A New Technique for Conchal Cartilage Harvest

The goal of auricular cartilage harvest is to obtain a sufficient amount for reconstruction and to minimize the change in ear shape. The cartilage can be harvested by a posterior or anterior approach, and each method has advantages and disadvantages. The posterior approach presents the advantage of scar concealment, but there are limits to the amount of cymba cartilage that may be harvested. In contrast, the anterior approach may cause a noticeable scar. However, as cartilage is collected, the anterior approach provides a view that facilitates the preservation ear structure. In addition, it is possible to obtain a greater amount of cartilage. From January 2014 to December 2015, we harvested auricular cartilage graft material in 17 patients. To prevent the development of trapdoor scars or linear scar contracture, short incisions were made on the superior border of the cymba and cavum. Two small and narrow incisions were made, resulting in suboptimal exposure of the surgical site, which heightens the potential for damaging the cartilage when using existing tools. To minimize this, the authors used a newly invented ball-type elevator. All patients recovered without complications after surgery and reported satisfaction with the shape of the ear.

Implant esthetic restoration with bone graft in the extended maxillary anterior area: A case report / 대한치과보철학회지

The maxillary anteriors play an important role in esthetics. Therefore after extraction, it is crucial to preserve the hard tissue and soft tissue in order to promote esthetics of restoration. There are several challenges when restoring the maxillary anteriors via implant. Some of the challenges are be maintaining consistency with neighboring teeth in terms of shade, form, and texture : as well as having harmonious emergency with the gingival margin. In this case, a traumatized patient with crown-root fracture of the maxillary central and lateral incisors is presented. The cracked teeth were extracted, and implants were inserted with bone grafts to compensate the volume of damaged area of the maxillary anterior. Cantilever implant prosthetics were planned while precise adjustments to the gingival area were made using customized impression coping to perform the esthetic restorations. The final outcome of the treatment was satisfying in both esthetic and utilitarian perspective.

Implant esthetic restoration with bone graft in the extended maxillary anterior area: A case report / 대한치과보철학회지

The maxillary anteriors play an important role in esthetics. Therefore after extraction, it is crucial to preserve the hard tissue and soft tissue in order to promote esthetics of restoration. There are several challenges when restoring the maxillary anteriors via implant. Some of the challenges are be maintaining consistency with neighboring teeth in terms of shade, form, and texture : as well as having harmonious emergency with the gingival margin. In this case, a traumatized patient with crown-root fracture of the maxillary central and lateral incisors is presented. The cracked teeth were extracted, and implants were inserted with bone grafts to compensate the volume of damaged area of the maxillary anterior. Cantilever implant prosthetics were planned while precise adjustments to the gingival area were made using customized impression coping to perform the esthetic restorations. The final outcome of the treatment was satisfying in both esthetic and utilitarian perspective.

Pyogenic Pancreatic Abscess Mimicking Pancreatic Neoplasm: A Four-Case Series / 대한소화기학회지

A pyogenic pancreatic abscess mimicking pancreatic neoplasm in the absence of acute pancreatitis is rare. We report four patients who each presented with a pancreatic mass at the pancreas head or body without acute pancreatitis. The presenting symptoms were abdominal pain, fever, or weight loss. Abdominal CT scans showed low-density round masses at the pancreas head or body with/without lymphadenopathy. In each case, a PET-CT scan showed a mass with a high SUV, indicating possible malignancy. Comorbid diseases were identified in all patients: chronic pancreatitis and thrombus at the portal vein, penetrating duodenal ulcer, distal common bile duct stenosis, and diabetes mellitus. Diagnoses were performed by laparoscopic biopsy in two patients and via EUS fine needle aspiration in one patient. One patient revealed a multifocal microabscess at the pancreatic head caused by a deep-penetrating duodenal ulcer. He was treated with antibiotics and a proton-pump inhibitor. The clinical symptoms and pancreatic images of all the patients were improved using conservative management. Infective causes should be considered for a pancreatic mass mimicking malignancy.

Development of a Semi-automatic Computer System to Register MRI Lesions Onto a Brain Template for Quantitative Analyses in Clinical Trials Having MRI Findings as Surrogate Endpoints: A Preliminary Report

BACKGROUND: Clinical trials that utilize imaging findings as surrogate endpoints are considered to be cost-effective. However, unlike numeric data, magnetic resonance imaging (MRI) findings are not quantifiable. Thus, we have begun to develop a software package that is able to convert qualitative MRI findings into quantifiable data. METHODS: Computer software (DUIH_Image) was created with which every patient's MRI data can be registered on a standard brain template. Interuser and intrauser reliabilities for the registration were measured, and then a proof-of-principle experiment was conducted to determine whether the system could identify factors that were associated with a greater National Institutes of Health Stroke Scale (NIHSS) score at admission. We studied 40 consecutive patients [65.1+/-14.2 years old (mean+/-SD); 22 males and 18 females] with first-ever acute lacunar infarction of the corona radiata, who were divided into two groups according to their NIHSS score (i.e., low: 0-2; high: > or =3). The following parameters were compared between these two groups: (1) data retrieved from clinical profiles, including demographic and risk factor variables; and (2) accumulated diffusion MRI lesions mapped on a standard template. RESULTS: Modest levels of interuser and intrauser reliability were observed (p<0.05, R(2)=0.63-0.84, Pearson correlations). Regarding the clinical profiles, no significant difference was found for the numeric data sets or infarct size between the two groups. However, on the accumulated lesion map image, the lesion area that overlapped the most was located more posterolaterally in the high NIHSS score group than in the low NIHSS score group. CONCLUSIONS: In this pilot study we have demonstrated the potential usefulness of the DUIH_Image software. We plan to update this software to enable its utilization in actual clinical trials.

A Case of Intraocular Thelasia Callipaeda Infestation

PURPOSE: We report a case of intraocular Thelazia callipaeda infestation in a patient with panuveitis who had a successful recovery after pars plana vitrectomy. METHODS: A 73-year-old female patients complained of a floating sensation and gradually decreasing visual acuity in her right eye. On slit lamp examination, severe intraocular inflammatory reaction was observed. Fundus examination revealed severe vitreous haze with mobile linear structure. Three-port pars plana vitrectomy was performed and then the worm was removed. RESULTS: The worm was confirmed to be Thelazia callipaeda. At postoperative 2 months, the patient's visual acuity was 0.6 and intraocular pressure 14 mmHg. There was no evidence of intraocular inflammatory reaction. CONCLUSIONS: Thelazia callipaeda usually lie in the conjunctival sac or lacrimal apparatus, causing ocular surface disease, but intraocular infestation rarely occurs. If intraocular infestation does occur, early surgical removal should be performed.

The Outcome of Inferonasal Trabeculectomy in Diabetic Patients Who Expected or Had Vitrectomy

PURPOSES: We evaluated the outcome of trabeculectomy using inferonasal bleb in diabetic retinopathy patients awaiting vitrectomy or on whom vitrectomy was performed. METHODS: We retrospectively reviewed the medical records of patients who had undergone trabeculectomy with an inferonasal bleb from December 2002 to May 2005. Seven eyes had neovascular glaucoma secondary to the proliferative diabetic retinopathy, 6 eyes primary open angle glaucoma, and 4 eyes steroid induced glaucoma. We evaluated postoperative complication, intraocular pressure, the number of ocular hypotensive eye drops, and preoperative and postoperative best corrected visual acuity. RESULTS: Mean follow-up period was 20.47+/-5.55 months. Most common complication was early ocular hypotony (4 eyes, 24%), but no blebitis and bleb associated endophthalmitis were observed. Mean intraocular pressure was reduced from 30.77+/-5.61 mm Hg preoperatively to 13.72+/-4.61 mm Hg at the most recent follow-up. The number of preoperative ocular hypotensive eye drops was 2.9+/-0.3 and that of postoperative eye dros was 1.4+/-1.0. The difference between these was statistically significant (p=0.000). Eleven eyes (61.11%) had a stable or improved visual acuity. CONCLUSIONS: Trabeculectomy using an inferonasal bleb appears to be a safe and effective surgical option that may be helpful in certain clinical situations, such as medically uncontrolled glaucomatous eyes with expected vitrectomy or vitrectomized eyes.

The Effect of Atropine on Myopic Progression in Children

PURPOSE: To examine the effects of atropine therapy on myopic progression in myopic children. METHODS: Fifty myopic patients, aged from 7 to 14 years and less than -5 diopters, visited our clinic for correction of refractive error from August 2001, and were followed up for at least 1 year. Of these 50 patients, the atropine therapy group was 23 and the control group was 27. Right eye cycloplegic refraction and axial length changes of the two groups were compared and analyzed. RESULTS: There was a mean increase of myopia of 0.25+/-0.43 D/yr in the atropine therapy group and of 0.83+/-0.37 D/yr in the control group (P=0.000). There was a mean increase of axial length of 0.12+/-0.19 mm/yr in the atropine therapy group and 0.39+/-0.21 mm/yr in the control group (P=0.000). In refraction and axial length changes according to age, there was no statistically significant difference within the group, aged from 7 to 9 years. However, there was a statistically significant difference within the group, aged from 10 to 14 years. In refraction and axial length changes according to myopic grade, there were a statistically significant differences between the groups. CONCLUSIONS: Atropine therapy is effective in slowing the myopic progression in myopic children with refractive error less than -5 diopters.

New Instruments and Techniques for Obtaining Septal Cartilage in Rhinoplasties

A symmetric approach, using external rhinoplasty, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. The external approach yields a full visualization of the underlying nasal framework and intraoperative evaluation of the deformities to be corrected subsequently. The nasal septal cartilage is unequivocally one of the best graft sources for reconstruction of the dorsum, columella or tip. It has fairly even surface and pliability in carving and shaping the graft. The graft can be obtained during the surgery with less morbidity and prepared easily for need of the shape. The only real disadvantage is the limited amount of cartilage that can be obtained from the septum. The dorsal and caudal rims, one or more cm in width, of the nasal septum should not be disturbed to maintain the nasal frame during harvesting the septal graft. Authors invented novel instruments, J & D knife and Flat (Spatula) suction tip, and have employed the devices for harvesting the septal cartilage. We were unable to gain enough amount of the cartilage by using a swivel knife or cartilage scissors. The septal cartilage can be resected as much as needed with newly invented instruments which facilitate a separation(method) technique.

Stepped Subciliary Skin Muscle Flap Versus Nonstepped Subciliary Skin Muscle Flap for Orbital or Zygomatic Fractures

Malposition of the lower eyelid is probably the most important following lower eyelid incision for orbital or zygomatic fracture repair. Its severity may range from increased scleral show to gross ectropion. There are two major determinants of lower eyelid position after surgery: the integrity of the tarsus, canthal ligaments, and pretarsal orbicularis and cicatrical forces within the skin, orbital septum, and capsulopalpebral fascia. A total of two hundreds and six patients were investigated for functional and aesthetic impairments following treatment of orbital or zygomatic fracture through stepped subciliary skin muscle flap or nonstepped subciliary skin muscle flap and periosteal repair. As a result, the incidence of scleral show, ectropion was reduced with statistical significance after stepped subciliary skin muscle flap and periosteal repair of infraorbital rim than nonstepped subciliary skin muscle flap incision and no periosteal repair. The reason is that stepped subciliary skin muscle flap has following characteristics than nonstepped subciliary skin muscle flap: Enough of the muscle must be left to allow for its normal contraction capacity and permit an adequate support of the palpebral rim. In addition, the remaining muscular volume in the tarsal portion, near the lashes, will be sufficient to maintain the lid tonicity. Also, repair of periosteum provides firm fixation of soft tissue to infraorbital rim and prevent hematoma due to decreased dead space. By combing the stepped subciliary skin muscle flap with periosteal repair of infraorbital rim for orbital or zygomatic fracture repair, it is expeced that complications will be reduced such as scar contracture, scleral show and ectropion.

New Zygometer Incorporating Exophthalmometer

The zygoma is essential key element determining midface contour and symmetry. The height and width of the zygoma are changed during midfacial surgery such as reduction of fractured zygoma, esthetic malar reduction and correction of congenital midfacial deformity. The exact preoperative and postoperative evaluation of the zygoma is very important step in midfacial surgery. The estimation of height and width of the zygoma usually depends on gross feature analysis or radiographic measurement. But the results are not accurate and subjective. Several device were used for measuring the height and width of the zygoma, but those are inconvenient and difficult to use. The fracture of the zygoma is frequently combined with blow out fracture resulting enophthalmos. The simultaneous measurement of accurate malar height and degree of enophthlmos is helpful. For this reason, we developed a new zygometer with the function of exophthalmometer. This device is convenient to use and easy for comparative measurement of malar height preoperatively and immediate postoperative period, and the degree of enothphalmos is measured simultaneously with this device. This new zygometer will be applied to many midfacial surgery and craniofacial study.

Mandible Angle Gauge for Accurate Angle Resection

No abstract available.

Effect of decorin on tensile strength of healing flexor tendon

Adhesion formed between tendon and its sheath after repair often impairs functional recovery. There have been many attempts to reduce adhesion around a repaired tendon, but most results have been unsatisfactory or impractical in clinical application. Moreover, most attempts were focused on extrinsic tendon healing. whereas studies on the intrinsic tendon healing are sacrce in the literature. We have previously reported that fibrotic tendon adhesion after repair was decreased by decorin, a natural inhibitor of TGF-beta. Accordingly, the serial tensile strength was measured after complete tensection and repair of the tendon severance in order to confirm the effect of decorin inhibition of intrinsic healing capability. Forty White Leghorn chickens were subject to complete transection and repair of the third toe flexor digitorum profundus tendon in Zone II. In the experimental group, 0.5ml of diluted decorin(50microgram/ml) was injected around the repaired site, and the same volume of saline solution in the control group. Tendons were harvested at 1, 3, 5 and 7 weeks. The disrupting force of the repair site was analyzed using tensiometry(LLOYD LR 30K, U.K). The tensile strength of repaired tendon was similar in both groups for all postoperative periods. This indicates that intrinsic healing proceeds normally within the decorin group in spite of the blockade of TGF-betaactivity. Decorin, a natural inhibitor of TGF-beta, showed a significant inhibitory effect on reducing post-repair tendon adhesions, without disruption of intrinsic healing in the chicken flexor tendon injury model. Therefore, decorin is expected to be a useful agent for preventnion on tendon adhesion after the repair in clinical usage.

A Case Report of Frontometaphyseal Dysplasia

Frontometaphyseal dysplasia is an uncommon genetic syndrome affecting bone and connective tissue. This condition is characterized by the prominence of supraorbital ridges, hyperostosis of the skull, mandibular hypoplasia and malocclusion with antegonial notching, underdeveloped paranasal flaring of the long bone, and a widened iliac wing. Frontometaphyseal dysplasia has an X-linked dominant trait. Clinical manifestations are more severe in males and have extreme variability in females. We present an 11-year-old boy who had frontometaphyseal dysplasia with disfigured face due to bilaterally urinary tract malformation and chronic urinary tract infection. To improve facial appearance, his prominent supraorbital ridges were contoured by ostectomy and burring through bicoronal incision. Urologic operation was performed simultaneously. Histologically, resected bony specimen revealed bony tissue with normal trabecular pattern suggesting exostotic bone. The patient healed without any postoperative complications and he and his parents were satisfied with his final facial morphology.

The Significance of the Cornal incision in Treatment of Complex Zygormatic Fractures

Restoration of anteroposterior projection of the zygomatic body and facial width are key elements in treatment of complex zygomatic fractures. Traditionally, it has been understood that for most fractures of the zygoma, three-point fixation of the zygomaticofrontal suture, inferior orbital rim, and zygomaticomaxillary buttress generally produces exact structural restoration. Recently, the importance of accurate reduction of the zygomatic arch through coronal incision has been favored in complex zygomatic fractures. Though coronal incision has the advantages of accurate reduction and fixation as a result of extensive exposure of the fractured area, this procedure also has many disadvantages including injury to the facial nerve, paresthesia, alopecia, scar formation, longer operating time, protracted hospitalization, etc. As well, there have been no objective data to prove the fact that four-point fixation through coronal incision is superior to traditional three-point fixation. From May, 1994 to December, 1998, the authors treated 45 patients by traditional three-point (n=20) and coronal four-point fixation (n=25) with random sampling. To assess the difference between the two methods the authors measured the axial angle of the zygoma, the axial angle of the zygomatic arch, and the degree of zygomatic arch inclination on submentovertex X-ray, and then analyzed the measurements by the paired T-test(p < 0.05). As a result, the axial angle of the zygoma and zygomatic arch assessed by anteroposterior projection, as well as the facial width showed no statistical difference between the two groups, respectively(p = 0.26, p = 0.18). Mean while, the degree of zygomatic arch inclination representing the local contour of the fractured zygomatic arch was statistically significant between the two groups(p < 0.05). Thus, the traditional three-point fixation method may be widely acceptable in treatment of complex zygomatic fractures with anterior three-point or zygomatic arch comminution.

ENDOSCOPIC FOREHEAD LIFT COMBINED WITH ALLODERM(R) IMPLANTATION TO CORRECT FOREHEAD DEEP WRINKLES

Forehead deep wrinkles make man's face ugly. Especially, in case that a young people has short forehead, one or two forehead deep wrinkles is likely go give a aggressive impression to people. Traditional forehead lift basically not only perfrom the selective excision of frontalis muscle which cause forehead wrinkles, but extend the width of forehead by practical lift through scalp excision. Recently, various filling materials such as collagen have been developing, and laser resurfacing and endoscopic plastic surgery has gradually been generalized, so the frequency of the traditional forehead lift which needs the extensive operation through coronal incision is gradually diminished. But collagen injection is repeatedly taken every regular times and it has a weak point that the width of forehead cannot be regulated. Laser resurfacing can't solve the problem of deep wrinkles. The purpose of endoscopic brow lift which has been generalized currently is mainly brow lift, and so this method is not good for deep wrinkles because it can't modualte frontalis muscle which cause forehead transverse wrinkles. Recently it has been reported that Alloderm composed of dermal collagen from cadavar skin is universally used in covering as well as filling up soft tissue defect and its usability is also successful. Authors recently correct three young persons who have forehead deep wrinkles by combination of endoscopic forehead lift and subcutaneous Alloderm implantation under the wrinkles for 2 years. At first, we extended the width of forehead and smoothed the depth of wrinkles by endoscopic brow lift. After having endoscopic operation, we inserted Alloderm in subcutaneous pocket and performed suspension suture outside. The average increase of forehead width is 5 mm and all patients had corrected transverse wrinkles remarkably. During the 9 months, wrinkles didn't recur and implanted Alloderm also didn't absorbed. As a better method, authors reported that combining endoscopic brow lift with Alloderm implantation for the correction of short forehead and deep wrinkles could be used in place of traditional forehead lift.

The effect of prostaglandin e1on the muscle flap in the rectus abdominis muscle of the rat

Flap survival is critical to the success in reconstructive surgery, there have been many investigations to increase the blood supply to the flaps such as surgical delay and pharmacologic delay. Prostaglandin(PG) is released from various tissues including blood vessel in response to physical stimulus. Among the Prostaglandins, PGE1 has been proven to be a vasodilatation property and many authors have demonstrated its effect to increase blood supply after random cutaneous flap surgery. Clinically, however, muscle flap or musculocutaneous flap is more significantly used in reconstructive surgery and hemodynamic effects of PGE1 of this type of flap are still not documented. The authors designed the random muscle flap to study the hemodynamic effects of PGE1 of the muscle flap. Superior based rectus muscle flap was elevated from rats and the superior epigastric artery, its major vascular pedicle, was ligated to create the random-type muscle flap. Twenty two rats were divided into two experimental groups and each group had 11 rats; Group I: No drugs Group II: PGE1 injection group for 7 postoperative days intraperitoneally The average muscle flap survival rate of group I was 46+/-3.0 precent and it had a higher survival rate than the control group(23+/-4.3%). The muscle flap survival rates showed significant differences between the two groups (p< 0.005) This study shows that the administration of the PGE1, in clinical usage of the rare random muscle flap with a pedicle injury or musculocutaneous flap with the risk of distal cutaneous flap necrosis, such as TRAM flap, which might be much safer and popular.

The significance of radiographic follow-up of mandibular fractures

For many years, healing membranous bone fractures have been known to show a persistent lucency at the fracture interface. Radiographic follow-up has proven to be of little value as a guideline for healing of mandibular fractures. Recently, a fracture has been treated by rigid internal fixation by metallic plate and screws rather than closed reduction and wire fixation, we expected that some difference in the radiographic features of fracture healing. To investigate these questions we undertook a retrospective radiographic and clinical analysis of 33 followed patients with fractures of the body and angle of the mandible from 1993 to 1997. There were 26 male and 7 female patients ranging in age between 5 and 74 years, with an average of 29.7 years. All patients were managed by open reduction with metallic plates and screws. The length of follow-up ranged from 9 to 187 weeks. Total 81 radiographic follow-up films were obtained and divided into 3 grades according to the degree of radiolucency of fracture lines; grade 0 radiolucent fracture line and no evidence of fracture interface calcification, grade 1 decreased radiolucent area and evidence of fracture interface calcification, and grade 2 disappearance of fracture line.Until follow-up of 8 weeks, all of the radiographs showed grade 0. From 8 weeks to 16 weeks, 62.5 percent showed grade 0 and 37.5 percent showed grade 1. From 16 weeks to 48 weeks, 38.5 percent showed grade 1 and 61.5 percent showed grade 2. After follow-up of 48 weeks, all showed grade 2.In this study we have shown that the radiographic disappearance of mandibular fracture lines was usually accomplished by 48 weeks. We feel that radiographic union of the mandible is lagging well behind clinical union, but disapperance of the fracture line in rigidly fixated mandibular fracture was occurred earlier than healed by fibrous union. We propose that radiographic union of the mandible by approximately 1 year can be a guideline for the normal mandibular bone healing.

Expression of LFA-3(CD58) After Intracorneal Infection of Candida albicans in Rabbits

In this immunohistochemical study we applied a monoclonal antibody(mAb) to evaluate the expression pattern of lymphocyte functionassociated antigen 3(LFA-3) in rabbit`s corneas before and after intracorneal injection of Candida albicans. Ten right eyes were induced to get immunocompromized cornea with subconjunctival injection of 2mg of dexamethasone once a day for 3 days(group I), and 10 left eyes had normal cornea without subconjunctival injection of dexamethazone(group II). Each 2 corneas in both group I and II were resected at 3, 12, 24 and 72 hours after intracorneal injection of C. albicans. Each 2 corneas without intracorneal injection of C. albicans in both groups were used as a control. The results were as follows: LFA-3 was expressed weakly on corneal epithlium in control of group I and group II. Expression of LFA-3 on vascular endothelium of group II was somewhat stronger than that of group I, LFA-3 was expressed moderately on vascular endothelium, and was detected on corneal stroma at 3 hors after intracorneal injection in both groups. Expression of LFA-3 on corneal stroma was slightly increased in both group II, and markedly increased in group I at 12 hours after intracorneal injection. Group II showed slightly increased LFA-3 expression on corneal and II to be expressed on corneal endothelium and inflammatory cells at 24 hours after injection. Its expression on corneal epithelium, stroma and endothelium was more increased in group II than in group I at that time. Group I showed moderate LFA-3 expression on corneal epithelium, corneal endothelium and inflammatory cells, and strong expression on corneal stroma and vascular endothelium at 72 hours after infection. Otherwise, LFA-3 expression in group II was weak to moderate n corneal epithelium, corneal endothelium and inflammatory cell, and moderate on corneal stroma and vascular endothelium. In this study, it was found that expression of LFA-3 in group I was weaker than that in group II in control and at 3 hours after intracorneal injection of C. albicans, but group I showed more strong LFA-3 expression than group II after 12 hours of intracorneal injection.

Reconstruction of median sternotomy dehiscence

Complications after a median sternotomy incision, which is used currently in most open heart surgery, are serious, although it is infrequent. Reconstruction of the sternal defect resulting from dehiscence of median sternotomy is still big challenge to the most plastic surgeons. Since vascularized greater omentum was transposed to eliminate mediastinal wound problems, many vascularized regional muscle flaps became mainstay in reconstruction of median sternotomy wound. We treated 13 patients with median sternotomy dehiscence between October of 1993 and March of 1998. In two patients, the wound problems were so confined to superficial tissue that debrided and closed primarily. Eleven patients with deep wound infection were managed with vigorous debridement of all necrotic tissues and resultant defects were covered with regional muscle flaps: rectus myocutaneous flap(3) and bilateral pectoralis advancement flap(8). We used the pectoralis major advancement flaps without counter incision at humeral insertion site and the dissections were limited only medial to the anterior axillary line to preserve the axillary fold. In five patients with larger defects, we elevated muscle and cutaneous flaps separately to make these flaps more mobile. Large portion of two rectus abdominis flaps could not survive, whereas pectoralis advancement flaps had mo special wound problems. Only one patient developed fistula due to remained wire, regardless to flap surgery.