Paradigm Shift in Orthognathic Surgery: Surgery First Orthognathic Approach and Aesthetic Two-jaw Surgery

Orthognathic surgery became more popular because people are more interested in facial profile changes and are more receptive to surgery. As people seek beauty as well as function in maxillofacial surgery, patient's aesthetic demand becomes higher. Considering these big changes, one of the major reasons is surgery-first orthognathic approach(SFOA), which removes pre-surgical orthodontic treatment. Pre-surgical orthodontic time has been a great barrier to patients in terms of time and social rehabilitation. By SFOA, patients can get surgery as soon as they make up their mind; Patients from abroad can get surgery and get back to their country; They can go back to their work more easily because their occlusion is more acceptable. Surgery first orthognathic approach is still developing in practice and principle. However, as it is based on patient's need, it will play a greater part in the field of orthognathic surgery. Surgery first orthognathic approach together with aesthetic two jaw surgery are expected to change the paradigm in orthognathic surgery.

Experience of Benign Multiple Symmetrical Lipomatosis

Benign symmetrical lipomatosis, also known as Madelung's disease, is a rare condition characterized by massive fatty deposits arranged symmetrically around the neck, shoulders, and arms. Patients usually complain of their cosmetic appearance, but treatment can be considered for decreased neck motion and/or aerodigestive problems. Surgical lipectomy and liposuction are treatment of choice, but recurrence is common. Because the distribution of the lesion tends to be wide and diffuse, single operation is not sufficient for improving contour and functional problems, especially in severely affected case. We experienced a progressed patient who suffered from limitation of neck motion, dyspnea including sleep apnea due to massive deposits on whole neck. We performed 2 staged operations for the purpose of removing as much lipomatous tissue as possible. After 2 staged excisions, patient's appearance and aerodigestive problems are much improved and recurrence is not observed.

Myoepithelioma of the Parotid Gland: A Case Report

PURPOSE: Myoepithelioma is a rare tumor that originates exclusively from myoepithelial cells of the salivary glands, breast and the prostate. Myoepithelioma accounts for less than 1% of all salivary gland tumors. The objective of our study is to present our experience of the infra- auricular mass which was finally diagnosed as a myoepithelioma. METHODS: A 54-year-old woman was presented with a firm, movable, slow-growing infra-auricular mass with 3 cm in diameter. MRI scans and fine needle biopsy was performed for preoperative diagnostic study. A superficial parotidectomy was preceded and removed tumor successfully. RESULTS: Histopathological study revealed a myoepithelioma of plasmacytoid type. Patient's postoperative course was uneventful without any complication and had no evidence of recurrence of tumor for 9 months follow- up period. CONCLUSION: Myoepithelioma in the parotid gland shows similar clinical courses and intraoperative finding to the pleomorphic adenoma and superficial parotidectomy was selective choice for treatment.

Malignant Transformation of Fibrous Dysplasia: A Case Report of Malignant Fibrous Histiocytoma of Facial Bone

PURPOSE: Malignant degeneration of fibrous dysplasia is an uncommon recognized complication of this disease. Especially, degeneration of fibrous dysplasia to malignant fibrous histiocytoma(MFH) in facial bone is rare and the publications had been limited. The purpose of this report is to share our experience. METHODS: A 46-year-old patient with facial fibrous dysplasia visited our clinic for recent facial tingling and swelling. Malignant degeneration of fibrous dysplasia was suspected. RESULTS: Total excision of the mass and adjacent facial bone was performed. Defect was immediately reconstructed with bone graft and bone cement. At a month follow up, metastasis was detected at ipsilateral parotid gland. Superficial parotidectomy and neck dissection was performed. The patient is currently taking chemotherapy. CONCLUSION: Because of the uncommon presentation of this entity, clinical course of treatment was dependent on other histological types of malignant degeneration. We report this case to share our experience.

Treatment of Beign Multiple Symmetrical Lipomatosis with Liposuction

PURPOSE: Benign symmetrical lipomatosis(Madelung's disease) is a disease of uncertain etiology that manifests as massive lipomatous deposits in specific area of the body. It is usually located on the neck, shoulder, proximal regions of the extremities and the abdomen. Madelung's disease is found many in middle-aged, Mediterranean man. Imaging using either computed tomography or magnetic resonance imaging is often recommended. Dietary restriction provides no relief of disease. Abstinence with alcohol may delay further progression but does not regression tumor mass. The objective of this study is to prove effectiveness of liposuction for treatment of benign lipomatosis. METHODS: We conducted liposuction as a treatment for benign lipomatosis. After general anesthesia, We conducted power assisted liposuction and amount of suctioned volume was about 2500 cc. After surgery, we did compressive dressing and then followed by pressure garment. RESULTS: Six months after surgery, patient was examined for follow up at outpatient department. Recurred lipoma was not observated. Patient was satisfied with result. CONCLUSION: The only effective therapy for Madelung's disease is surgical removal but recurrence could be occurring. Also multiple surgical scars will be visible. We report a patient with multiple large lipomatosis successfully treated with liposuction.

Anterolateral Thigh Flap: Our Experiences in Head and Neck Reconstruction

The anterolateral thigh(ALT) flap has been known as a very versatile and reliable flap. We report our experiences with the anterolateral thigh flap for the postoncologic reconstruction of head and neck region from April 2002 to March 2005. A total of 38 subjects (M: F=30:8, mean age:53.8 years) were taken. We reviewed primary site of tumors, size and thickness of flaps, location and number of perforators, course of perforators, length of pedicle, and postoperative complications. The mean flap size, thickness and pedicle length were 11.8 x 6.4 cm, 1.1 cm and 12.2 cm, respectively. We classified the pedicles based on the authors' criteria. Type I, pedicle with short intramuscular course, was with 29 cases(72.5%), type II, pedicle with long intramuscular course, with 6 cases(15%), type III, pedicle with septocutaneous course, with 3 cases(7.5%), and type IV, clinically unavailable pedicle, with 2 cases (5%). We experienced 1 case of partial and 1 case of total flap loss. There was 1 case of donor site wound dehiscence, which was treated by debridement and closure. According to the defect, efficient adjustment of the size and thickness of flap was possible, and favorable functional and aesthetic results have been obtained in our study. Our experience confirmed the versatility and usefulness of the anterolateral thigh flap for various reconstructions in head and neck region.

Cranioplasty in Frontometaphyseal Dysplasia

Frontometaphyseal dysplasia is a rare genetic syndrome first described by Gorlin and Cohen in 1969. This disease affects the skeletal system and connective tissue, and could be characterized by hyperostosis of the skull, prominence of supraorbital ridges, additional skeletal and extraskeletal abnormalities. It is believed that the condition is an X-linked dominant trait with severe manifextations in males and extreme variability in females. We described a case of 15-year-old boy manifested a pronounced supraorbital ridge associated with exorbitism. He also had bilateral progressive hearing deficit, thoracic spine scoliosis, chest wall deformity, bilateral maxillary sinusitis and both 5th finger arachnodactyly. The patient underwent a fronto-temporo-orbital cranioplasty through a coronal incision. The frontal bone including supraorbital region, orbital lateral rim and temporal bone were extensively contoured with burr. And then, burring of the medial aspect of lateral orbital wall was made to increase both orbital volume for correction of exorbitism. Postoperative results show well corrected prominent supraorbital ridge, hyperostosis of frontotemporal bone and exorbitism. The patient was satisfied with the improved appearance. No recurrence occurred during the 6 months of follow-up period. We report this case as it shows esthetically good result without any complication.

Atypical Fibroxanthoma of Scalp Involving Occipital Bone

Atypical fibroxanthoma is a pleomorphic spindle cell neoplasm characterized by a variable combination of cells with fibroblastic and histiocytic features. It occurs mostly on sun-exposed area of the head and neck of elderly person and is a clinically benign reactive lesion despite apparent malignant histologic features. However, because of its potential for metastasis, it is widely regarded as a low-grade sarcoma. We report a 30-year-old woman with atypical fibroxanthoma developed on the left occipital area. The lesion was 1.5 x 2 cm sized papule. There was no skin lesion such as ulcer or eschar. However, mass was involving occipital bone and composed of dense, pleomorphic spindle cells and several bizarre multinucleated giant cells. After wide excision of the scalp and occipital bone, the defect was covered with bone cement, bipedicled local flap and the donor site was covered with STSG. The wound healed completely without complication. It remained free of recurrence for a period of about 1 year follow up.

Noble Tip for Reduction of V-limb of C-V Flap for Nipple Reconstruction

A nipple can be reconstructed either by nipple sharing or local flap. But donor site scar is inevitable when nipple is reconstructed with local flap method. The scar which remains inside the nipple areolar complex can be hidden by medical tattooing, but elongated scar, which cross over the areolar border leads to poor esthetic result. So as to solve this problem, we used purse string suture method. We reconstructed nipple with C-V flap for 9 patients who previously reconstructed breast with extended latissimus dorsi flap. Purse string suture with 3-0 nylon was used for donor site closure. We minimize 10.7% of the scar length with this method. Enhancement of nipple projection due to the flattening of V limb was attained in addition. We expect the reduction of V-limb of C-V flap and amount of absorption of the reconstructed nipple with purse string suture method.

A Case of One Stage Correction of Pterygium Colli and Ptosis with Epicnathal Fold in Pediatric Ullrich-Noonan Syndrome

Ullrich-Noonan syndrome was first recognized as a unique entity in 1963 when Noonan and Ehmke described a series of patients with unusual faces and multiple malformations. These patients proved to have phenotypes of Turner syndrome with normal karyotyes, which is important feature that distinguishes Noonan from Turner syndrome. Typical features are triangular shaped face, hypertelorism, down slanting eyes, ptosis, strabismus, amblyopia, refractive errors, low set ears with thickened helices, high nasal bridge and webbed neck. A 5-year old female was admitted to our center for a surgical intervention of the known webbed neck deformity, ipsilateral upper eyelid ptosis and bilateral epicanthal fold. She had normal karyotye(46, XX) without further abnormality on physical examination. We corrected the webbed neck deformity, ptosis and epicanthal fold simultaneously with satisfactory result.

Volume and Weight Changes of Autologous Costal Cartilage Grafts with and without Perichondrium in Human

Autologous cartilage grafts have become an integral part of aesthetic and reconstructive plastic surgery. However, little objective information is available about the actual quantitative resorption of cartilage in human. This study sought to objectively quantify and compare the resorption of costal cartilage in human. To compare the resorption characteristics of rib cartilage autografts, we harvested rib cartilage grafts from 37 microtia patients. All autografts were implanted subcutaneously on chest and then removed after 6 to 17 months. Graft mass and volume were compared before and after implantion. Rib cartilage grafts with perichondrium averaged 10.8+/-7.4% resorption by volume, On the other hand rib cartilage grafts without perichondrium 25.5+/-6.8%. There was no evidence of necrosis or inflammatory changes. The rib cartilage is the preferred source of autogenous cartilage for auricular reconstruction. Short-term resorption of rib cartilage without perichondrium appears to be higher than with perichondrium. The low resorption of cartilage with perichondrium may be due to in part to cartilage forming capacity of the perichondrium. It remains to be seen whether these differences in resorption persist in the long term.

Differentiation and Labeling of Mouse Preadipocytes for Allogenic Transplantation Study

Due to its safety and softness, autologous fat transplantation has been commonly performed for soft tissue correction. However, the injected fat is absorbed resulting in the reduction of volume of the graft by 40- 60% within a few months. Thus, there was an attempt to use adipocytes differentiated from preadipocytes in vitro for transplantation. Differentiated adipocytes were biocompatible and matured with gradual volume increase at transplantation site in clinical study(unpublished data). In addition, they did not induce immune rejection in response to nonself lymphocytes in a mixed lymphocyte reaction(MLR)(unpublished data). The purpose of this study is to differentiate mouse preadipocytes following labeling into adipocytes to establish an animal model for allogenic transplantation. Preadipocytes isolated from inguinal and retroperitoneal fat pad of C57BL/6 mice were proliferated with growth medium by passage 3 and differentiated into adipocytes with different culture conditions after labeled with BrdU. At most suitable conditions, above 90% of preadipocytes were differentiated and BrdU labeling did not affect differentiation rate and function of differentiated adipocytes. These results demonstrate that BrdU-labeled adipocytes resulting from this in vitro differentiation protocol are useful for allogenic transplantation study.

Treatment of External Ear Hemangioma Using Surgical Reduction and Ligation

Hemangioma is one of the most common tumor in the region of the head and neck. There are many methods were tried for the treatment of hemangioma, however no single satisfactory method was introduced. The hemangioma which arised from the external ear are rare. Authors report three cases of the hemangioma which involved the external ear. The hemangioma was aesthetically treated with surgical reduction and ligation

Breast Reconstruction with the Extended Latissimus Dorsi Musculocutancous Flap

Breast cancer patients who underwent mastectomy often experience stress, depression from body changes and loss of femininity. Choice of surgical method is important, because Korean women tend to be sensitive to the shape of the reconstructed breast, donor site scars and the changes in body contour. The latissimus dorsi musculocutaneous flap was one of the first methods of breast reconstruction. However, due to lack of volume, the latissimus dorsi flap has become a secondary choice for breast reconstruction. The authors evaluated the clinical cases who underwent breast reconstruction with the extended latissimus dorsi flaps at the authors' institution from March 2002 to February 2005. During the period, 87 cases of breast reconstruction with the extended latissimus dorsi flap were performed in 86 patients. All flaps survived completely. There occurred no partial necrosis and fat necrosis. The extended latissimus dorsi flap alone without implant could provide good to excellent autologous breast reconstruction for small to moderate sized breasts. Free TRAM flap is currently considered the "Gold standard" in autogenous breast reconstruction. But, the extended latissimus dorsi flap without implant could provide sufficient volume for breast reconstruction in selected cases and it is a reliable method for autologous breast reconstruction.

Bilateral Type III Postaxial Polydactyly: A Case Report

An unusual case is presented as bilateral, complete digital duplication of the hand in a 32-year-old man. Radiographic evaluation showed complete duplication of intact phalanges and metacarpal bones in both hands. Although polydactyly of the hand is reported to occur among approximately 1 in 1000 live births, most of these malformations are rudimentary skin tags. Complete postaxial polydactyly is uncommon; it occurs in approximately 0.014% of all live births. The main goal of the surgical treatment is to establish adequate function and appearance. This case reports the preoperative evaluation and management of bilateral postaxial type III duplication of the fingers.

Surgical Treatment of Choanal Stenosis Associated with Craniodiaphyseal Dysplasia

Craniodiaphyseal dysplasia is a rare genetic disorder of bone due to modelling errors of long bones and skull bones. Facial and cranial thickening and distortion are particularly striking in this form. The genetic understanding of this disorder is unsatisfactory. We present one case of Craniodiaphyseal dysplasia involving facial bone, skull that causes nasal obstruction. This 3-year old female who was diagnosed of craniodiaphyseal dysplasia presented abnormal facial figuring, which is excessively thickened cortical bone resulting in very large craniofacial bony structure. The patient sufferred from respiratory difficulty due to complete obstruction of choana. We performed surgical recanalization of choanal atresia by transpalatal approach and gained good postoperative result.

Breast Reconstruction Using Bipedicled free TRAM in Patients with Subumbilical Vertical Midline Scar

Breast reconstruction using TRAM flap after mastectomy has been widely adopted and regarded as a gold standard method. In patients with the abdominal midline scar, insufficient blood circulation to regions contralateral to the pedicle disables inclusion of them in the TRAM flap design. So modifications including Double- pedicled TRAM, Super-charged, Turbo-charged, Bipedicled free TRAM et al. have been attempted to resolve the problem of circulatory interruption by midline scar. The authors designed a new bipedicled free TRAM flap to avoid limitations like epigastric buldging, significant abdominal weakness and complexity of flap insetting. The two donor arteries(right and left deep inferior epigastric arteries) are anastomosed to the proximal and distal ends of divided internal mammary arteries using the reverse flow. Vein anastomoses were performed in the same manner through the divided venae comitantes. Two patients having infraumbilical midline scar underwent breast reconstruction using author`s new flap. Flaps survived without fat necrosis or partial flap loss in both patients and their results in aesthetic aspects were very satisfactory. Compared to previous method for breast reconstruction of patients having infraumbilical midline scar, author's new method is useful and effective in terms of the aesthetic and technical aspect.

Surgical Excision after Selective Embolization of Congenital Arteriovenous Malformation

Arteriovenous malformation(AVM) is an abnormal communication between an artery and a vein and often causes significant hemorrhage or cosmetic problems. Treatment of these vascular anomalies is hazardous and has high incidence of recurrence. A multidisciplinary team approach is required in the assessment and treatment of the lesion, and preoperative angiography with superselective embolization followed by resection is required. The authors performed nine cases of the wide resection of the congenital arteriovenous malformation(7 on the head and neck, 2 on the trunk) between April 1998 and January 2002. All patients underwent preoperative embolization with n-butyl 2-cyanoacrylate at 1 week before operation. Preoperative embolization resulted in significant devascularization of the AVM thus leading to minimal bleeding during operation. After resection, direct closure were performed in 6 cases, skin graft in 1 case, free transverse rectus abdominis musculocutaneous flap in 1 case, and tissue expansion using tissue expander in 1case. There was one complication related with embolization procedure in temple AVM patient. No recurrence has been recognized during the follow-up period, which ranges from 16 to 61 months. Preoperative embolization with n-butyl 2-cyanoacrylate and surgical resection of the AVM provided excellent long-term palliation in patients with congenital AVM.

Treatment of Hemangioma Using Nd:YAG Laser

Although Nd:YAG laser(1064nm) showed good reduction effects on treatment of cutaneous hemangioma, its use was limited because of non-selective laser absorption and complications such as scar formation. So, we applied different modalities of Nd:YAG laser for more effective and safe treatment. We applied Nd:YAG laser to 9 patients with hemangioma on upper eyelid, cheek, back, arm, and parotid area from February, 1999 to February, 2002. The age at treatment ranged from 4 months to 4 years. Nd:YAG laser was irradiated both inside of the hemangioma by using a bare fiber through a 16G Tefflon cannula and outside of it by cooling the skin with a ice-cube. Nd:YAG laser was irradiated directly into the lesion through the bare fiber and safely to the skin through the ice cube. The mean number of treatment was 1.8, and the time interval between the next treatment was 4.5 months. The mean follow-up period was 13.5 months. Six patients showed almost full regression. Two patients had surgical excision after laser treatment, and one showed slow regression to be in the clinical observation.

Treatment of Mandibular Prognathism with Bilateral Sagittal Split Ramus Osteotomy and Paranasal Augmentation: Mandible-to- Paranasal Bone Transfer without Additional Bone Graft Donor-Site

The patients with mandibular prognathism frequently have a retrusion of the lower nasal base and around the piriform aperture. In such cases, paranasal depression or flattening gives a person a gloomy, tired, depressive and old appearance by accentuating the nasolabial folds. In this case, mandibular set back is not enough to achieve the maximum aesthetic results and facial harmony. Although severe retrusion of maxilla needs large graft for paranasal augmentation or Lefort osteotomies, mild retrusion around the piriform aperture can be restored by simple autogenous onlay bone graft. In order to correct the mild paranasal retrusion combined with mandibular prognathism, we performed sagittal split osteotomy of ramus and retropositioned the distal segment of mandible for mandibular set back. Thereafter, we harvested autogenous bone from the distal portion of a mandibular proximal segment. The harvested bone was about 1 X 2.5cm sized and sculptured in a semilunar shape to fit the paranasal region. Through two separate 1-cm upper buccal incision, the bone grafts were placed around the piriform aperture for contour restoration and fixed with screw. Our operative technique is simple and easy, moreover has no need for another donor site for paranasal augmentation. Using this method, we treated paranasal depression as well as mandibular prognathism at the same time and so, improved facial profile and contour in 5 cases. At the time of follow-up at 1 year, there has been no infection, extrusion or relapse with this technique and patients were satisfied with their aesthetic results.