The Usefulnesssof Cultured Allogenic Keratinocyte for Burn Treatment

PURPOSE: When choosing dressing method to treat skin defect by second degree or higher burn, we have to consider method of rapid epithelization and minimization of pain during the treatment. In this study, we used biologic dressing with cultured allogenic keratinocytes for skin defect due to burn. We followed up the degree of epithelization, the degree of pain, and patient satisfaction. METHODS: From June 2003 to June 2006, among the patients with skin defect due to burn, 31 cases with second degree burn(moderate to severe) were selected and biological dressing with cultured allogenic keratinocytes were done. 21 cases did not use cultured allogenic keratinocytes. Most of the patients had second degree burn. We applied cultured allogenic keratinocyte by Kaloderm. For wounds that were not deep enough to effect the dermis, escharectomy was done before applying Kaloderm. After the operation, moist wound site was maintained by dressing with saline gauze for 5-7 days. We compared the condition of the wound site before and after applying Keloderm by grading epithelization by standardized percentage scoring scale(1-5), and degree of pain and patient satisfaction by visual analogue scale(0-10). RESULTS: When cultured allogenic keratinocytes were applied for the same period of time, the mean score of epithelization were 3.29+/-0.529(mean+/-S.D.). Without the application, the mean score of epithelization were 2.86+/-0.655(mean+/-S.D.). The degree of pain was 7.71+/-1.419(mean+/-S.D.) and 2.35+/-0.950(mean+/-S.D.) before and after the application, respectively. The patients' satisfaction score was 6.45+/-0.850(mean+/-S.D.) and 8.45+/-0.961(mean+/-S.D.) before and after the application, respectively. CONCLUSION: Applying biological dressing with cultured allogenic keratinocyte to skin defect due to second degree burn showed satisfactory results in the degree of the epithelization, degree of pain and patients' satisfaction.

The Wound Healing Effects of Alginate-crosslinked Collagen Dermal Substitute of Artificial Skin

Alginate, which is isolated from brown seaweed, is a bioabsorbable long chain polysaccharides, beta-D-mannuronic acid and alpha-L-guluronic acid. The authors produced alginates and alginate-colllagen as a disc form. Then, to evaluate the efficacy of alginate and alginate-collagen complex as a wound healing material, three full-thickness skin defects of 2 cm in diameter were made at the back of the New Zealand white rabbits. Three groups of dressing materials-alginate, alginate-collagen complex and vaseline gauze as control group - were applied on the wound and the results were evaluated grossly and histopathologically. The authors compared gross findings of sizes of healed wound, wound epithelization and wound contraction by tracing the remaining wound area at 5th, 10th, 15th, 20th, 25th day after wound introduction, and wound biopsy was performed at 3rd, 7th, 14th, 21st day, respectively. Alginate and alginate-collagen complex showed statistically higher percentage of wound contraction and wound healing compared to control group(p<0.05). Alginate-collagen complex showed statistically higher percentage of wound contraction, epithelization and wound healing compared to alginate alone. In conclusion, the result suggests that alginate has a good effect of wound healing and that alginate-collagen complex is more effective in wound healing than alginate alone.

Early Adjusting Surgery after Blepharoptosis Repair

The challenge of accurately predicting eyelid height after blepharoptosis surgery is well-known problem even in complete hands. From May, 1988 to December, 2004, authors reviewed 182 cases(240 eyes) of blepharoptosis corrected by frontalis muscle transfer or levator resection and had experienced 10 cases(15 eyelids) of early reoperation around 1 week. The period from initial operation to reoperation are between six to eight days and mean period is seven days. Initial operative procedures were frontalis muscle transfer in 3 cases(4 eyelids) and levator resection in 7 cases(11 eyelids). Follow up period ranged from 6 months to 16 years. Early adjusting surgery was performed in accordance with the preoperative and postoperative degree of ptosis of patient and considering previous operative technique. The results are evaluated according to the criteria of an ideal correction by Souther and Jordan. Seven patients have good or satisfactory results(less than 1 mm asymmetry, good in 5 cases and satisfactory in 2 cases). Three patients(5 eyelids) recorded as poor results(more than 2 mm asymmetry). Even if early or late reoperation can be effective in correcting unsatisfactory results after correction of blepharoptosis, early reoperation is better than later reoperation because early reoperation can offer a reduction in time to final result, the ease with which it is performed, potential cost savings. The experience of surgeon is also important factor for the reatment of recurred blepharoptosis.

A Surgical Experience of Livedo Vasculitis: A Case Report

PURPOSE: Livedo vasculitis is recurrent painful ulceration of the feet, ankles and legs characterized by purpuric papules and plaques that undergo superficial necrosis and healing with residual white atrophic scars (atrophie blanche). The typical histopathologic findings of livedo vasculitis are characterized by endothelial proliferation and hyaline degeneration along with thrombosis of dermal vessels. Standard therapeutic strategies for treatment of livedo vasculitis are usually on the basis of rheologic, anti-inflammatory or immnosuppressive treatments, a aspirin, dipyridamole, glucocorticosteroids, pentoxyfylline, or high-dose intravenous immunoglobulin are often ineffective or partially effective. METHODS: We report a case of 24-year-old male patient with livedo vasculitis on the ankles and dorsal surfaces of both feet. RESULTS: The lesion that had been unresponsive to medical treatment were successfully healed with complete debridement and skin grafting without recurrences. CONCLUSION: Surgical treatment can be one of the therapeutic choice in Livedo vasculitis.

Anatomy of upper Eyelid in Korean

The anatomy of Korean eyelid is different from that of Caucasians. The cosmetic or reconstructive eyelid surgery is also different from that of Caucasians. Cosmetic eyelid surgery is one of the most popular forms of aesthetic surgery of the Korean face. For proper cosmetic eyelid surgery, plastic surgeon must to master the anatomy of eyelid of Koreans. The eyelids are complex specialized facial adaptations designed to protect, moisten, and clean the ocular surfaces. These components are modified by structures as skin, orbicularis oculi muscle, orbital septum and fat, levator palpebral superioris, Muller muscle, tarsal plate and conjunctiva. All of the complex structures of upper eyelid are morphologically and functionally connected with each other. And it is very important to understand these connections to perform the plastic surgery. However, it is difficult to find references an books that mentioned precise anatomy of Koreans. To get good result in cosmetic eyelid surgery in Koreans, we must have deep, precise knowledge of anatomy in Korean eyelid. We hope that this article offer to better understanding of complex eyelid anatomy and helpful to plastic surgeon for cosmetic eyelid surgery in Korean eyelid.

Epicanthoplasty Using the Modified Hiraga's Method

The medical epicanthal folds on eyelids is one of the unique features of Asians. Epicanthoplasty enhances the aesthetic results of eyelid surgery by lengthening the palpebral fissure and producing the image of a larger, more open eye. Many authors described surgical procedures for correction of epicanthal folds. But most of them leave additional scars. We used to use Hiraga's method for correcting the epicanthal folds. Hiraga's epicanthoplasty is simple and practicable method. However, Hiraga's method has the disadvantage of making vertical scar on the nasal side of the lower eyelid. To overcome this disadvantage, we transposed the incision line to be paralleled with the margin of lower eyelid. We presented here a simple epicanthoplasty with minimal scar based on modified Hiraga's method with 24 cases performed during the past 3 years. A double fold operation and ptosis correction was performed along with epicanthoplasty in 18 cases and a epicanthoplasty without a double fold operation was performed in the remaining 6 cases. The follow-up period ranged from six months to two years. The results, with the exception of one case of hypertrophic scarring and one case of undercorrection, were all satisfactory. The advantages of our procedure are simplicity in design and the minimal scarring produced in the medial canthal area compared with a Hiraga's method or complex W-plasty, Z-plasty, or half Z-plasty requiring multiple incisions and often creating unsightly scarring on the medial side of lower lid. This method can be one of the effective procedures for correcting the Asian epicanthal fold because of avoiding potential visible scar on the lower lid.

Intraorbital Cysticercosis Treatment with Lateral Orbitotomy

A 33-year-old female from Uzbekistan visited our hospital with symptoms of right blurred vision, ocular pain which were exacerbated by ocular movement, and exophthalmosis for 2 months. Preoperative facial CT scan showed 3.2x2.4cm-sized cystic mass at the right retrobulbar area. The mass was located at temporal aspect of retrobulbar area and displaced optic nerve medially. Right eyeball was anteriorly displaced at the degree of 7mm than left one and intra-ocular pressure was raised as 32 mmHg compared with left one which estimated at 15 mmHg. Removal of cytic mass was performed using lateral orbitotomy. After incision was made through Stellard- Wright incision, dissection was done to lateral outer orbital periosteum then the periosteum each side of lateral orbit were dissected for lateral orbitotomy. Removal of lateral orbital wall, which was enough to removal cystic mass, by lateral orbitotomy, was done then lateral rectus muscle was divided without cutting. Cystic mass could be resected after lateral rectus muscle was divided and resected lateral orbital bone piece was re-located and fixed by absorbable miniplate. A satisfactory result could be obtained by this procedure. Postoperative intra-ocular pressure was lowerd as 15mm Hg and exophthalmosis was corrected at the degree of 1mm on Hertel's exophthalmometery and visual acuity improved at the degree of 1.0 on optomety compared with preoperative one which estimated 0.04. Preoperative symptoms such as ocular pain, foreign body sensation, headache were disappeared without any complication just like retrobulbar hemorrhage, infection etc.

Frontalis Muscle Flap or Levator Resection for the Correction of Recurred Blepharoptosis

The challenge of accurately predicting eyelid height without recurrence after blepharptosis surgery is a well-known problem even in competent hands. The authors had experienced 24 recurred blepharoptosis cases from March 1999 to Feburuary 2004. 17 cases were unilateral recurred cases and the remains were bilateral cases. Previous methods in recurrent cases are as follows; Levator aponeurosis plication(2 cases), Levator resection(7 cases), Frontalis sling(15 cases). The period from first operation to secondary revision are between about 6 months to 25 years and mean period is about 6 years. The authors had managed recurrent cases with frontalis muscle advancement flap technique in 13 recurrent cases which had poor levator function or in case of frontalis muscle flap was already used. Levator resection was addressed in 11 cases which reserved levator function of more than 3mm. In Frontalis muscle flap case, the authors fixed superior-based frontalis muscle flap to tarsal plate through tunnel which was made with orbicularis oculi muscle. Among Levator resection cases, 8 cases were delayed correction cases and another 3 cases were immediate revision cases within 2 weeks after correction operation. The majority of our series recorded as satisfactory results. But, three of them gained undercorrection in follow-up period. Except for lid edema, troublesome complication just like exposure keratitis, corneal erosion was not observed. It can be safely suggested from our study that frontalis muscle advancement flap and levator resection are reasonable options in the correction of moderate to severe recurrent blepharptosis cases and the choice of recurred case management method should be accordance with levator function of patient and previously used techniques.

The Classification and Clinical Characteristics of the Crow`s Feet in Koreans

Most common signs of human aging often include skin fold and wrinkles in the lateral canthal area. It is called "crow's feet". The accordion-like activity of the orbicularis oculi muscle during movements of facial expression accentuates this phenomenon because the muscle shortens but the skin does not. The purpose of this study is to present the classification of the crow's feet and to look for it's clinical characteristics in Koreans. The pictures of lateral view of the crows feet in 105 patients taken with digital camera are classified by their age, sex, types and degree of direction. Results show that there are three types of crows feet such as upper, lower and bidirectional types. Bidirectional type is the most common type(85%), lower directional type is 15% and upper directional type is 5%. In thirties, bidirectional type is 50% but the rate of this type increases in older groups. So in over sixties, bidirectional type is almost 100%. There are no differences between the two sexes. The degree of the direction of wrinkles increases in thirties and forties, but in fifties or over no difference was seen. In summary, this study could be helpful to decide the procedure in correction of the crow's feet.

Surgical Treatment in Recurred Axillary Osmidrosis

There are several surgical or non-surgical methods for osmidrosis, which have their own merits and drawbacks. Especially, recurrence and scarring of operation site are cumbersome problems. One of the limitations of each method is recurrence of osmidrosis. The authors evaluated surgical treatments of recurrent cases. The authors experienced 14 recurrent osmidrosis cases from January 1998 to December 2003. Previous methods in recurrent cases are as follows; dermal shaving with Inaba dermal shaver(3 cases), liposuction method(10 cases), non-surgical hair removal method(4 cases). The authors managed recurrent cases with radical excision in 4 recurrent cases which had severe scar with large fibrotic tissue due to previous operations, and dermal manual resection in 10 cases. We had no recurrence in our series and no complications like hematoma, seroma, infection, wound disruption or dehiscence and brachial plexus compression. In conclusion, dermal manual resection can be applied to recurrent osmidrosis cases, and radical resection is also applicable to managing recurrent cases with severe scar with large fibrotic tissue.

A Case of Cellular Blue Nevus on the Dorsal Aspect of the Foot / 대한피부과학회지

Cellular blue nevus is a rare type of blue nevus, which shows blue-gray or blue brown nodules or plaques of 1 to 3cm in diameter, usually located on the buttocks or sacrum. We report a case of cellular blue nevus in a 42-year-old female. She presented with a 1x3.5cm blue-black multilobulated plaque on the dorsum of left foot since childhood. Histopathologic examination showed mixed biphasic pattern with ovoid islands of polygonal cells showing somewhat clear cytoplasm alternating with bundles with spindle cells, which are densely pigmented. Mitosis and necrosis were not identified. Overall features are consistent with cellular blue nevus.

Treatment of the Medial Blow-out Fracture by Medial Transconjunctival Approach

Blow-out fractures usually occur at the weakest point of orbital wall such as medial wall or orbital floor. The operative treatment of blow-out fracture involve restoration of intra-orbital soft tissue and bony structural integrity. The surgical reduction of medial blow-out fracture are mainly transcutaneous, transnasal and transconjunctival approaches. The conventional methods has several disadvantages, such as external scar, narrow operative field and injury of neurovascular bundle. But medial transconjunctival approach has advantages such as minimal scar, short operative time and relative safety. We experinced 26 cases of medial blow-out fracture using medial transconjunctival approach from June 2001 to May 2003. Preoperatively 21 cases showed diplopia and 14 cases showed enophthalmos. In postoperative complications, diplopia were 2 cases, enophthalmos was 1 case, anterior displacement of implant were 2 cases, conjunctival scar were 2 cases and injury of caruncle was 1 case. We report the medial transconjunctival approach that was effective treatment for medial blow-out fracture without specific complications.

Reconstruction of the Lower Extremity Using the Various Flap Operations

There are some difficulties in the reconstruction according to anatomic regions of the lower extremity such as thigh, knee, anterior tibia, heel and so on. The earlier the normal tissue saved and the necrotic tissue removed, the less the patients had complications and functional disability. There are many kinds of flap surgery in the reconstruction of the lower extremity such as local skin flap, local fasciocutaneous flap, local muscle flap and free flap. We have done 71 cases using the various flap operation excluding direct closure and skin graft among the patient of lower extremity injury from Jul. 1997 to Oct. 2002. Among 71 cases, 46 cases were due to traffic accidents and mechanical damages and 4 cases were burn, 5 cases were diabetic ulcer, 16 cases were cancer and other skin defects. Lower leg and foot were the most common lesion and the next was knee and thigh. And in the flap operations we have done, 32 cases(45%) were local skin flap, 18 cases(25%) were local fasciocutaneous flap, 6 cases(9%) were local muscle flap, 15 cases(21%) were free flap and so on. In early postoperative complications, the total flap necrosis was seen in 1 case, the partial necrosis in 6 cases, the infection in 5 cases and the hematoma or seruma in 3 cases. The bulky flap and ulceration were seen in 3 cases respectively and needed secondary operation after long term follow-up. The area below the knee joint is limited by its low vascularity, low tissue flexibility, high infectiousness and long periods of wound healing, and the reconstruction of the weight bearing heel needs proper skin thickness and durability. The better reconstruction of the lower extremity needs many experiences of various methods to us and we should know about their advantages and disadvantages.

The Treatment of Unilateral Comple Cleft Lip Using Lip Adhesion

It is difficult to treat the complete cleft lip because of wide cleft and malaligned alveolar process, outward rotation of greater(medial) alveolar segment, and severe nasal deformity. Lip adhesion without presurgical orthopedic appliance was performed on 8 consecutive infants with unilateral complete cleft of the primary palate before denfinitive lip repair with Millard I procedure. Among 8 patients, 6 patients had complete unilateral cleft lip with alveolar cleft only and 2 patients were accompanied with complete cleft palate. All patients had more than a 10-mm-wide lip cleft with alveolar arch discrepancy. Lip adhesions were performed at 1-2 months of age and definitive repair was done at 5-6 months of age. Lip adhesions were performed by Randall's method and cheiloplasty was done by Millard I technique. Satisfactory results of lip and nose were obtained aesthetically in 8 cases after an average follow-up of 32 months. The vertical height of the medial and lateral lip segment were a symmetric appearance, while the vermilion tubercle, philtrum, and Cupid's bow were natural. Disadvantages included increased operating time and the sacrifice of same-lip tissue. In conclusion, preliminary lip adhesion can have better functional, esthetic and emotional results since the disadvantages are minor compared to the advantages.

The Age-Related Anthropometric Analysis of Eyelids and Orbits in Koreans

The extensive knowledge of accurate anatomical morphology and acceptable proportion of the eyelid and orbit should be needed for plastic surgeons. The normal morphological and functional values of eyelids and orbits are variable according to races, sex and ages, and there are a few articles concerning them in Korea yet. The author measured eigt items of morphological and functional values of eyelids in Koreans and statistically analyzed them in 498 individuals including 234 males and 264 females. We divided them into nine age-related groups and measured the values. Especially, we subdivided 10 to 19 year-old group into three subgroup concretely because most of the values in the 10 to 19 year-old group reach the peak level of growth. The mean values in adults were recorded as follows: The horizontal dimension of the palpebral fissure was 27.0 +/- 1.8 mm in males and 26.8 +/- 1,7 mm in females and the vertical dimension of the palpebral fissure was 8.0 +/- 1.0 mm in female. The slant of the palpebral fissure was 7.9 +/- 2.4 degrees in males and 8.8 +/- 2.3 degrees in females and the height of the opened upper eyelid was 12.4 +/- 2.4 mm in males and 12.0 +/- 1.9 mm in females. The height of double fold in closed eye was 6.6 mm in males and 6.5 mm in femals and the intercanthal distance was 38.4 +/- 3.0 mm in males and 38.2 +/- 2.8 mm in females. The interpupillary distance was 64.6 +/- 2.9 mm in males and 63.6 +/- 2.9 mm in females. A double fold was seen in 36.1% of Korean. The average height of the double fold in closed eye was about 6.5 mm. The epicanthus present in 58.6% of Korean eyes and the most commom type was epicantus tarsalis. The growth of eyelids reached the peak level at teenager in a great portion. After the peak level, the changing pattern of eyelids could be divided into 3 groups; the first one was increasing more, the second was stationary, and the third was decreasing gradually. The peak levle of growth reached at 10 to 13-year-old in the vertical dimension of the palpebral fissure, at 14 to 16-year-old in the intercanthal distance, at 17 to 19-year-old in the horizontal dimension of the palpebral fissure.

The Treatment of Maxillary Fracture with Malocclusion

Twenty-five Le Fort fractures accompanying palatal fracture or malocculsion had been studied from October 1990 to May 1997. The patients were analyzed on the basis of classification causes, operative procedure treatment of fracture, status of malocclusion and complication. The most common cause of fracture was a traffic accident and diagnosis was performed by history, physical examination, reontgenogram, and computed tomography. The follow-up period ranged from 5 months to 5 years, averaging 17 months. Internal fixations with plates and screws were performed in 22 cases and external fixations with halo apparatus were used in 3 cases. Intermaxillary fixations with arch bar were applied during the preoperative and postoperative period in all cases. In 6 cases of Le Fort fractures, acylic splints were applied. In 3 cases of palatal fractures, transverse wiring of the palatal arch were also used. Overall 19 of 25 patients were satisfied with the results. Six patients complained about depression of the midface because of undercorrection 4 patients had persisting hypoesthesia of the infraorbital nerve for more than 6 months postoperative. In summary, the dental plast and acrylic splint are very helpful in correcting malocclusion in severe maxillary fractures. Also, in cases of palatal fracture, it is important to minimize maloccusion by rigid fixation or transverse wiring of the palatal arch.

TREATMENT OF MARCUS GUNN PHENOMENON

Marcus Gunn described for the first time a syndrome consisting of unilateral, congenital ptosis and rapid, exaggerated elevation of the ptotic eyelid on movement of the mandible to the contralateral side. The clinical findings and management of 2 patients with Marcus Gunn phenomenon had been reviewed. Preoperative measurement of ptotic amount, levator function by Berke's method, and marginal limbal distance were evaluated. The amount winking of the upper eyelid on primary gaze was graded on as scale from I to III. The operation was performed two patients under local anesthesia, one by unilateral levator resection, one by orbicularis oculi muscle flap. As a result, the correction of blepharoptosis was possible without severe complications. However, moderate degree of jaw-winking, slight undercorrection, transient lagophthalmos was inevitable. The management of patients with Marcus Gunn phenomenon is a challenging endeavor. Therefore, a comprehensive medical and ophthalmological evaluation of the patient and a detailed history are mandatory before undertaking the successful treatment of patients with this syndrome

Correction of recurred blepharoptosis

From May 1988 to January 1997 authors had experienced 13 cases of recurred blepharoptosis. Previous operative procedures were frontalis muscle suspension in 10 cases and levator resection in 3 cases. Follow up period ranged from 11 months to 9 years. We have treated recurred blepharoptosis using frontalis myofascial flap, orbicularis oculi muscle flap and levator resection in accordance with the postoperative levator function and degree of ptosis of patient and considering previous operative technique. The results were that 12 patients have gained the levator excursion over 7 mm and reduced the height difference between both palpebral fissures less than 2 mm after reoperation (good in 6 cases and satisfactory in 6 cases). From these results we might conclude that the frontalis myofascial flap technique is a good secondary blepharoptosis operation for patient with less than 2 mm of levator function, orbicularis oculimuscle flap technique with 2-4 mm of levator function, levator resection with over than 4 mm of levator function. The expert technique and experience are also important factor for the treatment of recurred blepharoptosis.

Endoscopic application in treatment of fracture of the zygomatic arch

Although the zygomatic arch can be employed as a key landmark to the accurate alignment of a displaced zygoma fracture, it has been traditionally avoided because of the need for a bicoronal incision. Exposure of the zygomatic arch by means of the conventional bicoronal incision has several possible disadvantages, including an increased risk of blood loss, alopecia, loss of sensation posterior to the incision, and traction palsy of the facial nerve. Endoscopic-assisted exposure of a zygomatic arch can largely obviate the disadvantages of a bicoronal incision and yield this site accessible to reduction and internal fixation in the routine treatment of displaced zygoma fractures. 9 cases of endoscope-assisted open reduction of zygomatic arch fracture and 3 cases of internal fixation of a moderately displaced zygoma fracture are presented. To accomplish this technique, a rigid 4 mm, 30 degree down-angled endoscope, trocar and cannula, endoscopic forehead lift instrument were used. The postoperative courses were satisfactory with few complications. The use of endoscope in the treatment of zygoma reduction provided an expanded field of vision, direct manipulation of lesions, minimal postoperative scar. In particular, exposure and fixation of the zygomatic arch were performed without the need for a bicoronal incision.

Endoscopic-assisted correction of deviated nose

Owing to the complexity of the deviated structures and the septal deformities accompanying the external nasal deformities, the complete correction of the deviated nose is regarded as a difficult one. The approach to the nasal bone and osteotomy in classic corrective rhinoplasty is almost blind technique, where the results depends on the feeling by surgeon's hand. To overcome these drawback, endoscopic-assisted corrective rhinoplasty and septoplasty performed for 8 cases of deviated nose between January 1996 and May 1997. Average follow-up period was 10 months. All patients were evaluated by symmetrical nasal pyramid, recurrence of the bony deflection and septal deviation. The postoperative courses were satisfactory in most of cases with few complications. It appears that endoscopic control during corrective rhinoplasty and septoplasty is a big step toward obtaining better results in bony and cartilage resection with extreme precision under monitor control and magnification. This technique is not an open approach but permits one to see more of the nasal skeleton and bony septum what is causing deformity, and the immediate effect of the corrective measures used. The use of endoscope in corrective rhinoplasty will provide expanded field of vision, direct manipulation of lesions, and better aesthetic an6 functional results.