Prevention for Collapse Using Aqua Splint(R) in Zygoma Arch Fractures

PURPOSE: The zygomatic arch is a key element which composes the facial contour. In many cases of zygomatic arch fracture, it is difficult to fix rigidly the fractured segments. If reduced bone segments were not fixed rigidly, they are proven to be displaced by mastication or unintentional external forces. So, unfixed zygomatic arch fracture after reduction may require a external device of prevention of collapse. We introduce a new protector which stabilizing the fractured segments to prevent for collapse of the reduced zygomatic arch fracture. METHODS: After reduction of zygomatic arch with blind approach(Gillies', Dingman or Keen's approach), bone segments was pulled with percutaneous traction suture in medial aspect of zygomatic arch. Then, the suture was fixed with Aqua splint(R), externally. And intraoperative and postoperative X-ray was done. The splint was removed on 14 days after the operation. RESULTS: 5 patients were treated with this method. 4 patients of total patients had no collapse in zygomatic arch. There was minimal collapse in one patient. Postoperative complications such as facial nerve injury, mouth opening difficulty, contour deformity, infection, scar were not observed. CONCLUSION: In comparison with other techniques, this technique has several advantages which are simple and easy method, short operation time, no scar, less soft tissue injury, and facilitated removal of splint. Therefore, Aqua splint(R) would be a good alternative to prevent for collapse in unstable zygomatic arch fractures

A Case Report: Surgical Treatment of Pachydermodactyly

Pachydermodactyly is a rare distinct form of fibromatosis characterized by acquired, asymptomatic dense fibrosis and fibroblastic proliferation around one or more proximal interphalangeal joints. Intralesional triamcinolone injection may be helpful in improving the clinical appearance. A 20-year-old unemployed female patient gave a four years history of progressive swelling of the fingers affecting predominantly the proximal interphalangeal joints of index fingers of left hand and index, middle fingers of right hand. There was no pain and tenderness. Physical examination, complete blood count, antinuclear antibody, rheumatoid factor were unremarkable and radiograph of both hands showed soft tissue swelling only without bony abnormality. We excised the redundant soft tissue from the both sides of proximal interphalangeal joint with longitudinal elliptical fashion. After operation, the fingers of the patient showed marked improvement cosmetically. There were no motor or sensory changes. Pachydermodactyly was first reported in 1996 in Korea. Histologic features include an increased dermal accumulation of collagen and occasionally an increased number of fibroblast. We report for one patient with pachydermodactyly treated with longitudinal elliptical excision and obtained an improvement of clinical appearance.

Reduction of Trapdoor Type Orbital Floor Fracture with Absorbable Mesh

The orbital floor fracture of trapdoor subtype is a pure orbital fracture, linear in form and hinged medially, which allows herniation of orbital fat and ocular muscles and then entraps these contents. The goals of the reconstruction of the orbital fracture are to restore the continuity and to avoid a relapse the orbital tissue. If the reconstruction is incomplete, it may result in enophthalmos with diplopia. The indications for surgical reconstruction are the imitation of ocular muscles, the persisting diplopia, enophthalmos, large size of bony defect. There are no uniformly guidelines for the materials for orbital reconstruction. The ideal material should be biocompatible, non-carcinogenic, easily kept in position and free of any potential for disease transmission. Among the materials, the absorbable mesh is used for the orbital reconstruction recently. We used the 0.8mm thickness absorbable mesh in 11 patients with orbital floor trapdoor fracture. The displaced bony fragment was reducted and the absorbable mesh was inserted below the reducted fragment. The absorbable mesh was fixated with absorbable screw, so the mesh can support the bony fragment with cantilever effect. The results were satisfactory and no significant problem was not happened during the follow up period. Absorbable meshes are gradually resorbed and the scar that formed after resorption provides the support of the globe. Our results suggest that the orbital floor trapdoor fracture with small to moderate defects is the advisable indication of orbital reconstruction with absorbable mesh.

Radiofrequency Treatment of Axillary Osmidrosis

Axillary osmidrosis is caused by excessive secretion of apocrine sweat gland and can cause extreme difficulty in social activities. The surgical removal of apocrine glands has been thought as an effective method. But this classical treatment results in many complications such as scarring, hematoma, skin necrosis and these complications have not been solved yet. Recently radiofrequency surgery as a minimally invasive technique is used for the treatment of snoring, benign prostate hypertrophy, hepatoma, reduction of masseter muscle and gastrocnemius muscle. From June, 2004 to March, 2005, 10 patients with axillary osmidrosis were treated by radiofrequency thermal ablation(PMC-1000). The generator was set to level 6-8 and the duration of time was 1.0 seconds. The maximum number of treatment sessions were two. The mean postoperative follow-up period was about average 6 month ranged from 2 to 9 month. The skin necrosis was developed in 2 patients. All patients were satisfied or partially satisfied with the results. Although suitable radiofrequency power and heating duration have not been defined yet, which is mandatory in order to obtain the best results, the radiofrequecy could be a safe and effective treatment modality for axillary osmidrosis with a good clinical outcome and few complications.

Sensory Restoration of Abdomen after Free TRAM Flap for Breast Reconstruction

The purpose of this study is to assess abdominal sensation after free TRAM flap for breast reconstruction. 74 patients underwent breast reconstruction with free TRAM flap by authors and were followed up to check the sensation on abdomen following the surgery at the out patient clinic. They are compared with 20 female volunteer controls. Abdomens were divided into 13 zones, and assessed for superficial touch, superficial pain, temperature, two-point discrimination, and vibration. For all five sensory modalities, subjects were found to have decreased sensation in the umbilical and infraumbilical regions. This was statistically significant compared with controls. Division following pedicle dissection showed more reduction of sensation than non-dissection side. Both Inguinal areas below the donor site closure also showed markedly decreased sensation. Sensation on most area of abdomen recovered in postoperative 1 year, however, there were remained hypoesthesia in umbilical and infraumbilical area after post operative 1 year. This study clearly demonstrates that there is a significant and persistent reduction in abdominal sensibility following free TRAM flap surgery.

Immediate Nipple Reconstruction in Breast Reconstruction with TRAM Free Flap

Immediate breast reconstruction in breast cancer patients is universalized and now with a wide variety of methods to choose from, we can select a breast reconstruction method according to the patient's condition. Among these methods, immediate breast reconstruction with TRAM free flap is the most commonly used. Nipple reconstruction is usually performed as a secondary procedure, reconstructed. Nipple is reconstructed with contralateral nipple composite graft or with local flap. Areola is reconstructed with skin graft and tattooing. Therefore, to reconstruct complete breast, two or more staged operations are needed and are troublesome to both the surgeon and the patient. If we could reconstruct breast mound and nipple at same time, we would reduce the operative stages and heighten the patient's satisfaction. The author performed delayed or immediate breast reconstruction with TRAM free flap and nipple reconstruction at the same time. If the TRAM flap was to situate in the whole of the breast or at the center of the breast mound, nipple was reconstructed with a local flap from the TRAM flap. If the TRAM flap was not situated in center of breast mound, nipple was reconstructed with a local flap from remnant breast skin. Immediate nipple reconstructions in breast reconstruction consisted total of 22 cases. Among these, delayed breast reconstruction were 5 cases and immediate breast reconstruction were 17 cases. According to patient's condition and mastectomy method, nipple reconstruction method was selected; nipple reconstruction with contralateral nipple composite graft(3 cases); nipple reconstruction with remnant breast skin(6 cases); nipple reconstruction from flap margin(10 cases); nipple reconstruction with prefabricated nipple on flap(3 cases). Malposition of the reconstructed nipple was the most common and serious complication(6 cases). The other complications were atrophy of the nipple(1 case), and necrosis(1 case). Reconstruction of the breast and nipple at the same time can reduce the need of a secondary operation and use remnant skin or redundant flap tissue maximally. On the other hand, it must be considered that position and shape of nipple could be deformed, because the nipple reconstruction is performed before the shape of reconstructed breast settles completely. Prudent attention is needed, because the danger of complication is higher than delayed nipple reconstruction.

Reversed Adipofascial Flap in Lower Leg: Can It Replace the Free Flap?

A soft tissue defect of the lower leg or foot presents a challenging problem. Reconstructive surgeon should be armed at all points of wound site, tendon and bone exposure, injury of major vessel and so on in the lower limb. We reconstructed the defects of lower legs and feet of 25 patients between February, 1997 and December, 2003. Applying reversed adipofascial flap with skin graft on a soft tissue defect of the lower leg or foot is challenging. We did a comparative study of 25 reversed adipofascial flaps with 51 free flaps. All 25 cases of reverse adpofascial flap reconstruction were successful except for a partial loss of skin graft in 3 occasions. The reversed adipofascial flap had a merit of a short operation time and hositalization, a high success rate and minimum complications. Besides major vessels in the lower leg are better preserved and donor morbidity is minimal. However, the flap is unmerited in reconstructing a hug hallowed defect and in the leg with poor blood circulation and once previous surgery. The operators may consider the feasible substitution of reversed adipofascial flap for free flap before applying in the lower leg.

Perineal Reconstruction with the Perineal Perforator Based Island Flap

Perineal area is composed of compact structures of urogenital organs and anus requiring a more sophisticated selection of flap and reconstruction. For achieving better outcome then conventional flap surgery, we use the perineal perforator based island flap for its reconstruction. After locating the perforator by Doppler, the flaps were designed according to the defect or expected vaginal orifice. The flaps were elevated bilaterally as island pattern. Finally defect or neovagina was reconstructed with inconspicious linear scar hidden in the inguinal crease. Five cases were performed with the perineal perforator based island flap. There were 3 cases of vulvar cancer, 1 case of transsexualism, and 1 case of ambiguous genitalia because of congenital adrenal hyperplasia. Operative results were satisfactory with good contouring and less prominent donor scar, when they were compared with other flap reconstructions such as latissimus dorsi perforator flap, groin flap, gracilis myocutaneous flap etc. The perineal perforator based island flap is highly recommended with the advantages of easy flap elevation, good rotation arc, and appropriate flap thickness for contouring. Compared with other conventional flaps, it can be selected as a good option for moderate defect of perineal area.

Application of ThermalCAMTM P40-Infrared Thermographic Imaging in the Monitoring of Survival of Lower Abdominal Random Flap in the Rabbit

The monitoring of viability of the flap is important in improvement of the flap survival. The flap survival depends on the vascularity of the flap, and the skin temperature is up to the vascularity. The authors applied ThermalCAMTM P40 infrared thermographic imaging system for the monitoring of the vascular supply of the flap. The various sized flaps are designed on the lower abdomen of rabbit, having expected risk rate of flap necrosis respectively. The surface temperatures on designed flap were checked with ThermalCAMTM P40 before flap elevation and after respectively. The flaps with high risk of necrosis, 1:4(width/length) designed flaps and some 1:3 flaps, showed remarkable color change in distal portion according to difference of surface temperatures. After 1 week, the flaps of lower abdomen showed different viability of flap, and the flap with remarkable color change showed partial necrosis distally. The Necrotic areas were identical with the color change area checked with ThermalCAMTM P40. This study shows that ThermalCAMTM P40 infrared thermographic imaging system has the utility in prediction on flap survival through detection of the vascularity with ease, quickness and safety for patient and flap.

Surgical Management of Acral Lentiginous Melanoma on Extremities

The ALM(acral lentiginous melanoma) on extremities are less common and less well studied. The purpose of the study is to investigate the surgical management for 19 cases of ALM on extremities for last 10 years. When tumor depth was less than 1.5mm on thumb, the lesion was removed with distal periosteum and full skin through degloving procedure and the defect was covered with wrap around procedure. When tumor depth was more than 1.5mm, distal amputation of thumb was performed, and new thumb was reconstructed through bone graft and wrap-around procedure. The ALM on palm was treated with wide excision, and then reconstruction was performed with reversed radial island flap. Because heel was required for weight bearing, the defect of heel after wide tumor resection was reconstructed with volume rich free flap. During 3 years follow-up period, local recurrence and general metastasis was 0% respectively in cases of tumor depth below 1.5mm. In cases of tumor depth more than 1.5mm, local recurrence and general metastasis rate were 0% and 20% respectively. In terms of function, the reconstructed thumb could have ability of pinch and grasp, and the reconstructed heel could be achieved good contour and weight bearing function.

Nipple Reconstruction Using Various Local Flaps

The existence of numerous methods of nipple reconstruction in the literature is indicative of the difficulties encountered while duplicating a normal nipple. We have performed breast reconstruction with free TRAM flap for last 10 years, and after the breast mound reconstruction we have performed nipple reconstruction with three different methods -star flap, double opposing tab flap, and C-V flap. We compared the final outcomes of these three reconstruction methods. From March 1992 to February 2001, we experienced the 82 cases of the breast reconstruction with free TRAM and the nipples were reconstructed in 54 cases by the same surgeon. 9 cases were reconstructed with star flaps, 19 cases were reconstructed with double opposing tab flaps and 26 cases were reconstructed with C-V flaps. We compared the results of the difference of the nipple projection and the patients' satisfaction in 2 weeks and 12 months after the operation. In 12 months after the operation, the average projection of the nipple was 4.2 mm in star flap, 4.5 mm in double opposing tab flap and 6.5 mm in C-V flap. The average reduction rate of the nipple projection was 46.6%, 57.4% and 32.5% respectively in 1 year after the operation. We considered that the star flap often showed the partial necrosis on the sharp tip of the flap and the contracture of the scar tissue. We assumed that double opposing tab flap showed the good projection initially. However, as time goes, it showed a widening shape on the base of nipple and disfiguring mound of breast because of high tension in the closure. The C - V flap showed round tip and less disfiguring mound of breast because of less tension and less spreading, so it shows the least reduction rate of nipple projection. We concluded that the reconstructed nipple with C-V flap showed the least reduction of nipple projection and the most satisfactory result among these 3 methods. We recommend that the nipple should be reconstructed initially much larger than the opposite nipple considering about one-third reduction rate 1 year after the surgery.

Correction of Syndactyly with Modified M Flap and Minimal Skin Graft

The principles of syndactyly correction are well established at the present time, such as the creation of dorsal and/or palmar rectangular flaps designed to reconstruct the web space, the utilization of zigzag incisions along the full length of the syndactyly to avoid contraction that might follow a straight line closure, and skin grafts to cover raw surfaces. Although numerous operative techniques based on the above principles have been introduced, most of them required skin graft inevitably because the separated fingers have a greater surface area than the syndactylized digits. The grafted hyperpigmented skin makes the finger and toe noticeable and the multiple small pieces of skin graft themselves are time-consuming procedure, and the grafted skin near the base of fingers could cause future recurrence or contracture. So we tried to develop a modified technique which could minimize the case of skin grafts by using regional skin as much as possible. A new method that we present here is a combination of first, a diverging M flap from syndactilized digital skin for commissure, second, an island flap from ventral or dorsal surface of the hand and foot to cover the raw surface at the base of divided digit, and third, the removal of fat tissue around the neurovascular bundles of the fingers for primary closure with flaps without tension at least in one digit. 11 patients composed of 5 hands and 16 feet syndactylies were operated for their correction with newly modified technique for 4 years. A long term follow-up indicates that gratifying functional and aesthetic results could be achieved without recurrences or disabling contractures of the interdigital space. This easy and rapid technique can be recommended for the correction of syndactyly because of its advantage of minimizing the problems appeared in cases by previous methods.

Areola Reconstruction: FTSG and Micropigmentation

The reconstruction of nipple and areola after breast mound reconstruction is fundamental in achieving final outcome. A variety of methods have been applied to make natural nipple and areola. The purpose of this study is to compare the operative methods and experience between FTSG and micropigmentation. Nipple-areolar complex was reconstructed after free TRAM flap for 33 breasts from May 1995 to August 2001. 20 patients underwent micropigmentation(Permark (R)) for areola and 13 patients underwent FTSG. Full thickness skin was obtained from inguinal area for FTSG method. Micropigmentation for areola was done 2 months after nipple reconstruction. There was no specific complication reported after areola reconstruction, but some differences in outcomes were noted between the two methods of areola reconstruction. First of all, there was an advantage in time saving for FTSG method due to simultaneous reconstruction of nipple and areola. However, FTSG has several disadvantages such as longer operation time, sometimes prominent scar formation of the inguinal and circumareolar region, feeling of shame due to location of the donor site, the lightening of the areolar color with time, and finally the color difference between the nipple and areola. Micropigmentation has advantages with simple procedure, short operation time, no donor site scar, no shameful feelings for dressing, no color change of areola with time, and easier color selection for the areola and nipple. It has disadvantages of double operation due to separate nipple and areola reconstruction, need for additional instruments, and experience in selection of well matched paste. FTSG from the inguinal region often had been used to produce the similar color of areola and was thought to be the standard method. However, we thought that areolar reconstruction utilizing micropigmentation is much better than FTSG in terms of cosmesis and convenience for operation.

Fat Necrosis in Reconstructed Breast Using Free TRAM Flap

Free TRAM flap is considered as the first choice of the breast reconstruction after mastectomy deformity. Complications such as partial flap loss and fat necrosis in reconstructed breasts are less common with free TRAM flap than conventional pedicled TRAM flap or deep inferior epigastric perforator flap(DIEP flap), because free TRAM flap has a robust blood supply by deep inferior epigastric artery. We evaluated the incidence, causes, diagnosis, and treatment of fat necrosis in reconstructed breast using free TRAM flap. A retrospective study was performed in all patients who had undergone free TRAM flap breast reconstruction between 1990 and 2002. Fat necrosis is a clinical diagnosis, usually made by physical examination alone. However we performed mammography and ultrasonography in all patients to rule out the recurrence of tumor, and get the objective and unbiased data. We performed needle biopsy for exclusion of cancer recurrence in selected cases. Of the 92 breasts reconstructed with free TRAM flap, 7 patients(7.6%) had clinically evident fat necrosis, and 2 patients(2.1%) had fat necrosis that was found only by mammography and ultrasonography. The size of fat necrosis in our study was various from 1.0 x 0.7 x 0.5 to 8 x 4 x 3 cm. The lesions of the fat necrosis were usually placed on superomedial and medial part of the reconstructed breast. In case of the fat necrosis, anchoring suture of flap which had been applied for the preservation of flap drooping and ptosis seemed to be related with the location. In addition, use of zone IV of TRAM flap would be associated the occurrence of fat necrosis. We suggest that fixation suture of flap, intraoperative injury of perforator vessel, extensive use of flap (including Zone IV), smoking and obesity, postoperative radiation therapy can be the causes of fat necrosis in the reconstructed breast with free TRAM flap. Fat necrosis is said to be relatively common in patients who were obese or had a history of smoking in literature, but it did not show any significant differences in our study. Five patients underwent excision during nipple-areolar complex reconstruction after 6 months of free TRAM flap breast reconstruction, and 4 patients did not undergo any treatment due to relatively small size. Hardness of fat necrosis became smaller in size, and softened with time. We conclude that the fat necrosis would be decreased if free TRAM flap breast reconstruction was performed with well organized design of flap, sensible assessment of perforators in the flap, careful use of zone IV in thin patient, and careful suture fixation of flap to chest wall.

Simultaneous calf augmentation and reduction in poliomyelitis patients

No Abstract Available.

Correction of Short Lateral Lip in Unilateral Cleft Lip

Deficiency of upper lip tissue is a difficult problem in cleft lip repair. Various kinds of operation technique such as triangular flap and Millard method has been developed. but, when the severe vertical tissue deficiency is present, there are limitations in making a symmetric lip contour. We defined the short lateral lip when the vertical distance from alar base to the imaginary peak of cupid bow pont is less than vertical distance from alar base to noncleft cupid bow peak. Rareoperation techniques to solve the short lateral lip has been suggested until nowadays. So, we classified the short lateral lip as mild, moderate and severe cases. And we tried the following 3 methods for correction of short lateral lip. In mild cases, we used the C-flap and small triangular flap which can lengthen the short lateral lip about 2 to 3 mm just above the white line. And the moderate cases, it can corrected with lattis method. For the lengthening of very short lateral lip in cleft side, full thickness skin from the posterior auricular area is grafted onto the redrapped muscle of cleft side muscle bulge.