A Modified Total Thigh Flap in the Reconstruction of Decubitus Ulcer

No abstract available.

Marjolin's Ulcer Secondary to Tuberculous Tenosynovitis of the Wrist: A Case Report

Tuberculous tenosynovitis usually presents as a chronic, slowly progressive disease. It is difficult to detect in early phase and diagnosis frequently requires biopsy in addition to stain or culture. Authors describe a case who had a Marjolin's ulcer secondary to tuberculous tenosynovitis of the wrist.

Correction of Depressed Nasal Base and Piriform Aperture Using Polyethylene Implants

Lower midface concavity due to depressed nasal base and pyriform aperture may be aesthetically displeasing. A relative deficiency in lower midface projection may be congenital or acquired, particularly after cleft surgery and trauma. People with normal occlusion associated with lower midface concavity due to depressed nasal base and pyriform aperture can be corrected with an autologous bone graft or artificial implants. The authors performed paranasal augmentation with an alloplastic implants using a porous polyethylene implants(Medpor(R)) on 430 patients who had visited authors' hospital for aesthetic correction of lower midface contour from January 2000 to June 2009. 425 patients were satisfied with the outcome, which gave them a natural contour. Complications such as dislocation, displacement, infection and extrusion were not observed. Only five patients had their implants removed due to displeasing and foreign body sensations. Alloplastic augmentation in the paranasal area is a very easy procedure and can simulate the visual effect as that of maxillary advancement osteotomy. Paranasal augmentation using a porous polyethylene implants(Medpor(R)) in patients having lower midface concavity with normal occlusion can contribute to the enhancement of the lower midface contour.

Near Total Excision in Patients with Angiosarcoma on Scalp

PURPOSE: Angiosarcoma is a rare malignant neoplasm of endothelial type cells that line vessel walls. It tends to occur in aged male and the prognosis of angiosarcoma is very poor because of frequent local recurrence and early metastasis. The treatment regimen is yet to be established from its rare occurrence but the wide excision in early stage is known to be the most effective. The authors report two cases of near totally excised angiosarcoma with more than a safety margin of 5cm. METHODS: The two subjects were aged male patients, one of the two was diagnosed with angiosarcoma from our institution confirmed by the biopsy. The other one went through the wide excision with a safety margin of 2cm and split-thickness skin graft but local recurrence was observed. The two patients underwent near total excision with more than a safety margin of 5cm, leaving only the periosteum. After confirming that the angiosarcoma had not infiltrated the excision margin, reconstruction with split-thickness skin graft was performed. RESULTS: Based on 6 months and 24 months post-surgery assessment, no local recurrence or remote metastasis in the lungs, liver, bones, and lymph nodes at the neck, where remote metastasis is common, was reported by the two subjects who underwent near total excision with a safety margin of 5cm. CONCLUSION: Angiosarcoma has very poor prognosis from its frequent recurrence and metastasis. To enhance the survival rate of angiosarcoma patients, early diagnosis, timely surgical treatment, and radiotherapy after surgery are critical. In addition, authors suggest that it is necessary to further study the efficacy of wide excision using a wider safety margin as much as possible, and to apply this to more cases.

Natural Curved Mandibular Angle: Mandible Angle Resection by Burring Hole Connecting Osteotomy

As Westernization has taken place in the Oriental society, people's concern focuses on the correction of their lower jaw shape. Various methods were recommended to make their mandibular angle slender and beautiful, but it was difficult to achieve natural curves as planned preoperatively. This study was conducted on 6 patients who received burring hole connecting osteotomy for mandibular angle correction from 2005 to 2007. A measurement of the most natural curved line for osteotomy was made by X-ray prior to the surgery. Through intraoral approach, three to five holes were made on the estimated angle line by burring, and the consecutive holes were connected by oscillating saw to perform the one piece osteotomy. There were no unnatural, irregular osteotomy sections or asymmetrical problems in comparison of before and after operation. All of the patients had satisfactory natural mandibular angle lines. Despite difficulties with the conventional techniques, it is possible for patients to achieve natural mandibular angle lines as they wish with the burring hole connecting osteotomy technique. In addition, it was possible to secure outstanding predictability and stability, thus resulting in satisfactory outcomes in the profile.

Usefulness of using Tissue Expander in Pediatric Patient

PURPOSE: Reconstruction of soft tissue defect using tissue expander can provide better flap which is more similar to surrounding tissue in color, skin texture and hair compared to other methods. Many pediatric patients need reconstruction of soft tissue defect because of giant congenital nevi, congenital or acquired malformations and burn scars. Reconstruction using tissue expander is adequate to minimize dysmorphism in these patients. We intended to assess outcomes of using tissue expander in pediatric patients by retrospective study. METHODS: Total cases were 168 of pediatric patients who received soft tissue reconstruction using tissue expander by the same surgeon from February, 1982 to May, 2009. All patients who received soft tissue reconstruction were under 10 years old. Mean age was 4.3 years old, the youngest 13 months, the oldest 8 years. Eighty-nine cases were male and 79 cases were female. Most common cause was giant hairy nevi (67 cases, 39.9%), secondary cause was burn scar/scar contracture (61 cases, 36.3%). Trunk (38 cases, 22.6%) was most common anatomical location. RESULTS: Soft tissue defects were successfully covered using tissue expander in 149 cases (88.7%) without major complications. There was infection on 8 cases (4.7%) and we treated by adequate antibiotics in these cases. There were tissue expander folding or valve displacement on 5 cases (3%). CONCLUSION: Usage of tissue expander is useful on pediatric patients because tissue expansion is rapid on children and there are less secondary contractures on operation site than full thickness skin graft. Because of psychological stress due to tissue expander, operation should be performed before school age.

Analysis of the Foreign Worker Patients in Plastic Surgery

PURPOSE: According to the data presented by ministry of justice, a number of foreign workers in Korea is approximately 700 thousands and among them 22 thousands are illegal workers. We would like to provide the basic information the foreign workers by analyzing clinical contents. METHODS: 1456 patients who visited the hospital were reviewed by nationality, medical department, gender and age. 62 patients have visited plastic surgery department and they were additionally reviewed by diagnosis, chief complant and operation. RESULTS: Mongolians were 388 cases (26.7%), followed by Chineses with 452 cases (31.1%). General surgery had 264 visits (18.1%) followed by internal medicine with 388 visits (26.6%). In gender grouping, 781 patients were males and 675 patients were females. Hand, face and extremity injuries were common in plastic surgery field but many foreign worker patients also wanted to take aesthetic surgery such as scar revision, blepharoplasty and augmentation rhinoplasty. CONCLUSION: It has been twenty years since foreign workers have come to the Korean society. In the past foreign workers were mostly neglected. However with the vast improvement in labor and welfare related services, demands for plastic surgery, especially aesthetic surgery are increasing among foreign workers. Therefore plastic surgeons' continuous interest in foreign workers is required.

Abbe Flap to Correct Tight Upper Lip Resulting from Secondary Deformities of Unilateral and Bilateral Cleft Lip

An Abbe cross-lip flap can be used when there is a deficiency of upper lip tissue and a disproportion between the upper and lower lip. This flap is particularly useful when reproduction of a central fullness or pout in the upper lip is desired. It should be designed to mimic the missing or deformed philtrum. A total of 21 cases of tight upper lip resulting from secondary deformities of unilateral and bilateral cleft lip were treated using the Abbe cross-lip flap(11 cases were unilateral and 10 cases were bilateral). In conclusion, advantages of Abbe cross-lip flap are as followings: 1)It is very efficacious to correct the tight upper lip 2)Widening of upper lip and simultaneous narrowing of lower lip can correct a disproportion between the upper and lower lip. 3)Central flap can recreate a philtrum like effect. 4)There was no significant scar problems in lower lip donor site. 5)In case of combined maxillary retrusion, best results were obtained after orthodontic and/or orthognatic treatment.

The Postoperative Laterality of the Oral Commissure in Lateral Facial Cleft

Lateral facial cleft is a very rare craniofacial malformation involving various degree of skeletal and soft tissue hypoplasia. For the reconstruction of the oral commissure, McCarthy and Fuleihan(1986) measured the distance between the unaffected philtral column and commissure and that distance is marked on the affected side of the upper lip. And it is moved 2 to 3mm lateral to allow for future wound contraction. The purpose of this study is to analyze the postoperative shift of the oral commissure in the lateral facial cleft. We have reconstructed lateral facial cleft and divided them into two groups. In group A, the distance between the commissure and philtral column is marked on the unaffected side and transferred to the affected side. And the transferred point was moved 2 to 3 mm in the lateral direction. In group B, the transferred point to the affected side was exactly the same distance between the commissure and philtral column on the unaffected side. This study involved 19 patients aged from 2 months to 3 years (mean age of 20.8 months) with lateral facial cleft who underwent the commissuroplasty from June 1997 to August 2002. Group A and group B involved 10 and 9 lateral facial clefts, respectively. By using the caliper, each patient's postoperative upper lip width was measured on both the unaffected side and the affected side by one panel. Follow-up was available in 12 patients. In group A, oral commissural point was lateralized by 2.57mm on average, and the mean follow-up period was 3 years and 2 months. In group B, oral commissural point was lateralized by 0.82mm on average, and mean follow-up period was 1 year and 10 months. In all patients, oral commissural points were displaced laterally. In conclusion, we have noticed the reconstructed oral commissural point was lateralized. And we propose that the point which is selected as the site of the reconstructed commissure should be moved more in the medial direction.

Midface Advancement with Rigid External Distraction System in Crouzon's Disease

Distraction osteogenesis has become an alternative technique to treat craniomaxillofacial anomalies. It was initially used to treat mandibular dysplasia and now it is applied to other regions of the craniofacial skeleton. We now present our clinical experience of midface distraction with the use of rigid external distraction for the treatment of an 8-years-old girl with midface hypoplasia in Crouzon's disease, who had undergone fronto-orbital advancement at the age of 6. We performed midface advancement by Le Fort III osteotomy with rigid external distraction system(RED II, KLS Martin, Jacksonville, FL). The active distraction was initiated on the 3rd postoperative day and was continued until the 20th postoperative day for 18 days. The rate of distraction can be adjusted during this time according to clinical judgment and cephalometric assessment. On completion of distraction, the RED II was left in place without activation for 25 days for rigid retention. The RED II was then removed and an orthodontic facemask was applied with elastic traction for 6wks. The total amount of distraction was 18.5mm, 28.5mm, 10.5mm, 14.5mm at right inferior orbital rim, left inferior orbital rim, right intraoral, left intraoral area respectively. The photography, cephalometry, and 3D CT(3 dimensional computed tomography) show that facial convexity was improved. We could correct midface deficiency successfully by LeFort III osteotomy and rigid external distraction.

A Verification of Neogenesis of Vascular Cells by BrdU Immunohistochemistry During Callotasis of the Tibiae in Sprague-Dawley Rats

The callotasis is widely used in lengthening of bones without bone graft. We thought that the accompanying vessels is critical in the viability of distal tissue to the lengthened area and has an important effect on the bone-lenthening itself. So we made an assumption that the accompanying vessels is adapted to the lengthening via neogenesis more than simple physical stretching. At this, we placed a pair of small external fixator in the left tibiae of ten Spraugue-Dawley rats and made an osteotomies. At two weeks after 25% lengthening, vessels of both lengthened and unlengthened side was harvested and five sections from each vessels were stained with BrdU immunohistochemical staining. We investigated the DNA synthesis counting the number of BrdU labeled cells. The number of BrdU labeled cells is significantly increased in the lenthened side arteries(p<0.0001). The synthesis of DNA was significantly increased in the center rather than the ends (p<0.0001). And there was no difference between the number of the BrdU labeled cells of proximal part and that of distal parts(p=0.316). It means that the accompanying vessles in the distraction-lengthening are adapted to the lengthening not only by just physical stretching but also by neogenesis of vascular cells.

Bilateral Rapid Distraction of Mandible

Bilateral mandibular hypoplasia is found in Treacher Collins syndrome, Pierre Robin sequence, and bilateral craniofacial microsomia. It causes many aesthetic and functional problems such as facial deformities with malocclusion and airway problems. We have corrected bilateral hypoplastic mandible with distraction osteogenesis, which is a highlighted method in mandibular lengthening. For last 3 years 8 months, We applied this method to four bilateral cases, where were Treacher Collins syndrome patients and bilateral craniofacial microsomia patient in rapid multidirectional fashion. A complete ostectomy was made at angle of the mandible and the mandible was fixed 5 days after lengthening was started serially 1mm every 12 hours. After consolidation period for one to three month, the device was removed. We have distracted the mandibles in vertical plane, left.18.8mm, right. 13.4mm, in horizontal plane, left 13.9mm, right 13.7mm on the average. We could achieve good aesthetic results, and their airway problems were improved without any complications.

Correction of Vertical Excess of the Lower Face

Since Wilmar first described term "Long face", various methods have been performed to enhance features of the patients with vertical excess of face, but Kawamoto established that the sole method to correct these deformities is to shorten the height of maxilla by LeFort I osteotomy. Features of the lower long facial pattern, conveniently called "Long face syndrome", "Horse face" has following characteristics; 1) Disproportionally elingated lower half of the face. 2) Widely separated lip and visible anterior teeth. 3) Hyperactivity of mentalis muscle. 4) The smile is typically "Gummy" 5)On profile, convex dorsum of nose, and receded double bump appearance of chin. 6) Tendency of class II malocclusion. From May, 1994 to April, 1999 we have treated 6 cases of vertical maxillary excess, "Long face syndrome" patient using maxillary LeFort I osteotomy and ancillary mandibular surgery. Sometimes there were combined bimaxillary prognathi and hemifacial hypertrophies. Age varied from 22 to 31(mean 23) and follow-up period varied from 6 months to 3 years(mean 1 year). Vertical shortening, rotation of the maxilla and combined mandibular adjustment surgery resulted in good facial harmony improvement of characteristics above and satisfaction of the patient with long face syndrome.

Auricular Reconstruction with Autogenous Rib Cartilage Graft using Tissue Expander after Canaloplasty in Microtia

Along with aural atresia, abnormalities of the middle ear and external ear canal can impede the audition of the developing infant. In cases of bilateral atresia when bone-conduction aids fail to adequately restore impaired hearing, unilateral canal reconstruction may be required at a very early age to enable proper speech and language development. We are often confronted by cases in which canaloplasty has previously been performed by ENT surgeons, leaving auricular canals of various locations and sizes in addition to scars. In such cases, it can be difficult to prepare a skin flap sufficient in size to cover the cartilagenous framework for auricular reconstruction. Scar tissues with relatively poor vascularity induced by a prior incision and elevation of the soft tissue may compromise the ultimate result of auricular reconstruction. To obtain the sufficient, thin, pliable and well vascularized skin, we used tissue expansion at the first stage of the auricle reconstruction in microtia patients who previously received canaloplaty. From December, 1988 to February, 1999, we attempted tissue expansion using volume 35cc, cresent- type inflatable silicone expanders(SebbinR) in 12 patients who previously received canaloplasty. Ear frameworks were prepared using autologous rib cartilage. The expanded skin provided sufficient, thin, pliable, and well vascularized skin for easy draping and better contouring. The reconstructed auricle was satisfactory in both color and texture and had nearly normal sensation. No resorption of the inserted rib cartilage has been observed from 7 months to 9 years and 9 months after the operation.

Total Craniofacial Correction of Plagiocephaly using Intracranial Remodeling Including Occipital Area

Plagiocephaly is a premature unilateral coronal craniosynostosis consisting of flattening of the involved frontal region and low-set orbit in affected side and compensatory occipital bulging in contralateral side with resultant facial asymmetry. The authors experienced a 20-year-old male having frontal and posterior palgiocephaly with asymmetric mid-facial appearance in left side who had undergone the strip craniectomy of the coronal suture when he was 100 days old. We performed total intracranial total calvarial remodeling including occipital region followed by two-jaw operation seven months later. Cranial vault was cut into three transverse bone flaps; anterior bi-frontal bone flap, posterior bi-fronto-parietal bone flap, and bi-parieto-occipital bone flap. Unilateral supra-orbital bar advancement with tongue-in-groove arrangement was performed. To restore contour of occipital region, the transposition cranioplasty was done after mid-sagittal osteotomy of posterior bone flap. Seven months later, Le Fort I osteotomy and BSSRO was performed to correct jaw asymmetry and cross-bite. We believe that total correction of orbito-fronto-occipital vault including jaw surgery in plagiocephaly is mandatory for more excellent aesthetic result and effectiveness.

Management of Hair Line Using Skin Graft after Tissue Expansion for the Auricular Reconstruction of Microtia

Reconstructing the ear with autogenous rib cartilage is one of the most preferred methods for microtic ear reconstruction. Sometimes, when using this method, the skin envelope size is not large enough for the cartilage framework. With tissue expansion, a more adequately sized hairless skin envelope can be developed. Usually we recommend that canaloplasty be delayed after external ear reconstruction. But when the external ear canal has been reconstructed before external ear reconstruction, the remaining hairless skin for an envelope is so deficient that even though using tissue expansion, it is nearly impossible to develop well-qualified hairless skin envelope. From January, 1996 to December, 1998, we reconstructed auricles using tissue expansion, followed by excision of hair-bearing skin and grafting of full-thickness skin in five microtic patients whose external ear canals had been reconstructed before external ear reconstruction. The skin donor area was the contralateral postauricular area. Two to three weeks after the skin graft, autogenous cartilage grafts followed. No graft was lost. Color and texture was well matched, and the hair-bearing tissue portions were almost completely removed. Our method has several advantages: 1) it uses local tissue maximally; 2) it leaves the capsule intact, which can improve flap circulation; 3) it may thin the flap as much as it can be, which can reveal well defined cartilage framework; 4) it allows easy removal of hair-bearing tissue portions; 5) it provides a well-vascularized bed for graft survival and preserves the temporoparietal fascia, which can be used for secondary reconstruction if necessary; 6) Tissue expansion can reduce the amount of hair-bearing portion which should be removed.

Le Fort III Advancement for the Correction of Crouzon's Disease

Crouzon's disease, first described by Crouzon in 1912, is characterized by craniosynostosis, exorbitism and midface hypoplasia. As well, it has been known to be transmitted as an autosomal dominant trait. Clinically, Crouzon's disease not only has aesthetic problems, but also many functional disabilities, such as increased intracranial pressure, hydrocephalus, visual disturbance. difficulty in nasal breathing and malocclusion. The surgical correction of Crouzon's disease includes: 1) frontal bone advancement and release of the craniosynostosis; 2) correction of the midface retrusion; and 3) other ancillary procedures for better aesthetic results. The authors performed Le Fort III advancement for the correction of midface retrusion in 5 cases of Crouzon's disease. These advancements were performed at about the age of 15 in consideration of facial bone growth disturbance, psychosocial effects, and the recurrence of class III malocclusion after operation. The average advancement of the midface was 9. 2 mm. We experienced favorable aesthetic and functional results without severe complication in all cases or relapse of the advanced segment.

Scar Tissue Expansion for the Treatment of Scar Contracture

The treatment of scar contracture has a relatively long history in the department of plastic surgery. Flap surgery, including Z-plasty and skin graft has been a common surgical modality for the treatment of scar contracture. However, the 'deficiency' of the tissue is basically responsible for the limitations of this treatment. The concept of tissue expansion has contributed to the solution of tissue deficiency and thus tissue expansion is currently widely used for various purposes in plastic and reconstructive surgery. Nevertheless, tissue expansion has not yet clearly solved the problems in cases of seven deficiency of surrounding normal tissues, or in cases of multiple and diffuse scar contracture. We have tried to 'expand the scar tissue' to overcome these limitations. The authors 'several decades of experience in tissue expansion has taught us to find the usefulness of incidentally expanded scar tissues. Thirty-one patients with scar contracture urderwent expansion of surrounding normal and/or scar tissues, including 5 cases of pure scar tissue expansion. The postoperative results were satisfactory with a minimal complication rate. In conclusion, scar tissue expansion was usefully applicable for the scar contracture with no surrounding normal tissues. Scar tissue could be expanded safely and sufficiently, designed to various flaps, and the flap survival was reasonable. The functional and aesthetic quality of the scar tissue seems to improve following tissue expansion. In addition, meticulous planning is essential from the initial operation, including the area of expander insertion, flap design considering the aesthetic unit and functional aspect.

Lateral Osteotomies in Oriental Rhinoplasty

No abstract available.

Facial form analysis of the lower and middle face in young Korean women

Nowadays facial skeletal contouring which have developed in craniofacial surgery, acquired popularity in aesthetic surgery. On planning aesthetic surgery, patient's desire must be considered first but it seems to be essential to have an objective standard of facial form. Anthropometric analysis, cephalometric analysis, and photogrammetric analysis were developed for this purpose but with a limitation in three dimensional analysis. Barnett and Whitaker(1986) developed a simple three dimensional analytic system of middle and lower face and reported average values and standard deviations for young Caucasian women. We performed the same analysis for age matched young Korean women and found some difference between young Caucasian women and young Korean women as follows; 1. Young Korean women's middle and lower face is wider than young Caucasian women's face in horizontal dimension. 2. Young Korean women's middle and lower face is shorter than young Caucasian women's face in anterior-posterior dimension. 3. The difference in vertical dimension between the two groups is minimal. 4. In angular relationship, young Korean women's anterior and inferior angles are larger than young Caucasian women's angles. These findings are coincident with other author's observations that Oriental face is wider and rounder than Caucasian face and Orientals have more prominent malar area and mandible angle. For Korean people, with many needs for aesthetic correction of prominent zygoma and mandible angle, this three dimensional analytic system will be useful in planning surgery and research for middle and lower face deformities.