Treatments of Phyllodes Tumor in Breast and Immediate Breast Reconstruction

PURPOSE: There have been limited reports on breast reconstruction after excision of phyllodes tumor. This paper reports four patients who had immediate reconstruction of the breast following excision of phyllodes tumor. METHODS: We retrospectively reviewed the medical records of 14 patients from March 2000 to March 2008. Clinical data were analyzed including age, presenting symptoms and signs, type of surgery and metastasis. RESULTS: The mean age was 38.6 years. The mean follow-up period was 40.6 months. Reconstruction was performed with latissimus dorsi musculocutaneous flap in 3 patients and transverse rectus abdominis musculocutaneous flap in 1 patient. Other cases were covered with skin graft or primary repair. 2 local recurrent cases were noted. CONCLUSION: The breast affected by phyllodes tumor must undergo complete excision. Followed by mastectomy, immediate reconstruction of breast improved cosmetic results, and allowed a wider surgical excision margin of tumor.

The Effect of Botulinum Toxin-A on the Survival of Random-Pattern Cutaneous Flap in Rat

PURPOSE: Botulinum toxin type A(BoTA) can block the release of vasoconstriction cotransmitters as well as acetylcholine in nerve terminal. The authors observed that BoTA increases flap survival by preventing sympathetic collapse of peripheral vessels. METHODS: 10 Sprague Dawley rats were divided into control(n=5), and BoTA group(n=5). 3x10cm sized random pattern cutaneous flaps were elevated on the dorsal side in both groups. In BoTA group, BoTA was injected into the flap via intradermal to subdermal route, 7 days before the flap elevation. Flap survival rates (survival area/total area) were measured 7 days after the elevation. Cutaneous blood flow was measured in proximal, middle and distal compartments of the flap using laser Doppler flowmetry initially, preoperatively, at immediate postoperation, and 7 days after flap elevation, respectively. Histological examination was performed 7 days after the flap elevation. The number and shape of the vessels were evaluated under microscope. RESULTS: Mean flap survival was 53.18+/-6.58% in control group and 93.79+/-6.06% in BoTA group, displaying statistically significant difference(p=0.0008, p< 0.05). In the control group, blood flow to the middle and distal compartments of the flap decreased significantly immediately after flap elevation. In the BoTA group, blood flow to the middle compartment did not decrease(p=0.002) and slightly decreased in the distal compartment(p=0.001). Cutaneous blood flow was significantly higher in all compartments of the flap in BoTA group than in control group, 7 days after the flap elevation. In histopathologic examination, greater number of vessels were noted in the BoTA group than in the control group. CONCLUSION: Botulinum toxin A can increase the survival of the random pattern cutaneous flap in rats by preventing the sympathetic collapse of peripheral vessels.

A Case of Kimura Disease on Parotid Gland

Kimura disease is a relatively uncommon chronic inflammatory disorder of unknown etiology. Kimura disease occurs mainly in oriental young males. The majority of lesions occur in the head and neck and most patients have involvement of regional lymph nodes and major salivary glands. Although Kimura disease is similar to malignancy clinically and radiologically, it is benign disease showing good prognosis in only conservative management. So it is important to familiarize clinical, histological and radiological findings. We experienced a case of mass which developed on parotid gland of 40-year-old male. On impression of malignancy, total parotidectomy was performed. The Histological report was Kimura disease. There has been no recurrence during follow-up period of two years.

Visual Disturbance following Autologous Fat Injection into Periorbital Area

PURPOSE: Autologous fat injection into the facial area is a frequently used technique in aesthetic plastic surgery for augmentation of the soft tissue. Fat injection is a very safe procedure because of the advantage of being autologous tissue. Minimal foreign body reaction or infections are noted after fat injection. However, there may be some complications including those as severe as blindness. There have been some case reports on visual disturbances after autologous fat injection reported in the literature. METHODS: A 21-year-old female patient underwent autologous fat injection into left eyebrow area to correct depression of soft tissue. Immediately after injection of autologous fat, she complained sudden visual loss on the left eye. She had come to our emergency room and ophthalmologic evaluation showed that the patient could only recognize hand motion. There was no abnormality of the optic nerve on magnetic resonance imaging. Suspecting an ischemic optic neuritis from fat embolism of the central retinal artery, the patient was treated conservatively with occular massage, antiglaucomatic agent, anti-inflammatory drugs and antibiotics. Visual field examination showed visual defect of half the lower hemisphere. RESULTS: While maintaining antiglaucomatic agents and non steroidal anti inflammatory drugs, fundoscopic examination showed no abnormalities on the second day of admission. Visual field examination showed an improvement on the fourth day along with decreased eyeball pain. Significant improvement of vision was noted and the patient was discharged on the fifth day of admission. The patient was followed-up 2 days afterwards with improved vision and visual field defect. CONCLUSION: We describe an unusual case of sudden unilateral visual disturbance following autologous fat injection into periorbital area.

Multiple Symmetric Lipomatosis: Characteristics and Treatment in Korean Patients

PURPOSE: Multiple symmetric lipomatosis (MSL) is a relatively rare disorder characterized by presence of multiple, symmetric, nonencapsulated fat masses in face, neck, shoulder and other areas. There has been only a few cases reported in Korea. The main purpose of this research is to examine the Korean patients to see what kinds of special characteristics occurred due to this disease and to decide the proper treatment. METHODS: A total of 16 patients were evaluated retrospectively. 5 patients were treated at our hospital. The other patients were reviewed from literature. We analyzed the biological characters of patients, location of fat deposit, morphologic characters of patients, clinical evidence of neuropathy, associated metabolic disorders and treatment modality. RESULTS: All cases were male patient. The mean age of onset was 47.43 years. All patients were moderate to heavy alcoholics. The most common location of fat deposition was posterior neck and abdomen. In neurologic exam of 9 patients, 5 patients showed muscle weakness, tremor, pain and autonomic nerve dysfunction. In metabolic studies of 9 patients, total cholesterol values were higher in 1 patient. A glucose tolerance test was abnormal in 1 patient. In treatment modality, 14 patients were treated with surgical resection, 1 patient was treated with liposuction and surgical excision, 1 patient was treated only with liposuction. CONCLUSION: To treat MSL patients successfully, we should concentrate not only on the removal of the fatty tissue but also on neurologic abnormities, metabolic disorders and associated diseases.

Large Intraorbital Cyst after Silicone Implant Insertion : A Case Report

PURPOSE: Alloplastic implants, such as methylmethacrylate, Teflon, silicone, Supramid are commonly used to cover the floor defect and to prevent reherniation of the displaced orbital tissue in orbital floor fracture. Silicone implant has been used for reconstruction of orbital wall defects because of pliability, advantage of carving and chemically inert nature. However, silicone implant also has complications including infection, extrusion, pain, dystopia and tissue reaction. Cyst formation around the silicone implant is a very rare complication. According to many reports, cysts around alloplastic implant in an orbital area are mostly hemorrhagic cysts consisted of blood breakdown product with fibrous capsule cell in histologic examination. METHODS: The authors report atypical case and successful treatment of intraorbital hemorrhagic cyst around silicone implant of a 37-year-old male patient. RESULTS: Preoperative symptoms of diplopia, exophthalmos, proptosis, vertical dystopia and ectropion of lower eyelid were resolved after surgical removal of implants with surrounding capsule. CONCLUSION: Clinical suspicion of plastic surgeon is important in diagnosis of intraorbital cyst of patients who have history of silicone implantation and computed tomography is the standard tool of diagnosis. During the operation, caution must be taken on delivering the whole capsule of intraorbital cyst along with silicone implant to prevent recurrence of the cyst.

The Usefulness of Costochondral Cantilever Graft for Correction of Saddle Nose

PURPOSE: Saddle nose deformity results from lack of support to the nasal dorsum. The integrity of both the cartilaginous or bony portion of the nose is compromised. Cantilever bone graft is the mainstay for correction of saddle nose deformity, but the problems of bone graft are stiffness of the nasal tip and resorption. Thus the authors propose a costochondral cantilever graft, with the bony and cartilaginous portion harvested as one block, using cartilaginous portion as support to the nasal tip. METHODS: Between October of 1996 and July of 2005, 8 cases of saddle nose deformity were treated by the same surgeon. All patients had undergone costochondral cantilever graft. Postoperative evaluation included the depression of the nasal dorsum and tip. Comparisons of preoperative and postoperative photographs was done if possible. RESULTS: The mean follow-up period was 5.9 years. The results were excellent aesthetically and there was no complication. Conclusion: The authors' method maximize the benefits of each bone and cartilage graft while minimizing their inherent limitations.

Plate Platform Formation Technique in Mandible Angle Fracture

There are various surgical fixation techniques for fractures of the mandible angle due to traumatic facial injuries. Among those surgical treatment modalities, fixation methods using plates, screws, lag screws and wires have been commonly used. With the introduction of absorbable plates, the plate fixation technique has been popularized. However, plate fixation requires an external incision or an external approach using trochar for the direction of screw fixation to be perpendicular to the mandible. The external approach has disadvantages in that it leaves a scar and involves some risk to damage the marginal mandibular branch of the facial nerve. To overcome these disadvantages, the authors used a plate platform formation technique on the fractured mandible angle. The result was satisfactory with no complications. Plate platform formation technique, as performed by the authors, can be a new and simple surgical technique for stable fixation and with minimal postoperative complication by an internal approach to avoid an external scar and nerve injury.

Retrospective Study of Postoperative Radiation Therapy in Keloids Treatment

PURPOSE: Keloid is a clinical term characterized by elevation and extension of scar tissue beyond wound margin. Currently, there is no known treatment that shows consistent effect in all patients. Postoperative radiation therapy is known to prevent recurrence of keloid. METHODS: We reviewed data of patients who had undergone operation or operation followed by radiation therapy at our institute for the last 12 years. Follow up was possible in 39 patients(21 patients treated only by operation and 18 treated by operation and radiation therapy) We then investigated recurrence in both groups by VAS score. By mail, patients were asked to score their current condition on the bar in 4 aspects(itching, pain, mass lesion(by patients and other persons)). Two criteria were used for defining successful treatment. One is the case which total VAS score was 0, and the other is sum of VAS score of mass lesion was 0 to 5. RESULTS: In the former, recurrence rate is 90.5% in operations-only group but 66.7% in operations plus radiation therapy group(p 0.05). In the latter, recurrence rate is 66.7% in operation-only group but 22.2% in operations plus radiation therapy group(p 0.05). CONCLUSION: These results shows postoperative radiation therapy is effective method in keloid treatment.

Dual Plane Method with Orbital Fat Repositioning in Lower Blepharoplasty

Blepharoplasty is a commonly performed aesthetic surgery, but there is still no commonly used standard method for the correction of orbital fat bulging in lower blepharoplasty. We performed dual plane method by elevating skin flap and muscle flap separately, and then repositioned orbital fat with preserving orbital septum for correction of orbital fat bulging in lower blepharoplasty. Between July, 1998 and June, 2005, one hundred and fifty six patients underwent lower blepharoplasty by author's method. The results were satisfactory in all of the patients. Complications were six cases of hematoma and ten cases of visible scar in lateral canthal area. There was no skin flap necrosis, hyperpigmentation, skin irregularity or ectropion. In lower blepharoplasty for the sufficient excision of skin and operation of orbicularis oculi, we performed precise correction of skin and muscle independently by dual plane approach, by separate elevation of skin flap and muscle flap, and were able to reposition orbital fat easily and safely with preservation of orbital septum.

Clinical Experiences of Acrylic Splint on Pediatric Mandile Fracture

The goal of open reduction in mandibular fracture is to restore the underlying bony architecture to its pre-injury position in a stable fashion, with a minimal of aesthetic and functional impairment. Many cases of mandibular fracture are treated by intermaxillary fixation using arch bars after open reduction. In this study, after open reduction of fracture, 23 patients were grouped according to acrylic splint appliction. All patients was younger than 15 years old. Open reduction was performed by miniplate or interosseous wire fixation. After open reduction, 8 patients were applied with acrylic splint and 15 patients were applied with arch bar for intermaxillary fixation. Physical examination and postoperative panoramic x-ray were reviewed for the evaluation of occlusion. In the group where acrylic splint was used, 75% of the patients showed excellent subjective satisfaction and 25% showed good satisfaction. In the group where the acrylic splint was not used, 33% showed excellent and good satisfaction, 27% fair satisfaction and 1 patient showed poor satisfaction. On long-term follow- up, the group where acrylic splint was applied showed better occlusion compared to the group where acrylic splint was not applied.

Treatment of the Scalp Avulsion by Ultrasonic Surgical Aspiration

A large scalp avulsion injury may lead to severe bleeding and may cause trauma to the forehead, eyebrows and periauricular tissue. This may bring fatal results aesthetically and functionally. Severe deformity may result after treatment and may also lead to psychological trauma disabling the patient to lead a normal social life. The scalp is made up of 5 layers histologically. They are the skin, subcutaneous fat, galea aponeurotica, subepicranial space and the periosteum. The external 3 layers of the scalp exist fairly independent of the cranial bone and function as one structure in the movement of the frontalis muscle and the occipitalis muscle. Therefore, scalp avulsion injuries usually involves the 3 outer layers along with the subepicranial space but may sometimes include the periosteum as well. Treatment methods are split thickness skin graft, replantation after defatting of the avulsed flap, composite graft and microsurgical procedures. Only methods that can preserve the hair are composite graft and microsurgery. However, limitations of composite graft and the environment of the donor and degree of vessel injury of the donor may limit microsurgical procedures. The authors report 1 case of scalp avulsion injury involving the parietal area where ultrasonic surgical aspiration was used to defat the avulsed flap and grafted onto the donor site. At the time of injury, the size and degree of vessel injury of the donor site was not suitable for a composite graft or microsurgery. Therefore, an ultrasound liposuction machine(for ultrasound assisted lipoplasty) was first used on the avulsed flap before replantation after defatting to minimize hair loss. This procedure has almost no traumatic effect on hair loss and distribution and although it may decrease the density of hair follicles, it does not lead to irregular patterns of hair loss. The avulsed flap was transplanted after minimizing hair follicle injury while removing the subcutaneous fat layer of the avulsed flap. On 1 year follow-up postoperatively, although thinning of the hair and decreased density was noticed, but regrowth of the hair was confirmed.

Management of Malignant Melanoma Using Sentinel Lymph Node Biopsy: A Case Report

The single most powerful prognostic factor in malignant melanoma is the status of the regional lymph node metastases. The surgical excision of involved node is the most effective treatment for local disease control. Surgical management of malignant melanoma has been the therapeutic value of elective lymph node dissection in the clinically node-negative individual. However, more recent prospective randomized trials have failed to demonstrate an overall survival benefit for patients undergoing prophylactic elective lymph node dissection. The histologic status of the sentinel lymph node reflects the status of the total nodal basin. Therefore the status of the regional lymph node metastases was confirmed by the sentinel lymph node biopsy in malignant melanoma without lymphedema and nerve injury in the patients undergoing elective lymph node dissection. In this case, we performed sentinel lymph node biopsy using lymphoscintigram and radioactive materials and confirmed no evidence of regional lymph node metastases. After wide excision of the primary tumor, the soft tissue defect with bone exposure on the heel was reconstructed with skin-grafted muscle free flap. There is no evidence of recurrence or distant metastases in this patient 1 year after excision.

Treatment of Congenital Hairy Nevus using Superficial Tangential Excision, Laserablation and Dermal Overgraft: Case Report

Even though a variety of treatment modalities for the congenital hairy nevus have been introduced, a standard method that satisfies both aesthetic outcome and complete resection has not yet been established. Due to the malignant potential of congenital hairy nevus, full thickness skin graft or surgery using flaps after complete excision has been widely used. However, in the case of small & medium sized congenital hairy nevi, aesthetic results have greater emphasis due to therir low malignant potential. Three patients who presented with a congenital hairy nevus of 20 cm or less were treated from 1999 to 2001. In order to preserve the function of skin and acquire a more satisfying aesthetic outcome, we performed a tangential excision of the epidermis and papillary dermis under the loupe while preserving the lower dermis as much as possible. Following this procedure, laserablation with CO2 laser was executed to remove remnant nevus cells with dermal over graft. We estimated the postoperative results of pigment disapperance, amount of contracture and skin texture. Satisfying results were obtained during a 6 month to 2 year follow up period. In cases of congenital hairy nevus that can not be covered with full thickness skin graft or flaps after total excision, this procedure seems to be an appropriate alternative treatment modality.

Strut Graft with Septal Cartilage for Nasal Tip Plasty; Increment of the Nasolabial Angle

There are several characteristics of the nasal tip of Orientals. The skin is thick with severe tension and a bulbous nasal tip, the nostrils are wide, and the projection of the nose is limited due to a poorly developed alar cartilage with a short columella. Until now, in order to well outline the nasal tip and project the nose, the alar cartilage was realigned, the domes of the cartilage sutured together, silicone or cartilage was used to improve the appearance of the tip. However, it was difficult to achieve satisfactory results in Orientals due to a short columella and a acute nasolabial angle. From May 1998 to March 2000, the authors attempted to realign the alar cartilage with an open rhinoplasty approach and used the septal cartilage to project the nasal tip and lengthen the columella by designing the increased nasolabial angle in 20 cases. The cartilage was then inserted in the alar cartilage and fixed on the anterior nasal spine. The results, considered satisfactory in all patients without any complications, are as follows: 1. The changes of nasolabial angles were from 88.7 degrees to 95.3 degrees, 2. The average increase in columellar height was 3.5 mm, 3. The average decrease of the alar width was 3.0 mm, 4. The changes of the angle between the long axis of the external naris was from 92.2 degrees to 71.5 degrees. This procedure is an effective method in improving nasolabial angle and columella length.

Face Lift with SMAS and FAME(Finger Assisted Malar Fat Elevation) Technique

Although many methods have been developed to correct the aging process of the head and neck, the correction of nasolabial folds still remains a difficult area. The difficulty of correcting nasolabial fold is due to the anatomical location and the difference of aging process. From March 2000 to February 2001, the authors operated on 10 aging face patients using face lift with SMAS and FAME(Finger-assisted malar fat pad elevation) technique. The authors repositioned the SMAS-platysma flap posterosuperiorly and used finger dissection of the malar fat pad enabling a 3-dimensional correction and repositioning of the fat pad without detachment of the zygomatic ligament. The finger dissection of the malar fat pad attached to the skin enables a more anatomical correction of the malar fat pad with a more natural looking layer and longer lasting results in addition to decreased hematoma, edema and postoperative pain compared to previous methods.

Reconstruction of Soft Tissue Defect of the Finger with Second Dorsal Metatarsal Arterial Flap

To cover a large soft tissue defect of the finger, we have successfully applied free flaps using second dorsal metatarsal artery in 2 patients and obtained satisfactory results. It can be used to reconstruct the defect located from the proximal phalanx to the fingertip of all fingers as a new indication. The procedure is a time-saving, one stage operation. It also causes no disfigurement and no functional loss of the involved digit. Our clinical experience showed favorable results. Second dorsal metatarsal artery free flap is an alternative method to reconstruct a soft tissue defect of the finger with one-stage operation. This flap with its lengthy pedicle provides enough tissue padding. In the meantime, the vascular anatomy of the second dorsal metatarsal artery has to be investigated with regard to its general distribution and variation.

Correction of Glabellar Frown Wrinkles with Selective Neurotomy

No abstract available.

The Study of Expression of E-selectin of Fetal Skin Vessel and Cultured Fetal Dermal Microvascular Endothelial Cell

Inflammation is the characteristics of scar formation which is abscent in fetal wound healing. The adhesion molecules such as selectin groups are believed to have key roles for migration of inflammatory cells through the microvascular endothelial cells to the wound 77re purpose of this study was to evaluate the expression of E-selectin on the cultured human fetal and neonate dermal microvascular endothelial cells. The back skin of spontaneously delivered dead fetus (IUP 18-22 wks) and circumcised prepuce skin of neonate were used Human fetal dermal microvascular endothelial cells (HFDMEC) were isolated by extracting microvascular segment pom trypsin treated fetal and neonate skin tissue and isolated by sieving with nylon mesh and then by 35% Perocoll gradient centrifugation. Further purification was done with the Ulex europaeus I coated magnetic dynabead To confirm the fetal and neonatal endothelial cells, expression of factor VIII antigen on cell surface and uptake of acetylated low-density lipoprotein were checked Expression of E-selectin on cultured fetal and neonatal endothelial cells in response to IL-1alpha TNF-alpha INF-gamma was examined by ELISA. And the expression of E-selectin on fetal and neonatal dermal microvascular endothelial cells was examined by immunohistochemical study using monoclonal 3B7 anti E-selectin antibody in cultured fetal and neonatal skin. The expression of E-selectin on endothelial cells was not significantly digerent between fetal and neonatal endothelial cells. This expression was augmented 10 times more by IL-1alpha, TNF-alpha, INF-gamma. Augmented endothelial E-selectin expression by IL-1alpha, TNF-alpha, INF-gamma showed peak level 4 hours after stimulation and return to baseline level after 48 hrs. This time course was similar in both fetal and neonatal endothelial cells. Immunohistochemically, the expression of E-selectin molecule of unstimulated fetal and neonatal tissue was not observed However, on both fetal and neonatal tissue cultured for 4 hours after stimulation by 100 u/ml of IL-1 and 100 u/ml of TNF, expression of E-selectin molecule in microvasculature of upper dermis was observed and this expression persisted for up to 16 hours of culture. Also after culturing for 48hrs with 500 qlml of IFN, expression of E-selectin was observed in the microvessels of upper dermis. In conclusion, we could not find any digerences between the fetal and neonate skin in the expression of E-selectin on the endothelial cells spontaneously or stimulated by IL-1alpha, TNF-alpha or INF-gamma in vivo and vitro which means the expression of E-selectin vny not be an important mechanism of scarless wound healing in fetus.

Long-term Follow-up of Severe Blepharoptosis

In case of severe blepharoptosis, frontalis muscle suspension with fascia or frontalis transfer has been popular for decades, but these static procedures have some disadvantages such as lagophthalmos, lid lag and remnant ptosis. Twenty-six patients with severe blepharoptosis who underwent frontalis suspension, frontalis transfer, or levator resection at Yonsei University Severance Hospital from 1980 to 1988 were studied. The follow-up period of patients ranged from 10 to 18 years with a mean of 12 years. Surveys and clinical results were obtained, In our review of postoperative complications, lagophthalmos persisted in sleep and even in forced eye closure in most patients 2 to 6 months after operation. But no recurrence was noted. In conclusion, undercorrection of ptosis is more desirable than overcorrection. As well levator resection can be considered in selected cases to prevent complications.