Clinical and Histological Correlation in Post-Burn Hypertrophic Scar for Pain and Itching Sensation

BACKGROUND: Hypertrophic scar following a burn is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The burn patient complains of pain and itching over the scar, which can give rise to cosmetic and functional problems. OBJECTIVE: The aim of this study was to investigate the clinical and histological correlation of a hypertrophic burn scar for itching and pain sensations. METHODS: Thirty-eight patients underwent a scar release and skin graft. the modified Vancouver scar scale and the verbal numerical rating scale were recorded. All biopsies were taken from scar tissue (scar) and normal tissue (normal). Histologically, tissues were observed in the epidermis, the monocytes around the vessels, the collagen fiber, elastic fiber, and the mast cells. RESULTS: The mean total score of MVSS was 8.4+/-2.7 (pliability 2.0+/-0.9; thickness 1.8+/-0.9; vascularity 2.0+/- 0.9; and pigmentation 2.1+/-0.9). Pain and itching were 2.4+/-2.0 and 2.9+/-3.0. Epidermis were 7.9+/-2.8 layers (scar) and 4.0+/-0.8 layers (normal). The collagen fibers were thin and dense (scar) and thicker and loose (normal). The elastic fibers were thin and nonexistent (scar) and thin and loose (normal). Mast cells were 11.2+/-5.8/high power field (scar) and 7.4+/-4.1 (normal). CONCLUSION: As the scar tissue thickens, the itching becomes more severe. The stiffness of the scar with the pain appeared to be associated with the condition of the tissue. The correlation between clinical and histological post-burn hypertrophic scars will help further studies on the scar. This helped with the development of the base material for therapeutic strategies.

Proposed Treatment Protocol for Frostbite: A Retrospective Analysis of 17 Cases Based on a 3-Year Single-Institution Experience

BACKGROUND: This paper discusses the treatment protocol for patients with frostbite. METHODS: We performed a retrospective analysis of a series of 17 patients with second- and higher-degree frostbite who had been treated at our medical institution between 2010 and 2012. RESULTS: Our clinical series of patients (n=17) included 13 men and four women, whose mean age was 42.4+/-11.6 years (range, 22-67 years). The sites of injury include the foot in six patients (35.3%), the hand in six patients (35.3%) and the facial region in five patients (29.4%). Seven patients with second-degree frostbite were completely cured with only conservative treatment during a mean period of 12.7+/-3.3 days (range, 8-16 days). Of the five patients with third-degree frostbite, two underwent skin grafting following debridement, and the remaining three achieved a complete cure with conservative treatment during a mean period of 35+/-4.3 days (range, 29-39 days). Five patients with fourth-degree frostbite were treated with surgical procedures including amputation. CONCLUSIONS: With the appropriate conservative management in the early stage of onset, surgeons should decide on surgery after waiting for a sufficient period of time until the demarcation of the wound. Continuous management of patients is also needed to achieve functional recovery after a complete cure has been achieved. This should also be accompanied by patient education for the avoidance of re-exposure to cold environments.

Clinical and Histological Analysis after Laser Treatment in Hypertrophic Scar

PURPOSE: A hypertrophic scar following a burn injury is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The aim of this study was to investigate the clinical and histological analysis after laser treatment in hypertrophic scar. METHODS: Three patients underwent a hypertrophic scar contrcture release and skin graft. The Modified Vancouver Scar Scale (MVSS) is commonly used to evaluate scars. It was composed of pliability, height, vascularity and pigmentation. Thickness was measured by an ultrasound. Pain and itching over the scar were recorded by using the Verbal Numerical Rating Scale (VNRS). All biopsies were taken from scar tissue and normal tissue for grafting area in the operation room. Epidermis and monocytes around vessels, collagen fiber, elastic fiber and mast cell of scaring dermis part observed histologically. RESULTS: On the basis of microscopic findings in patient 3, there are two patterns. The upper part of dermis shows thickened, glassy, eosinophilic collagen bundles which is similar to that of keloid formation. The lower part of dermis shows hypercellular collagen fibers, which is similar to that of regular hypertrophic scar pattern. Probably this patient may have a tendency of keloid formation or secondary change of Laser therapy. Clinical correlation is suggested. CONCLUSION: The laser has the improvement of hypertrophic scaring but can make histological changes due to many procedures. We should be aware of the side effects of the laser.

Clinical Efficacy of Pre-operative 18F-FDG-PET/CT in Marjolin's Ulcer

PURPOSE: Marjolin's ulcer is a rare malignancy that occur in chronic wounds or scars. Marjolin's ulcers tend to infiltrate adjacent tissue more extensively than squamous cell carcinoma that occurs in normal skin, and it is prone to recurrence and metastases, leading to a poor prognosis. Hence, its accurate diagnosis and treatment is very important. The aim of this study was to investigate the diagnostic value and clinical efficacy of preoperative 18F-FDG-PET/CT. METHODS: The study population consisted of 27 patients who were suspected to have Marjolin's ulcer who visited this hospital between January 2009 and June 2012, and who had also received preoperative PET/CT. To confirm the diagnostic efficacy of preoperative PET/CT, the PET/CT findings of the primary lesion and the lymph node, as well as the post-operative histology results were compared to investigate the sensitivity, specificity, false-positive and false-negative rates. RESULTS: The sensitivity and the specificity for the primary lesion of the Marjolin's ulcer in the preoperative PET/CT were 93.3% and 100% respectively. The false-positive rate and the false-negative rate here were 0% and 6.7% respectively. The sensitivity and the specificity for the lymph node metastases of the Marjolin's ulcer in the preoperative PET/CT were 100% and 66.7% respectively. The false-positive rate and the false-negative rate here were 33.3% and 0% respectively. The histological results of Marjolin's ulcer showed that 14 patients had squamous cell carcinoma and 1 had sarcoma. CONCLUSION: Preoperative PET/CT used for the assessment of Marjolin's ulcer and its primary lesion showed a high level of sensitivity and specificity. It was also useful because it allowed the assessment of the primary lesion, lymph node metastases, and distant metastases with a single test. However, the specificity for lymph node metastases was relatively lower, and more research would be needed to improve this.

Clinical Efficacy of the 830 nm LED Phototherapy for Burn Patients

PURPOSE: Phototherapy uses the changes caused by the athermal and atraumatic absorption of the photon's energy by the tissue for therapeutic effect. Phototherapy has been proven to be useful in various conditions, for example, in pain attenuation, wound healing and skin rejuvenation. The aim of this research was to evaluate the clinical efficacy of 830 nm LED phototherapy for burn patients. METHODS: We recruited 11 patients who visited this hospital between June and December 2012 with superficial 2nd degree burns to the face for comparative analysis. For phototherapy, we used infrared LED with wavelength of 830 nm. For comparative analysis, we covered one side of the face with sterile aluminum foil and fabric during the treatment. Photographs were taken at the time of each treatment and the time taken for epithelialization and the level of patient satisfaction were also investigated. RESULTS: All 11 patients were male and the mean age was 44.0+/-11.9 years (range of 28~63 years). The cause of the burns was flame burn for 7 patients, and electric sparks in 4 patients. The time taken to achieve epithelialization after the burns was 8.1+/-2.2 days (range 4~12 days) for the side that received phototherapy, while it was 9.1+/-2.9 days (range 4~14 days) for the side that was not treated with phototherapy. In terms of patient satisfaction, 3 patients were 'Very Satisfied', 6 patients were 'Satisfied', 2 patients replied 'Adequate' and none of the patients were 'Unsatisfied'. CONCLUSION: LED phototherapy of 830 nm wavelength can shorten the time taken for burn wound healing. It also was not associated with serious complications except for skin dryness, so it can be a useful treatment method for burns that produces satisfactory outcome for the patients.

Algorithm for Primary Full-thickness Skin Grafting in Pediatric Hand Burns

BACKGROUND: Pediatric hand burns are a difficult problem because they lead to serious hand deformities with functional impairment due to rapid growth during childhood. Therefore, adequate management is required beginning in the acute stage. Our study aims to establish surgical guidelines for a primary full-thickness skin graft (FTSG) in pediatric hand burns, based on long-term observation periods and existing studies. METHODS: From January 2000 to May 2011, 210 patients underwent primary FTSG. We retrospectively studied the clinical course and treatment outcomes based on the patients' medical records. The patients' demographics, age, sex, injury site of the fingers, presence of web space involvement, the incidence of postoperative late deformities, and the duration of revision were critically analyzed. RESULTS: The mean age of the patients was 24.4 months (range, 8 to 94 months), consisting of 141 males and 69 females. The overall observation period was 6.9 years (range, 1 to 11 years) on average. At the time of the burn, 56 cases were to a single finger, 73 to two fingers, 45 to three fingers, and 22 to more than three. Among these cases, 70 were burns that included a web space (33.3%). During the observation, 25 cases underwent corrective operations with an average period of 40.6 months. CONCLUSIONS: In the volar area, primary full-thickness skin grafting can be a good indication for an isolated injured finger, excluding the web spaces, and injuries of less than three fingers including the web spaces. Also, in the dorsal area, full-thickness skin grafting can be a good indication. However, if the donor site is insufficient and the wound is large, split-thickness skin grafting can be considered.

Contacts Burns Caused by Electric Pad

PURPOSE: The use of the Ondol, which is a traditional Korean floor heating system, has made the electric heating pad popular in Korea. Although the surface temperature of electric pads is around 45 degrees, rarely they can cause severe contact burns. Because an electric pad is usually used while sleeping, the skin could be exposed to heat and pressure for a prolonged period. The purpose of this study was to investigate the epidemiology and clinical features of these types of burns and to advise caution in the use of electric heating pads. METHODS: We performed a retrospective analysis of 58 cases identified from March 2007 to March 2012 at the Hangang Sacred Heart Hospital plastic surgery department. Collected data included sex, age, seasonal variation, distribution and extent of the burn, underlying disease, related factors, and treatment. RESULTS: Patients (23 females and 10 males) were predominantly in their twenties, with an average age of 40.7 years (range, 14~83). The majority of the burns occurred during winter (51.5%). According to the patients' histories, sleeping in a drunken state was the most common associated factor, with taking hypnotics and lying under spinal anesthesia being the second and third factors, respectively. Eight patients had diabetes mellitus and four patients had hypoesthesia after spinal cord injury and cerebral stroke. The lower extremity was the most commonly involved site (42.4%), followed by the buttocks (33%). The extent burn areas accounted for less than 2% of the total body surface area. But deep second degree and third degree burns were sustained that required surgical intervention. CONCLUSION: Unconsciousness and hypoesthesia were the primary factors that provoked contact burns related to the use of electrical pads. Although the percentage of body surface area burns is often small, the burns caused by electric pads can cause deep thermal injuries, necessitating the use of skin grafts and local flaps. These injuries could be prevented by taking precautions when using electric pads and by educating the public.

Coverage of Electrically Burned Upper Extremity Amputation Stumps by a Pedicled Latissimus Dorsi Flap

PURPOSE: In cases of high voltage electrical burns, a wound occurs as current enters or leaves the body and is accompanied by deep tissue injury. If upper extremity amputation is inevitable, consideration should be given to the residual limb functions, secondary reconstruction, and wearing of an upper prosthesis. Our hospital has achieved satisfactory outcomes through the use of a pedicled latissimus dorsi (LD) flap in patients undergoing transhumeral amputation and shoulder disarticulation due to upper extremity damage from high voltage electrical burns. METHODS: The study was targeted to five patients who suffered high voltage electrical burns, underwent above-elbow amputation, and were reconstructed in the acute and secondary phases using a pedicled LD flap from January 2005 to December 2011. All patients underwent equilateral pedicled LD flap surgery, with primary closure at the donating site. RESULTS: The average age of patients was 49.6 years (38~64); they were all male. One patient underwent sublayer skin grafting after a pedicled muscular LD flap, and four patients had a pedicled myocutaneous LD flap: one patient among the four had a forearm flap after the pedicled myocutaneous LD flap. All flaps were well adhered, and post-surgical flap reduction and local flaps were performed for adequate sizing and aesthetic improvement. CONCLUSION: In cases of upper arm amputation due to wide upper extremity damage caused by electrical burns, the use of the pedicled LD flap and adequate amputation length made subsequent wearing of a prosthesis possible. The pedicled LD flap procedure allowed reconstruction of a relatively large area of soft tissue and the surgery to the donating site was unproblematic.

Deep Burn Following DC Cardioversion: A Case Report

PURPOSE: DC cardioversion is the treatment choice for atrial fibrillation and flutter. Because of the high voltage power across the thorax, most patients suffer some degree of superficial erythema or burn at the pad site. 2nd or 3rd degree burn and muscle necrosis is very rare after shock. We experienced one case of 3rd degree burn with ulceration after DC cardioversion. METHODS: A 44-year-old male was admitted to local hospital with the presenting palpitation and atrial fibrillation on ECG. During radiofrequency catheter ablation (RFCA) for the treatment of atrial fibrillatoin, DC cardioversion was performed. The patient did not complain of any pain or discomfort at the pad site during or immediately after the procedure. Approximately 14 days after the shock, he had blisters at the pad site. But he received simple dressing treatment at the local hospital for 6 months. When he visited our burn clinic, there was 3x5 cm sized 3rd degree burn with eschar and necrotic fat tissue at the pad site of right back. Surgical removal of a necrotic tissue was performed on the patient by STSG (Split thickness skin graft) with Matriderm(R). RESULTS: Muscle fascia was exposed after debridement of the necrotic skin and fat tissue. The skin graft was well taken within 2 weeks after operation. CONCLUSION: In case of using monophasic 360 J, approximately 3,000 V energy is discharged. The energy is sufficient to cause burn injury to skin. Damage may result both thermal burn and electrical burn. The burn degree in the electric circuit is proportional to amperage and time, is inversely proportional to pad site area. We therefore suggest that in order to reduce deep burn, DC cardioversion is started with lower energy shocks, proper pad placement and correct pad application is important. And we give a notice that deep pad burn possibly occur after the cardioversion procedure.

Elbow Reconstruction Using Island Flap for Burn Patients

BACKGROUND: Deep burns of the elbow lead to soft tissue necrosis and infection, with exposure of deep structures. Adequate wound coverage of this area requires thin, pliable, and durable tissue, while optimal functional recovery requires early coverage and functional rehabilitation. We have found 3 types of island flaps that provide reliable coverage for the elbow. METHODS: A retrospective study was performed on all patients who underwent flap coverage of an elbow defect at our hospital. The patients' data including age, sex, cause of injury, wound dimensions, timing of flap coverage, postoperative elbow motion, and complications were investigated. RESULTS: Between 2001 and 2012, 16 patients were treated at our hospital. The mean age was 53.3 years. Three kinds of flaps were performed: 9 latissimus dorsi flaps, 4 lateral arm flaps, and 4 radial forearm flaps. The average defect size was 183.5 cm2 (range, 28 to 670 cm2). Wound coverage was performed at mean duration of 45.9 days (range, 14 to 91 days). The mean postoperative active elbow flexion was 98degrees (range, 85degrees to 115degrees). Partial flap failure occurred in 1 latissimus dorsi flap. Minor complications included partial flap loss (11.8%), hematoma (23.5%), seroma (35.3%), and wound infection (5.9%). CONCLUSIONS: Flap selection for elbow reconstruction is determined by the defect size and the extent of the adjacent tissue injury. Elbow reconstruction using an island flap is a single-staged, reliable, and relatively simple procedure that permits initiation of early rehabilitation, thereby improving a patient's functional outcome.

One Stage Reconstruction of Skull Exposed by Burn Injury Using a Tissue Expansion Technique

BACKGROUND: An area of the skull exposed by burn injury has been covered by various methods including local flap, skin graft, or free flap surgery. Each method has disadvantages, such as postoperative alopecia or donor site morbidities. Due to the risk of osteomyelitis in the injured skull during the expansion period, tissue expansion was excluded from primary reconstruction. However, successful primary reconstruction was possible in burned skull by tissue expansion. METHODS: From January 2000 to 2011, tissue expansion surgery was performed on 10 patients who had sustained electrical burn injuries. In the 3 initial cases, removal of the injured part of the skull and a bone graft was performed. In the latter 7 cases, the injured skull tissue was preserved and covered with a scalp flap directly to obtain natural bone healing and bone remodeling. RESULTS: The mean age of patients was 49.9+/-12.2 years, with 8 male and 2 female. The size of the burn wound was an average of 119.6+/-36.7 cm2. The mean expansion duration was 65.5+/-5.6 days, and the inflation volume was an average of 615+/-197.6 mL. Mean defect size was 122.2+/-34.9 cm2. The complications including infection, hematoma, and the exposure of the expander were observed in 4 cases. Nonetheless, only 1 case required revision. CONCLUSIONS: Successful coverage was performed by tissue expansion surgery in burned skull primarily and no secondary reconstruction was needed. Although the risks of osteomyelitis during the expansion period were present, constant coverage of the injured skull and active wound treatment helped successful primary reconstruction of burned skull by tissue expansion.

Clinical and Statistical Analysis with Age in Cases of Pediatric Burn Patients

PURPOSE: The objective of this study is to analyze the epidemiological characteristics of pediatric burn patients and to determine the targets for a pediatric burn prevention program. METHODS: A retrospective review of all medical records of acute pediatric burn patients (age < 15 years old) admitted to our hospital between January 2005 and December 2009 was performed. RESULTS: 1472 males and 1323 females were investigated, with a male to female ratio of 1.11 : 1. The greatest number of burn patients were those with an age of 1~2 years (1,463, 52.3%). Scalding burn was the most common cause of injury, which accounted for 2183 (78.1%) patients, followed by contact burns (10.5%), flame burn (4.9%), steam burn (3.6%). Especially steam burn was the second cause of injury in the age under 1 year, while flame burn was the second cause of injury in the age over 7 years. During recent 5 years, incidence of flame burn, steam burn, electrical burn gradually decreased. Variation of seasonal incidence is minimal and most of the patients (2,716 cases, 97.2%) had burns less than 20% TBSA (Total body surface area). The median hospital stay was 18.79 days, and the rate of operation was 28.6% with a high rate in electrical burn (76.2%), flame burn (50.0%), steam burn (46.1%). 6 patients died in this series, which yielded a mortality rate of 0.2%. CONCLUSION: Prevention efforts should reflect recent study results. Focused prevention program and campaign to make people aware of risk factors and their avoidance is required to reduce the number of burn accidents in children.

Reconstruction of Post Burn Ala Defect Using Adiposocutaneous Graft

PURPOSE: As a central feature of the face, the nose has considerable significance in appearance and expression. Reconstruction of full thickness defects of the nasal ala has always been a challenge because of the 3-dimensional structure. For reconstruction of post burn defects of ala, skin graft, local or pedicled flap and composite graft are optionally available. We have reconstructed the ala defects using adiposocutaneous graft and observed the outcome. METHODS: From March 2003 to December 2010, 19 cases in 11 patients with scar contracture and defect on ala portion were performed operation using adiposocutaneous graft. As a donor site, we used the inguinal crease and posterior auricular area and the donor site was primarily closed. We made incision through the superior rim of ala and released fully. A graft is applied to recipient site with larger size than recipient volume. RESULTS: The mean age of the patient was 38.6 years (16~51), males are seven patients and females are four patients. The operation was performed bilaterally in 5 patients and unilaterally in 6 patients. Composite grafts were harvested from inguinal area in 13 cases and posterior auricular area in 6 cases. In one case, we did 4 times of operation to get enough volume. All the grafts were well taken. The mean size of the graft was 3.63 cm2. CONCLUSION: For reconstruction of post burn defects of ala, it's not easy to use local flap or pedicled flap because of hardness and fibrosis of surrounding tissue. So, we choose adiposocutaneous graft for ala deformity reconstruction, got satisfactory outcome in color matching and texture.

Surgical Treatment of Recalcitrant Wart

PURPOSE: A wart is caused by epidermal infection with the human papilloma virus. Although wart naturally disappears in some cases, it require treatment because of pain, aesthetic problem, and the possibility of malignant change. Conventional non-surgical treatment cannot be a fundamental solution for the pain and has such disadvantages as frequent recurrence and difficulties in achieving a satisfactory outcome. A surgical procedure was performed on patients with wart and the procedure had a good outcome. METHODS: We investigated the gender, age, lesion site, mean treatment duration, and presence or absence of recurrence in 21 patients with a wart within the period of January 2007 to July 2011. For local lesions, primary closure, including subcuticular suture after the excision, was performed. If the defect size was too big to do primary closure, we performed rotation flap. For wide multiple lesions, a split thickness skin graft was performed. RESULTS: Among the 21 patients, 12 patients were male and 9 patients were female, and their mean age was 42 years(SD=17.38, range: 11~75 years). The lesion site was the foot in 10 patients, the hand in 8 patients, the face in 2 patients, and the scalp in 1 patient. The mean treatment duration was 13.5 days(SD=4.36, range: 6~15 days) for the primary closure or rotation flap, and 18.5 days(SD=2.12, range: 17~20 days) for the skin graft. 20 patients were cured without recurrence. No recurrence was observed in the patients who underwent primary closure or rotation flap. One of the two patients who underwent a skin graft of their wart that had covered their entire palm had local recurrence in part of her finger tips. CONCLUSION: We performed surgical procedure on recalcitrant wart. As a results, we can treat it with short treatment duration, low recurrence rate and less scarring and get high patient satisfaction.

Cases of Chemical Burn by Aesthetic Phenol Peel

PURPOSE: Recently there are upgrowing public interest of cosmetics and anti-aging and also public request of chemical peel and its complications. It is a strong chemical agent and can occur severe chemical burn. METHODS: This research surveyed from August 2008 to March 2010 by 3 patients who had gotten chemical burn by phenol peel. We investigated age, sex, site, size and treatment. RESULTS: The average age of cases was 43 years old. They were all female. Damaged area was all on face. Wound size was 3.3% in average. Wound depth was deep second degree in 2 cases and mid second degree in 1 case. In one case, ectropion on both lower eyelids was occurred by scar contracture. We did release and thick split thickness skin graft to resolve ectropion. To other milder cases, we managed conservatively. CONCLUSION: People who had gotten chemical burn by phenol therapy didn't get proper therapy instantly. We suggest that phenol peel must be performed very carefully and by professional and experienced surgeon.

Spontaneous Flexor Tendon Rupture of the Burned Hand

PURPOSE: Spontaneous tendon rupture of finger is defined the rupture of tendon without any intrinsic or extrinsic pathological processes in finger. Spontaneous flexor tendon ruptures are rare. Burn affects not only skin but also muscle and tendon according to the depth. Particularly, burn in hand badly affects movement of finger. Thus, We report the case of spontaneous flexor tendon rupture of finger that happened after burn. METHODS: We studied a 42 year old male presented with third degree electrical burn at the palm of the right hand. And then, Terudermis(R) was applied on 23rd day after burn and split thickness skin graft was applied on 37th day after burn. After operation, there were no special symptoms for some period. But, on 74th day after burn, while providing physical therapy to finger, he could not flex his thumb of the hand with popping sound and edema. So we performed US and MRI scan, finally diagnosed complete tear on FPL tendon of the right hand which was in flexor tendon injury zone IV. We harvested donor from Palmaris longus and tendon graft was applied. RESULTS: After operation, graft was well taken without other problem. And after applying splint, 4th day after tendon graft, active finger extension was done with passive flexion achieved using a rubber band attached to the finger tip. 4 weeks after the operation, splint was removed and the patient gently started active exercise. CONCLUSION: Spontaneous rupture of flexor tendon is rare and moreover, there was no case report of rupture after burns so far. We are now reporting that we early diagnosed the spontaneous flexor tendon rupture of the burned hand and functionally corrected by tendon graft.

The Usability of Various Flaps for Hindfoot Reconstruction

PURPOSE: Anatomically, the foot is provided with insufficient blood supply and is relatively vulnerable to venous congestion compared to other parts of the body. Soft tissue defects are more difficult to manage and palliative treatments can cause hyperkeratosis or ulcer formation, which subsequently requires repeated surgeries. For weight bearing area such as the heel, not only is it important to provide wound coverage but also to restore the protective senses. In these cases, application of flaps for hind foot reconstruction is widely recognized as an effective treatment. In this study, we report the cases of soft tissue reconstruction for which various types of flaps were used to produce good results in both functional and cosmetic aspects. METHODS: Data from 37 cases of hind foot operation utilizing flaps performed between from June 2000 to June 2008 were analyzed. RESULTS: Burn related factors were the most common cause of defects, accounting for 19 cases. In addition, chronic ulceration was responsible for 8 cases and so forth. Types of flaps used for the operations, listed in descending order are radial forearm free flap(18), medial plantar island flap(6), rotation flap(5), sural island flap(3), anterolateral thigh free flap(2), lattisimus dorsi muscular flap(2), and contra lateral medial plantar free flap(1). 37 cases were successful, but 8 cases required skin graft due to partial necrosis in small areas. CONCLUSION: Hind foot reconstruction surgeries that utilize flaps are advantageous in protecting the internal structure, restoring functions, and achieving proper contour aesthetically. Generally, medial plantar skin is preferred because of the anatomical characteristics of the foot (e.g. fibrous septa, soft tissue for cushion). However alternative methods must be applied for defects larger than medial plantar skin and cases in which injuries exist in the flap donor/recipient site(scars in the vicinity of the wound, combined vascular injury). We used various types of flaps including radial forearm neurosensory free flap in order to reconstruct hind foot defects, and report good results in both functional and cosmetic aspects.

Treatment of Heterotopic Calcification with Ulceration in Burn Scar

PURPOSE: Heterotopic calcification is a pathological event in which deposits of calcium salts build up, usually in the joint area or soft tissues. It can occur under many conditions and in some rare cases may develop in burn scars. In particular, ulcerations in burn scars accompanied by heterotopic calcification are difficult to treat through conservative treatment. This study reports methods for accurate diagnosis and adequate treatment of ulceration in burn scars accompanied by heterotopic calcification. METHODS: Fourteen patients who visited our hospital from March 2008 to January 2010 were subjected to this study. Their sex, age, modes of burn, degree, TBSA(%), ulcerated area, the time of occurrence of the ulcerations in the burn scars were investigated. In addition, radiological examination and biopsy was performed to diagnose heterotopic calcification. RESULTS: Among the 14 cases, 6 were male and 8 were female. The average age of the patients was 48.2(27-69 yrs). As for the mode of burn, 11 were flame burns and 3 were scalding burns. The average time of occurrence of the ulcerations in the burn scars was 4.5 months. The ulcerated areas were situated in the legs in 12 cases, arms in 1 case, and torso in 1 case. The diagnosis was confirmed through X-ray and biopsy, and skin graft was performed after wide excision. CONCLUSION: Diagnosis of the ulceration in burn scars accompanied by heterotopic calcification is possible through radiological and pathologic studies. Surgical treatment is the most reliable method of treatment, and we chose to perform skin graft after wide excision. Also, we learned that the complete removal of the calcified tissue and the inflammatory fibrotic tissues is crucial in preventing recurrence. Also, in contrast to Marjolin's ulcer, heterotopic calcification had a small size, little or no granulation tissue, and lacked fungating type ulceration. Therefore, favorable prognosis could be achieved through adequate treatment.

Reconstruction of Post Burn Auricular Defect

PURPOSE: Patients with serious burns are prone to chondritis due to lack of soft tissue in the auricle, which can cause severe defects in the auricular morphology. In addition, skin damage occurs frequently in the vicinity of post-burn wounds, presenting difficulties in reconstruction surgery. An auricular reconstruction has functional and cosmetic significance. The aim of this study is to develop appropriate reconstruction methods for auricular defects. METHODS: Thirty seven patients, who were treated for auricular defects from 2005 to 2009, were enrolled in this study. A local flap, multiple regional flaps and cartilage framework with or without a temporal fascial flap were applied in reconstruction surgery according to the location of the auricular defect. RESULTS: The age of the subjects ranged from 11 to 56. Some subjects had defects that cover more than half of the helical rim with most exhibiting post-burn scars in the vicinity, for whom a multiple regional flap was used. A single use of a tubed flap was sufficient for subjects with defects that covered less than half of the helical rim. A regional flap was also used for reconstruction in subjects with defects covering both the helical rim and antehelix. CONCLUSION: Achieving satisfactory results from the skin flaps and skin grafts for post-burn auricular defects in both functional and cosmetic aspects is a difficult task. Therefore, selecting an appropriate surgical method through proper diagnosis of the auricular defect and the state of the available skin in the vicinity is essential.

The Facial Tissue Expansion to Achieve the Natural Cervicomental Angle

PURPOSE: Wide scars occurring on the lower face and neck cause both functional and esthetic problems. Consequently, we can use skin grafts, pedicled flaps, free flaps, and tissue expansion for the reconstruction of this area. Compared with other reconstruction techniques, tissue expansion is advantageous in that it enables the maintenance of a color and texture similar to that of the adjacent tissue. However, the conventional method of tissue expansion has been reported to lead to an unnatural cervicomental angle and to the deformity of adjacent structures. We have therefore made efforts to prevent these problems through the use of several operative procedures. METHODS: Forty-one patients with lower facial and cervical scars underwent tissue expansion. The tissue expansion was performed using a rectangular-shaped Nagosil(R) tissue expansion device. On insertion of the tissue expander, the intermediate area of superficial fat layer was dissected and then the tissue expander was inserted to make a flap that was as thin as possible. In advancement of the flap, a capsule formed by the tissue expander was used for the interrupted fixed suture of the flap to the fascia of the platysma muscle of the neck. This procedure was performed multiple times and also performed between the flap and the periosteum of the mandible, such that the tension was removed during the suture of the flap margin. Finally, the patients were fitted with a Jobst(R) facial garment in order to stabilize the operation site at least twelve months. RESULTS: The most prevalent location of the scar was the cheek(15 cases), followed by the chin in 14 cases and the neck in 12 cases. The mean size of scar was 55.7+/- 39.4cm2. CONCLUSION: Using our procedures, we have experienced no significant deformities and have also achieved a more natural cervicomental angle in the patients.