Lyophilized allogeneic costal cartilage graft for septorhinoplasty

Background@#As rhinoplasty techniques have become more complex, surgeons often need more than what septal or conchal cartilage can provide. While costal cartilage became more popular for that reason, some surgeons are still uncomfortable with its invasiveness and donor site morbidity. Here, we used lyophilized allogeneic costal cartilage for septorhinoplasty and investigated its safety and usefulness. @*Methods@#The costal cartilage was harvested from a cadaveric donor and treated via multiple steps, including defatting and lyophilization, to remove all viable cells and antigenicity. The cartilage was then stored at room temperature and rehydrated 24 hours before use. Lyophilized cartilage allografts were used in 20 patients. Three types of septal graft were performed — spreader, batten, and extension — to correct septal or columellar deviation and enhance the nasal tip. @*Results@#The mean follow-up period was 4.3 years. In all cases, the graft successfully met the rhinoplasty purpose. No significant deformation was detected in any of the patients. Although warping was observed in one patient (5%), there was no case of clinical infection, extrusion, or graft removal and no revisional surgery for an unfavorable aesthetic result. @*Conclusions@#Lyophilized allogeneic cartilage was used for septorhinoplasty very safely and effectively. It can be carved into any shape and has all other properties required for perfectly replacing autologous costal cartilage. The main advantage of cartilage allografts is a limitless supply of high-quality cartilage without donor site morbidity. The disadvantages include the need for special facilities and manpower and extra covering cost.

Appropriate Administration of Prophylactic Antibiotics in Clean Operations: A Preliminary Report

Surgical site infection is one of the most common hospital infections and surgical complications. Appropriate administration of prophylactic antibiotics is, therefore, important to reduce surgical site infection rate. The use of prophylactic antibiotics in Korea tends to be too long and clinical confirmation of safe reduction of oral antibiotics use is mandatory. This is a preliminary report on the results of reducing oral antibiotics from 5 to 2 days in clean plastic surgery patients. Patients who underwent clean operation under local anesthesia between June 2008 and December 2008 were included in this study. The patients were divided into two groups, and they received oral antibiotics for 2(group O2) or 5(group O5) days. Complication rates, related expenses, and patients' complaints regarding the medication were compared between the two groups, considering the intravenous antibiotics use. There was no significant systemic or infection-related complication. An overall complication rates were 2.8% in group O2, 4.8% in group O5. All the complications were regional and required no surgical intervention. There were no significant differences between total(p=0.72), intravenous antibiotics administered patients(p=0.08), and intravenous antibiotics non-administered patients(p=1.00). Oral antibiotics could safely be reduced to 2 days in clean plastic surgery excluding intravenous antibiotics.

Post-operative Continuous Positive Airway Pressure (CPAP) Therapy in Velopharyngeal Insufficiency Patient

PURPOSE: There are several surgical methods for correcting a velopharyngeal insufficiency (VPI) but in some cases, it is not possible to achieve complete recovery of the velopharyngeal function. This paper introduces a new therapy for treating hypernasality without further surgery using continuous positive airway pressure (CPAP). METHODS: CPAP therapy was applied to seven VPI patients for eight weeks from April of 2007 to September of 2009. All patients underwent palatoplasty for the cleft palate and six patients underwent palatal lengthening for VPI before CPAP therapy. A speech pathologist performed an auditory perceptual evaluation to evaluate the improvement in hypernasality after 8-week CPAP therapy. RESULTS: Six patients showed an improvement in hypernasality after CPAP therapy according to the auditory perceptual evaluation. One patient with severe hypernasality responded to the early part of therapy but the hypernasality did not improve after therapy. CONCLUSION: CPAP therapy might be effective in reducing the hypernasality in patients with VPI by providing resistance training to strengthen the velopharyngeal closure muscles. In particular, CPAP therapy could be more effective for patients who show mild to moderate hypernasality after surgery.

Analysis of Repeated Bone Graft after Secondary Bone Graft in Children with Alveolar Cleft

PURPOSE: The most widely accepted protocol for alveolar cleft reconstruction is to repair it during the mixed dentition stage. There were lower resorption rate (about 88%) at this stage. However we found some cases that need repeated bone grafting. Therefore we sought to analyze the cause of repeated alveolar bone grafting in connection with other factors. METHODS: From January 2000 to January 2006, thirty-nine secondary alveolar bone grafts with iliac crest spongiosa were carried out. In 39 patients, 5 patients who had significant bone graft resorption received repeated alveolar bone graft. In all the cases, the causes of repeated bone grafts were dental root exposure(angulation), and the deficiency of the bony support for lateral incisor or canine eruption. In 3 cases, there was deficiency of the alveolar bone at the cleft side. There was the need of repeated bone grafts for orthodontic treatment in 2 cases and for application of dental implants in 1 case. RESULTS: During the follow-up period, the clinical and radiologic examinations showed that repeated alveolar bone grafts were maintained successfully without any complications. The volume of the repeated bone graft was sufficient for orthodontic treatment and implantation. CONCLUSION: The essential conditions for successful alveolar bone grafting includes the status of cleft sided teeth, further treatment and planed schedule, as well as canine eruption. Alveolar bone grafting has to be performed with difference of each case in mind.

Usefulness of External Monitoring Flap in the Buried Jejunal Free Flap

PURPOSE: The jejunal free flap has the shorter ischemic time than other flap and requires a laparotomy to harvest it. As the evaluation of the perfusion the buried flap is very important, the perfusion of the buried jejunal free flap requires monitoring for its salvage. We tried to improve the monitoring flap method in the jejunal free flap and examined its usefulness. METHODS: From March 2002 to March 2006, the monitoring flap method was applied to 4 cases in 8 jejunal free flaps for the pharyngeal and cervical esophageal reconstructions. The distal part of the jejunal flap was exposed without suture fixation through cervical wound for monitoring its perfusion. The status of perfusion was judged by the color change of jejunal mucosa and mesentery. If necessary, pin prick test was performed. Doppler sonography was applied to mesenteric pedicle of the monitoring flap in case of suspicious abnormal circulation. RESULTS: The monitoring flap shows no change in 3 cases, but the congestion happened in one case at the 12 hours after the operation. This congestion was caused by the twisting or kinking of the mesenteric pedicle of the monitoring flap. So, we fixed up the monitoring flap close to adjacent cervical skin for prevention of rotation. Finally, the main part of transferred jejunal flap was intact. CONCLUSION: The success of a jejunal free flap depends on close postoperative monitoring and early detection of vascular compromise. So, various monitoring methods have been tried, for instance, direct visualization using a fiberoptic pharyngoscope, through a Silastic window placed in the neck flap, or external surface monitoring with an Doppler sonography, use of a buried monitoring probe. But, all of the above have their own shortcomings of simplicity, non-invasiveness, reliability and etc. In our experience, monitoring flap can be a accurate and reliable method.

Prenatal Diagnosis of Accompanying Alveolar Cleft and Cleft Palate in Fetuses with Cleft Lip Using Prenatal 3D Sonographic Identification and Antenatal Counseling

PURPOSE: Cleft lip and/or palate is the most common congenital facial anomaly whose incidence is about 1 in 500~1000 live births. As this anomaly may be associated with the serious chromosomal anomalies or the multiple organ abnormalities resulting in the fetal loss or perinatal maternal morbidity and mortality, careful prenatal counseling with early and accurate detection is important. Although conventional prenatal ultrasound(US) examination in midterm pregnancy has been applied for screening of cleft lip, there are definite limitations in the diagnosis of accompanying cleft palate or alveolar cleft. We applied high-resolution 3D US along the serial axial, coronal and sagittal plane so that we could diagnose the cleft palate and/or alveolar cleft in fetuses with cleft lip. METHODS: From May 2005 to September 2005, 20 fetuses with cleft lip were examined with prenatal 3D US. Average maternal age was 28.8 years old(24-35 years old), and average gestational age was 24.8 weeks(17.6 to 34.2 weeks). Consecutive axial, coronal and sagittal multislice view were obtained via prenatal 3D US examination and diagnosis of cleft palate and/or alveolar cleft in cleft lip fetuses was followed. RESULTS: With noninvasive and safe prenatal 3D US examination, 17 of 20 cleft lip fetuses were demonstrated to have cleft palate and/or alveolar cleft. Prenatal counseling according to the result was made. CONCLUSION: Existing prenatal US examination is suitable for screening the cleft lip fetuses but has limitation in identifying the related existence of cleft palate and/ or alveolar cleft. Authors verify the presence of cleft palate and/or alveolar cleft acquiring the successive multislice axial, coronal, and sagittal view with prenatal 3D US examination. Therefore, prenatal 3D US examination could be regarded as a noninvasive and secure screening modality in fetuses with cleft lip for confirming whether cleft palate and/or alveolar cleft is accompanied.

Velopharyngeal Insufficiency Accompanied with Hypertrophic Tonsils: A Case Report

It is well documented that adenoidectomy is attributed to hypernasality in certain cases, but not clear that the enlarged tonsils affect the quality of speech. Hypertrophied tonsils may cause and complicate the problem of velopharyngeal incompetency. The huge tonsils prevent lateral pharyngeal walls from a medial movement and interfere velar elevation, being hypernasality. Hyponasality developes as the tonsils encroach in nasopharyngeal space. Voluminous tonsils also interfere airflow in the oropharyneal passage and produce the phenomenon of cul-de-sac resonance or muffled sound. The authors and et al. present a case of velopharyngeal insufficiency accompanied with hypertrophic tonsils. Improving the lateral constricting pharyngeal wall and velar elevation after tonsillectomy minimized the velopharyngeal gap. Accordingly, the procedures of sphincter pharyngoplasty and palatal lengthening resolved the problem of hypernasality instead of pharyngeal flap. Tonsillectomy prior to pharyngeal flap surgery tends to reduce the postoperative airway problems. Sometimes, however, only tonsillectomy does without pharyngeal flap. Surgical approach by stages and intermittent evaluation are recommended at intervals of at least six weeks.

Reconstruction of the Cone-shaped Defect in the Temporal Area with Rectus Abdominis Free Flap

Defect on the temporal area caused by, surgical ablation of a tumor or an infection should be reconstructed immediately to prevent potentially life-threatening complications such as meningitis and cerebrospinal fluid leakage. The defect on the temporal area usually presents as a typical 'cone-shape'. Successful reconstruction requires sufficient volume of well-vascularized soft tissue to cover the exposed bone and dura. From 1994 through 2003, the authors applied rectus abdominis free flap for the reconstruction of the temporal defect from 1994 through 2003. There were 10 patients with a mean age of 52.1 years. Of these 10 patients, external auditory canal cancer was present in four patients, temporal bone cancer in two, parotid gland cancer in one and three patients were reconstructed after debridement of infection(destructive chronic otitis media). All the free flaps survived, and flap-related complications did not occur. Compared to a local flap, the rectus abdominis free flap can provide sufficient volume of well-vascularized tissue to cover the large defect and can be well-tolerated during an adjuvant radiation therapy. The long and flat muscle can be easily molded to fit in to the 'cone-shape' temporal defect without dead space. It is also preferred because of the low donor site morbidity, a large skin island and an excellent vascular pedicle. Two-team approach without position change is possible. In conclusion, the authors think that rectus abdominis free flap should be considered as one of the most useful method for the reconstruction of a cone-shaped temporal defect.

Avoidance of Injury to the Inferior Alveolar Nerve in Mandibular Angle Contouring; Maneuver of One Inch

Complications of mandibular angle contouring may include damage to the inferior alveolar nerve. This study was undertaken to quantify the path of the inferior alveolar nerve in the normal human mandible and in the mandibles of patients presenting for cosmetic reduction of the mandibular angles. The study was based upon the panorama radiography of 20 normal population (ten men, ten women) and 20 patients (ten men, ten women) complaining of square face. Using panorama radiographs and paper tracing, the distance from the "A" point (Fig. 1) to the inferior alveolar nerve was recorded within its mandibular osseous canal in the mandibular angle. The nerve was identifiable in each ramus. The average distance between A point and the other points along the osseous canal is 21.48mm. Therefore together with an additional margin of several millimeters, it is important to maintain a safe distance of at least an inch (25mm) between the saw and the anterior border of the ramus. From our clinical experiences, we are suggesting that this "1 inch maneuver" to be very helpful in avoiding injury to the inferior alveolar nerve, especially for the novice surgeon.

Use of 2-Octylcyanoacrylate (Dermabond(r)) for Repair of Hand Trauma

Dermabond(r) (2-Octylcyanoacrylate) has an eight-carbon alkyl derivative that is less inflammative and stronger than its short chain derivatives (i.e. 2-Butylcyanoacrylate, Histoacryl(r)). This study is to compare a tissue adhesive, 2-octylcyanoacrylate (Dermabond(r)), with conventional wound closure techniques for hand trauma. Thirty-eight patients presenting to Asan Medical Center Emergency Department with hand trauma from March 2003 to June 2003 were enrolled into this prospective clinical trial study. These patients were randomly assigned to treatment with either 2-octylcyanoacrylate or 5-0 monofilament sutures. The two groups were similar in both clinical and demographic characteristics. Photography taken at three months after treatment was rated by two plastic surgeons blinded to the method of closure. There was no difference between the two groups for appearance scores based on a visual analog scale (73.3mm for 2-octylcyanoacrylate versus 69.9mm for 5-0 monofilament sutures). The length of time for skin repair was similar between these two groups. (9.2 minutes for 2-octylcyanoacrylate versus 8.9 minutes for 5-0 monofilament sutures) Moreover, the use of 2-octylcyanoacrylate obviates the need for suture removal. In conclusion, the use of 2-octylcyanoacrylate for hand skin repair is an acceptable alternative, which includes many advantages to conventional suturing with a comparable cosmetic outcome.

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.

Congenital Lateral Sinus of the Upper Lip

Congenital sinuses of the lips are uncommon congenital malformations. Congenital lateral upper lip sinuses or pits are more rare than those that occur in the midline, and only 10 cases have been reported previously. Congenital sinus of the upper lip usually present as a pit, which is the opening of a blind sinus penetrating the orbicularis oris muscle and ending just beneath the mucosal surface of the lip, without communication with oral cavity. Most sinus tracts are lined by stratified squamous epithelium, and mucous drainage or secretion is the most common symptom. In the literature, there are several theories of pathogenesis in which the invagination theory recieves the most attention but its etiology remains controversial. Surgical resection is the tratment of choice and an elliptical excision gives the most acceptable aesthetic result. The authors present 2 rare cases of congenital lateral upper lip sinus with pits found below right vermilion border, and just above the vermilion border on the left ridge of the philtrum.

Median Facial Dysplasia in Cleft Lip and Palate

The term median facial dysplasia was first reported by Noordhoff and Cheng to describe a subgroup in the cleft lip and palate patients exhibiting the following characteristic facial defects; lack of Cupid's bow, short prolabium, absence of the labial frenulum and columella, poorly developed premaxilla, absent upper central and lateral incisor of the cleft side, and deficient septal cartilage and nasal spine. But gross brain anomalies were usually absent. From May 1998 to February 2002, four cleft lip and palate patients at the Asan Medical Center were diagnosed as median facial dysplasia. Lip was repaired at 3 months of age and palate was repaired at 1 year of age. All patients showed significant midface disturbances during the follow-up period. We report 4 cases of median facial dysplasia who showed severe midface growth disturbances.

Application of 2-Octylcyanoacrylate (Dermabond(R)) on the Incisional Wound of Thyroidectomy

2-Octylcyanoacrylate(Dermabond(R)) has an eight-carbon alkyl derivatives that is less inflammative with stronger adhesive property than its short chain derivatives (ie. 2-ethylcyanoacrylate, 2-butylcyanoacrylate).1 To assess the effectiveness of the tissue adhesiveness of 2-octylcyanoacrylate with dermal suture for the closure of head and neck incision wound, 20 patients who underwent thyroidectomy at Asan Medical Center were studied. Ten patients underwent skin closure with paper adhesive and the other 10 with the new tissue adhesive, 2-octylcyanoacrylate. At the time of 2 weeks and 3 months respectively, the incisions were evaluated by authors. Photographs of the incisions were rated using a visual analogue scale by 2 plastic surgeons who had no idea of the method of skin closure. The length of time required for skin repair was increased(161 seconds 2-octylcyanoacrylate vs 65 seconds paper adhesive), and the incision closed with tissue adhesive had similar cosmetic scores(84mm 2-ocylcyanacrylate vs 82.5mm paper adhesive). But the satisfaction of patient was higher in 2-octylcyanoacrylate group. The practical advantages of tissue adhesives are easy application, convenience of taking early showers and no need of suture removal. In conclusion, 2-octylcyanoacrylate is found to be an effective method of skin closure in clean head and neck incisions.

Salvage Surgery for Locally Recurred Nasopharyngeal Carcinoma / 대한이비인후과학회지

There are several options for the management of patients with locally recurred nasopharyngeal carcinoma after irradiation. Many patients can benefit from reirradiation but the complications of high dose irradiation for the second time are often severe and unbearable. In some patients, the recurred lesion may persist even after the reirradiation. Obtaining an adequate exposure of the nasopharynx for an oncologic surgical procedure has been challenging because of its surgical inaccessibility. However, improvements in the surgical approaches to the nasopharynx and paranasopharynx have been made in recent years. Two illustrative cases, in which we performed salvage surgery, are presented in this article. Using the maxillary swing approach, we removed the recurrent nasopharyngeal tumor in a 43 year old female patient. The reassembly of the osseous and soft tissues was not difficult and the associated morbidity was acceptable. In a 19 year old male patient, subtemporal-preauricular infratemporal fossa approach was performed with low morbidity for the removal of tumor recurred at the pterygopalatine fossa.

Repair of Complete Cleft Palate by Modified 2-Flap Palatoplasty

The goal of palatoplasty is focused on two points. One is to close the palatal defect completely and the other is to create velopharyngeal system for normal speech production. After palatoplasty, scaring of palatal bare area is an important factor contributing to maxillofacial growth aberration. Bardach reported that most palatal clefts could be closed without bare bone by using the two-flap palatoplasty. On the basis of clinical experiences of the two-flap palatoplasty, authors made the lateral incision on the noncleft side to decrease the chance of bony exposure. From November 2000 to January 2001, nine children with complete cleft palate underwent two-flap palatoplasty without lateral incision on noncleft side (modified two-flap palatoplasty). Mean age at cleft repair was 11.2 months, and mean follow-up period was 2.9 months. Incision was performed on the medial edges of both side and the alveolar ridge of the cleft side. After elevation, the mucoperiosteal flaps of both sides were rotated downward. The palatal gap was simply closed without tension. Palatal fistula did not occur, and there was no postoperative bleeding. Modified two-flap palatoplasty method can be suggested to reduce the bare bone exposure, scarring and resultant growth disturbance. However, more in-depth study by long term follow-up is needed to evaluate growth pattern and speech evaluation.

Correction of Complete Bilateral Cleft Lip with Noordhoff Method: Problems and Solutions

Bilateral cleft lip shows various clinical characteristics and the typical bilateral complete cleft lip usually features prominent premaxilla, short columella, non-protruded nasal tip, flared alar base and asymmetrical alar cartilage. The prolabium is usually short and demonstrate total absence of oricularis oris muscle. Therefore a satisfactory reconstruction of the lip in both the functional and cosmetic aspect is very difficult, especially in philtral column, columella, and nasal portion. Various techniques of cleft lip repair are being developed. The staged repair of bilateral cleft lip, one side and then the other, has been superseded by simultaneous/symmetrical repair of both sides that also included complete muscular closure. And by Mulliken1 and Cutting2,3, simultaneous/symmetrical repair also has been changed to one stage repair of bilateral complete cleft lip together with nasal deformity correction. The authors performed one stage closure by means of Noordhoff method without presurgical orthopedics, which provided simultaneous/symmetrical repair including complete muscular closure and at the same time reproduced the tubercle and Cupid's bow by using both lateral lip segment. There were some problems after surgical repair. First, short or absent columella were inevitably present which could be corrected by columellar lengthening. Secondly in complete cleft lip without cleft palate, there is persistent protruding of the premaxilla and finally resultant scar widening of the cupid's bow and philtral column, which could be corrected by orthognathic surgery. But these procedures are only secondary solutions for correction of already-made deformity. We demonstrated problems and their solutions in the performance of the Noordhoff method and introduced Cutting's presurgical nasoalveolar molding as a fundamental solution2,3.

Configuration of Upper Lip in Newborn

Millard presented the concept of rotation advancement for unilateral cleft lip repair, and today this method of cleft lip closure is acknowledged by most as optimal in principle. However, it has been noted that this procedure occasionally can produce a scar that is symmetrical on the lower two-thirds of philtral column. The scar crosses the upper one third of the philtrum obliquely. The purpose of our study is to determine the configuration of the philtrum. 200 newborn infants were examined from June 1998 to September 1998. Mean gestational ages were 39 weeks and 5 days. Mean birth weight was 3226 gm. Multiple parameters such as philtral shape, nostril sill shape, vermilion shape, curvature of Cupid's bow, mean philtral length, mean white roll length, mean Cupid's bow length, and mean distance between both commissures were applied. An arbitrary classification of the philtrum was established to divide these infants into five groups. As a result, the parallel philtral column from nostril base to vermilion border(Type lla) was found to be the most popular type. Most common vermilion shape was protrusion type. Normal curve of Cupid's was most common. Mean values of philtral length, white roll length, Cupid's length, and distance between commissures were 8.3+/-1.1 mm, 13.9+/-1.3 mm, 5.7+/-1.0 mm, 24.7+/-2.3 mm, respectively. We believe this classification system will be useful for newborn infants evaluation and analysis, systemic planning and application of proper cleft lip repair procedure.

Microvasclar Free Tissue Transfer for Aesthetic Facial Contouring

The facial contour deformity can cause significant handicaps in social life and a psychological stress to the patient. From January 1991 to November 1998, ten patients were operated on for correction of facial contour deformities with three types of free flap: deepithelialized scapular (n = 6), deepithelialized groin (n = 3) and omental free flap (n = 1). The distribution of diseases were Romberg's disease (n = 3), hemifacial microsomia (n = 2), facial lipodystrophy (n = 1), sequelae after surgery (n = 3) and post-traumatic deformity (n = 1). The patient ages ranged from 12 to 42 years. An incision was made at preauricular (n = 3) or submandibular area (n = 7). After making a subcutaneous pocket just above SMAS, the flap was placed within the pocket. The microvascular anastomosis was performed using superficial temporal vessel (n = 3) or facial vessel (n = 6) as a recipient. The flap margin was sutured to the fascia or periosteum and fixed by bolster sutures to reduce gravitational migration. There were no flap loss. Flap revisions consisting of minor contour corrections were performed in eight patients. A stable restoration of facial contour was achieved in all patients. Microvascular free tissue transfer has the advantages that it can be used on the irradiated bed and restore a large defect of facial contour. The deepithelialized groin free flap is suitable for correction of generalized defect of facial contour such as hemifacial microsomia because of its abundance of fatty tissue. In the deepithelialized scapular free flap, the dorsal thoracic fascia can be folded and tailored into variable width and thickness to correct subtle deformity of facial contour such as Romberg's disease or facial lipodystrophy. The omental free flap is not considered the first choice in facial contouring surgery as it requires laparotomy and has a greater tendency to gravitational migration.

The Clinical Experiences of Ultrasound-Assisted Lipo plasty

Suction-assisted lipoplasty is now flrequently-performed pre cedure in plastic surgery, but it has several drawback including bleeding contour irregularity due to its traumatic nature. The recently introduced ultrasound-assisted lipoplasty (UAL) technique uses ultrasonic energy which has specificity in lower density tissue like fat tissue. Therefore, UAL can minimize these compli cations. We performed UAL in 21 patients from OCt. 1988 to Jun 1999. There were 17 females and 4 males, and patient age ranged from 18 to 52 years(average 40 years). A total of 58 areas were operated on for an averge of 28 areas per patient. We used a fivestage technique consisting of tumescent infiltration, ultrasonund treatment, emulsion suction, endermology, and postperative pressuregarment application. Total volume (fluid and fat) removed ranged from 200 to 4,050 cc(averge 1,750 cc) per patient and the lipocrit within the aspirate was 4-8%, which was significantly lower compared with traditional liposuction Residual emulsion was evacuated by endermology and pressuregarment was applied to all patients for postoperative 2-3 months. Pestoperative complications were seroma, induration, and paresthesia, but all these problems resolved spontaneously within a month. One patient required secondary UAL for correction of excess fat at the medial knee. We believe that UAL is a safe and excellent technology in liposuction because of reduced surgical bleeding and good contral of body contour.