Clinical Application of the Delayed Procedure in the Distally Based Sural Flap

PURPOSE: Reconstruction of soft tissue defects with osteomyelitis in the lower third of the leg represents a challenge to plastic surgeons. Moreover, it is more arduous in multimorbid patients. One excellent option for reconstruction of these defects is to use a delayed distally based sural flap. METHODS: We successfully used delayed distally based sural flap with a two-step procedure. During the first operation, radical debridement and elevation of flap were performed. The raised flap was fixed again at the donor site. The delay period ranged from seven to ten days. Between August 2008 and July 2009, we underwent operations for five patients using this technique. The size of flap varied from 10 x 6 cm to 12 x 14 cm. RESULTS: All flaps successfully survived. Partial skin loss of the grafted site was seen in two patients but no further surgical procedure was required for wound healing. Complaints of hypoesthesia on the lateral part of the foot was observed. In a three month follow-up period, hypoesthesia was resolved spontaneously. CONCLUSION: Delayed procedure improves the viability of distally based sural flap in high risk, critically multimorbid patients. We recommend that, if a two-stage operative approach is required, the delayed procedure should be considered.

Lower Eyelid Retraction and Scleral Show induced by Subciliary Approach in Inferior Orbital Rim Fracture

PURPOSE: The objective of this study is to prevent postoperative lower eyelid retraction and scleral show. There are several approaches for orbital rim reconstruction. But these techniques are sometimes difficult to perform, and have some merits and faults. Maybe most common unwanted and unpleasant result that we have experienced by subciliary incision preseptal approach is the lower eyelid retraction and the scleral show. Therefore, I want to find out the causes and the solutions for such complication. We must know the mechanics for those unpleasant result first of all. METHODS: We conducted a comparison of postoperative photographs between retroseptal approach group and preseptal approach group, both with subciliary incision. In experimental retroseptal group, incision was applied at subciliary region. After elevating skin flap to preserve pretarsal muscle, not with muscle flap elevation, but direct oblique incision through the muscle, retroseptal dissection was applied to the ROOF and the septum. Fixating fracture line, periosteal and septal repair was followed by skin repair. The light compressive dressings and protection were kept in place for 7 days. The effectiveness of this operative method was made comparison with control group which the preseptal approach was applied to, by postoperative 2nd week and 2nd month. RESULTS: Author's technique had been used in 20 patients and control group was composed of 50 patients over 19months period. There were better results in experimental group than in control group and all of experimental group had no complaint about the lower eyelid retraction and the scleral show. CONCLUSION: It must be known about the reason of the lower eyelid retraction and the scleral show induced by subciliary and preseptal approach. Mechanically it can be easily proved. And the solution maybe will be easier if we get more information about the mechanics. I recommend the retroseptal subciliary approach

The Signficance of Intraoperative Radiograph in Treatment of Zygoma Fracture

PURPOSE: The surgical treatment of zygoma fracture use generally three point fixation of the zygomaticofrontal suture, inferior orbital rim and zygomaticomaxillary buttress. But, this procedure has the disadvantage that we cannot know symmetry of the zygoma and visualize the reduction of the zygomatic arch. So, we take a intraoperative simple radiograph(zygomatic arch view) in reduction of zygoma fracture. METHODS: From 2004 to 2006, We compared 21 patients with taking a intraoperative simple radiograph and 28 patients with not taking a radiograph. To assess the difference between the two groups, the authors compared the patients' subjective symptoms and measured the axial angle of the zygoma and zygomatic arch and the degree of the zygomatic arch inclination on zygomatic arch view. And we compared intraoperative simple radiograph with postoperative facial bone CT scan. RESULTS: There was significant difference in appearance of subjective symptoms and the degree of zygomatic arch inclination representing the local contour of fractured zygomatic arch. And intraoperative simple radiograph is accorded with the postoperative facial bone CT scan. CONCLUSION: We think that taking a intraoperative simple radiograph in the treatment of zygoma fracture is satis-factory methods in cosmetics and accuracy of reduction.

Retrospective Photogrammetric Analysis of Surgical Correction of Korean Hump Nose

A nose is an important organ in a human body and it is an anatomical structure which plays significant roles functionally and cosmetically in many respects of one's whole life. Therefore, the authors have thought that for improving the quality of the cosmetic surgery, it is worthy to analyze and consider the reasonabilities of each case of all cosmetic or reconstructive operations which may result in the modification of nasal structures. As the common criterion of the beauty is globalized, many plastic surgeons in Asia including Korea have developed the regionally adapted concepts of the rhinoplasty, whereas they have not been successful in introducing a new concept of correcting a hump nose other than the prevailing concept of the 'reduction'. Accordingly, for the purpose of reducing the unnecessary procedures of the surgical operations and the consequent unwanted results from the conventional treatment on a hump nose. The authors have made a retrospective analysis on photographic profile data of 27 cases which have been available for the past 7 years, in comparison with the prevailing ideal criteria, in order to confirm reasonabilities of operations on patients group corrected with the conventional formulars. The analysis showed us that the hump nose in each of 27 cases was less protruded than the ideal criteria data. We found out that, if the nasal framework is not deviated, the nasal hump is not the object to be removed, but the touchstone of the augmentation rhinoplasty, in terms of non- destructive cosmetic operations.

Eccrine hidrocystoma of the Nasal Tip

Eccrine hidrocystoma is a cyst origined from the secretory portion of the eccrine sweat gland and tends to occur as a solitary facial lesion. Clinically, an eccrine hidrocystoma presents as a small, translucent and cystic swelling(often having a bluish hue) which measures 1 to 3 mm in diameter. In some patients, the mass is appeared with numerous lesions. The mass has the tendency that the number of cyst increases in warm weather and decreases during winter. The histologic finding is an intradermal cyst with a thin wall composed of two layers of eosinophilic- staining cuboidal cells. Eccrine hidrocystoma has not yet reported in the journal of korean society of plastic and reconstructive surgeons. Thus, we report a case of 65-years-old female patient with eccrine hidrocystoma, which presents 2.1 x 1.6 x 1.6 cm in size and bluish hue color, occurring on the nasal tip.

Prevention of Secondary Depression Deformity after Tissue Expansion

Tissue expansion is commonly used method in reconstruction of skin defect after removal of various skin lesions or scars in face, trunk and extremities. However, the expansion pressure not only expands the overlying skin but also compresses the base tissue itself, which may result in depression or asymmetry. Many patients could not be satisfied with these deformities although their skin lesions were removed and reconstructed successfully. Many plastic surgeons have not taken into consideration of these facts. A total of 24 patients underwent 36 implants. The authors tried to fill the depression by manipulating surrounding capsular tissues with elevation of the capsular flap and its transposition to the depressed area, free graft of the resected capsular tissues into the depression. We also used adjacent soft tissues such as fascial flaps to fill the depression and prevented the expected depression deformity or asymmetry after removal of tissue expander. With this method, we achieved satisfactory aesthetic results without depression. There happened 4 cases of remnant depression due to under correction of it and 2 cases of hematoma formation and 1 case of skin necrosis.

Secure and Convenient Three-point and Multi-point Suture Technique

Skin closure is the surgeon's final operation technique. Although there have been many descriptions about the different kinds of sutures, the report on a 'three-point suture' were quite limited to the horizontal half buried suture technique up till now. The three-point suture can be met frequently in cases like irregular laceration, V-Y advancement flap, and reduction mammaplasty. Authors came up with and thereby introduce a more secure and convenient three-point suture technique, which proved to be superior to the horizontal half buried suture technique in that it gives a better skin approximation and eversion. It can also be applied to a multi- point suture such as a four-point suture or a five-point suture and a three-point mattress suture.

Locally advanced unresectable gastric cancer successfully resected after neoadjuvant chemotherapy with FADE regimen

The prognosis of unresectable advanced gastric cancer is extremely poor. We tried a neoadjuvant chemotherapy in locally advanced unresectable stomach cancer diagnosed by initial explo-laparotomy. After chemotherapy with the FADE regimen (5-fluorouracil + adriamycin + cisplatin + etoposide), the patient was diagnosed clinically as a complete response state on re-staging with radiological gastrointestinal study, fiber-gastroscopy and computerized tomography. During the second-look operation, the advanced cancer was completely resected and the pathological diagnosis was early gastric cancer (EGC) type IIc, stage II (T1N2Mo).

Phase II study of cyclophosphamide, doxorubicin, and vincristine (CAV) and etoposide plus cisplatin (EP) alternating chemotherapy combined with radiotherapy in small cell lung cancer

The development of drug resistance is the major limiting factor influencing the survival of patients with small cell lung cancer (SCLC). We have thus examined the activity of cyclophosphamide, doxorubicin and vincristine (CAV) alternating with etoposide and cisplatin (EP) in 35 patients with SCLC. The treatment courses were alternated every 3 or 4 weeks. After induction chemotherapy, patients with limited disease (LD) received thoracic radiotherapy (5000 cGy), prophylactic cranial irradiation (3000 cGy) and maintenance chemotherapy and patients with extensive disease (ED) received maintenance chemotherapy only. In this group of 35 patients, 13 had limited disease (LD) and 22 had extensive disease (ED). After completion of the therapy, 100% of the patients with LD achieved complete plus partial remission (CR + PR) and 68% of the patients with ED achieved CR + PR. The median survival time was 66 weeks (15.3 months) in patients with LD and 44 weeks (10.2 months) in patients with ED. The over all survival for patients with LD was superior to that for patients with ED (p less than 0.05). Also, median response duration for patients with LD (35 wks) was longer than that for patients with ED (17 weeks) (p less than 0.05). The primary site was the most vulnerable site to relapse (18 patients). Toxicity was mild to moderate and acceptable, and there were no treatment-related deaths. These results suggest that the alternation of CAV and EP is effective treatment strategy in the management of SCLC. A randomized controlled study will be required to discriminate the actual effect of this alternating regimen.

Chlorophyll derivatives: a new photosensitizer for photodynamic therapy of cancer in mice

The in vivo photosensitizing efficacy of chlorophyll derivatives(CpD), which had been developed as a new photosensitizer, was compared with that of hematoporphyrin derivatives (HpD). A murine tumor model implanted subcutaneously with S-180 cells on the abdomen was used. The CpD or HpD was administered by intratumoral injection, and light of appropriate wavelength was irradiated on the tumor areas for 10 minutes at 1h and 24h or 24h and 48h after the injection of photosensitizer. When CpD was injected, the early irradiation group (1h and 24h) showed a 100% tumor cure rate; however, the late irradiation group (24h and 48h) showed a 60% tumor cure rate (p less than 0.01). This showed that the early irradiation with light after injection of CpD was an important factor for obtaining better results. With HpD, there was no difference in tumor cure rate between early (1h and 24h, 80%) and late irradiation (24h and 48h, 80%) groups. Thus, in early irradiation groups, the tumor cure rate using CpD (100%) was superior to that of HpD (80%) (p less than 0.05). However, in late irradiation groups, the tumor cure rate using CpD (60%) was inferior to that of HpD (80%), but this difference was not statistically significant (p greater than 0.1). Pathologic sections of these tumors were made before treatment and 48h and 3 weeks after treatment. These showed geographic necrosis at 48h after treatment and no viable tumor tissue at 3 weeks after treatment. Our results showed that CpD was as effective as HpD as a photosensitizer for in vivo photodynamic therapy.

Chlorophyll derivatives: a new photosensitizer for photodynamic therapy of cancer in mice

The in vivo photosensitizing efficacy of chlorophyll derivatives(CpD), which had been developed as a new photosensitizer, was compared with that of hematoporphyrin derivatives (HpD). A murine tumor model implanted subcutaneously with S-180 cells on the abdomen was used. The CpD or HpD was administered by intratumoral injection, and light of appropriate wavelength was irradiated on the tumor areas for 10 minutes at 1h and 24h or 24h and 48h after the injection of photosensitizer. When CpD was injected, the early irradiation group (1h and 24h) showed a 100% tumor cure rate; however, the late irradiation group (24h and 48h) showed a 60% tumor cure rate (p less than 0.01). This showed that the early irradiation with light after injection of CpD was an important factor for obtaining better results. With HpD, there was no difference in tumor cure rate between early (1h and 24h, 80%) and late irradiation (24h and 48h, 80%) groups. Thus, in early irradiation groups, the tumor cure rate using CpD (100%) was superior to that of HpD (80%) (p less than 0.05). However, in late irradiation groups, the tumor cure rate using CpD (60%) was inferior to that of HpD (80%), but this difference was not statistically significant (p greater than 0.1). Pathologic sections of these tumors were made before treatment and 48h and 3 weeks after treatment. These showed geographic necrosis at 48h after treatment and no viable tumor tissue at 3 weeks after treatment. Our results showed that CpD was as effective as HpD as a photosensitizer for in vivo photodynamic therapy.