Chung Hun Kim

Fingertip Reconstruction With Simultaneous Flaps and Nail Bed Grafts Following Amputation

PURPOSE To report our technique and results with treating fingertip amputations with flaps and simultaneous nailbed grafts. METHODS We reconstructed 20 fingertip amputations with loss of bone and nail with flaps combined with nailbed grafts. We reconstructed the volar side of the fingertip with a flap, and the dorsal side of the fingertip with a nailbed grafted to the raw inner surface of the flap. We employed volar V-Y advancement flaps for transverse or dorsal oblique fingertip injuries and generally used abdominal flaps for volar oblique fingertip injuries. We harvested nailbeds from the amputated finger or from the patients first toe. RESULTS The length of the amputated fingertips was restored with the flaps, and the lost nailbeds were restored to their natural appearance with the nailbed grafts. We classified the results according to the length of the reconstructed fingertip and the appearance of the nail. Excellent or good results were achieved in 16 cases. Three cases had fair results and 1 had a poor result. We observed favorable results for distal fingertip amputations (Allen type II or III). In particular, most cases that were reconstructed with volar V-Y advancement flaps combined with nailbed grafts demonstrated favorable results. CONCLUSIONS This method is useful for the restoration of dorsal oblique or transverse type fingertip amputations and is a good alternative when replantation is not an option.

Prospective 1-Year Follow-Up Study of Breast Augmentation by Cell-Assisted Lipotransfer

BACKGROUND Breast augmentation by cell-assisted lipotransfer (CAL) may achieve a more natural breast contour than silicone implants. Moreover, certain complications associated with these prosthetic devices can be avoided with CAL. Few prospective studies of CAL have been performed to examine long-term volume changes, effects on breast parenchymal tissue, and the effect of stromal vascular fraction (SVF) on graft survival. OBJECTIVES In a 1-year prospective study of patients who underwent CAL, the authors examined changes in breast volume, effects on parenchymal tissue, and the impact of SVF on graft survival. METHODS Following preoperative radiologic examination, patients underwent primary augmentation mammaplasty by CAL to both breasts. The SVF was characterized, and changes in breast volume were determined from magnetic resonance imaging studies performed postoperatively at 3 months and 1 year. A breast-imaging specialist reviewed all scans to detect changes in breasts. RESULTS Five patients (10 breasts) were enrolled. Averagely 23% of grafted fat in volume was additionally harvested from each patient to isolate SVF cells. One year after CAL, breast volume had decreased to 47% of the initial postoperative volume. There was no parenchymal changes except small oil cysts. The ratio of SVF cell count to grafted fat volume showed no correlation with graft survival. Patterns of breast-volume decrease differed between older women with a history of breastfeeding and younger women without a history of breastfeeding. CONCLUSIONS The addition of SVF cells did not appear to improve the retention of grafted fat in these patients. Skin tension may be an important factor influencing the absorption pattern of grafted fat. LEVEL OF EVIDENCE 4: Therapeutic.

Treatment of frontal sinus fracture using bioabsorbable mesh plates.

AbstractAccurate reduction and stable fixation are important in the treatment of frontal sinus fracture. Usually, metal plates and screws were used because of easy handling and delicate fixation. However, palpability and possibility for secondary operation for plate removal were shortcomings. For improving these problems, we used absorbable mesh plate for fixation of reduced frontal bones.In this study, 14 patients with frontal sinus fracture were treated by open reduction and rigid fixation using absorbable mesh plates. Mean follow-up period was 17.6 months. Considering anterior and posterior table involvement, nasofrontal duct injury, and concomitant neurosurgical problems, additional surgical procedures including degloving sinus mucosa, cranialization, and obliteration of nasofrontal duct were also conducted.There was no remarkable early and late postoperative complication. Aesthetic results were also satisfactory. Absorbable mesh plates were easy to mold and convenient for screw fixation. Moreover, there was no necessity of secondary operation for removal of plates.We believe that absorbable mesh plates might be a useful material for fixation instead of metal plates and screws especially in mild to moderate degree of frontal bone fractures.

Human Embryonic Stem Cell-Derived Endothelial Precursor Cell Conditioned Medium Reduces the Thickness of the Capsule Around Silicone Implants in Rats.

BackgroundWe postulated that the fibrotic capsule around a silicone implant could be induced by ischemic conditions, based on previous reports that hypoxia is an important microenvironmental factor in the development of tissue fibrosis. ObjectiveThis study aimed to determine the effect of human embryonic stem cell (hESC)-derived endothelial precursor cell (EPC) conditioned medium (CM), which has strong angiogenic potential, on the development of capsule around the silicone implant in a rat model. Methods and MaterialsThree groups had a mini-silicone implant with a smooth surface inserted. In 2 experimental groups, hESC-EPC CM was administered into the subcutaneous pocket either 1 or 2 times. After 2 months, the capsules were harvested and analyzed by histologic examination. ResultsThere was a significant reduction in the thickness of the peri-implant capsules (P < 0.05) between the control and experimental groups. There is no tendency that hESC-EPC CM reduces inflammatory reaction in early postoperative periods. The experimental group showed increased angiogenesis compared to the control group (P < 0.05). ConclusionsTissue hypoxia around the implant may be another cause for the peri-implant capsule. A preventive or therapeutic strategy to decrease capsular contracture by relieving the ischemic condition around the implant can be investigated in the future.

Transport distraction osteogenesis with recombinant human bone morphogenic protein-2 for large calvarial defect reconstruction.

BackgroundTransport distraction osteogenesis (TDO) has been used in attempts to treat large calvarial defects but has, until now, lacked consistency and reliability. To achieve sufficient bone formation, the effect of TDO was compared to the effect of TDO combined with recombinant human bone morphogenic protein-2 (rhBMP-2). MethodsFourteen dogs were divided into 2 groups; 6 animals in the control group received TDO only, and 8 received TDO combined with rhBMP-2. A calvarial defect 33 × 35 mm in size was generated, and the drug-delivering internal distractor was applied. After a 5-day latency period, distraction with rhBMP-2 at 10 &mgr;g/day was initiated at a rate of 2 mm/day. This was followed by a consolidation period of 3 months, after which areas of osteogenesis and strength were measured and histologic examinations were conducted. ResultsThe average area of osteogenesis was higher in the experimental group (P < 0.01). Regenerated bone of the experimental group showed increased strength (P < 0.05). Histological examination showed typical mature bone in the experimental group. Prominent osteoblastic rimming was observed in the bone marrow of the experimental group. ConclusionsTDO with an internal distraction device delivering rhBMP-2 can enhance bone regeneration of large calvarial defects in a dog model. These results suggest the potential for human clinical testing of TDO combined with rhBMP-2.

Trichilemmal Carcinoma from Proliferating Trichilemmal Cyst on the Posterior Neck

Trichilemmal cysts are common fluid-filled growths that arise from the isthmus of the hair follicle. They can form rapidly multiplying trichilemmal tumors-, also called proliferating trichilemmal cysts, which are typically benign. Rarely, proliferating trichilemmal cysts can become cancerous. Here we report the case of a patient who experienced this series of changes. The 27-year-old male patient had been observed to have a 1×1 cm cyst 7 years ago. Eight months prior to presentation at our institution, incision and drainage was performed at his local clinic. However, the size of the mass had gradually increased. At our clinic, he presented with a 5×4 cm hard mass that had recurred on the posterior side of his neck. The tumor was removed without safety margin, and the skin defect was covered with a split-thickness skin graft. The pathologic diagnosis was a benign proliferating trichilemmal cyst. The mass recurred after 4months, at which point, a wide excision (1.3-cm safety margin) and split-thickness skin graft were performed. The biopsy revealed a trichilemmal carcinoma arising from a proliferating trichilemmal cyst. This clinical experience suggests that clinicians should consider the possibility of malignant changes when diagnosing and treating trichilemmal cysts.

Traumatic Oculomotor Nerve Palsy

Oculomotor nerve palsy generally presents with mydriasis, blepharoptosis, and impairment of extraocular muscle movement. The incidence of primary traumatic oculomotor nerve palsy in craniocerebral trauma is approximately 1.2% [1]. The causes of oculomotor nerve palsy are congenital, traumatic, vascular, migrainous, and parainfectious. Especially in children, it is often caused by congenital factors, postnatal trauma, or infections [2]. Previous reports indicated that complete recovery is unusual [3]. Here, we report a case of a child with traumatic oculomotor nerve palsy accompanying an orbitozygomaticomaxillary fracture. To our knowledge, it is the first such case report to appear in a Korean plastic surgery journal and is of note because the patient experienced a near-complete recovery, contrary to the grave prognoses described in previous case reports. An 8-year-old girl was admitted to the hospital after a car accident. The patient had no specific past history. Right periorbital swelling was too severe for the patient to be able to open her right eye, and therefore the pupil size discrepancy was only recognized after four days. The right pupil was dilated up to 5.5 mm, compared with 2.0 mm dilation on the unaffected side. The complete impairment of eye adduction was also noted in the affected eye. However, results of the forced duction test were normal. Thus, her right eyeball was deviated to the inferolateral side in the neutral gaze (right exotropia) (Fig. 1). Complete blepharoptosis remained in the right upper eyelid after the periorbital swelling subsided seven days after the trauma. These findings were consistent with oculomotor nerve palsy. Visual acuity was normal at 20/20. The laboratory data, other aspects of the medical history, and the review of systems were in the normal range. There were also no specific neurological abnormalities except oculomotor nerve palsy. A facial computed tomography scan displayed a right orbitozygomaticomaxillary fracture and a nasal bone fracture, which were so minimal that they were not expected to affect oculomotor nerve function. Magnetic resonance images also revealed no abnormal findings associated with oculomotor nerve palsy. A cerebrospinal fluid test was not performed because there was no leakage of cerebrospinal fluid. One week after the trauma, an operation was performed to address the facial bone fracture. We employed steroid therapy to reduce periorbital swelling and possible endoneurial edema, in order to prevent secondary neuronal damage. Solu-Medrol (1 mg/kg, methylprednisolone) was injected intravenously for four days after the operation. After postoperative day five, prednisolone was administered and tapered gradually for six days. During the first three weeks, there was little improvement of levator function and the pupillary reflex (Fig. 1). However, at four weeks post-trauma, the movement of the paretic extraocular muscles and the state of ptosis were slightly improved. Levator function was measured at 3 mm (Table 1, Fig. 2). After 20 weeks, levator function was gradually improved and a measurement of 6.5 mm elevation was taken. However, pupillary function had not recovered to its normal range (Figs. 3, ​,4).4). One year after the trauma, levator function and pupillary function had almost recovered to the normal range (Fig. 5). The patient is still being followed and is expected to improve further. In adults, common causes of oculomotor nerve palsy are aneurysms, trauma, diabetes mellitus, and neoplasms. The relevant neoplasms are mostly pituitary adenomas and metastatic tumors [4]. The prognosis of oculomotor nerve palsy varies according to its etiology and associated cranial nerve problems. In children, common causes are congenital factors, trauma, inflammation, neoplasms, aneurysms, and others [4]. The exact pathophysiology of oculomotor palsy is not well understood. However, it is generally assumed that lesions in the sphenocavernous region, the orbital apex, and the brain stem may affect the oculomotor nerve. Direct injury or indirect compression can also result in palsy. If the cause is inflammation, postinfectious neuropathy may affect the nerve, but this mechanism of pathogenesis is not well understood [4]. Clinically, pupillary function shows great variability. Pupil-sparing oculomotor palsy can be caused by the infarction of the oculomotor nerve. Such patients may have diabetes mellitus [5]. Oculomotor nerve palsy that presents with smaller pupils may be due to Horners syndrome or diabetic autonomic neuropathy. Partial oculomotor nerve palsy can resolve in one to three months [4]. The improvement of visual acuity has been known to be difficult to achieve [2]. Many patients may develop amblyopia. In fact, in pediatric cases of oculomotor nerve palsy, it is difficult to measure visual acuity quantitatively because young children are incompliant. However, regardless of the practical difficulties involved in measuring the visual acuity of children, visual acuity is known to be impaired in this condition. In our case, we saw a considerable improvement of levator function during the first 20 weeks. During the first eight weeks, about 50% of levator function was recovered. However, medial rectus muscle function had not recovered at that point. It was necessary to wait at least six months for the recovery of function in the pupil and medial rectus muscle because only a small restoration of the pupil size was noted after five months. One year after the trauma, levator and pupillary function almost recovered to the normal range (Fig. 5). Based on the course of the patients recovery, we surmise that these functions will continue to improve with time. The patient is still being followed. Fortunately, the patients visual acuity is normal. In our case, treatment was limited to early steroid therapy and occlusion therapy. The prognosis of oculomotor nerve palsy varies according to its etiology and the associated neurological problems. Some authors suggest waiting for at least six months before strabismus surgery, which permits the cause of oculomotor palsy to be evaluated and allows for possible spontaneous recovery [2]. A surgical approach, including strabismus surgery and ptosis surgery, should be considered according to the degree of recovery. We suggest that plastic surgeons keep in mind that facial trauma may occur in combination with various cranial nerve injuries and therefore should evaluate patients with facial trauma for the symptoms and signs of cranial nerve injuries. Fig. 1 One week post-trauma. Complete ptosis and a dilated pupil were noted. Fig. 2 Four weeks post-trauma. The movement of paretic extraocular muscles and the amount of ptosis were somewhat improved. Levator function was measured as no more than 3 mm. Fig. 3 Eight weeks post-trauma. Levator function was improved compared to at 4 weeks. Fig. 4 Twenty weeks post-trauma. Levator function was gradually improved, as shown by a measurement of 6.5 mm elevation. However, pupillary function had not recovered to the normal range. Fig. 5 One year post-trauma. Levator and papillary function had almost recovered to the normal range. Table 1 Flowsheet of ocular examination

Cheek drooping in 2 patients with maxillary fractures after rigid fixation with bioabsorbable mesh.

AbstractBioabsorbable plate-screw systems are commonly used for the internal fixation of facial bone fractures. The anterior maxilla has a unique curved shape, and fractured bony fragments tend to be small and fragile; therefore, more effective rigid fixation can be achieved using a molded bioabsorbable mesh rather than a bioabsorbable plate. Herein, we describe 2 patients with cheek drooping after a rigid fixation of comminuted maxillary fracture using bioabsorbable meshes and screws.The postoperative courses were uneventful, but both showed soft tissue bulging in the cheek area of the operation site for 12 to 13 months after the operation. No other symptom or sign related to inflammation or foreign body reaction was noted.In comminuted maxillary fractures, bone fragments are more conveniently fixed with a 1-piece molded bioabsorbable mesh. However, it is believed that a single large mesh may interfere with adhesion between the maxillary surface and the overlying soft tissue. Therefore, we recommend using the least amount of mesh to fixate maxillary bone fragments.