Guide Lines of Successful Augmentation Rhinoplasty

Augmentation rhinoplasty is one of the most popular aesthetic procedures in Korea. It is precise surgery in which the margin of error is measured in millimeters, thus the surgeon must have a full knowledge of nasal anatomy and the basic principle of surgical procedures. In fact, many surgeons, in particular, inexperienced with lack of the basic principle, face dissatisfactory surgical result frequently. While a considerable number of studies have been made on the "advanced procedures" of rhinoplasty over the past few years, few attempts have so far been made on the "basic principle". This article shows what is the basic principle of successful augmentation rhinoplasty. The six steps for successful augmentation rhinoplasty are as follows: incision, approach, pocket dissection, implant fabrication, suture, and dressing. Marginal incision should be made at the caudal border of the alar cartilages to avoid disruption of soft triangle area and visible scar formation, which could be occurred when it is made at the immediate nostril rim area. The soft tissue envelope is sharply elevated in a plane intimate to the perichondrium with Peck- Joseph dissecting scissors to minimize tissue trauma and bleeding. The periosteum is sharply elevated with a Joseph periosteal elevator at the caudal margin of the nasal bone and dissection continued superiorly in a subperiosteal plane to the radix area. This pocket must be made with ample and symmetric dissection. Silicone rubbers, especially, soft type are the best as implants for rhinoplasty. It should be fabricated at the nasofrontal angle and its contact surface with the nasal bone should be carved more concavely to have a plastic suction pad effect. Silicone rubbers carved like this adhere closely to the nasal bone and make an even capsular formation. The incision should be closed very carefully, if not, asymmetric nostril or deviated columella can be occurred. Joseph dressing is routinely placed at the final step. In this procedure, we expect that any dead space between implants and the nasal bone can be obliterated by placing two or three pieces of gauze on the nasal root. We are sure that this article can be a little help to inexperienced plastic surgeons by providing the basic principle of successful augmentation rhinoplasty.

Problems of Expanded Polytetrafluoroethylene (Gore-Tex(R)) in Augmentation Rhinoplasty

Augmentation rhinoplasty is one of the most popular aesthetic procedures in Asians. Numerous alloplastic implants have been used, however alloplastic implants may cause many problems in nasal and perinasal areas because of thin soft tissue cover. For these reasons, an ideal implant should be nonpalpable, readily exchangeable and biocompatible. Among these alloplastic implants, Gore-Tex(R) is a polymer of carbon bound to fluorine composed of solid nodes connected by very fine fibers. It has been reported that this material become permeated and surrounded by mature connective tissue, forming a strong supporting envelop for the material, yet the implant is easily removed because of limited tissue ingrowth. Since it's development, Gore-Tex(R) has found many applications in the field of facial plastic and reconstructive surgery. From November, 2001 to December, 2002, Gore-Tex(R) implants were removed from 17 patients due to several problems such as; decreased dorsal height, tip deformity, chronic inflammation. The implants were very hard to remove and coinciding injury of the surrounding tissue were inevitable. An analysis of the length and thickness changes in these removed implants was made. The results showed, decrease in length and thickness with a volume loss averaging, 46.3% in 45x4.0mm implants, 49.3% in 50x5.0mm implants. In view of the experiences of 17 cases of Gore-Tex(R) implants in rhinoplasty, we have concluded that Gore-Tex(R) implants were structurally unstable, fibrovascular tissue ingrowth into pores were minimal, the implants were very hard to remove and the implants caused a postoperative volume reduction. Therefore, Gore-Tex(R) use in augmentation rhinoplasty should be approached with caution.

Histologic Change of Injected Fat Cell Taken by Different Technique

No abstract available.

Delivery Alar Sculpturing Technique Through a Marginal Incision

No abstract available.

Comparrison of End - to - side Loop Neurorrhaphy with Epineurium Versus without Epineurium

The high incidence of pain recurrence in traumatic neuromas continues to be a major problem in about 10% of patients. There are more than 100 techniques that have been proposed, but no single reliable method prevents painful neuroma formation. The end-to-side neurorrhaphy published by Viterbo1, and demonstrated encouraging results in prevention of neuroma with end-to-side loop neurorrhaphy. The aim of this study is to compare with the result that end-to-side loop neurorrhaphy with intact epineurium versus resected epineurium. Thirty Spraque-Dawley rats were divide in two group; control and experirnental group. In control group (n = 20), both sciatic nerve are transected and the ends were left unrepaired. In experimental group A (n = 20), the left sciatic nerve are transected and repaired with end-to-side loop neurorrhaphy with intact epineurium. In experimental group B (n = 20), the right sciatic nerve are transected and repaired after removal of epineurium. After 6 weeks, the cantrol and experimental group are sacrificed and examed grossly and histopathologically. In the control group, there were typical neuromas with irregular disorderly growth of axons, spreading out into the surrounding connective tissue. In experimental group A, there was no gross evidence of neuroma formation. In histology, there was some minirnal pattern of disorganized growth of the axons in the end-to-side surface, in only 1 case, but limited to the sutured area without typical spread out growth pattern. In experimental group B, the aspect were similar to the experimental group A. The end-to-side loop neurorrhaphy prevents disorganized axonal spouting seen in typical neuroma. And the interposing epineural sheath has no specific role in prevention of neuroma.

Reconstruction of the Leg with a Vertically-Based Deep Fascia Turnover Flap

The reconstruction of soft tissue defects on the leg remains a difficult challenge for plastic surgeons. If the defect is large and complicated by bone or joint defects, and excellent result can be obtained with free tissue transfer. In cases with no bony problem, no severe osteomyelitis and small medium-sized defects local flap is more acceptable than free tissue transfer because of its simple onestage and reliable operation. Fasciocutaneous turnover flaps revolve around the lack of criteria for safely designing these random pattern flaps as well as the risk of donorsite problems. Vertically-based deep fascia turnover flaps nourished by the subfascial plexus within deep fascia were used successfully for reconstruction of the leg in 5 patients. A vertically-based deep fascia turnover flap consists of deep fascia of the leg and its subfascial and epifascial plexus. As musculofascial, septofascial and periosteofascial branches these contribute to a richly anastomosing vascular network within deep fascia. Unlike adipofascial turnover flaps, the transversely-oriented deep fascia turnover flap keeps its subcutaneous layer with its intact vascular plexus so that the overlying skin is adequately perfused, even in patients with sizable flaps or extremely thin skin. Between March 1998 and February 1999, five cases underwent this procedure to reconstruct soft tissue defect on the leg. The advantages of this method are fast, safelyelevated preservation of the superficial vascular plexus, thus preserving the shape of the leg minimizing donor site scar and hypertrophy.

Microscopic Studies of PTFE Microvenous Conduit for Rabbit Femoral Vein

In this study, 42 Polytetrafluoroethylene prostheses (Gore Tex: internal diameter 1.5 mm, length 8 mm, fibrilar length 30micromiter, wall thickness 0.2 mm) were used to reconstruct the vascular gap of rabbit femoral vein. To enhance the patency rate and promote the healing process, the prostheses were connected to rabbit femoral vein by means of stair-like sleeve anastomosis. The specimens were obtained in 12 hours (n=4), 1 day (n=4), 3 days(n=4), 1 week (n=10), 2 weeks (n=10), 3 weeks(n=10). After determination of patency, the specimens were prepared with H&E stains and investigated under microscope. After 1 week, endothelial-like cells were observed around anastomotic area from the adjacent vein. After 3 weeks, all microvenous grafts were completely covered by endothelial lining. The anastomotic area was more prominent in the endothelial lining than in the central area. There was some evidence of migrating cells from adjacent soft tissue through micropores of PTFE prostheses. Overall patency rate of PTFE prostheses connected by stair-like sleeve anastomosis was 85.7%. We concluded stair-like sleeve anastomsis of PTFE prostheses in the rabbit femoral vein result in better overall patency rate than end-to-end anastomosis.

Clinical Consideration of Complications of Free Flap Donor Sites

Various remedies have been developed for broad damage to soft tissue in limbs by traffic accidents and mechanical mishaps that have greatly increased in modern society. If the damaged part is trivial, it may be generally treated with local flap or skin graft. However, this has been limited by the ability to choose the flap available depending on the condition of the wounded part, so that, if it is rather large or severly inflamed, or if it occurred with a bone-fracture, it is inevitable to practice the free flap. In the past, the focus was on whether the free flap would survive or not. However, the function of donor the and recipient, as well as the problem of aesthetic appearance, gas become a matter of increqsing interest and concern as the survival rate of the flap has greatly improved due to the development of precise operations. In thes study, therefore, some complications were analyzed which may develop in a donor by a variety of free flaps. Preoperative plans, as well as intraoperative and postoperati-ve treatment were also studied to minimize the cause of complications. To investigate these questions, we undertook a clinical analysis of 91 followed patients from 1990 to 1997. There were 68 male and 23 female patients ranging in age from 6 to 67 years, with an average of 34.7 years. The length of follow-up ranged from 8 months to 6 years. The results of this study were as follows: Sufficient plans must be made on the donor before operation, single textures like muscle or fascia should be used if possible, and incision should be arranged along Langer`s line. Some measures to reduce wound tension should be pursued, and plans must be made to immobilize the site for an ample period after the operation. Some precautious should also be considered during the operation, such as avoiding traction surrounding nerves and vessels, preserving paratenon, practicing osteotomy with great care and properly stopping any bleeding. In addition, formation of a hematoma or seroma should be preventcd and the donor must be sutur-ed as soon as possible to reduce infection. With the application of the basic operational principles on the treatment of donors, the complications which might be caused by each free flap can be reduced, and furthermore, be protected against.

Surgical Correction for Minimal Cleft Lip

Minimal cleft lip has been defined as a cleft which does not extend over the vermilion. Minimal cleft lip has no specific classification and few methods for its correction. Based on our operative experience with secondary cleft lipnose deformities, we have developed principles of operation for minimal cleft lip: minimal incision, nostril and alar reconstruction, philtrum reconstruction. alignment of cupid's bow, and vermilial notching correction. Nine patients of minimal cleft lip were operated on from March 1992 to June 1998 in our department. Each partients was evaluated for lip and nose deformities presurgically: the nasal tip, columella, ala, scar, cupid's bow, lip pout and lip length. Every patients required a different technique for repair. Satisfactory results were obtained by treating the cleft following the principles.

Chinical Analysis of Lower Leg Reconstruction with Free Flaps (47 Cases)

Traumatic injury to the lower legs has been increasing in Korea and often leads to skin and soft tissue loss, exposing blood vessels, nerves, tendons or bones. Salvaging these legs often requires free flaps. Over the past two decades, the use of free tissue transfer has produced an increasing salvage rate for severely injured lower leg. Between April. 1988 to July, 1997, 47 cases of lower soft tissue defects were reconstructed with free flaps, and retrospective analysis was performed to determine more about the factors associated with free flap failure or immediate vascular complications. We evaluated wound status before operation, operation time after injury, vascular status of recipient site, use of vein graft, use of reverse flow, salvage protocol in compromised anastomosis, survival rate and complications. There were 9 cases of venous thrombosis and 2 cases of arterial insufficiency while 7 out of 9 cases of venous thrombosis were reexplorated. However, 2 cases of partial flap necrosis and 1 case of total necrosis. Two cases of arterial insufficiency were necrotized, so the overall free flap failure rate was 9.6%. The results were analyzed to determine the factors promoting either failure or vascular complication, Many factors which are often blamed for failure (trauma cause, preoperative general condition, preoperative infection status, intraoperative ischemic time) were not significant in this study, but prolonged time after injury correlated with free flap failure, We concluded the adequate debridement and infection control, adequate selection of recipient vessel, accurate vascular anastomosis and most of all, early free flap transfer after injury, will improve the success rate.

Treatment of Facial Hypertrophic Scar with Cervical Flap and Intraoperative Tissue Expansion

Many plastic surgeons have been tried to attain ultimate goal lies in restoring the original shape and function of the facial aesthetics, in reconstruction of deformities resulting from facial hypertrophic scar and skin defects. This would require consideration in terms of hanmony in color match, skin texture and thickness. Various forms of skin graft, local flap, distant flaps, free flap and tissue expander have been employed in restoring skin defects and deformities of the cheek and submental area, and the use of large local flaps utilizing the cervicofacial skin flaps or tissue expander have brought about improved aesthetic results. the authers have obtained satisfactory results in treating 2 cases of wide hypertrophic scar of the cheek and submental area with combination of wide cervical flap and intraoperative tissue expansion using foley catheter. the merits of this combined operative methods are as follows : 1. It is not necessory to keep tissue expander for a long period. 2. This technique is able to diminish the cost of multistage operation and using of tissue expander. 3. There is no psychologic problems due to undesirable facial appearance during tissue expansion period. 4. Rapid intraoperative tissue expansion by foley catheter during elevating wide cervical flap can allow to dissect one, preserving the perforators without bleeding in a short time. 5. Wide cervical flap and additional expanded tissue by means of intraoperative tissue expansion could brought into suturing avoiding tension of oral commissure and lip eversion. 6. Preservation of perforators of cervical flap above the platysma muscle raised flap's survival rate and then this result could prevent distal ischemic necrosis after flap coverage.

Clinical Analysis of the Removed Nasal Implants

No abstract available.

Correction of Mandibular Prognathism Using Modified Kole Procedure

No abstract available.

Secondary augmentation rhinoplasty with dermofat graft

The nose is an important aesthetic projection affecting the profile of the face. Correction of the flat nose is one of the most popular aesthetic procedures in the orient. The Asian nose is characterized by flat, bulbous appearance due to thick and dense skin. Flared nostrils and restriction of nasal tip projection due to underdevelopement of the medial crus of alar cartilage, and short columella are also characteristic of Asian noses. Nasal augmentation has taken an increasingly important role in rhinoplasty. There are many procedures and materials for augmentation. Various implants have been used for many years but several kinds of complications have still occurred after these augmentations. After the primary augmentation rhinoplasty using foreign body such as paraffin, silicone, and ivory, some patients experienced complications. Experienced complications such as : 1) thinning of the skin on nose dorsum 2) hypertrophy of capsule 3) displacement of nasal tip 4) thinning of the skin creating dead space 5) movable implants In above cases, we could not reapply with silastic implant. In general, the use of foreign materials was mentioned only to be condemned for the purposes of above cases. The failure and complication rates were high, and the complications frequently result in distortions that were permanent and irreparable. In view of the availability, variety, and quality of autogenous materials, it was impossible to recommend anything but autogenous materials for secondary rhinoplasty. Dermofat was an autogenous material that could be as effectively used in nose dorsum. Its clinical record of survival and contouring in the author's practice has been excellent. Originally 276 patients underwent primary augmentation rhinoplasty. Out of the 276, 29 patients with nose complications underwent secondary augmentation rhinoplasty with dermofat. Our study, which began in September 1993 and ended in September 1996, concerned these 29 Patients. The follow up interval ranged for 3 to 36 months. Tissues must have time to heal so that an accurate assessment of the secondary procedure is made possible. The minimal time of two or three months is recommanded of patients with previous operation but we removed foreign body and then simultaneously augmented with dermofat when there is no evidence of inflammation and further resolution. As part of the procedure in order to minimize the scar on donor site, we harvested dermofat, in an elliptical shape, 5cm above from infra-gluteal fold. We harvested about 10% more dermofat than was required because of its potential decreased in volume caused by primary contracture and resorption. Primary contracture is the main cause of the decrease in volume. To prevent contracture, resorption and displacement of the dermofat, we have to accurately fix the implant in the central porticn of the nose. Using this method, we could have prevented complications and yielded more satisfactory results by accurately fixing the dermofat in the central portion.

Involvement of nitric oxide in post ischemic injury of rat island skin flap

A free radical gas, nitric oxide NO), has many useful functions when produced under physiological conditions by neurons and endothelial cells. However, excess NO has been reported to exert cytotoxic effects by direct toxicity or by reaction with superoxide. Nitric oxide can react with superoxide to generate peroxynitrite which is as reactive as the hydroxyl radical. This study was attempted to observe formation of peroxynitrite and change in amount of NO synthase(NOS) in reperfused skin flap of rats following ischemia. 3-nitro-L-tyrosine, as direct evidence of peroxynitritemediated tissue damage, as well as endothelial and inducible NO synthase(eNOS and iNOS) were studied in ischemic and reperfused skin using western blot analysis. In addition, HNE-modified proteins, as direct evidence of oxidative tissue damage by reactive oxygen species(ROS), was also evaluated. Skin specimens were obtained over time from island skin flaps(3x3 cm2) of rats under the following two conditions: 1) reperfusion following 5 hours of ischemia, and 2) reperfusion following 10 hours of ischemia. In reperfused skin after 5 hours of ischemia, formation of 3-nitro-L-tyrosine and HNE-modified proteins was decreased 1 hour after reperfusion. However, they were thereafter increased and reached a maximum (3-nitro-L-tyrosine: 142%,HNE-modified proteins:237%) 6 hours after reperfusion. In reperfused skin after 10 hours of ischemia, formation of 3-nitro-L-tyrosine and HNE-modified proteins was increased 3 hours post reperfusion, and reached a maximum (3-nitro-L-tyrosine:178%, HNE-modified proteins: 204%) 6 hours after reperfusion. eNOS and iNOS were decreased 1,3 and 6 hours reperfusion following both 5 and 10 hours of ischemia. These results indicate that peroxynitrite-mediated cytotoxicity is involved in ischemic reperfused skin despite the fact that the amounts of both iNOS and eNOS are decreased.

A case report of large orbital cavernous hemangioma treated with inferolateral orbitomomy

Cavernous hemangioma is the most common primary tumor occurred in adults' orbit. This tumor has symptoms characteristically developing over several years with slowly progressive proptosis, eyeball deviation, hyperopia, diplopia and optic nerve compression. It's removal, necessary when there is progressive exophthalmos and visual deficit, is best performed en bloc to avoid intraoperative vleeding, the risk of residue, and potential further growth. In principle, surgical approach to the orbit must provide maximum safety and optimal visualization. The noncompressibility of the globe imposes greater demand on the need for some removal of the osseous orbit for surgical approach. This also must permit immediate functional and aesthetic reconstruction. The authors have experienced a case of large cavernous hemangioma in the orbit inferomedially. The surgical treatment of tumor was achieved by inferomedial approach combined with inferolateral orbitotomy. This surgical approach allows better visualization of the tumor and greater protection of essential anatomic structures. This also permits immediate functional and aesthetic reconstruction. So we present our case with a brief review of the literature related to orbital cavernous hemangioma.

Treatment of postburn scar and scar contracture using various modified local flaps

Application of local flaps for releasing postburn scar contracture has been limited because of a problem of invisible loss, difficulty to obtain the satisfactory result against correction of limitation of motion and possibility of contour deformity. However, proper use of local flaps, accurate designs and complete wound compression for a long term after operation enable to obtain good results in correction of some cases of postburn scar contracture. It will be related to reduce unsightly scaring when contractures are released. For this purpose, we have used a modified planimetric Z-plasty, a subcutaneous pedicle flap, a new classification V-Y plasties which was proposed based on the new concept and their combination. Proper application of local flaps corresponding to the degree of contracture and shape of burn scar have enabled to increase the use of local flaps against correction of postburn scar contracture during our past 15 years, from 1982 to 1997, we treated 235 cases of postburn scar or scar contracture in various regions except for the face. Of these, 177 cases were applicated with local flaps and we could have a good results in both aspects of function and appearance. We report our operative methods, a criterion to application of local flaps and representative results.

FEMALE PSEUDOHERMAPHRODITISM DUE TO ADRENOGENITAL SYNDROME

Female pseudohermaphroditism due to adrenogenital syndrome is a condition in which individuals with a 46XX karyotype, negative H-Y antigen, normal mullerian duct derivatives, and a lack of development of w lffian duct structures differentiate partially as phenotypic males. They usually manifest masculinization of the external genitalia as a result of excess endogenous androgens. Most female pseudohermaphrodities have one of the types of congenital virilizing adrenal hyperplasia. Adrenogenital syndrome is inborn errors transmitted by autosomal recessive genes and may be due to defects in any of the enzymic steps in the biosynthesis of cortisol. Most affected individuals have a failure of 21-hydroxylation which prevents the conversion of 17 alpha-hydroxyprogesterone to 11-deoxycortisol. Such a defect in 21-hydroxylase leads to excessive production of adrenal androgens causing virilization. The treatment is early endocrinologic support and surgical reconstruction. There are some considerations in surgical repairs including normal sized clitoris with adequate erogenous sensation, sufficiently wide vaginal introitus and normal aesthetic appearance of the external genitalia for her normalized life as a female. We have experienced four cases of female pseudohermaphroditism due to adrenogenital syndrome. In two cases, we performed clitoroplasty with nerve sparing technique, vulvoplasty with mons pubis augmentation, vaginoplasty with posterior perineal flap and urethral reconstruction. In the other cases, we performed clitoroplasty with nerve sparing technique, vulvoplasty and vaginoplasty There was no specific operative complication and the result of the correction was satisfactory.

A CASE OF MALIGNANT LYMPHOMA OF THE PAROTID GLAND

Malignant lymphoma is a neoplastic proliferation of cells in the lymphoreticular system and deviled largely as Hodgkin's disease and non-Hodgkin's lymphoma. Non-Hodgkin's lymphoma occurs primarily in lymph nodes and is rare found in extralymphatic organs. The most frequently affected extranodal sites area head and neck, gastrointestinal tract, followed by bladder, skin, brain, eye and bone. Primary lymphomas arising in salivary glands are very uncommon. Lymphomas in salivary glands represented 1.7 ~ 5% of all reported salivary neoplasms. Recently authors experienced one case of primary malignant lymphoma in carotid gland and report that with a brief review of literature.

CONSERVATIVE PAROTIDECTOMY BY THE ANTERIOR APPROACH

The principle of surgery of the parotid gland is adequate removal of the tumor with functional and anatomical preservation of all blanches of the facial nerve. There are two main surgical approaches to superficial or total conservative parotidectomy. Anterior approach and posterior approach. Preliminary identification of the main trunk of the facial nerve is probably the most favoured techniques, but identification of the peripheral blanches of the facial nerve, with subsequent Proximal dissection to the main trunk, is long established but less popular technique. We have prospectively experienced the low incidence of facial nerve damage in series of 55 conservative parotidectomies performed using the anterior approach. The techniques employed is described with a deport of results obtained in the belief that this approach warrants greater popularity and saute technique.