Use of Human Placentas for Practice of Microvascular Surgery

PURPOSE: Microsurgical exercise has been performed with rat femoral vessels. But, it needs animal laboratory, anesthesia and its keeping facilities. MATERIALS AND METHODS: Ten human placentas were studied for suitability in a microvascular exercise. The size and useful length of vessels were measured, and various microvascular anastomoses were performed. RESULT: The human placenta has many vessels traversing its fetal surface. A variety of sizes are available down to vessels of diameter 1 mm and up to vessels of diameter 6.5 mm (1.0

Periareolar Dual Plane Augmentation Mammaplasty

Although several reports have been introduced about dual plane augmentation mammaplasty, the description of periareolar approach dual plane augmentation mammaplasty was few. This article describes specific characteristics, and different classification and techniques for the periareolar dual plane breast augmentation while postoperative scars resulted from inframammary crease approach caused complaints. A total of 124 patients(248 breasts) had periareolar dual plane augmentation surgery from 1998 to 2004. Anatomic implants were used in 43 cases. Most of the patients were satisfied with the outcomes of periareolar dual plane augmentation. Periareolar dual plane augmentation mammaplasty adjusts implant and tissue relationships to ensure adequate soft-tissue coverage while optimizing implant-breast parenchymal dynamics to offer increased benefits and fewer faults compared to a single pocket location in a wide range of breast types with minimal scars. Two types of dual plane classifications are discussed in this study for the periareolar approach exclusively. The boundaries of retroglandular dissection remain constant, as the costal origin of pectoralis major are divided. Type A dual plane implies that the inferior edge of pectoralis muscle lies below the inferior areolar border, and type B dual plane implies that the inferior edge lies above the superior areolar border.

Breast Augmentation using Expandable Implants

Ideal results of augmentation mammaplasty consist of symmetry, natural shape, soft feeling and inconspicuous scar. In addition, patient's preferences about size and shape should be included. Static implants could not perfectly satisfy patients' desires for size and shape, but expandable implants enable to change the volume after the operation. From September 2001 to September 2004, 76 patients(150 breasts) underwent breast augmentation using permanent expandable implant. The procedure was unilateral in 2 women and bilateral in 74 women. Age ranged from 19 to 50 years(mean, 29 years). Fifty nine patients underwent simple augmentation mammaplasty, 7 patients were corrected of their severe asymmetry, 2 patients with the congenital breast deformity underwent mammaplasty using this, and 2 patients who had undergone unilateral mastectomy were reconstructed of their breasts using expandable implant. There were no definite complications such as capsular contracture, implant rupture, asymmetry. And there reported little dissatisfaction about the size. The permanent expandable implants might be good alternatives in cases of ordinary breast augmentation as well as tissue deficient patients, asymmetry, congenital anomaly, and breast reconstruction.

Immediate Umbilical Reconstruction after Removal of Umbilicus due to Urachal Cancer: Defatting, Anchoring and Purse-String Suture

Reconstruction of the umbilicus is not a frequent event. Umbilical restoring should always be aimed at creating an umbilicus of sufficient depth and good morphology(circular and cylinder shape) with less scarring. A wide range of techniques has been described to reconstruct neoumbilicus; nevertheless, a perfect result is difficult to obtain. I provide another alternative to reconstruct the umbilicus using defatting, anchoring and purse-string suture. The important steps are the following; the first step is defatting of 2.0cm umbilicus' circle. The second step is to umbilical fixation to the fascia wall using anchoring suture. The third step is purse-string suture to decrease new formative umbilicus and to make the circular and cylinder shape umbilicus. The author's method is a simple, easy and useful technique and renders better aesthetic result. So, I reviewed two cases and discussed the literatures.

Reduction Umbilicoplasty for Bizarre Big Umbilicus after Abdominoplasty

A cosmetically pleasing shape of the umbilicus is essential, especially in aesthetic operation. Umbilical restoring should always be aimed at creating an umbilicus of sufficient depth and good morphology with less scarring. But such a goal is often difficult to attain. The author's reduction umbilicoplasty is a useful technique in case of abnormal large umbilicus after abdominoplasty. The operation renders better aesthetic result. Technically, the procedure is easy to do and learn. The important steps are the following; the first step is reduction of original umbilicus' circle. The second step is umbilical fixation to the fascia wall using anchoring suture. The third step is cinching suture for decrease "the window" of abdominal flap and this step is more important than other steps. Finally, the suture performed between "the window" and reduced umbilicus. I operated the abdominal large umbilicus using above reduction umbilicoplasty. So, I reviewed that case and discussed the literatures.

The Configuration and Location of the Nipple-Areola Complex of Young Korean Adult

The absence of the nipple-areolar complex(NAC) in men are seldom stated, as a result of trauma, burn, mastectomy, or after the correction of extreme bilateral gynecomastia. A total of 50 healthy men aged 21 to 27 years were examined. We recorded the configuration (dimensions and shape) and the location of the NAC with respect to fixed skeletal anatomic landmarks. Of the 50 subjects examined, 44 had oval and 6 had a round NAC. The mean diameter for a round NAC was 24.3 mm. The center of the NAC was in the fourth intercostal space in 41 volunteers and in the fifth intercostal space in 9 of the subjects. To localize the NAC on the chest wall, at least three reproducible measurements proved to be necessary, composed of a horizontal line(distance from the midsternal line to the nipple, A), a medial oblique line(distance from the sternal notch to the nipple, B) and a lateral oblique line(distance from the acromioclavicular joint to the nipple, C). Using these three parameters, we recommend that the appropriate location can be calculated derived from the circumference of the chest.

Comparison of Fat Necrosis between Zone II and III in TRAM Flaps: A Prospective Study

Fat necrosis in transverse rectus abdominis musculocutaneous(TRAM) flaps is considered to be primarily affected by blood supply. Unreliability of blood supply in zone II has been claimed for years but no accurate comparison has been reported between fat necrosis in zone II and III. A prospective study about the incidences and extent of fat necrosis in zone II and III was designed, comparing relative vascularity between zone II and III. Immediate breast reconstructions after modified radical mastectomy or skin sparing mastectomy were performed in 150 consecutive patients with unipedicled TRAM flaps and 138 contralateral and 12 ipsilateral rectus muscles were used as pedicles. Twenty-one patients(14 percent) suffered from fat necrosis and 22 fat necroses were diagnosed in total. 17 fat necroses occurred in zone II, 3 in zone III and 2 in zone I. The incidence of fat necrosis in zone II was significantly higher than zone III, which was consistent with previous studies claiming poor vascularity of zone II. Therefore placing zone I and zone III medially and zone II laterally after discarding part of zone II will cause less deformity of reconstructed breast if resection of necrotized tissue is needed.

A Case of Breast Reconstruction Using Pedicled TRAM Flap in Psoriasis Patient

Psoriasis is a common and unpredictable chronic immune mediated disease charcterised by skin lesions and associated with arthritis. Complete remission is very rare. Prevention of acute exacerbation is mainstay of the treatment. At present, risk of surgery in psoriasis patient is uncertain although some dermatologic literatures reported that well controlled psoriasis is usually not cause surgical complications. We experienced a case of wide necrosis of flap in chronic psoriasis patient after immediate breast reconstruction with pedicled transverse rectus abdominis flap. Psoriasis is well known to have chronic skin damage from characteristic histopathologic findings of Munro's micro abscess, dermal arteriolar tortursity and hyperplasia. Such pathologic feature may induce congestion of flap and wide necrosis of flap.

Simultaneous TRAM Flap Breast Reconstruction with Contralateral Reduction Mammoplasty

Symmetry is an important parameter for breast reconstruction. Contralateral breast frequently provides model to be reconstructed. But hypertrophic and ptotic breast is aesthetically unacceptable. And if the contralateral breast is large, larger flap which is required to reconstruct the breast including the zone of poor vascularity. Therefore, reduction of hypertrophic breasts may be preferable. Many surgeons prefer to perform contralateral procedures at least several months after reconstruction. However authors performed simultaneous contralateral reduction mammoplasty in 18 patients at the same time as pedicled TRAM flap reconstruction. The expected disadvantages of the simultaneous operation are increased hospitalization time, blood loss, and complications. But according to our result, it showed that there was no significant difference in hopitalization time and hemoglobin-decrease. Furthermore, simultaneous operation showed lower complication rate because of the reduced size of the required flap. Our results revealed that TRAM flap breast reconstruction and simultaneous contralateral reduction mammoplasty is a safe procedure. And the results were aesthetically acceptable.

Stability and Relapse of Facial Asymmetry following Orthognathic Surgery in Patients with Asymmetric Prognathism

The purpose of this study is to evaluate the amount of correction and relapse after orthognathic surgery in patients with facial asymmetry and prognathism by means of the frontal cephalogram. Out of twenty prognathism patients who had been diagnosed as having skeletal facial asymmetry in need of orthognathic operation at our institute during last 6 years, only thirteen patients with pre-existing pre-operative(T0), immediate postoperative (T1) and long term follow up(T2) frontal cephalograms were included in the study. The population was divided according to the kind of surgical operation and severity of asymmetry. The midline sagittal reference line (MSR) was drawn and four basic landmarks were marked on the frontal T0, T1 and T2 cephalograms. Radiographic facial asymmetry was found most obviously in the lower jaw(Deviation from MSR: 2.21mm at ANS, 8.34mm at menton). Facial asymmetry was corrected to minimal degree(1.34 at menton) with orthognathic procedures. On long-term follow up, the correction of deviation was maintained as 1.98mm. The relapse rate was 24.1% at menton. The contributing factor was searched and the amount of asymmetry correction and the amount of prognathism correction proved to have statistical significance (p<0.05). In conclusion, asymmetry could be corrected with orthognathic procedures, which could be maintained with minimal degree of relapse. However, in preoperative planning, the degree of relapse should be considered to maximize the aesthetic outcome.

Avoidance of Injury to the Inferior Alveolar Nerve in Mandibular Angle Contouring; Maneuver of One Inch

Complications of mandibular angle contouring may include damage to the inferior alveolar nerve. This study was undertaken to quantify the path of the inferior alveolar nerve in the normal human mandible and in the mandibles of patients presenting for cosmetic reduction of the mandibular angles. The study was based upon the panorama radiography of 20 normal population (ten men, ten women) and 20 patients (ten men, ten women) complaining of square face. Using panorama radiographs and paper tracing, the distance from the "A" point (Fig. 1) to the inferior alveolar nerve was recorded within its mandibular osseous canal in the mandibular angle. The nerve was identifiable in each ramus. The average distance between A point and the other points along the osseous canal is 21.48mm. Therefore together with an additional margin of several millimeters, it is important to maintain a safe distance of at least an inch (25mm) between the saw and the anterior border of the ramus. From our clinical experiences, we are suggesting that this "1 inch maneuver" to be very helpful in avoiding injury to the inferior alveolar nerve, especially for the novice surgeon.

Use of 2-Octylcyanoacrylate (Dermabond(r)) for Repair of Hand Trauma

Dermabond(r) (2-Octylcyanoacrylate) has an eight-carbon alkyl derivative that is less inflammative and stronger than its short chain derivatives (i.e. 2-Butylcyanoacrylate, Histoacryl(r)). This study is to compare a tissue adhesive, 2-octylcyanoacrylate (Dermabond(r)), with conventional wound closure techniques for hand trauma. Thirty-eight patients presenting to Asan Medical Center Emergency Department with hand trauma from March 2003 to June 2003 were enrolled into this prospective clinical trial study. These patients were randomly assigned to treatment with either 2-octylcyanoacrylate or 5-0 monofilament sutures. The two groups were similar in both clinical and demographic characteristics. Photography taken at three months after treatment was rated by two plastic surgeons blinded to the method of closure. There was no difference between the two groups for appearance scores based on a visual analog scale (73.3mm for 2-octylcyanoacrylate versus 69.9mm for 5-0 monofilament sutures). The length of time for skin repair was similar between these two groups. (9.2 minutes for 2-octylcyanoacrylate versus 8.9 minutes for 5-0 monofilament sutures) Moreover, the use of 2-octylcyanoacrylate obviates the need for suture removal. In conclusion, the use of 2-octylcyanoacrylate for hand skin repair is an acceptable alternative, which includes many advantages to conventional suturing with a comparable cosmetic outcome.

Use of 2-Octylcyanoacrylate(Dermabond(R)) for Repair of Pediatric Facial Lacerations

This study is to compare a tissue adhesive, 2-octylcyanoacrylate(Dermabond(R)), with conventional wound closure techniques for pediatric facial lacerations. Twenty children presenting to Asan Medical Center Emergency Department with facial lacerations in July 2001 were enrolled into this prospective clinical trial study. These patients were randomly assigned to treatment with either 2-octylcyanoacrylate or 6-0 monofilament sutures. The two groups were similar in both clinical and demographic characteristics. Photography taken at three months after treatment were rated by two plastic surgeons blinded to the method of closure. There was no difference between the two groups for appearance scores based on a visual analog scale(60.4mm for 2-octylcyanoacrylate versus 62.9mm for 6-0 monofilament sutures). The length of time for laceration repair was decreased in the 2-octylcyanoacrylate group(3.1 minutes for 2-octylcyanoacrylate versus 9.3 minutes for 6-0 monofilament sutures, p<0.001). The parents' assessment of the pain felt by their children in the 2-octylcyanoacrylate group was less. Moreover, the use of 2-octylcyanoacrylate obviates the need for suture removal. In conclusion, the use of 2-octylcyanoacrylate for pediatric facial laceration repair in Korean is an acceptable alternative which includes many advantages to conventional suturing with a comparable cosmetic outcome.

Application of 2-Octylcyanoacrylate (Dermabond(R)) on the Incisional Wound of Thyroidectomy

2-Octylcyanoacrylate(Dermabond(R)) has an eight-carbon alkyl derivatives that is less inflammative with stronger adhesive property than its short chain derivatives (ie. 2-ethylcyanoacrylate, 2-butylcyanoacrylate).1 To assess the effectiveness of the tissue adhesiveness of 2-octylcyanoacrylate with dermal suture for the closure of head and neck incision wound, 20 patients who underwent thyroidectomy at Asan Medical Center were studied. Ten patients underwent skin closure with paper adhesive and the other 10 with the new tissue adhesive, 2-octylcyanoacrylate. At the time of 2 weeks and 3 months respectively, the incisions were evaluated by authors. Photographs of the incisions were rated using a visual analogue scale by 2 plastic surgeons who had no idea of the method of skin closure. The length of time required for skin repair was increased(161 seconds 2-octylcyanoacrylate vs 65 seconds paper adhesive), and the incision closed with tissue adhesive had similar cosmetic scores(84mm 2-ocylcyanacrylate vs 82.5mm paper adhesive). But the satisfaction of patient was higher in 2-octylcyanoacrylate group. The practical advantages of tissue adhesives are easy application, convenience of taking early showers and no need of suture removal. In conclusion, 2-octylcyanoacrylate is found to be an effective method of skin closure in clean head and neck incisions.

Fat Preservation Lower Blepharoplasty: Septal Draping Over Inferior Orbital Rim

Although the surgical excision of the fat pad has been the mainstay of the management of lower palpebral bulge in cosmetic blepharoplasty, procedures that depend on fat removal may render the patient deficient of fat, with the appearance of a hollow orbit. The concept of fat conservation during lower blepharoplasty has been developed by several authors in recent years. Attenuated orbital septum was released along the arcus marginalis and transposed to cover the bony framework. The orbital septum meticulously sutured to the pre-periosteal soft tissue with 5-0 polyglactin. This technique of septal draping over the inferior orbital rim was performed in 30 consecutive individuals (60 lower eyelids) for an year period. The overall results obtained were satisfactory and morbidity was minimal.

A Study on the Preparation of Acellular Lyophilized Porcine Dermal Matrix and Xenograft

Biological skin substitutes can be used in human skin defects. However, with the exception of autograft, they are not permanent due to incompatible tissue antigenicity. In our study, we planned to determine the fate of porcine skin, preliminarily processed, in order to eliminate tissue antigenicity after implantation onto nude athymic mice. Harvested porcine skin was meshed and put through epidermal separation, decellular, lyophilization and antiseptic processes. After rehydration, the processed skin is grafted to the skin defect made on the back of a nude mouse. Then thin autologous skin is overlaid and secured with suture(Experimental group). The control group is recovered by autologous skin graft only. Evaluation for wound contraction area(1st, 2nd, 4th, 8th week) and histological analysis(2nd, 4th, 8th week)were performed.The porcine dermis became completely incorporated into the wound without evidence of rejection. The reduction in wound contraction in the experimental group was significant in comparison with that of the control group. In conclusions, the decellularization and lyophilization process was found to have destroyed cells regulating immune re sponse while preserving the structural organization of extracellular matrices. We are trying to focus on establishment and management of the skin bank for the preparation, storage of the porcine xenograft in the future.

A Study on the Preparation of Acellular Lyophilized Porcine Dermal Matrix and Xenograft

Biological skin substitutes can be used in human skin defects. However, with the exception of autograft, they are not permanent due to incompatible tissue antigenicity. In our study, we planned to determine the fate of porcine skin, preliminarily processed, in order to eliminate tissue antigenicity after implantation onto nude athymic mice. Harvested porcine skin was meshed and put through epidermal separation, decellular, lyophilization and antiseptic processes. After rehydration, the processed skin is grafted to the skin defect made on the back of a nude mouse. Then thin autologous skin is overlaid and secured with suture(Experimental group). The control group is recovered by autologous skin graft only. Evaluation for wound contraction area(1st, 2nd, 4th, 8th week) and histological analysis(2nd, 4th, 8th week)were performed.The porcine dermis became completely incorporated into the wound without evidence of rejection. The reduction in wound contraction in the experimental group was significant in comparison with that of the control group. In conclusions, the decellularization and lyophilization process was found to have destroyed cells regulating immune re sponse while preserving the structural organization of extracellular matrices. We are trying to focus on establishment and management of the skin bank for the preparation, storage of the porcine xenograft in the future.

The Anatomical Study of Internal Mammary Vessels Using Sonography and 2-Dimensional Computed Tomography

The aim of the present study is to get anatomical information of internal mammary vessels(IMV), which is usually used for recipient vessels in the breast reconstruction. The past anatomical studies of these vessels had been done primarily with cadavers in the Occidentals. Because there is no report for the anatomical study of these vessels and also the cadaver study is pretty limited in this country, we studied the anatomical pattern of IMV in Koreans by using two dimensional reconstructive computed tomography (2DCT) and Doppler ultrasound (US). The branching patterns, level of bifurcation, size of IMV and the distance from the sternal edge to the IMV were measured. This study was performed in 30 breast cancer patients from May 1999 to May 2000. One artery and one vein on both sides(type I) was the most common type that were observed in 22 of 30 patients(73%). The diameter of the internal mammary artery(average 2.1 mm) was constant but that of the internal mammary vein had a wide variation(ranged 0.8 to 4.8 mm). The distance from sternum to IMV gradually got narrower as it went caudally. In three cases the size of vein was not enough for anastomosis, but the bifurcation point may be used for anastomosis due to the wider point. Compared with the result of Caucasian, the incidence of bifurcation of internal mammary vein was lower and the level of bifurcation was higher. The result showed that the most successful level of anastomosis was the 3rd intercostal space in Korean due to shorter chest. The combination of 2DCT and US provided us with useful preoperative information as well as general anatomical data in Korean.

The Anatomical Study of Internal Mammary Vessels Using Sonography and 2-Dimensional Computed Tomography

The aim of the present study is to get anatomical information of internal mammary vessels(IMV), which is usually used for recipient vessels in the breast reconstruction. The past anatomical studies of these vessels had been done primarily with cadavers in the Occidentals. Because there is no report for the anatomical study of these vessels and also the cadaver study is pretty limited in this country, we studied the anatomical pattern of IMV in Koreans by using two dimensional reconstructive computed tomography (2DCT) and Doppler ultrasound (US). The branching patterns, level of bifurcation, size of IMV and the distance from the sternal edge to the IMV were measured. This study was performed in 30 breast cancer patients from May 1999 to May 2000. One artery and one vein on both sides(type I) was the most common type that were observed in 22 of 30 patients(73%). The diameter of the internal mammary artery(average 2.1 mm) was constant but that of the internal mammary vein had a wide variation(ranged 0.8 to 4.8 mm). The distance from sternum to IMV gradually got narrower as it went caudally. In three cases the size of vein was not enough for anastomosis, but the bifurcation point may be used for anastomosis due to the wider point. Compared with the result of Caucasian, the incidence of bifurcation of internal mammary vein was lower and the level of bifurcation was higher. The result showed that the most successful level of anastomosis was the 3rd intercostal space in Korean due to shorter chest. The combination of 2DCT and US provided us with useful preoperative information as well as general anatomical data in Korean.

Epidemiologic Study in 428 Cases of Cleft Lip and Palate in Koreans: A Prospective Study

This prospective study was carried out to provide an clinical data on congenital cleft lip and/or palate. With the data obtained from formal cleft lip and cleft palate sheets taken at the time of admission of 428 patients who had been admitted to Chungnam National University Hospital (December, 1983-October, 1996) and Asan Medical Center(November, 1996-July, 2000), the epidemiological data and influencing factors were studied. The results were as follows, 1.A distribution according to types of cleft were cleft lip alone in 23%, cleft lip with cleft palate in 37% and isolated cleft palate in 40%. 2.For types in cleft lip, the ratio of left side: right side: bilateral was 3.4 : 1.8 : 1.0 3.The ratio of complete type: incomplete type was 0.8 : 1.0 4.The rate of positive prenatal medication history during the first trimester of pregnancy was 39.9% of total patients 5.The percentage of positive family history was 9.3% of total patients 6.The rate of association with other congenital anomalies was 19.7% 7.The social class was not an definitive contributing factor according to monthly income comparison. The authors believe that this prospective study produced more accurate and reliable data in the assessment of the rates in positive family history and congenital anomalies than restropective ones.