and a topical antibiotics was frequently applied to avoid desiccation. Their ages ranged from 10 months to 73 years. We assessed the success rate based on age, amputation level, ischemic time and etiology. RESULTS: Of these 100 composite grafts, grafting had been successful in 65. Evaluation by age revealed that grafting had been successful in 13 of 18 fingers among patients less than 6 years old, in four of five fingers among those 6 to 15 years old and in 48 of 77 fingers among those 16 years of age and older. Assessment by level of amputation showed that grafting had been successful in 37 of 56 fingers amputated in zone I, in 12 of 19 fingers amputated in zone II and in 16 of 25 fingers amputated in zone III. No statistically significant differences in graft survival were found in relation to age, amputation level, ischemic time or type of amputation. CONCLUSION: Our results demonstrate that composite finger tip graft in adult is feasible and a very high rate of survival is obtained. We believe that moist-exposed dressings should improve the success rate associated with fingertip composite grafting.

Large Auricular Chondrocutaneous Composite Graft for Nasal Alar and Columellar Reconstruction

BACKGROUND: Among the various methods for correcting nasal deformity, the composite graft is suitable for the inner and outer reconstruction of the nose in a single stage. In this article, we present our technique for reconstructing the ala and columella using the auricular chondrocutaneous composite graft. METHODS: From 2004 to 2011, 15 cases of alar and 2 cases of columellar reconstruction employing the chondrocutaneous composite graft were studied, all followed up for 3 to 24 months (average, 13.5 months). All of the patients were reviewed retrospectively for the demographics, graft size, selection of the donor site and outcomes including morbidity and complications. RESULTS: The reasons for the deformity were burn scar (n=7), traumatic scar (n=4), smallpox scar (n=4), basal cell carcinoma defect (n=1), and scar contracture (n=1) from implant induced infection. In 5 cases of nostril stricture and 6 cases of alar defect and notching, composite grafts from the helix were used (8.9x12.5 mm). In 4 cases of retracted ala, grafts from the posterior surface of the concha were matched (5x15 mm). For the reconstruction of the columella, we harvested the graft from the posterior scapha (9x13.5 mm). Except one case with partial necrosis and delayed healing due to smoking, the grafts were successful in all of the cases and there was no deformity of the donor site. CONCLUSIONS: An alar and columellar defect can be reconstructed successfully with a relatively large composite graft without donor site morbidity. The selection of the donor site should be individualized according to the 3-dimensional configuration of the defect.

Treatment of Axillary Osmidrosis Using a Subcutaneous Pulsed Nd-YAG Laser

BACKGROUND: Axillary osmidrosis is characterized by an unpleasant odor, profuse sweating, and in some instances, staining of clothes that may socially and psychologically impair affected individuals. Various types of surgical procedures have been developed for the treatment of axillary osmidrosis. This study was undertaken to evaluate the effectiveness of subcutaneous pulsed neodymium: yttrium-aluminum-garnet (Nd-YAG) laser treatment for the treatment of axillary osmidrosis. METHODS: Twenty-nine patients with axillary osmidrosis were included in this study. Patients were categorized according to the results of an axillary malodor grading system, and a subcutaneous pulsed Nd-YAG laser was applied to all patients. The treatment area for the appropriate distribution of laser energy was determined using the iodine starch test (Minor's test) against a grid pattern composed of 2x2 cm squares. The endpoint of exposure was 300 to 500 J for each grid, depending on the preoperative evaluation results. The results were evaluated by measurement of axillary malodor both pre- and postoperatively using the grading system and iodine starch test. RESULTS: The average follow-up period was 12.8 months. Nineteen patients had a fair-to-good result and ten patients had poor results. The postoperative Minor's test demonstrated that there were remarkable improvements for patients with mild to moderate symptoms. Complications including superficial second degree burns (n=3) were treated in a conservative manner. A deep second degree burn (n=1) was treated by a surgical procedure. CONCLUSIONS: Subcutaneous pulsed Nd-YAG laser has many advantages and is an effective noninvasive treatment for mild to moderate axillary osmidrosis.

Correction of Upper Lip Depression Using Conchal Cartilage Graft in Unilateral Cleft Lip Deformity

PURPOSE: To correct the upper lip depression after the correction of unilateral cleft lip, autologous grafts such as bone, dermal, fascial grafts and fat injections or alloplastic implants are used. Transplanted bones, dermis and fascia have a tendency to be absorbed and have donor morbidity. Fat injections are absorbed inconsistently and alloplastic implants have problems such as foreign body reactions, protrusions and infections. Authors corrected the upper lip depression using conchal cartilage graft in unilateral cleft lip deformity and the results was analysed with photos. METHODS: 26-unilateral cleft lip and 2-microform cleft lip cases, totally 28 cases were performed. Their mean age was 21.89 years. The male and female cases were 12 and 16, respectivley. Under anesthesia (general: 18 cases and local: 10 cases), cavum conchae (n=8), cymba conchae (n=16) and whole conchae (n=4) were harvested. Transversely cut the margin of the obtained cartilage, we cut out the most bent portion and put a partial-thickness incision on concave surface in cases of excessive convexity. Then, we performed the onlay graft of the conchal cartilage via scar revision site in unilateral cleft lip and via the reconstruction site of the cupid bow in microform cleft lip. The augmentation of the upper lip was evaluated with photos. Adapting the baseline connecting between the both cheilions as a horizontal standard line, we measured the highest point among the tangents between the upper lip and nose (point a), the lowest point (point c), the middle point between a and c (point b) and the vertical line from the alare (point d) to the horizontal standard line. To assess the postoperative symmetry, we compared cleft side upper lip contour index (%) A,B,C,D=(a,b,c,d)-ch x 100/(ch-ch) and non-cleft side upper lip contour index (%) A',B',C',D'= (a',b',c',d')-ch x 100 / (ch-ch).h) RESULTS: After the surgery, no complication was found except in one case which double layers graft performed in the cleft lip deformity, the lateral portion was protruded. The upper lip contour index, the difference of A and A' were-0.83%, and thus the mild depression was persisted. Difference of B and B', C and C', D and D' were 0.83%, 1.07%, 0.90%. There were statistically significant difference, and thus the depression of upper lip were improved generally. CONCLUSION: Authors performed the onlay graft of the conchal cartilage in unilateral cleft lip deformity and found that the depression of the upper lip was well corrected except the uppermost part when photogrammetrically analyzed.

Web Uni-Limb Z-Plasty for Correction of Alar Web Deformity in Unilateral Cleft Lip Nasal Deformities: Photogrammetric Analysis

PURPOSE: In the treatment of the unilateral cleft lip nasal deformities, the correction of the low-nostril height and short-columella are very difficult problems. We report the treatment outcomes of web uni-limb Z-plasty used for correction of unilateral cleft lip nasal deformities by using photographic analysis. METHODS: A total of 36 patients with unilateral cleft lip nasal deformities were enrolled in this study, who underwent web uni-limb Z-plasty and were followed up for at least 6 months. First, a triangular flap was made on the medial side of alar-columella web. The nostril apex of cleft side was corrected to a higher point compared to noncleft side by 2 mm. The flap was transposed into the defect of the vestibule. To reduce the bulging of the flap, horizontal cinching sutures were added. Postoperative outcomes were evaluated by using photographic analysis. 2 indices and 1 angle were measured on their photographs taken before and after the surgery. Symmetry was also evaluated by means of the noncleft side to cleft side index. For anthropologic assessment, observers described postoperative outcomes, using Ordinary Scale Method. RESULTS: The postoperative values obtained in photographic analysis improved compared to preoperative ones. More improving anthropologic assessment was shown in post-than pre-operative. CONCLUSION: Although, further long term follow up is needed, we found this technique to be an effective procedure to the symmetry of nostril apex level and the lengthening of columella in the unilateral cleft lip nasal deformities.

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.

Characteristics of Wound Contraction according to the Shape and Antomical Regions of the Wound in Porcine Model

PURPOSE: The shape and location, the amount of the wound and the characteristics of the remaining tissues are known to influence wound contraction. The previous studies using small animals have not been an appropriate model because the wound healing mechanisms and skin structures are different from those of the human. The purpose of this study is to evaluate wound contraction according to the shape and location of the wound using a Micropig(R). METHODS: Four Micropigs(R)(Medikinetics, Pyeongtaek, Korea) that were 10 months of age weighed 25kg were used. Full thickness skin defects were made by clearing all the tissues above the fascial layer in the shape of square, a regular triangle and a circle of 9cm2 each on the back around the spine. Eight wounds were created on the back of each pig, 50mm apart from each other. The randomly chosen wound shapes included 11 squares, 11 regular triangles, and 10 circles. Wound dressing was done every other day with polyurethane foam. The wound size was measured using a Visitrak Digital(R)(Smith & Nephew, Hull, UK) on every other day after surgery from day 2 to day 28. A biopsy was performed on day 3, and 1, 2, 3 and 4 weeks to investigate the degree of acute and chronic inflammation, the number of microvesssel and myofibroblast density using H & E stain and immunohistochemistry. The wound contraction rate was calculated to figure out the differences among each of the shapes and the locations. RESULTS: The ultimate shape of the circle wound was oval, and that of the regular triangle and square were stellate. The maximum contraction rate was obtained on 8 to 10 days for all the shapes, which corresponds with the immunohistochemical finding that myofibroblast increases in the earlier 2 weeks whereas it decreases in the later 2 weeks. Epithelialization was seen in the wound margin on day 7 and afterwards. The final wound contraction rates were highest for the regular triangle shapes; however, there were no statistically significant differences. The wound contraction rates by locations showed statistically significant differences. The wound in the cephalic area presented more contractions than that of the wounds in the caudal area. CONCLUSION: The location of a wound is more important factor than the wound shape in wound contraction.

Treatment of Venous Stasis Ulcer with 3M(TM) Coban(TM) 2 Layer Compression System: A Case Report

PURPOSE: Venous stasis ulcer is the most severe form of chronic venous insufficiency and this commonly appears in the lower limb. Pharmacological therapy, reconstruction of the venous system, surgical management, cellular therapy and compression therapy are known as the treatments of venous stasis ulcer, but relapses are common, which make it a typical chronic wound. We report here on a case of recurrent venous stasis ulcer that healed with compression therapy without any other treatment. METHODS: A 35-year-old man with a 13 years history of venous stasis had developed an ulcer on the distal third portion of the lower left limb which was developed 12-year before enrollment in this study. He had been treated with vacuum assist closure, 2 times of cell therapy and 3 times of skin graft for 8 years, but the lesion recurred. From November, 2008 compression therapy was done with the 3M Coban(TM) 2 Layer Compression System(3M, St. Paul, USA). The ulcer at that time was oval shaped and 3x4cm in size. A comfort layer bandage was applied from the proximal phalanx of the great toe to the knee. A compression layer bandage was applied on the previous layer with it being overlapped one half the width of the comfort layer bandage. The dressing was changed every 4 days and the change was recorded with photography. RESULTS: A total of 12 Coban(TM) 2 Layer Compression Systems were used. The size of the ulcer decreased to 2.5x2.5cm in one month, to 2x2cm in 2 months, it was 1x1.8cm in size at 3 months and it completely healed in 4 months. CONCLUSION: The venous stasis ulcer was completely healed using the 3M Coban(TM) 2 Layer Compression System. This method was easy to apply, made the patient comfortable and it provided an excellent compression effect. As in the previous studies, this compression therapy has been proven to play an important role for the treatment and prevention of venous stasis ulcer.

Chronologic Change of Korean Cephalic Index (0 to 20 years) Obtained from a Cephalograph

PURPOSE: The cephalic index (CI) is used to classify the head and every race has its unique characteristics. Previous studies published in Korea were limited to demonstrating the periodical change of the CI. This study was done to determine the CI change in 0 to 20 year-old Koreans by sex and age. METHODS: The measurement was done on 1,222 Koreans ranging from 0 to 20 years of age, randomly selected from 2,156 who were diagnosed with simple concussion, had no other diseases or anomalies, and took cephalographs from January, 2000 to July, 2008. The files were obtained from Marosis(R) and then photogrammetry was done by Photoshop(R). To standardize the cephalograph, the Frankfort horizontal line was selected as the reference line on lateral view and the line connecting both lateral-orbitales on AP view. The maximal length was obtained from the lateral cephalograph and the maximal breadth from the AP cephalograph. RESULTS: The CI showed no difference by sex (p=0.4848). The CI and age showed negative correlation (p<0.0001). Analyzed separately by the male and the female, the CI showed statistical significance in the male (p<0.0001), but not in the female (p=0.4741) group. Comparing the CI above the age of 11, the CI of the female became greater than that of the male. CONCLUSION: This study contributes to the standardization of CI measurement and the authors were able to obtain the average CI by age. We concluded that the CI decreased according to age and most Koreans belonged to barchycephalic or hyperbrachycephalic.

Characteristics of Fat Tissue According to the Anatomical Regions of the Body: Computed Tomographic and Histological Findings

PURPOSE: The subcutaneous fat tissue is separated into 2 layers by the subcutaneous fascia: the superficial and deep fat layers. The two fat layers have different structures according to the body regions. The purpose of this study is to evaluate the distribution and pattern of the two fat layers in the human body by computed tomography (CT) and histological analysis according to age, sex, anatomical region, and body mass index (BMI). METHODS: This study included 200 males and 200 females who underwent 64-channel dynamic CT in our hospital. The patients were divided into 5 groups according to 10 years of their ages separately in either male or female gender. The thickness of the superficial and deep fat layers was measured in the abdominal, pelvic, and femoral regions, and we analyzed the values. Statistical analyses were performed using SPSS software. The 3 x 3-cm whole fat layers were harvested from the same sites of 3 cadavers for histological examination, and one cadaver was dissected for gross evaluation. RESULTS: The total thickness of subcutaneous fat tissue was greater in females than in males, and the ratio of the superficial fat layer to the whole fat layer was higher in females. The superficial fat layer became thinner with increasing age in males. As BMI increased, the total fat layer became thicker, and the superficial fat layer became thicker than the deep fat layer. On histological examination, the superficial fat layer had small adipose lobules and showed a densely distributed pattern in the abdominal region, whereas in the femoral region, it had large adipose lobules and showed a sparsely distributed pattern. There were no significant differences in the histological findings of the deep fat layer between the 3 body regions. CONCLUSION: Significant differences in histological findings of the two fat layers were found in relation to age, sex, anatomical region, and BMI. The superficial fat layer became thinner with increasing age in males, but it was constant in females. As BMI increased, the total thickness of subcutaneous fat tissue became greater, and the superficial fat layer became thicker than the deep fat layer. Our measurements can be used to understand the characteristics of the fat layers in relation to age, sex, anatomical region, and BMI.

Vacuum Assisted Wound Closure Appliance and Continuous Irrigation on Infected Chronic Wound

PURPOSE: Continuous irrigation method is an important step in managing wound infection. V.A.C. devices have been used in intractable wounds for reducing discharge, improving local blood flow, and promoting healthy granulation tissue. We expect synergistic effects of reduced infection and more satisfactory, accelerated wound healing when using both methods simultaneously. This study evaluated continuous irrigation combined with V.A.C. appliance for treatment of infected chronic wounds. METHODS: We reviewed data from 17 patients with infected intractable chronic wounds. V.A.C. device(Group A) was used in 9 patients, and V.A.C. with antibiotics irrigation(Group B) was used in 8 patients. We placed Mepitel(R) on the surface of wound and placed an irrigation and aspiration tube on each side. A sponge was placed on the Mepitel(R) and covered with film dressing. The wound was irrigated continuously with mixed antibiotics solution at the speed of 200 cc/hr and aspirated through the wall suction at the pressure of -125 mmHg. V.A.C. applied time, wound culture and wound size were compared between the two groups. RESULTS: No complication were seen in two groups. Compared with Group A, in the Group B, V.A.C. applied time was shortened from 32.7 days to 25.6 days and showed efficacy in the reduction rate of wound size. No statistical differences were shown in bacterial reversion. CONCLUSION: V.A.C. appliance with continuous irrigation is an effective new method of managing infected chronic wounds and useful to reduce treatment duration and decrease wound size. Moreover it could be applied more widely to infected wound.

Rhinoplasty using Various Autogenous Tissues

PURPOSE: In Korean rhinoplasty, alloplasts such as silicone rubber have been used for dorsal and tip augmentations. However, alloplasts have produced complications such as deviation, exposure, and infection. Although autogenous tissue is an ideal material, the amount of the cartilage in Korean is not sufficient. Therefore, the authors developed a method to harvest the maximum amount of the septal and conchal cartilage. The authors first performed a complete septal extension graft for short and retruded columella and then performed nasal augmentation using various autogenous tissues. METHODS: These surgical techniques were performed on 11 patients. Their average age was 27 years. An open approach with a V-shaped columellar labial incision was performed. At first, the complete septal extension graft was fixed on the entire caudal margin of the septum, and the alar cartilage was suspended to the septal extension graft to make the tip projected and the columella advanced caudally. A temporal fascial ball was used for radix augmentation. For dorsal augmentation, a batten-shaped septal cartilage graft wrapped with or without the temporal fascia or a diced cartilage graft wrapped with the temporal fascia was performed. For nasal tip augmentation, a shield graft and a cap graft or a folded conchal cartilage graft was performed. RESULTS: The mean follow-up period was 11.2 months. The overall results were natural and satisfactory. Two patients underwent slight absorption and caudal displacement. With the exception of these cases, no complications were observed. CONCLUSION: Korean rhinoplastic surgeons are accustomed to using the alloplasts despite of serious complications. When rhinoplasty using autogenous tissue was performed, some complications occurred such as the displacement of the diced cartilage graft wrapped with the fascia, but many of the complications of alloplastic rhinoplasty were avoided. Therefore, we propose that by this time Korean rhinoplastic surgeons need to change their preference from alloplastic rhinoplasty to autogenous rhinoplasty.

Viability of Cells in Aspirated Fat Tissue after 1 Year Cryopreservation

PURPOSE: The use of an autogenous fat graft has become a common procedure in plastic surgery. However, questions remain concerning on the viability of fat cells and preservation method of aspirated fat. The purpose of this study is to examine the viability of fat cells stored at -20degrees C in the freezer for 1 year after harvest from abdominal liposuction. METHODS: Eighteen adults(aged from 24 to 65 years, 16 female and 2 male) were selected for this study. Harvested aspirated fat tissues were obtained by suction-assisted lipectomy and frozen at -20degrees C commercial refrigerator for one year(average 12.5 months). The viability of fat cells in specimens were measured after thawing. The numbers of viable cells were measured on a fluorescence microscope after staining with fluorescein diacetate and propidium iodide. GPDH(Glycerol-3-phosphate dehydrogenase) activity was measured. Cell culture was done for 3 weeks. RESULTS: There were no viable cells under the fluorescence microscope, no detectable GPDH activity, and no cultured cells. CONCLUSION: These findings suggest that aspirated fat after frozen storage for one year at -20degrees C freezer is inadequate to reuse.

Improvement of the Inferior Epigastric Artery Flap Viability Using Adenovirus-mediated VEGF and COMP-angiopoietin-1

PURPOSE: Partial necrosis of skin flaps remains a substantial problem in reconstructive surgery. We investigated the potential use of an adenovirus vector encoding the VEGF, COMP-angiopoietin-1 gene in an attempt to promote the viability of the inferior epigastric artery flap in a rat model. METHODS: Three by six cm lower abdominal transverse skin flaps, supplied only by the left inferior epigastric artery, were designed. After skin flap elevation, the adenovirus VEGF and adenovirus COMP-angiopoietin-1 were injected into the distal portion of the flap, which has a high tendency of developing flap ischemia. Control animals were injected with the same volume of normal saline. On 3, 7 and 14 days after the flap elevation, the flap survival and vascularization were assessed using Visitrak digital(R), CD31 immunohistochemistry in addition to evaluating the general histological characteristics. RESULTS: There was a significant increase in the mean percentage of flap viability by 89.8%, 91.1% and 94.8% in flaps transfected with adenovirus VEGF, COMP- angiopoietin-1, coadministraion of VEGF and COMP- angiopoietin-1 at seven days, and by 95.6%, 94.8% and 96.3% at 14 days. Histological assessment revealed that there were more blood vessels formed after adenovirus with VEGF, COMP-angiopoietin-1 or VEGF plus COMP- angiopoietin-1 than with adenovirus Lac Z. CONCLUSION: The results of this study suggest that adenovirus-mediated VEGF, COMP-angiopoietin-1 gene therapy, promote therapeutic angiogenesis in patients that undergo reconstructive procedures. Key Words:

Preserved Superficial Fat Skin Composite Graft for Correction of Burn Scar Contracture of Hand

PURPOSE: Split or full thickness skin graft is generally used to reconstruct the palmar skin and soft tissue defect after release of burn scar flexion contracture of hand. As a way to overcome and improve aesthetic and functional problems, the authors used the preserved superficial fat skin(PSFS) composite graft for correction of burn scar contracture of hand. METHODS: From December of 2001 to July of 2007, thirty patients with burn scar contracture of hand were corrected. The palmar skin and soft tissue defect after release of burn scar contracture was reconstructed with the PSFS composite graft harvested from medial foot or below lateral and medial malleolus, with a preserved superficial fat layer. To promote take of the PSFS composite graft, a foam and polyurethane film dressing was used to maintain the moisture environment and Kirschner wire was inserted for immobilization. Before and after the surgery, a range of motion was measured by graduator. Using a chromameter, skin color difference between the PSFS composite graft and surrounding normal skin was measured and compared with full thickness skin graft from groin. RESULTS: In all cases, the PSFS composite graft was well taken without necrosis, although the graft was as big as 330mm2(mean 150mm2). Contracture of hand was completely corrected without recurrence. The PSFS composite graft showed more correlations and harmonies with surrounding normal skin and less pigmentation than full thickness skin graft. Donor site scar was also obscure. CONCLUSION: The PSFS composite graft should be considered as a useful option for correction of burn scar flexion contracture of hand.

Cadever dissection and Dynamic CT for Vascular Anatomy of Rectus Abdominis Muscle

PURPOSE: Pedicled transverse rectus abdominis myocutaneous(TRAM) flap has been a gold standard for breast reconstruction and one of surgical techniques preferred by many surgeons. The authors examined the course of deep epigastric artery focusing on distance from margins of rectus abdominis to pedicle and location of choke vessels to get minimal muscles during pedicled TRAM flap operation. METHODS: Eleven rectus abdominis muscle from nine cadavers were used in this study. Rectus abdominis was separated from the cadavers, deep inferior and superior epigastric artery were isolated and then 8 anatomical landmarks in medial and lateral margins of rectus abdominis were designated. Distance to a pedicle meeting first horizontally was measured and vertical location from umbilicus to choke vessel was determined. In addition, 32 rectus abdominis images of 16 women(average age: 37.2 years old) from 64 channel abdomen dynamic computerized tomography were also examined with the same anatomical landmarks with those of cadavers. RESULTS: Average distance from four landmarks on lateral margin of rectus abdominis to pedicle was 1.9-3.4cm and 1.8-3.8 cm on medial margin. Choke vessel was located between middle and inferior tendinous intersection in all cases and average distance between two tendinous intersection was 6.7-7.0cm on medial margin and 6.2cm on lateral margin. Location of inferior tendinous intersection was on umbilicus or superior of it in all cases and its average distance from umbilicus was 1.8-5.6cm on medial margin and 2.7-6.2cm on lateral margin. CONCLUSION: Distance from medial and lateral margins of rectus abdominis muscle to pedicle was the shortest in inferior tendinous intersection and that was averagely 1.8cm on medial margin and 1.9cm in average on lateral margin. All choke vessels were located between middle and inferior tendinous intersection.