How to approach orthognathic surgery in patients who refuse blood transfusion

Background@#Some patients who need surgery refuse a blood transfusion because of their religious beliefs or concerns about blood-borne infections. In recent years, bloodless surgery has been performed successfully in many procedures, and is therefore of increasing interest in orthognathic surgery. @*Methods@#Ten Jehovah’s Witnesses who visited our bloodless surgery center for orthognathic surgery participated in this study. To maintain hemoglobin (Hb) levels above 10 g/dL before surgery, recombinant erythropoietin (rEPO) was subcutaneously administered and iron supplements were intravenously administered. During surgery, acute normovolemic hemodilution (ANH) and induced hypotensive anesthesia were used. To elevate the Hb levels to >10 g/dL after surgery, a similar method to the preoperative approach was used. @*Results@#The 10 patients comprised three men and seven women. Their average Hb level at the first visit was 11.1 g/dL. With treatment according to our protocol, the average preoperative Hb level rose to 12.01 g/dL, and the average Hb level on postoperative day 1 was 10.01 g/dL. No patients needed a blood transfusion, and all patients were discharged without any complications. @*Conclusions@#This study presents a way to manage patients who refuse blood transfusions while undergoing orthognathic surgery. rEPO and iron supplementation were used to maintain Hb levels above 10 g/dL. During surgery, blood loss was minimized by a meticulous procedure and induced hypotensive anesthesia, and intravascular volume was maintained by ANH. Our practical approach to orthognathic surgery for Jehovah’s Witnesses can be applied to the management of all patients who refuse blood transfusions.

Clinical Study on Percutaneous Intramedullary Bioresorbable Pin Fixation for Fourth and Fifth Metacarpal Bone Fracture

PURPOSE: Metacarpal fracture of a ring and little finger occurs frequently. Percutaneous intramedullary fixation is a simple and effective method with a low incidence of complications. To date, Kirschner wire (K-wire) fixation has been widely used, but this has problems such as pin infection. Moreover it is difficult to start early active motion exercise. So, we replaced the K-wire with a bioresorbable implant and evaluated the results. METHODS: This study was conducted from 2014 to 2016 and involved 10 consecutive patients with 10 metacarpal neck fractures. All cases underwent percutaneous intramedullary fixation using the ActivaPin (Bioretec Ltd.) within 7 days after injury, and the average follow-up period was 13 months. At the final follow-up, all cases were assessed in terms of total active motion (TAM), bony union and angular deformity based on plain radiographs. RESULTS: The patients started active motion exercise within 1 week and regained a full range of motion after average 4 weeks. The TAM results were excellent at 250° to 270° in all cases. Regarding radiographic findings, fractures united in all cases and there were no malunion and knuckle deformity. CONCLUSION: Replacement of a K-wire with a bioresorbable pin prevented soft tissue damage and dorsal scarring. And our percutaneous intramedullary bioresorbable pin fixation technique resulted in early recovery of range of motion and correction of deformity. The patients regained range of motion and returned to daily life early.

The Effect of Acellular Dermal Matrix in Implant-Based Immediate Breast Reconstruction with Latissimus Dorsi Flap

BACKGROUND: Capsular contracture is the most frequently reported complication after implant-based breast reconstruction. This study was first undertaken to present our experience with acellular dermal matrix for prevention of capsular contracture in implant-based immediate breast reconstruction with latissimus dorsi flap, and to assess the final aesthetic outcome. METHODS: We performed a retrospective review of all patients who underwent immediate latissimus dorsi flap breast reconstruction in combination with implant and acellular dermal matrix from January 2014 to December 2015. Demographics and clinical characteristics and postoperative complications, especially focused on capsular contracture, were assessed. They were also analyzed as the potential risk factors for the development of capsular contracture. The aesthetic outcome of the overall reconstruction and the final outcome of the inframammary fold were evaluated. RESULTS: During the study period, a total of 30 patients (30 breasts) were reviewed. The mean Baker grades for all 29 breasts (one breast was dropped out due to implant loss), evaluated at one year after reconstruction, was 1.21±0.49 capsular contracture. None of risk factors except seroma/hematoma (P=0.033) were significantly associated with the development of capsular contracture. Overall aesthetic outcome was 8.2±1.2 and aesthetic outcome of the inframammary fold was 3.5±0.6 for physician and 3.4±0.6 for patients. CONCLUSIONS: In this study, we have shown the ability of acellular dermal matrix to prevent capsular contracture observed in implant-based immediate breast reconstruction with latissimus dorsi flap and its use was proven to create superior aesthetic results.

Biomechanical Analysis of Resorbable Barbed Suture Tenorrhaphy

PURPOSE: To evaluate the tensile strength and repair-site profile of a technique of resorbable barbed suture tenorrhaphy. METHODS: Forty-eight flexor digitorum profundus tendons were collected from the 8 adult cadavers. In the test group, the tendons were sutured using absorbent 2-0 barb knotless sutures in a 2-strand or 4-strand zig-zag pattern. In the control group, 2-0 Prolene and 3-0 polydioxanone (PDS) were used to suture the tendons using the 2-stand Modified Kessler method and the 4-strand cruciate suture method. Using a tensile force measurement machine, the breaking load (N) and the stiffness (N/mm) were measured. The types of rupture were categorized into suture breaking, knot rupture, and pullout. RESULTS: In the comparative analysis between the absorbent 2-0 Quill (Angiotech Pharmaceuticals, Canada) suture that used the 2-strand core suture and the 3-0 PDS and 2-0 Prolene sutures, the average breaking load for the 2-0 Quill suture was 26.83±7.47 N, and 21.96±6.78 N and 17.20±4.93 N for the 2-0 Prolene and 3-0 PDS sutures. In the comparison using the 4-strand core suture, the average breaking load for the 2-0 Quill suture was 62.50±13.34 N, and 22.35±5.72 N and 18.67±4.27 N for the 2-0 prolene and 3-0 PDS sutures. The most common type of rupture were knot rupture. CONCLUSION: For flexor tendon sutures using the absorbent barb sutures, compared to the conventional 2-0 Prolene or 3-0 PDS sutures, absorbent barbed sutures have a higher tensile strength.

Expression of AKR1C3 Protein in Human Keloid Skin Tissue

BACKGROUND: Keloids are abnormal wound responses that are caused by hyperproliferative growth of connective tissue during the healing process. Recent research findings introduced the roles of reactive oxygen species (ROS) in the process of keloid formation. ROS induces oxidative stress and promotes the activities of oxidative damage-inducible genes. Aldo-keto reductase 1C3 (AKR1C3) prevents destructive ROS toxicity by detoxification of reactive carbonyl species. Thus, this study aimed to compare the expression of AKR1C3 in both normal and keloid skin in vivo. METHODS: Six specimens of normal skin and six specimens of keloid tissues from human subjects were used to evaluate the expression of AKR1C3 by immunofluorescent staining of tissues and western blotting. RESULTS: By western blotting, it was confirmed that the amount of AKR1C3 protein is significantly reduced in keloid tissues compared to normal tissues. Weak expression of AKR1C3 was also found in keloid tissues by immunofluorescent staining. CONCLUSIONS: This study confirmed that the expression of AKR1C3 protein participates in ROS metabolism and plays a part in the downregulation of human keloid formation. To the best of our knowledge, this is the first work that reveals that AKR1C3 can affect the formation of keloids.

Correction of Cryptotia using Mastoid Fasciocutaneous Flap and Chondroplasty

Cryptotia is a rare congenital anomaly among Caucasian but more common auricular malformation in Asia. Cryptotia characterized by the anterosuperior portion of the auricle lying beneath mastoid skin. From May of 2005 to May of 2010, three cryptotia were operated on. We use mastoid fasciocutaneous flap (MFF) raised from mastoid region and post-auricular area. And two triangular flaps (TF) which are raised from temporal region can release tension of skin and cover defect of skin. Note that two-thirds of the skin paddle should be taken from the mastoid region. After ear release, MFF and two TF are rotated into the defect. For appropriate correction of the cartilage deformity, the conchal cartilage should be pulled cephalad and fixed to the temporal periosteum. All the patients had a satisfaction for operation. There was no case of partial or full through skin necrosis. There was no wound dehiscence and relapse. The mastoid fasciocutaneous flap is a simple technique, retaining the depth of the auriculocephalic sulcus. This technique can correct deformity of cartilage at same time. There was no distorting hair line, skin color dismatching, visible scar and wound dehiscence.

Does Fibrin Sealant Reduce Seroma after Immediate Breast Reconstruction Utilizing a Latissimus Dorsi Myocutaneous Flap?

BACKGROUND: The most common complication of latissimus dorsi myocutaneous flap in breast reconstruction is seroma formation in the back. Many clinical studies have shown that fibrin sealant reduces seroma formation. We investigated any statistically significant differences in postoperative drainage and seroma formation when utilizing the fibrin sealant on the site of the latissimus dorsi myocutaneous flap harvested for immediate breast reconstruction after skin-sparing partial mastectomy. METHODS: A total of 46 patients underwent immediate breast reconstruction utilizing a latissimus dorsi myocutaneous island flap. Of those, 23 patients underwent the procedure without fibrin sealant and the other 23 were administered the fibrin sealant. All flaps were elevated with manual dissection by the same surgeon and were analyzed to evaluate the potential benefits of the fibrin sealant. The correlation analysis and Mann-Whitney U test were used for analyzing the drainage volume according to age, weight of the breast specimen, and body mass index. RESULTS: Although not statistically significant, the cumulative drainage fluid volume was higher in the control group until postoperative day 2 (530.1 mL compared to 502.3 mL), but the fibrin sealant group showed more drainage beginning on postoperative day 3. The donor site comparisons showed the fibrin sealant group had more drainage beginning on postoperative day 3 and the drain was removed 1 day earlier in the control group. CONCLUSIONS: The use of fibrin sealant resulted in no reduction of seroma formation. Because the benefits of the fibrin sealant are not clear, the use of fibrin sealant must be fully discussed with patients before its use as a part of informed consent.

The Effect of Platelet-rich Plasma on Wounds of OLETF Rats Using Expression of Matrix Metalloproteinase-2 and -9 mRNA

BACKGROUND: Complicated diabetic patients show impaired, delayed wound healing caused by multiple factors. A study on wound healing showed that platelet-rich plasma (PRP) was effective in normal tissue regeneration. Nonetheless, there is no evidence that when plateletrich plasma is applied to diabetic wounds, it normalizes the diabetic wound healing process. In this study, we have analyzed matrix metalloproteinase (MMP)-2, MMP-9 expression to investigate the effect of PRP on diabetic wounds. METHODS: Twenty-four-week-old male Otsuka Long-Evans Tokushima Fatty rats were provided by the Tokushima Research Institute. At 50 weeks, wounds were arranged in two sites on the lateral paraspinal areas. Each wound was treated with PRP gel and physiologic saline gauze. To determine the expression of MMP-2, MMP-9, which was chosen as a marker of wound healing, reverse transcription polymerase chain reaction (RT-PCR) was performed and local distribution and expression of MMP-2, MMP-9 was also observed throughout the immunohistochemical staining. RESULTS: RT-PCR and the immunohistochemical study showed that the levels of MMP-2, MMP-9 mRNA expression in PRP applied tissues were higher than MMP-2, MMP-9 mRNA expression in saline-applied tissues. MMP-9 mRNA expression in wounds of diabetic rats decreased after healing began to occur. But no statistical differences were detected on the basis of body weight or fasting blood glucose levels. CONCLUSIONS: This study could indicate the extracellular matrix-regulating effect observed with PRP. Our results of the acceleration of wound healing events by PRP under hyperglycemic conditions might be a useful clue for future clinical treatment for diabetic wounds.

Alternative Treatment of Osteoma Using an Endoscopic Holmium-YAG Laser

Osteoma is one of the most common tumors of the cranial vault and the facial skeleton. For osteoma in the facial region, endoscopic resection is widely used to prevent surgical scarring. Tumors in a total of 14 patients were resected using an endoscopic holmium-doped yttrium aluminium garnet (Ho:YAG) laser with a long flexible fiber. Aside from having the advantage of not leaving a scar due to the use of endoscopy, this procedure allowed resection at any position, was minimally invasive, and caused less postoperative pain. This method yielded excellent cosmetic results, so the endoscopic Ho:YAG laser is expected to emerge as a good treatment option for osteoma.

Anthropometric Analysis of Frontal Sinus Using 3D CT in Koreans

PURPOSE: The frontal sinuses are a pair of triangularly shaped, air-filled chambers lined by mucoperiosteum and located between the inner and outer tables of the frontal bone. Until recently, our understanding of gender variations in craniofacial anatomy has been chiefly built upon anthropometric studies, which typically employ facial surface measurements or plain film radiography. The aim of this study i to determine the sizes of the frontal sinus in both sexes in Koreans. METHODS: 95 Korean subjects who underwent maxillofacial 3-Dimensional computed tomography(CT) between January 2009 and December 2009 were enrolled. Frontal sinus dimensions and forehead measurements were taken at midline and at 10, 20, and 30mm to the left and right of midline using sagittal, coronal, and axial images. The data was analyzed for significant differences between measurements made at the selected points in the frontal sinus, for left to right variations, for gender variations, and for racial differences. RESULTS: The mean thickness of the anterior table ranged from 2.31 to 3.23mm. Mean anteroposterior depth of the frontal sinus ranged from 7.38 to 9.45mm and did not vary significantly at any distance from midline. Frontal sinus height was greatest at midline(mean=29.24mm) and progressively lessened at lateral distances. Mean total width at the level of the supraorbital ridge was 53.66mm. For all measurements, no significant left to right variation was noted. Comparing the sexes, males were found to have greater dimensions in most frontal sinus measurements, though these differences were only found to be significant at or close to midline. The male forehead was marked by more acute nasofrontal angle(133.3degrees versus 141.6degrees) and a steeper posterior forehead inclination(14.9degrees versus 7.7degrees). CONCLUSION: Using CT imaging, forehead and frontal sinus dimensions have been described. Generally, males had larger overall frontal sinus dimensions. And Korean had similar sized frontal sinus to Caucasian in height and width. But in AP distance Korean had lesser measurement. The result of this study may be helpful in the comprehension of normal size of frontal sinus in Korean.

An Anatomic Study of the Extensor Tendons of the Human Hand

PURPOSE: Hands are the chief organs for physically manipulating the environment, using anywhere from the roughest motor skills to the finest, and since the fingertips contain some of the densest areas of nerve endings on the human body, they are continuously used organ with complex functions, and therefore, often gets injured. To prevent any functional loss, a detailed anatomical knowledge is required to have a perfect surgical treatment. Also it is necessary to have a thorough understanding of arrangements of the human extensor tendons and intertendinous connections when tenoplasty or tendon transfer is required. We performed a study of the arrangements of the human extensor tendons and the configuration of the intertendinous connections over the dorsum of the wrist and hand. METHODS: A total of 58 hands from Korean cadavers were dissected. The arrangements of extensor indicis proprius, extensor digitorum communis, and extensor digiti minimi tendons and intertendinous connections were studied. RESULTS: The most common distribution patterns of the extensor tendons of the fingers were as follows: a single extensor indicis proprius(EIP) tendon which inserted ulnar to the extensor digitorum-index(EDC-index); a single EDC-index; a single EDC-middle; a double EDC-ring; an absent EDC-little; a double extensor digiti minimi(EDM), a single EDC-index(98.3%), a single EDC-middle(62%), a double EDC-ring(50%), and an absent(65.5%) or a single (32.8%) EDC-little. A double(70.6%) EDM tendons were seen. Intertendinous connections were classified into 3 types: type 1 with thin filamentous type, type 2 with a thick filamentous type, and type 3 with a tendinous type subdivided to r shaped 3r type and y shaped 3y type. The most common patterns were type 1 in the 2nd intermetacarpal space, type 2 in the 3rd intermetacarpal space, and type 3r in the 4th intermetacarpal space. And in the present study, we observed one case of the extensor digitorum brevis manus(EDBM) on the boht side. CONCLUSION: A knowledge of both the usual and possible variations of the extensor tendon and the intertendinous connection is useful in the identification and repair of these structures.

Cervical Ganglioneuroma Associated with Neurofibromatosis Type 1

PURPOSE: Ganglioneuromas are well-differentiated tumors derived from neuroectodermal neural crest cells. Although these tumors can occur anywhere along the sympathetic chain from the base of the skull to the pelvic cavity, they usually develop in the posterior mediastinum and retroperitoneum these tumors are rarely found in the cervical region. METHODS: We report the case of a 16-year-old male patient with neurofibromatosis type 1 who was admitted because of a palpable mass centrally located on the left side of the neck. A preoperative contrast-enhanced neck computed tomography image showed a low-density homogeneous mass on the parapharyngeal space along with marked displacement of the trachea and carotid vessels. Round and soft masses were also detected on both axillae. RESULTS: The patient subsequently underwent complete excision of the neck mass via the transcervical approach. The mass was smooth and well encapsulated between the sternocleidomastoid muscle and the trachea. Further, the mass appeared to arise from the cervical sympathetic chain, which was preserved during surgery. Both the axillary masses were also excised. The histopathological findings were ganglioneuroma for the neck mass and neurofibroma for both the axillary masses. CONCLUSION: Cervical ganglioneuromas are rare tumors that present as enlarging parapharyngeal cervical masses in the oropharynx or neck. To our knowledge, a case of cervical ganglioneuroma associated with neurofibromatosis type 1 has never been reported. In patients with neurofibromatosis, multiple tumors may develop, and therefore periodic clinical and radiological follow-up is recommended. Further, repeated imaging analysis should be performed if the presence of another tumor is suspected.

Correction of Blepharoptosis using Posterior Check Ligament Sling

There are various options on proper surgical repair for blepharoptosis. We have treated 7 patients with posterior check ligament sling and evaluated the advantages of this method from September 2006 to July 2009. These patients were blepharoptosis with moderate to severe ptosis with poor levator function. Through the blepharoplasty incision, the upper half of tarsal plate was exposed and the orbital septum was opened to show the levator aponeurosis. The M?ller's muscle was dissected from the upper border of the tarsal plate and from the posteriorly located conjunctiva. We exposed the posterior check ligament and fixed it on approximately upper one third of the tarsal plate. We obtained satisfactory result for more than 18 months with blepharoptosis corrected with all cases with no significant complications: among satisfactory degrees of all blepharoptosis patients, 4 were "Excellent" and 3 were "Good". The correction of blepharoptosis using posterior check ligament sling showed less traumatic to levator and The M?ller's muscle and more naturally correcting vector, compared with other methods. Especially in patients who had insufficient correction of blepharoptsis, the correction of blepharoptosis using posterior check ligament sling appears to be a good alternative method.

Surgical Treatment of Mallet Finger Deformity with Hook Plate

PURPOSE: The bony mallet finger injury is generally managed by conservative treatments. But operative treatments are needed especially when the fractures involve above 30% of articular surface, or when distal phalanx is accompanied by subluxation in the volar side. This is the reason why they often result in chronic instability, articular subluxation and cosmetic dissatisfaction. In this report, We describe new method using the hook plate as an operative treatment of mallet finger deformity. METHODS: Among 13 patients with mallet finger deformity who came from February 2006 to February 2008, six patients were included in surgical indication. Under local anesthesia, H or Y type incision was made at the DIP joint area. After the DIP joint extension, the hook plate was put on the fracture line, and one self tapping screw was used for fixation. 2 hole plate which was one of the holes in 1.5 mm diameter was cut in almost half and bended by approximately 100 degrees. RESULTS: In all six cases which were applied the hook plate, complications such as loss of reduction or nail deformity were not seen. In only one patient, hook pate was removed due to inflammatory reaction after the surgery. In 2 weeks after the operation, active motion of DIP joint was performed. The result was satisfactory not only cosmetically but also functionally. In 6 weeks after the operation, the range of motion of DIP joint was average 64 degrees. CONCLUSION: The purpose of the operative treatment for mallet finger deformity using the hook plate is to provide anatomical reduction with rigid fixation and to prevent contracture at the DIP joint. While other operations takes 6 weeks, the operation using the hook plate took only two weeks to enable active motion. Complication rate was low and the method is rather simple. Thus, the operation using the hook plate is recommended as a good alternative method for the mallet finger deformity treatment.

Surgical Treatment of Sacrococcygeal Pilonidal Sinus with the Partial Deepithelized Gluteal Transposition Flap

PURPOSE: Pilonidal sinus is a frequent disease that occurs mostly in hairy young men, defined as chronic inflammation and infection of the postsacral sinuses. Wide excision of the affected area is the treatment of choice. Many techniques have been described to cover the defect. However none appears to be the ideal procedure to prevent infection, recurrence, and delayed wound healing. We present the results of an alternative technique that we performed by using partial deepithelized gluteal transposition flap for reconstruction of the defect following wide excision. METHODS: From October 2004 to September 2007, we performed the partial deepithelized gluteal transposition flap method on 6 patients. We modified the transposition flap techniques by deepithelialising the medial parts of the flap and burying them under the opposing edge of the flap. The results were compared with previous studies and evaluated regarding duration of surgery, size of defect, hospitalization periods, and complications. RESULTS: All the flaps were healed well with no partial or complete loss of the flap. Hospitalization and immobilization periods were acceptably shortened. Recurrence was not seen. The aesthetic outcome was also satisfactory and all patients were satisfied with the results. CONCLUSION: The main advantage of our techniques is using healthy tissues to obliterate the dead space, to provide an extra-cushion, and to prevent deep dehiscence. We believe that the partial deepithelized gluteal transposition flap is a good alternative method for treatment of pilonidal sinus.

Reconstruction of Fingertip Amputation by Using Digital Artery Perforator Flap

PURPOSE: Fingertip injuries are the most common hand injuries and may lead to significant disability. Knowledge of fingertip anatomy is mandatory to treat these injuries effectively. All surgical techniques used for coverage of fingertip injuries must be based on the nature of the injury and the patient's age. Many authors have studied the method of fingertip reconstruction because goals of these treatments should include maintaining length, sensibility, motions, and appearance. The purpose of this study is to evaluate the effect of digital artery perforator flap for fingertip reconstruction without aesthetic and functional problems. METHODS: From November 2006 to March 2007, the authors performed fingertip reconstruction on 3 fingers of 3 patients, aged between 41 to 54 years (average age, 47 years) using digital artery perforator flap. RESULTS: All fingers recovered successfully and there were no necrosis of the flap. We followed up 3 cases more than 5 months. Light touch and temperature sensation could be detected in all flaps and the static two-point discrimination test was 8 mm. CONCLUSION: This flap is an alternative choice for coverage of fingertip defects. This method also takes short time to procedure and to recovery. The digital artery perforator flap has never been reported in Korea, however it is considered as a useful method for treatment of fingertip injury.

Clinical Experience of Radial Forearm and Anterolateral Thigh Perforator Faciocutaneous Free Flap for Hypopharyngeal Reconstruction

The reconstruction of hypopharynx after ablation of carcinoma is quite challengeable to plastic surgeons and requires the recovery of anatomic continuity and its own function such as swallowing and speech. Various surgical methods have been evolved through the years from local flap to microvascular free flap. The latter, obviously has improved the surgical outcome playing a main role in reconstruction of hypopharynx and universally been divided into visceral free transfer and fasciocutaneous free flap. Though lots of surgical options are reported depending on the shape and size of defect, patient's desires or surgeon's empirical background, no general agreement about the reconstruction of hypopharynx exists because the advantage of the one flap can be a disadvantage of the other and vice versa. The fasciocutaneous free flaps were used for reconstruction of hypopharynx in 18 patients, radial forearm free flap for 14 and anterolateral thigh perforator flap for 4 patients, respectively and indicated following that the first is the patients have partial defect that retain the remnant mucosa more than 50% of hypopharyngeal circumference. the second indication is the patient with previous abdominal operation and the third is the patient with risk of long ischemic time of transferred bowel. the last cases is the elderly patient with other comorbid condition even though the remnant mucosa are less than 50% of hypopharyngeal circumference. We have designed the flap to have a sufficient lumen of neohypopharyngeal diameter more than 4cm and the cephalic margin of hypopharynx be wider than caudal one, like a funnel shape, to eliminate the size discrepancy between the pharyngeal and esophageal lumen. The small triangular flap extension was designed in the caudal margin to prevent the distal enteric anastomosis site from the stricture, making the circumference of distal margin to be enlarged. In this paper, we contemplate our speculation for use of fasciocutaneous free flap for reconstruction of hypopharynx with surgical finesse to get a fine surgical outcome.

The Clinical Analysis of Epicanthoplasty

No abstract available.

Congenital bronchoesophageal fistula in adult: report of a case / 대한흉부외과학회지

No abstract available.

Mediastinal tuberculous abscess: report of two cases / 대한흉부외과학회지

No abstract available.