A New Method of Umbilical Transposition

BACKGROUND: Creating a natural-looking umbilicus during closure of the donor-site in abdominally based free flap breast reconstruction is a factor of satisfaction for both the patient and surgeon. We present a simple method of umbilical transposition that results in an aesthetic, natural-looking umbilicus. METHODS: From March 2011 to November 2014, fifty three consecutive female patients received abdominal flap breast reconstruction. Twenty patients (from March 2011 to February 2013) underwent umbilical transposition through a cross like incision in the abdominal flap, with fascial fixation sutures but no dermal flaps. Thirty three patients (March 2013 to November 2014) received umbilical transposition in the following method. An oval-shaped incision is made at the location of the new umbilicus on the abdominal flap. This oval is deepithelialized, and full-thickness incisions are made at the 2, 6, and 10 o'clock directions to create three triangular dermal flaps. These are pulled down to the abdominal fascia using sutures that pass through the umbilical stalk and the abdominal fascia at the 3, 9, and 12 o'clock directions. This results in an umbilical stalk lined with dermal flaps, creates a natural periumbilical concavity, and anchors the abdominal flap inward to minimize tension. The cranial flap enhances superior hooding. RESULTS: Patient and surgeon satisfaction, surveyed 2 months after surgery with a satisfaction scoring system, were higher in the dermal flap group. CONCLUSIONS: The technique using three dermal flaps in an oval skin incision is simple, relatively easy to learn, and results in an aesthetic, natural-looking umbilicus.

Warthin's Tumor of the Parotid Enlarged by a Facelift Suture

No abstract available.

Extravasation of a Percutaneous Femoral Hepatic Infusion Device

No abstract available.

Dermoid Cyst Excision under Muller Muscle in a Patient with Blepharoptosis

No abstract available.

Upper Arm Contouring with Brachioplasty after Massive Weight Loss

BACKGROUND: As the obese population increases in Korea, the number of patients who are trying to lose weight has been increasing steadily. In these patients, skin laxity and deformation of the body contour occurs, which could possibly be corrected by various body contouring surgeries. Here, we introduce the brachioplasty method and our experience of various body contouring surgeries performed in our center. METHODS: From November 2009 to August 2011, five cases of brachioplasty were performed. When the patient presented with sagging of the lateral inframammary crease and bat wing deformity in the axilla, extended brachioplasty was performed; in this case, the deformation of the axilla and lateral chest was corrected at the same time. A traditional brachioplasty was performed when contouring was needed only for skin laxity in the upper arm. RESULTS: Complications, such as hematomas or nerve injuries, were not evident. Some patients experienced partial wound dehiscence due to tension or hypertrophic scars found during the follow-up. In general, all of the patients were satisfied with the improvement in their upper arm contour. CONCLUSIONS: Given the demands for body contouring surgery, the number of brachioplasty surgical procedures is expected to increase significantly, with abdominoplasty comprising a large portion of these surgeries. For the brachioplasty procedure, preparation and preoperative consultation regarding design of the surgery by experienced surgeons was important to prevent complications such as nerve damage or hematoma formation.

Clinical Experience of Stewart-Treves Syndrome in the Lower Leg

No abstract available.

Use of a Silicone Gel Sheet Vaginal Mold in McIndoe Vaginoplasty

No abstract available.

Desmoid Tumor of the Rectus Abdominis Muscle in a Postpartum Patient

No abstract available.

Two Cases of Lower Body Contouring with a Spiral and Vertical Medial Thigh Lift

Massive weight loss results in skin excess, leading to an unsatisfying body contour. Various thigh lift procedures can correct flabby skin in the lower leg. We present a lower body contouring technique with a report on two patients. The procedure is determined by the body contour of the patient. As the skin excess in the thigh area tended to appear mostly on the medial side, a vertical medial thigh lift was considered. Moreover, for patients with a pear/guitar-shaped body contour, we added the spiral thigh lift for skin excess in the buttocks and the lateral thigh area. The extent of tissue to excise was determined by pinching the patient in a standing position. The inferior skin flap was fixed to non-movable tissue, which was helpful for lifting the tissue and preventing the widening of the scar. After the operation, a drain was kept for 3 to 4 days. A compressive garment was used after removing the drain. There were no complications. The patients were discharged 6 to 8 days after the operation. In conclusion, skin excess, especially in the lower body, can be corrected by a thigh lift combining several procedures, varying from person to person.

Desmoplastic Fibroblastoma of the Finger Tip in an Adult

No abstract available.

Effective Reduction of the Frontal Process of the Maxillary Fracture Segment Using Intermaxillary Fixation Screw

PURPOSE: It is relatively unusual that infraorbital rim fracture is accompanied by nasal bone fracture. In order to correct effectively, subciliary approach and intranasal manipulation are applied simultaneously. But if reduction is not successful, intranasal manipulation may become aggressive and this often causes complications. We introduce a method using intermaxillary fixation screws for decreasing such complications and effective reduction of fracture. METHODS: Total seven patients with fracture of frontal process of maxilla were treated with this method. The fracture site was exposed through the subciliary approach, and one or two screws were inserted into the displaced fracture fragment. During the traction of the screws using the wire, the fracture fragment was pushed upward from the intranasal side using an elevator supplementarily and fixed with a plate and the screws. RESULTS: In all patients, the fracture fragment was reduced successfully and no complication occurred during one year's postoperative follow-up. CONCLUSION: When reduction cannot be attained through a bone hook or an elevator alone, reduction of fracture fragment can be done easily using intermaxillary fixation screws. This method is less likely to cause a mucosal injury because intranasal manipulation is not aggressive. Furthermore, as the screw can be inserted and removed easily, this method is considered effective not only for fracture of frontal process of maxilla but also for fractures in other regions.

Systemic Pemphigus Vulgaris: A Case Report

PURPOSE: Pemphigus vulgaris, a rare autoimmune blistering disease of the skin and mucous membranes remains a challenging disease to treat. Management is focused on immunotherapy against autoimmune antibodies that target keratinocyte cell adhesion molecules, and antibiotics preventing secondary infections. There is no established dressing protocol and skin is usually manipulated the least amount possible in order to minimize irritation. The authors suggest that early initiation of aggressive bathing and debridement of skin lesions, with nutritional support, is essential in accelerating resolution. METHODS: A 40 year-old male previously diagnosed with pemphigus vulgaris was admitted due to exacerbation of mucocutaneous lesions involving the epidermis and mucosa of the whole body. Steroids, immunosuppressants, intravenous immunoglobulin and antibiotics were administrated, but infection and de-epithelialization progressed, while his general condition deteriorated with a weight loss of over 20 kilograms. The plastic surgery department intervened with daily bathing, debridement of unhealthy debris and non-traumatizing coverage of growing epithelium. Total parenteral nutrition and mobilization with rehabilitation therapy was initiated as early as possible. RESULTS: After bathing, healthy epithelium gradually covered the patient's entire body, while his general condition improved with a corresponding weight gain of 14 kgs. CONCLUSION: Treatment of pemphigus vulgaris focuses on immunotherapy and infection control. However, an equal amount of attention should be laid on early intervention with daily dressings including bathing and irrigation, nutritional support, and exercise as this accelerates resolution of existing infections, promotes healthy epithelialization and leads to faster recovery.

Direct Aspergillosis Invasion to the Anterior Wall of the Maxillary Sinus: A Case Report

PURPOSE: With an increase in the population of immunocompromised patients, the incidence of maxillary sinus aspergillus infection has also escalated. Maxillary sinus aspergillosis is generally extended to the sinus antrum, base or thin orbital wall and ethmoid air cell region. We experienced a case of maxillary sinus aspergillosis which was extended directly to the soft tissue of the cheek. METHODS: A 46-year-old man with acute myelogenous leukemia was consulted for the defect of the anterior wall of the maxillary sinus, and cheek. Radiologic and histologic findings were consistent with invasive maxillary sinus aspergillosis. The otolaryngology department performed debridement via endoscopic sinus surgery first. Coverage of the resulting defect in the anterior wall of the maxillary sinus and its inner layer was undergone by the plastic and reconstructive surgery department, using a pedicled superficial temporal fascia flap and a split thickness skin graft. The remaining skin defect of the cheek was covered with a local skin flap. RESULTS: The patient went through an uneventful recovery. There was no recurrence during 6 months of follow-up. CONCLUSION: Maxillary sinus aspergillosis usually involves the orbit or the gingiva but in some cases it may directly invade soft tissues of the cheek. Such an atypical infection extending into the cheek may lead to a large soft tissue defect requiring coverage. Thus, any undiagnosed soft tissue defect involving the cheek or maxillofacial area, especially in immunocompromised patients, should be evaluated for aspergillosis. We present this rare case, with a review of the related literature.

Comparative Analysis about the Effect of Isolated Phosphatidylcholine and Sodium Deoxycholate for the Viability of Adipocyte

PURPOSE: Lipobean(R)s, widely used in lipodissolving techniques, contain phosphatidylcholine and sodium deoxycholate as its main substances. They have been approved only as medication for liver disease by the FDA. However, they have been used under various clinical settings without exact knowledge of its action mechanism. The authors designed an in vitro study to analyze the effects of different concentrations of phosphatidylcholine and sodium deoxycholate on adipocytes and other types of cells. METHODS: Human adipose-derived stem cell were cultured and induced to differentiate into adipocytes. Fibroblasts extracted from human inferior turbinate tissue, and MC3T3-E1 osteoblast lines were cultured. Phosphatidylcholine solution dissolved with ethanol was applied to the culture medium at differing concentrations (1, 4, 7, 10 mg/mL). The sodium deoxycholate solution dissolved in DMSO applied to the medium at differing concentrations (0.07, 0.1. 0.4. 0.7 mg/mL). Cells were dispersed at a concentration of 5 x 10(3) cells/well in 24 well plates, and surviving cells were calculated 1 day after the application using a CCK-8 kit. RESULTS: The number of surviving cells of adipocytes, fibroblasts and osteoblasts decreased as the concentration of sodium deoxycholate increased. However, all types of cells that had been processed in a phosphatidylcholine showed a cell survival rate of over 70% at all concentrations. CONCLUSION: This study shows that sodium deoxycholate is the more major factor in destroying adipocytes, and it is also toxic to the other cells. Therefore, we conclude that care must be taken when using Lipobean(R)s as a method of reducing adipose tissue, for its toxicity may destroy other nontarget cells existing in the subcutaneous tissue layer.

Predicting the Degree of Breast Size in Augmentation with Cohesive Gel Implant

PURPOSE: Predicting the change in breast size for a specific patient's need is a challenging problem in breast augmentation. We intended to investigate the post-augmentation degree of breast size according to the size of cohesive silicone gel implant. METHODS: To predict post-augmentation breast size, we measured 100 patients' pre-and postoperative 3 month's bust circumference. All patients were performed by total subfascial breast augmentation with moderate profile cohesive silicone gel implant through areolar omega (transareolar-perinipple) incision. RESULTS: According to this study, each additional one pair of 100mL in implant size yielded an approximate 1.5cm increase in bust circumference(p=0.006). CONCLUSION: From this result, we conclude that each additional one pair of 100mL in implant volume yielded about 1.5cm increase in bust circumference. Although this result may not be applied to every patient, we believe that it yields a practical chart that can help to predict the amount of increase in breast size with the use of cohesive silicone gel implant of a specific size preoperatively.

Effective Reconstruction of Extensive Orbital Floor Fractures Using Rapid Prototyping Model

PURPOSE: Orbital bone is one of the most complex bones in the human body. When the patient has a fracture of the orbital bone, it is difficult for the surgeon to restore the fractured orbital bone to normal anatomic curvature because the orbital bone has complex curvature. We developed a rapid prototyping model based on a mirror image of the patient's 3D-CT (3 dimensional computed tomography) for accurate reduction of the fractured orbital wall. METHODS: A total of 7 cases of large orbital wall fracture recieved absorbable plate prefabrication using rapid prototyping model during surgery and had the manufactured plate inserted in the fracture site. RESULTS: There was no significant postoperative complication. One patient had persistent diplopia, but it was resolved completely after 5 weeks. Enophthalmos was improved in all patients. CONCLUSION: With long term follow-up, this new method of orbital wall reduction proved to be accurate, efficient and cost-effective, and we recommend this method for difficult large orbital wall fracture operations.

Management of Intractable Cerebrospinal Fluid Collection after Cerebellar Tumor Resection: A Case Report

PURPOSE: CSF (Cerebrospinal fluid) leakage is the most common complication of neurosurgery. Early management with conservative care or surgery must be followed appropriately due to the increased risk of lethal complications, such as meningitis. We report a case of intractable CSF leakage that occurred after a cerebellar tumor resection, which was treated successfully. METHODS: A 53-year old male consulted our department for continuous CSF leakage for 3 months after having received conservative care and lumbar drainage. CSF collection was observed in the dead space of the posterior fossa after a cerebellar tumor resection and postoperative radiotherapy. Using a free latissimus dorsi muscle flap, the dead space within the skull was filled and the defects were covered successfully. RESULTS: At 6 weeks after surgery, the follow-up MRI and CT revealed proper coverage and filling in the area where cerebellar tumor had been removed. No CSF leakage was observed at the postoperative 3 month follow-up. CONCLUSION: Recurrent CSF leakage was treated after cerebellar tumor resection with a relatively satisfactory result. In terms of the patient's treatment, much better results can be achieved by performing dead space filling using a flap with a sufficient size, in addition to coverage of the defects of the dura.

Bilateral Fasciocutaneous Sliding V-Y Advancement Flap for Meningomyelocele Defect

PURPOSE: Meningomyelocele is the most common type of neural tube defect disease. Early surgical treatment is recommended to prevent central nervous system infection. Several reconstruction methods were reported previously regarding surgical wound defect closure following meningomyelocele excision. In this article, we report two successful patients using the bilateral fasciocutaneous sliding V-Y advancement flap as a covering for meningomyelocele defects. METHODS: Two patients with meningomyelocele were evaluated. Both patients were male and received their operations on the 1st and 4th day of life. After neurosurgeons completed their part of the operation, the V-Y advancement flap was used to close the defect. Initially a bilateral V-shape incision design was made on the skin such that the base of the V-flap measures identical to the size of the wound defect. An incision was made down to the fascia in order to allow the V-flaps to slide into the defect. Subfascial dissection was performed up to 1/3 to 1/4 the length of the V-flap from the wound while minimizing injury to the perforating vessels. RESULTS: Both patients were treated successfully and there was no evidence of complication in 2 months follow up. CONCLUSION: Several reconstruction methods such as local flaps, skin graft and myocutaneous flaps were reported regarding meningomyelocele surgical wound defect closure. Bilateral fasciocutaneous sliding V-Y advancement flap is an easy method without involving the underlying muscles or a secondary skin graft in a short operation time. Therefore we recommend this treatment option for reconstruction of the wound defect following meningomyelocele excision.

A New Flap for 3-Dimensional Vulvar and Vaginal Reconstruction: The "Butterfly Flap"

PURPOSE: Traditional radical surgery for vulvar cancer produces severe skin and soft tissue defects in the vulvar and vaginal area. Vulvoperineal V-Y advancement fasciocutaneous flaps have limitations in advancement and tension at the wound margin and vaginal orifice area, causing wound disruption or vaginal wall exposure. Therefore, we designed the "Butterfly flap" using a vulvoperineal V-Y advancement fasciocutaneous flap and an inguinal rotational skin flap for 3-dimensional reconstruction of vagina and vulvar area. METHODS: A 27 year-old female was diagnosed with vulvar intraepithelial neoplasia. Radical vulvectomy and full-thickness-skin-graft was performed. We designed a vulvo-perineal V-Y advancement fasciocutaneous flap as the greater wing and inguinal rotational skin as the lesser wing. After flap elevation, the inguinal flap was rotated 180degrees to reconstruct the labia major and vaginal orifice. The perineum was reconstructed using V-Y advancement flaps. RESULTS: The flap survived completely, without any complications. After 6 months, the patient was able to perform normal sexual activities and after 18 months, the patient was able to give birth to normal child by caesarean section. CONCLUSION: The traditional vulvoperineal V-Y advancement fasciocutaneous flap is thin, reliable, easily elevated and matches local skin quality. However, the vaginal wall becomes exposed due to limited advancement and tension of the flap. The "Butterfly flap" using a vulvoperineal V-Y advancement fasciocutaneous flap and an inguinal rotational skin flap is useful for the release of vaginal orifice contracture, reconstruction of the labia major, and 3-dimensional reconstruction of vagina and vulvar area.

Wound Infection of Spinal Cord Stimulator: A Case Report

PURPOSE: Nowadays spinal cord stimulator is frequently used for the patients diagnosed as complex regional pain syndrome. The lead is placed above the spinal cord and connected to the stimulation generator, which is mostly placed in the subcutaneous layer of the abdomen. When the complication occurs in the generator inserted site, such as infection or generator exposure, replacement of the new generator to another site or pocket of the abdomen would be the classical choice. The objective of our study is to present our experience of the effective replacement of the existing stimulation generator from subcutaneous layer to another layer in same site after the wound infection at inexpensive cost and avoidance of new scar formation. METHODS: A 50-year-old man who was diagnosed as complex regional pain syndrome after traffic accident received spinal cord stimulator, Synergy(R) (Medtronic, Minneapolis, USA) insertion 1 month ago by anesthetist. The patient was referred to our department for wound infection management. The patient was presented with erythema, swelling, thick discharge and wound disruption in the left upper quadrant of the abdomen. After surgical debridement of the capsule, the existing generator replacement beneath the anterior layer of rectus sheath was performed after sterilization by alcohol. RESULTS: Patient's postoperative course was uneventful without any complication and had no evidence of infection for 3 months follow-up period. CONCLUSION: Replacement of existing spinal cord stimulation generator after sterilization between the anterior layer of rectus sheath and rectus abdominis muscle in the abdomen will be an alternative treatment in wound infection of stimulator generator.