An Algorithmic Approach to Total Breast Reconstruction with Free Tissue Transfer

As microvascular techniques continue to improve, perforator flap free tissue transfer is now the gold standard for autologous breast reconstruction. Various options are available for breast reconstruction with autologous tissue. These include the free transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap, and transverse/vertical upper gracilis flap. In addition, pedicled flaps can be very successful in the right hands and the right patient, such as the pedicled TRAM flap, latissimus dorsi flap, and thoracodorsal artery perforator. Each flap comes with its own advantages and disadvantages related to tissue properties and donor-site morbidity. Currently, the problem is how to determine the most appropriate flap for a particular patient among those potential candidates. Based on a thorough review of the literature and accumulated experiences in the author's institution, this article provides a logical approach to autologous breast reconstruction. The algorithms presented here can be helpful to customize breast reconstruction to individual patient needs.

Finger Necrosis Following Percutaneous Radial Artery Cannulation: A case report / 대한마취과학회지

Anesthegiologists commonly use arterial cannulation for both close blood pressure monitoring and repeated blood sampling for gas analysis. Radial artery cannulation is generally thought of as a safe and uncomplicated procedure, however, some possible complications have been reported. These include bleeding, hematoma, infection, pseudoaneurysm and thromboembolism, which do not usually result in any serious clinical problems. Although it is not common, thromboembolism could be serious because it can lead to digital ischemia and necrosis. We report here a case of finger necrosis following radial artery cannulation in a patient who underwent radical hysterectomy under general anesthesia.

Treatment of Nasal Telangiectasis with Carbon Dioxide(CO2) Laser

Telangiectasis is defined as permanent visible dilatation of the cutaneous blood vessels. Clinically, its diameter ranges from 0.1 to 1.0 mm which represents either an expanded venule, an capillary, or sometimes an arteriole on the face. Until now, many treatment methods have been reported such as various laser therapy, sclerotherapy, electrodessication and so on. We used superpulse CO2 laser to remove nasal telangiectasis in 8 patients between May 2004 and July 2007. Laser therapy was done in continual 5 sessions with intervals of 3 - 5 weeks. In each session, laser beam was shot to the point of the bifurcation, trifurcation of telangiectatic vessels or to the points of the widest diameter. In each point, shots of the laser beam were repeated 5 times to reach deep dermis. The laser setting was 7 W with 0.5 mm diameter in superpulse mode. Photographs were taken before and after procedures to ascertain the changes of nasal telangiectasis. Our results showed that the main lesions were cleared effectively. We think that irradiation of CO2 laser onto the bifurcating points can be a valuable tool to treat nasal telangiectasis.

Convenient Nipple Suspension Method Using Aquaplast Thermoplastic (Optimold) Splint after Surgical Correction of Inverted Nipple

In spite of various surgical treatments to correct the inverted nipple, no one is free form its recurrence. It is well known that stable suspension of projected nipple is required after nipple reduction. To minimize the recurrence rate, authors designed a new suspension device using Aquaplast Thermoplastic(Optimold) which is heat-malleable. The retracted nipple was held up with 2 traction sutures using 4-0 nylon, and then the surgical correction was performed. The projected nipple was suspended by 2 traction sutures with 4-0 nylon. A sheet of Aquaplast Thermoplastic (Optimold) was tailored by 1.5x5cm. It was soaked in hot water for 5-10 seconds. In 30 seconds, it was molded by manual in " omega" shape after dry-up. This prepared splint was applied on the nipple and areolar. 2 ends of nylon threads were pull upward and other 2 ends downward from the splint. Then, they were tied on top of the splint. The suspension sutures maintained for 7 days. From January of 2003 to December of 2006, we corrected 12 inverted nipples in 9 patients. After operation, we applied these devices for suspension to all nipples and 11 of them were kept corrected for more than 6 months. The authors consider this suspension method is simple, quick and effective. And the splint is very comfortable to patient because it is small, light and fits in nipple. In addition, it is very convenient to check the circulation of the operated nipple by sight.

Total Tongue Reconstruction with Innervated Latissimus Dorsi Free Flap

Total tongue resection result in severe speech problem, swallowing difficulty and life threatening aspiration. When a total glossectomy is performed, the functional recovery of swallowing, articulation, and airway protection are important for maintaining life quality of the patient. To achieve good functional results, First, the donor tissue should be bulky. Second, the tissue should be pliable and capable of movement. Third, the neotongue should be innervated by anastomosis to the hypoglossal nerve. Innervated latissimus dorsi free flap satisfies the above conditions. The authors performed two immediate total tongue reconstruction using a innervated latissimus dorsi myocutaneous free flap in which the thoracodorsal nerve was anastomosed to the hypoglossal nerve. Decanulation was performed on the 15th and 20th day respectively after the operation. The oral intake of pureed diet was possible in both patients without aspiration. After 3 months, it was confirmed in videofluoroscopic study that the neotongue was able to contact with the palate effectively. And the articulation was satisfactory. Considering speech and feeding rehabilitation, innervated latissimus dorsi flap can be more valuable method of tongue reconstruction than any other methods and we recommend it for better life quality of the patient.

Correction of Alar Cartilage Malposition

The alar cartilage malposition is defined as any displacement of lateral crura from the usual parallel alignment with nostril rims. It has several characteristics including parentheses deformity, notches in alar rims, flat nasal tip, square basal perimeter. It tends to be misdiagnosed as cartilaginous hump or bulbous tip because of its longitudinally prominent lobule. But, exact diagnosis can be easily attained with careful examination and recognition in the clinical diagnosis of bulbous or ambiguous tips. It is confirmed by the resistless collapse of lateral alar rim when light compression is applied by cotton stick. Its incorrect diagnosis can bring about inappropriate tip graft, soft tissue resection, rasping, humpectomy and secondary nasal deformity may develope as a result. Authors performed open approach followed by meticulous dissection of displaced alar cartilages. Each medial portion, corresponding to the cephalic portion of normal lateral crus, was resected. Then, each lateral crus was symmetrically rotated in the infero-lateral direction along the axis of the medial crura. If needed, autocartilage on-lay graft and dorsal augmentation were done for optimal aesthetic result. We believe accurate evaluation of the anatomical variation should be checked out preoperatively and recommend out method for the effective correction of unusual bulbous or broad tips.

Correction of Blunt Nasal Tip with "Contour Tip Gragt" and Alar Cartilage Modification

The aim of aesthetic rhinoplasty is to produce harmonious contour of the nasal tip as well as to provide dorsal augmentation. The nasal tip should look definite but not too pointed or artificial. Natural contour is most desirable. Among the patients(n = 140) who had augmentation rhinoplasty between 1995 to 1999, 107 patients were classified to have blunt tips. The cases who have other types of tip deformities were excluded. In this study, we present our tip plasty technique for the correction of blunt tips. The blunt tip deformities were divided into bulbous tip(n = 82) and broad tip(n = 25). As for the operation, different tip thinning procedures were done according to this classification. Then dorsal augmentation with silastic implant was performed. Authors used "Contour Tip Graft" technique to produce aesthetic oriental nasal tip. This technique made use of the graft of stacked autogenous cartilages with small pieces of diced cartilage around it. The stacked cartilages were for tip projection and surrounding pieces for natural contour. This method can yield more natural appearance of the tip and lobule. Our tip plasty technique combined with dorsal augmentation is very useful and effective procedure in the correction of blunt tip.