Chul Hoon Chung

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.

Weight-bearing plantar reconstruction using versatile medial plantar sensate flap

The medial plantar flap serves as an ideal tissue reserve for reconstructing the weight-bearing plantar areas as these areas require a sensate and glabrous skin. Furthermore, the flap provides tissue that is structurally similar to the plantar foot as it is also composed of thick glabrous plantar skin, shock-absorbing fibro-fatty subcutaneous tissue and plantar fascia. During the past 25 years, 20 patients (10 men, 10 women) with skin and soft-tissue defects over the weight-bearing plantar foot were treated. They ranged in age from 20 to 70 years (mean, 31.5 years). The causes of the defects were trauma (n=14) and malignant tumour (n=6); the defects were localised at the heel (n=16) and plantar forefoot (n=4). The medial plantar flap was transposed to the defects in three different ways: proximally pedicled sensorial island flaps (n =8), distally pedicled sensate island flaps based on the lateral plantar vessel (n =3) and neurovascular free flaps (n =9). Flap size varied from a width of 4-8cm and a length of 6-12cm. The mean size of the medial plantar flap was 49.5cm(2) (range, 28-96cm(2)). The follow-up period ranged from 6 to 80 months (mean, 19.9 months). Partial flap loss was observed in two proximally pedicled sensorial island flaps and one distally pedicled sensate island flap. Two free flaps restored normal sensation within 5 years of surgery. Minor skin graft loss at the donor site was observed in seven patients. However, no revision or re-grafting was performed. Hyperkeratosis was observed in one case. All patients achieved normal gait within 3 months after surgery and none noticed recurred ulceration. Durable, sensate coverage of the defects was achieved in all patients. We advocate variable sensate medial plantar flaps for the reconstruction of moderate-size defects of the weight-bearing plantar subunits.

Fist position for skin grafting on the dorsal hand : I. Analysis of length of the dorsal hand surface in hand positions

In skin grafting for reconstruction of burns and contracture deformities of the dorsal hand, the hand is kept in a proper position to provide the greatest amount of skin and to avoid the secondary functional deformity. The safe position has been commonly used for immobilizing the hand, but this is to protect the hand function rather than to provide maximal surface for skin grafting. Split-thickness skin graft contracts up to 30 to 50 percent of the original size owing to secondary contraction. If insufficient skin is grafted, contracture deformity of the dorsal hand may occur. To graft the greatest amount of skin on the dorsal hand, the hand should be kept preoperatively in a position flexing all joints of the wrist, metacarpophalangeal joints, and interphalangeal joints and maximally stretching the dorsal hand (a fist position). We studied the surface length of the dorsal hand between the wrist, the metacarpophalangeal joint, and the eponychium in the anatomic, safe, and fist positions of the right hand in 60 adults. Difference of total length between the anatomic and safe positions was not statistically significant (p > 0.05). The total length in a fist position was significantly increased in comparison with the other two positions (p < 0.05). In a fist position compared with the safe position, the increase in length of the dorsal surface of the proximal hand was 11 to 20 percent except in the thumb, and the increase in length of the dorsal surface of the finger was 12 to 17 percent. The increase in total length of a fist position was about 9 mm (7 to 8 percent) in the thumb and 20 to 32 mm (14 to 18 percent) in the index to little fingers. It suggests that the safe position fails to provide an increased dorsal hand surface area for skin grafting compared with the anatomic position. The greatest amount of skin can be grafted in a fist position. Hand immobilization in a fist position for 7 to 9 days after skin grafting has not resulted in irrevocable joint stiffness in our experience. If injury of the deep structures is not present, the hand should be immobilized in a fist position before skin grafting on the dorsal hand.

Free-flap reconstruction of the scalp: donor selection and outcome.

Wide, complex defects of the scalp caused by various insults always represent reconstructive challenges for surgeons. Our study group consisted of 18 patients (14 males and 4 females) with a mean age of 40.2 years. Nineteen free-tissue transfers were used to reconstruct the scalp defects. The selected cases included 8 latissimus dorsi muscle flaps, 3 latissimus dorsi myocutaneous flaps, 2 rectus abdominis muscle flaps, 3 omental flaps, 1 scapular flap, 1 radial forearm flap, and 1 groin flap. Twelve patients had acute or subacute wounds resulting from trauma or craniotomy, 4 had primary cancer, and 2 had neurofibromatosis. Commonly used recipient vessels were the superficial temporal artery and vein. No flap procedure had morbidity due to vessel compromise, and the overall flap success rate was thus 100%. No major donor-site morbidity was observed. All cases underwent primary closure of donor sites except for one receiving split-thickness skin grafting. In cases where muscle or omental free flaps covered skin grafts, patients were more satisfied because of increased durability and well-fitted wigs. We advocate variable free-tissue transfers for the reconstruction of large defects of the scalp related to the sizes, sites, and extents of the involvement.

Comparison of sensory recovery and morphologic change between sensate and nonsensate flaps in oral cavity and oropharyngeal reconstruction

Sensory recovery after oral cavity and oropharyngeal reconstruction is 1 of the most important goals of free flap reconstruction. The aim of this study was to compare sensory recovery of sensate and nonsensate free flaps and to evaluate the morphologic differences between sensate and nonsensate free flaps.

Rice cooker steam hand burn in the pediatric patient.

&NA; Burn injuries often lead to significant cosmetic and functional deformity. In the Orient, household electric rice cookers have caused a significant number of steam burns to infant hands. The clinical course and treatment outcome of these burns have been studied retrospectively in a review of the medical records of 79 pediatric patients treated for acute hand steam burns and of 38 other patients who underwent correction for postburn contracture. Electric rice cookers caused all of the acute pediatric steam burns treated at our institute. Of the 81 hands treated between 1995 and 1998, 38.3 percent healed with conservative treatment and 61.7 percent required skin grafting. The volar aspects of the index and middle fingers were those most frequently involved. Eighteen of 36 hands (50 percent) grafted with split‐thickness skin developed late contractures requiring additional procedures. Among the 38 patients who underwent correction for postburn deformity, initial treatment was split‐thickness grafting for 60.5 percent, full‐thickness skin grafting for 7.9 percent, and spontaneous healing for 31.6 percent. Awareness among medical personnel and continued public education should be promoted to help prevent this unique type of pediatric steam burn from occurring. (Plast. Reconstr. Surg. 106: 76, 2000.)

A review of microvascular ear replantation.

Microvascular ear replantation is a significant challenge because of the small size of the vessels and the fact that traumatic amputations are frequently avulsed. The zone of trauma is therefore extended and the primary repair of the injured vessel is rendered unlikely. The purpose of this study is to review the literature of ear replantation. A review of the relevant literature that has been published since 1980 revealed 47 cases reported in 37 publications. We present 5 cases from our own experience and analyze a total 52 cases of microvascular ear replantation. The patients age, sex, degree of amputation, cause of injury, ischemic time, method of arterial and venous anastomosis, complications, any additional outflow used, postoperative medications, the requirement for transfusions, and the number of hospital admission days are described. Successful microvascular ear replantations require anastomosis of the vessels if possible. Rather than a vein graft, primary repair of the vessels, or at least pedicled repair of the artery, should be considered to ensure flap survival. In addition, vein repair should be considered if possible to ensure the secure drainage of blood from the replant. With secure circulation, the replant can survive, resulting in a very satisfactory outcome.

Twin digital and in-step neurovascularised free flaps for reconstruction of the degloved mutilated hands

BACKGROUND Degloved mutilated hand injury results in severe contracture of palmar surfaces after avulsion defects of soft tissue and insensate scarring of amputated digits at the proximal interphalangeal level. In an effort to restore the basic function of such hands, we simultaneously used a sensate in-step free flap for re-surfacing the first web space and sensate twin digital free flaps for re-surfacing the palmar defects of the thumb and index finger. METHODS Three male patients sustained degloved mutilated hand injury from a machine in a factory. The average age of the patients was 26 years. These injuries were reconstructed by concomitant twin digital neurovascularised free flaps harvested on the contralateral hands and the in-step neurovascularised free flaps harvested on the feet. The lateral plantar vascular pedicle of the in-step flaps was anastomosed to the vascular pedicle of the twin digital flaps by a flow-through fashion. RESULT All flaps survived. These flaps provided durable sensate coverage and improved pinch and grasp. The morbidity of donor fingers and feet was minimal. CONCLUSION These described flaps supply durable glabrous sensate skin of prehensile function in degloved mutilated hands. Our method is useful in the reconstruction of degloved mutilated hands with amputated stumps of the thumb and counter digit more than 3 cm in length required for pinch and grip.

Wide thumb and the first web reconstruction using a neurovascularised instep free flap

Deformed hands result in palmar defects of the thumb. The sensate instep free flap can be used for wide palmar coverage of the thumb. Three hands with palmar defects of the thumb extended to the first web space underwent soft-tissue reconstruction using a neurovascular instep free flap. These flaps provided sensate coverage with static two-point discrimination values of 8-15 mm. Key pinch strengths of reconstructed thumbs were nearly half of those on the normal side. Donor foot morbidity was minimal with no hyperkeratosis. The neurovascular instep free flap supplies sensate, similar pliable and tough glabrous skin to the palmar surface of the thumb extended to the first web area.

Upper-lip reconstruction using a free dorsalis pedis flap incorporating the extensor hallucis and digitorum brevis muscles.

The combined dorsalis pedis cutaneous, extensor hallucis and digitorum brevis muscle conjoined free flap is useful for a moderate or subtotal defect of the full-thickness lip when local or regional flaps are not applicable. This method can restore good oral competence, adequate oral aperture allowing dental hygiene, and an ability to purse the lips and create a seal.