Transfacial Surgical Approaches to Secure Wide Exposure of the Skull Base

BACKGROUND: Treatment of skull base tumors is challenging due to limited access and presence of important neurovascular structures nearby. The success of a complete tumor resection depends on the extent of tumor exposure and secure field of view. While these tumors are often removed by transcranial endoscopic access, transfacial approach is sometimes required depending on the location and size of the tumor. This study describes various transfacial approaches in patients undergoing skull base tumor resection. METHODS: From March to November 2013, 15 patients underwent skull base tumor resection via transfacial accesses at a tertiary institution. Data were reviewed for patient demographics, type of access used, completeness of tumor resection, surgical outcome, and postoperative complications. RESULTS: Two clivus tumor patients underwent transmaxillary approach; three tuberculum- sellae and suprasellar-hypothalamus tumor patients underwent transbasal approach; three clinoid and retrobulbar intraconal orbital tumor patients underwent orbitozygomatic approach; and seven petroclival-area, pons, cavernous sinus, and lateral-sphenoid-wing tumor patients underwent zygomatic approach. In all cases, the upper and lower margins of the tumor were visible. Complete tumor removal consisted of 10 cases, and partial tumor removal in 5. There were no immediate major complications observed for the transfacial portion of the operations. The overall cosmetic results were satisfactory. CONCLUSION: Plastic surgeons can use various transfacial approaches according to the location and size of skull base tumors to secure a sufficient field of view for neurosurgeons.

Preoperative Identification of a Perforator Using Computed Tomography Angiography and Metal Clip Marking in Perforator Flap Reconstruction

In perforator flap reconstruction, vascular mapping using preoperative computed tomography (CT) angiography is widely used to confirm the existence and location of an appropriate perforator. This study proposes a rapid, accurate, and convenient method for marking the perforator location on the skin surface. For 12 patients who underwent perforator flap reconstruction between November 2011 and November 2013, metal clips were fixed on the skin surface at the anticipated perforator locations, which were decided using a handheld Doppler. CT angiography was used to compare the location between the metal clip and the actual perforator. The metal clip was moved and repositioned, if needed, on the basis of the CT images. The locations of the appropriate perforator and the metal clip, which were observed during the surgery, were then compared. In CT angiography, the mean distance between the metal clip and the perforator was 3+/-3.9 mm, and the mean distance that was measured during surgery was 0.8+/-0.8 mm. In conclusion, we report a simple, rapid, and precise technique to indicate the accurate location of the appropriate perforator on the skin surface.

A Rabbit Model of Fat Graft Recipient Site Preconditioning Using External Negative Pressure

BACKGROUND: Fat is widely used in soft tissue augmentation. Nevertheless, it has an unpredictably high resorption rate. Clinically, external expansion with negative pressure is used to increase fat graft survival. In this study, fat graft recipient sites were preconditioned by external application of negative pressure in order to test for improvements in vascularity and fat graft survival. METHODS: Negative pressure was applied randomly to either the left or right dorsal ear of 20 New Zealand male white rabbits at a pressure of -125 mm Hg. The negative pressure was removed one week after the skin perfusion was measured. The skin flap at each ear was elevated, and 1 g of fat was grafted above the dorsal perichondrium. After one week, the fat weight, microvessel density, mature vessel density of the skin and fat, and amount of glycerol released were measured. Three months after the grafting, the same measurements were performed, with the exception of glycerol release. RESULTS: The fat survival rate of the experimental group (75.4%+/-3.9%) was higher than that of the control group (53.1%+/-4.3%) (P<0.001). Skin perfusion was higher in the experimental group. The glycerol release in the experimental group was significantly higher than in the control. The microvessel density of the skin and fat was significantly higher in the experimental group. Three months after the grafting, the skin and fat mature vessel density was significantly higher in the experimental groups. CONCLUSIONS: Negative pressure prior to fat grafting increased the vascularity of the recipient site, and, accordingly, enhanced fat graft survival.

The Effect of Platelet-Rich Plasma on Survival of the Composite Graft and the Proper Time of Injection in a Rabbit Ear Composite Graft Model

BACKGROUND: Administration of growth factors has been associated with increased viability of composite grafts greater than 1-cm in diameter. Platelet-rich plasma (PRP) contains many of the growth factors studied. In this study, we evaluate the effect of PRP injection on composite graft viability and the proper time for injection. METHODS: A total of 24 New Zealand White rabbits were divided into four groups. Autologous PRP was injected into the recipient sites three days before grafting in group 1, on the day of grafting in group 2, and three days after grafting in group 3. Group 4 served as control without PRP administration. Auricular composite grafts of 3-cm diameter were harvested and grafted back into place after being rotated 180 degrees. Median graft viability and microvessel density were evaluated at day 21 of graft via macroscopic photographs and immunofluorescent staining, respectively. RESULTS: The median graft survival rate was 97.8% in group 1, 69.2% in group 2, 55.7% in group 3, and 40.8% in the control group. The median vessel counts were 34 (per x200 HPF) in group 1, 24.5 in group 2, 19.5 in group 3, and 10.5 in the control group. CONCLUSIONS: This study demonstrates that PRP administration is associated with increased composite graft viability. All experimental groups showed a significantly higher survival rate and microvessel density, compared with the control group. Pre-administration of PRP was followed by the highest graft survival rate and revascularization. PRP treatments are minimally invasive, fast, easily applicable, and inexpensive, and offer a potential clinical pathway to larger composite grafts.

Regional Analysis of Soft Tissue Thickness on Korean Buttocks and Application to Fasciocutaneous Flap Design

BACKGROUND: Various shapes and designs of the gluteal artery perforator flap have been used for treating sacral pressure sores and reconstructing breasts. To establish the ideal fasciocutaneous flap design for use in the gluteal area, the soft tissue thickness distribution was measured. METHODS: Twenty-one buttocks of adult Korean cadavers were analyzed through rectangular subfascial dissection. Each buttock was divided horizontally into 10 sections and vertically into 10 sections, and then, the thickness at the corners of the sections was measured. For the sake of comparison and statistical verification with living bodies, computed tomography (CT) images of 120 buttocks of patients were randomly selected. Five horizontal sections and 4 vertical sections were made, and the thickness at each corner was recorded. RESULTS: According to the dissection and the CT images, the area with the thinnest soft tissues in the buttock was around the posterior superior iliac spine, close to the sacral area. The thickest area was the superolateral area of the buttock, which was 3.24 times and 2.15 times thicker than the thinnest area in the studies on cadaver anatomy and the CT images, respectively. CONCLUSIONS: The thickness of the soft tissues in the buttocks differed by area. The superolateral area had the thickest soft tissues, and the superomedial area had the thinnest. This study includes information on the distribution of the thickness of the gluteal soft tissues of Koreans. The outcome of this study may contribute to the design of effective local flaps for pressure sore reconstruction and free flaps for breast reconstruction.

Craniometaphyseal Dysplasia

No abstract available.

A New Method for Creating a Definite Philtrum by the Flipping of an Orbicularis Oris Muscle Flap in a Patient with an Indistinct Philtrum

The philtrum plays a key role in the appearance of the upper lip and nostril sill. Therefore, construction of the philtrum is crucial for attaining a natural appearance of the upper lip. We used a flipping myoplasty of the orbicularis oris muscle on a patient with a flat philtrum in order to effectively reconstruct the philtral dimple and column. A 35-year-old female presented to our department with the complaint of a flat upper lip. A superficial layer of the orbicularis oris muscle on the median aspect of the upper lip was vertically incised and elevated to a thickness of 2 mm. Both sides of the elevated muscle flap were then folded to the lateral sides so that the border could be sutured onto the outer portion of the orbicularis oris muscle. The patient was observed for one year postoperatively. Her philtrum deepened by 1.25 mm, with the central angle of her Cupid's bow improving from a preoperative measurement of 146degrees to 128degrees postoperatively. In a patient with an indistinct philtrum, a flipping orbicularis oris myoplasty was performed to attain a definite philtral column and a philtral dimple. Natural upper lip movement was maintained, and an aesthetically and functionally satisfactory reconstruction was achieved.

Application of Digital Infrared Thermographic Imaging (DITI) in the Monitoring of Change of Skin Temperature about Vascular Supply of Lower Abdominal Axial Flap in the Rabbit / 고신대학교의과대학학술지

OBJECTIVES: Monitoring viability of flap is important. The flap survival depends on the vascularity of the flap, on which the skin temperature depends. The authors applied digital infrared thermographic imaging (DITI) for monitoring the vascular supply of the flap and for the prediction of the prognosis of the flap survival. METHODS: Eight male New Zealand white rabbits with average weight of 3kg were used. A 10 x 10 cm unipedicled fasciocutaneous island flap was elevated based on the left superficial inferior epigastric vessel. The surface temperatures on designed flap were checked with DITI for 24 hours after the operation. On 14th day after the operation, the surviving area was measured and compared with DITI image which was taken on 24 hours after the operation using digital analysis software ImageJ. Statistical analysis was evaluated by paired T-test. RESULTS: On DITI image 24 hours after the flap elevation, distal portion of the flap showed remarkable color change. The average percentage and the standard deviation of the survival area of the flap which is predicted by DITI and the average percentage and the standard deviation of the survival area of the flap which was actually measured 2 weeks after flap elevation were 55.3 (16.6), 56.2 (18.0), respectively. This shows no significant difference between the two. CONCLUSIONS: This study shows that DITI system could be used in evaluation of flap vascularity with ease, quickness and safety for patient and flap. Thus, it could be used clinically for the prediction of flap survival.

The Usefulness of Nasal Packing with Vaseline Gauze and Airway Silicone Splint after Closed Reduction of Nasal Bone Fracture

BACKGROUND: Packing after closed reduction of a nasal bone fracture causes inconvenient nasal obstruction in patients. We packed the superior meatus with Vaseline gauze to support the nasal bone, and packed the middle nasal meatus with a Doyle Combo Splint consisting of an airway tube, a silastic sheet, and an expandable sponge to reduce the inconvenience. In addition, we aimed to objectively identify whether this method not only enables nasal respiration but also sufficiently supports the reduced nasal bone. METHODS: Nasal ventilation was measured via spirometry 1 day before surgery and compared to 1 day after surgery. To compare support of the reduced nasal bone by the 2 methods, 2 plastic surgeons assessed the displacementon X-rays taken after the surgery and after removing the packing. The extent of nasal obstruction, dry mouth, sleep disturbance, headache, and swallowing difficulty were compared with visual analog scales (VAS) on a pre-discharge survey. RESULTS: In the experimental group, the nasal respiration volume 1 day after surgery remained at 71.3%+/-6.84% on average compared to 1 day prior to surgery. Support of the reduced bone in the experimental group (2.80+/-0.4) was not significantly different from the control group (2.88+/-0.33). The VAS scores for all survey items were lower in the experimental group than in the control group, where a lower score indicated a lower level of inconvenience. CONCLUSIONS: The nasal cavity packing described here maintained objective measures of nasal respiration and supported the reduced bone similar to conventional methods. Maintaining nasal respiration reduced the inconvenience to patients, which demonstrates that this packing method is useful.

A Survey of Patient Satisfaction after Treating Zygomatic Complex Fractures Using a Coronal Approach

PURPOSE: It is difficult to objectively evaluate the outcomes of plastic surgical procedures. The combination of aesthetic and medical factors makes outcome quantification difficult. In this study, fracture reduction accuracy was objectively evaluated in patients with zygomatic complex fractures. Patients satisfaction with the accuracy was also examined. In addition, the patients' overall satisfaction and discomfort due to complications were analyzed. METHODS: Eighty-five patients who had surgeries via bicoronal incision for zygomatic complex fracture from March 2006 to December 2009 were included in this study. Two plastic surgeons evaluated the accuracy of the fracture reduction with postoperative computed tomography. A survey questionnaire was administered to evaluate the patients' overall satisfaction and the impact of symptoms associated with the procedure on the patients' daily lives. RESULTS: The overall patient satisfaction rate was 82.1 +/- 10.9% (range, 45~100%). The level of deformation was 6.7 +/- 10.9%, the levels of discomfort in daily life due to pain, paresthesia, scar, and facial palsy were 8.5 +/- 13.2%, 5.8 +/- 8.9%, 4.4 +/- 9.9%, and 1.9 +/- 9.2%, respectively. According to the visual analogue scale, paresthesia was found to be the most frequent symptom (43.5%), and pain was the most troublesome symptom. CONCLUSION: The use of bicoronal incision for treating zygomatic complex fractures can cause various complications due to wide incision and dissection. However, this technique can provide optimized reduction and rigid fixation. Most of these postoperative complications can cause significant discomfort in the patient. It is thought that the use of correct surgical technique and the accurate knowledge of craniofacial anatomy will result in a reduction of complications and significantly increase patient satisfaction.

Hyoid Bone Fracture Associated with Hypoglossal Nerve Palsy: A Case Report

PURPOSE: Hyoid bone is a U-shaped bone in the anterior of the neck. Hyoid bone fractures are exceedingly rare and represent only 0.002% of all fractures because of its protective position relative to the mandible and its suspension by elastic musculature. We report a patient who presented hyoid bone fracture associated with hypoglossal nerve palsy. We also discuss the possible complication and treatment. METHODS: A 69-year-old man was transferred from another institution because of persistent purulent discharge from the left chin. He had a history of trauma in which a knuckle crane grabbed his face and neck in the construction site. A CT scan at the time of the accident demonstrated a comminuted fracture of the right side of the mandible and hyoid bone fracture at the junction between body and right greater cornua. The displaced fracture of hyoid bone and fullness in the pre-epiglottic space were noted, probably indicating some edema. The patient was transferred into ICU after treatment of emergency tracheostomy because the patient showed respiratory distress rapidly. When the patient was hospitalized in our emergency room, he complained of dysphagia and pain when swallowing. On examination of oral cavity, the presence of muscle wasting with fasciculation of the tongue was noted and the tongue deviates to the left side on protruding from the mouth. Pharyngolarygoscopy was performed to make sure that there was no evidence of progressive swelling and pharyngeal laceration. RESULTS: The patient underwent surgical removal of dead and infected tissue from the wound and reconstruction of mandibular bony defect by iliac bone grafting. Hyoid bone fracture was managed conservatively with oral analgesics, soft diet and restricted movement. Hypoglossal nerve palsy was resolved within 7 weeks after trauma without complications. CONCLUSION: Closed hyoid bone fracture is usually uncomplicated and thus it can be treated conservatively. Surgical intervention for hyoid bone fracture is recommended for patient with airway compromise, pharyngeal perforation and painful symptoms which show no response to conservative care. Furthermore, since respiratory distress syndrome may develop quickly, close observation is required. Besides, hypoglossal nerve palsy is a rarely recognized complication of hyoid bone fracture.