Eun Key Kim

The effect of human adipose-derived stem cells on healing of ischemic wounds in a diabetic nude mouse model.

Background: Among hundreds of pathophysiologic factors that impair healing of the diabetic foot, diminished perfusion and neovascularization are critical. This study aimed to show the effect of human adipose-derived stem cells on healing of ischemic wounds in diabetic nude mice and thus to estimate the possibilities of adipose-derived stem cells for diabetic wound care. Methods: Sixty nude mice were assigned randomly into group Ia (diabetic control, n = 20), group Ib (diabetic experimental, n = 20), or group II (nondiabetic control, n = 20). After creation of an ischemic limb, human adipose-derived stem cells were injected locally. Gross and histologic observations were made after 3, 7, and 25 days, and plasma and tissue levels of vascular endothelial growth factor were quantified. Results: Group Ia animals typically showed gangrene formation with a delayed and sustained inflammatory reaction, which led to a high rate of autoamputation and a lower survival rate. Group Ib animals had a tendency for earlier and abundant neovessel formation and better tissue remodeling rather than fibrotic cicatrization, resulting in lower rate of autoamputation and a survival rate comparable to group II. Surviving stem cells were identified at day 25, but no specific differentiation was observed. Plasma and tissue vascular endothelial growth factor level in group Ib was higher than in group Ia and comparable to that in group II. Conclusions: This study demonstrated the beneficial effect of human adipose-derived stem cells on healing of ischemic wound in diabetic nude mice. Elevation of vascular endothelial growth factor levels in plasma and tissue suggests the importance of secretory factor, which regulates local angiogenesis and triggers a systemic response.

Sole reconstruction using anterolateral thigh perforator free flaps.

Background: The goal of sole reconstruction should be functional and aesthetic. These goals can be achieved by providing the sole with a durable and comfortable weight-bearing surface, adequate contour, protective sensation, and solid anchoring to deep tissue to resist shearing. Various flaps such as fasciocutaneous, musculocutaneous, or split skin grafted muscle flaps have been reported for reconstruction of the weight-bearing foot. The perforator flap, however, deserves attention in the debate for the ideal flap because of its anatomical characteristics. Methods: Between June of 2002 and February of 2005, 69 patients were treated for soft-tissue defects in the plantar areas with anterolateral thigh perforator free flaps. Sensory nerve coaptation was performed in 17 cases. The follow-up period ranged from 4 to 38 months, with a mean of 14.7 months. Results: Satisfactory aesthetic and functional results were observed using 4- to 6-mm-thick anterolateral thigh perforator flaps. All flaps survived, with the exception of one case. Partial necrosis and dehiscence of the wound developed in three cases, but secondary healing was achieved and final outcome was not impaired. Partial weight bearing began at 3 weeks, and acceptable gait recovery was noted by 3 months as evaluated by clinical observation and gait analysis. Most patients regained protective sensation by 12 months regardless of nerve coaptation, but earlier sensory recovery was noted in patients who underwent reconstruction with sensate flaps. Conclusion: This article suggests the anterolateral thigh perforator flap to be a reliable option in sole reconstruction, resulting in an acceptable functional and aesthetic outcome.

The efficacy of prophylactic low-molecular-weight heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap.

Background: Immediate breast reconstruction using the transverse rectus abdominis musculocutaneous (TRAM) flap is associated with multiple risk factors for pulmonary thromboembolism, the incidence of which has been reported to be as high as 6.3 percent. The authors conducted a prospective study of the efficacy of prophylactic use of low-molecular-weight heparin to prevent pulmonary thromboembolism. Methods: Six hundred fifty consecutive patients who underwent immediate breast reconstruction with TRAM flaps between August of 2001 and April of 2007 were included in this study. No medical prophylaxis was administered for the former 450 consecutive patients (group 1). Since February of 2006, enoxaparin was routinely given to the latter 200 consecutive patients (group 2) for 7 days, from the day of surgery. Fifty-four patients in group 1 (group 1c) and 68 patients in group 2 (group 2c) were routinely examined for asymptomatic pulmonary thromboembolism. Incidences of symptomatic and asymptomatic pulmonary thromboembolism, decreases in hemoglobin, and bleeding-related complications were compared. Results: Although the incidence of symptomatic pulmonary thromboembolism did not differ significantly between groups 1 and 2 (1.8 percent versus 0 percent; p = 0.107), that of asymptomatic pulmonary thromboembolism was significantly higher in group 1c than in group 2c (16.7 percent versus 0 percent; p = 0.009). The hemoglobin decrease was significantly different (2.5 g/dl in group 1 versus 2.8 g/dl in group 2; p = 0.001), but the incidences of transfusion, hematoma, and seroma showed no statistically significant difference. Conclusion: Prophylactic use of low-molecular-weight heparin was effective in preventing pulmonary thromboembolism without increasing problematic bleeding-related complications in TRAM flap immediate breast reconstruction patients.

Efficacy of negative pressure therapy to enhance take of 1-stage allodermis and a split-thickness graft.

Negative pressure therapy has been used in various conditions to promote wound healing. It has also been used to secure a skin graft by improving microcirculation and providing tight adhesion between the graft and the recipient bed. The authors coupled the idea of negative pressure therapy for 1-stage allodermis and a split-thickness skin graft. This prospective study presents 47 cases of skin defects treated by 1-stage allodermis and a split-thickness skin graft. The patients were divided into 2 groups either treated with simultaneous aid of negative pressure therapy for 5 days (group 1, n = 37) or a classic tieover dressing (group 2, n = 10). In group 1, 97.8% graft take was noted at day 5 and the mean time until complete healing was 5.8 days. In group 2, 84% graft take was noted at day 5 and mean time until complete healing was 8.9 days with an average number of 3.2 dressings. Statistically significant graft take (day 5) and time until complete healing was noted (P < 0.05). Good aesthetic and functional result mimicking a full-thickness skin graft was achieved in both groups. However, frequent dressings, longer time to heal, and more restriction to the graft site were needed for group 2. Split-thickness skin added to allodermis provided a sufficient amount of dermis to prevent contracture, and the negative pressure therapy ensured fast and complete take of the 2-layered composite graft. This option can be used to achieve healing mimicking a full-thickness skin graft without requiring large full-thickness donor sites.

Comparison of fat necrosis between zone II and zone III in pedicled transverse rectus abdominis musculocutaneous flaps : A prospective study of 400 consecutive cases

Fat necrosis in transverse rectus abdominis musculocutaneous (TRAM) flap is considered to be mainly affected by blood supply. This prospective study compares the incidence of fat necrosis between zones II and III in 400 consecutive patients who had undergone unipedicled TRAM flap breast reconstruction. Fifty-eight patients (14.5%) suffered from fat necrosis, and 7 had 2 separate nodules. Fifty-four occurred in zone II, 10 in zone III, and 1 in zone I. The incidence of fat necrosis in zone II was significantly higher than in zone III (P < 0.001). The weight of the mastectomy specimen and the relative amount of zone II tissue included in the flap had positive correlation with the incidence of fat necrosis. This result implies relatively poor perfusion of zone II compared with zone III.

The Distribution of the Perforators in the Anterolateral Thigh and the Utility of Multidetector Row Computed Tomography Angiography in Preoperative Planning

This prospective study searches for the clinical relevance of preoperative multidetector row computed tomography (MDCT) angiography (CTA) for anterolateral thigh (ALT) free flap. Preoperative CTA data were collected in 100 patients between November 2004 and April 2008, and data from 139 limbs were evaluated for the number, type, and location of the ALT perforators. This information was used as operative roadmap and correlated with intraoperative findings in 58 patients. The MDCT revealed an average number of perforators of 2.28 per unilateral ALT (range, 0–4) and projected that 23% of the limb have at least 1 septocutaneous perforator. When the reference line connecting the anterior superior iliac spine ASIS and patella was divided into 10 equal parts, most of the perforators were concentrated in 4/10 to 7/10 and the most common was on the proximal 5/10. Two-thirds of septocutaneous perforators were present in the proximal half. Fifty-two of 58 patients had operative findings consistent with CTA, but 4 perforators failed to appear in preoperative CTA and 3 musculocutanenous perforators were initially identified as septocutaneous type but actually had a short intramuscular course. Preoperative mapping using MDCT angiography is fast, simple, and provides fairly accurate information about the location, type, and the course of the perforators. It allows appropriate selection of the sizable perforator with the shortest intramuscular course preoperatively leading to safer and easier operation with optimal outcome.

The Effect of Recombinant Human Erythropoietin on Ischemia-Reperfusion Injury : An Experimental Study in a Rat TRAM Flap Model

Background: Erythropoietin is traditionally known to regulate erythropoiesis, but recently its protective effect against ischemia-reperfusion injury has been studied in cardiovascular and neuronal systems. This study investigated the effect of recombinant human erythropoietin on ischemia-reperfusion injury in a rat transverse rectus abdominis musculocutaneous (TRAM) flap model. Methods: Twenty-four Sprague-Dawley rats were divided into a control group (n = 12) and a group treated with erythropoietin (n = 12). A superiorly based TRAM flap was elevated and ischemic insult was given for 4 hours. Thirty minutes before reperfusion, single-dose recombinant human erythropoietin (5000 IU/kg) was injected through the intraperitoneal route in the treatment group. At 24 hours postoperatively, systemic neutrophil count, tissue myeloperoxidase activity, amount of malondialdehyde, nitric oxide content, tissue water content, and histologic finding of inflammation were evaluated. At day 10 postoperatively, flap survival rate, angiogenesis, and change in hematocrit level were evaluated. Results: The myeloperoxidase activity and tissue water content were significantly lower (p < 0.01 and p < 0.005, respectively), and the tissue nitric oxide level was significantly higher (p < 0.005) in the treatment group 24 hours after reperfusion. Perivascular neutrophil infiltration and intravascular adhesion were marked in the control group. Mean flap survival after 10 days was 69 percent in the treatment group and 47 percent in the control group, demonstrating a significant difference (p < 0.005). Neovascularization in the treatment group was also greater than that in the control group. No significant hematocrit rise was noted 10 days after erythropoietin administration. Conclusion: Recombinant human erythropoietin improved flap survival in ischemia-reperfusion–injured rat TRAM flaps by the possible mechanism of suppressed inflammation, decreased infiltration of neutrophils, increased nitric oxide, and enhanced angiogenesis.

Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients.

Although free flap has largely replaced pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, the latter has also evolved by increased understanding of anatomy and physiology. We report the outcomes in 500 consecutive pedicled TRAM in Asian patients performed by a single surgeon, providing incidences of complications and ideas of prevention. Fascia was minimally harvested with full width of muscle. The eighth intercostals nerve was severed and back-cut was made at the lateral belly. Anterior rectus sheath was directly repaired. Breast complication occurred in 24.6% with the most common being skin envelope necrosis. Major flap loss occurred in 1 (0.2%), and the incidence of fat necrosis was 14.2%. Abdominal complication rate was 16.4%, and bulging occurred in 3%. Exercise performance was almost completely restored after 1 year. Pedicled TRAM is still a competitive procedure with overall flap survival rate of 99.8%, yielding consistent results with acceptable complication rates for most patients under experienced hands.

Effect of Unrestricted Bottle-Feeding on Early Postoperative Course After Cleft Palate Repair

Although bottle-feeding after cheiloplasty is widely accepted, postoperative feeding regimen after palatoplasty is still controversial. The aim of this prospective randomized study was to evaluate the effect of bottle-feeding on early postoperative course after palatoplasty in a relatively homogeneous group of patients. Eighty-two consecutive patients with nonsyndromic cleft palate undergoing 2-flap palatoplasty by a single surgeon were randomized to feeding from a bottle with the usual nipple (G1, N = 42) or to feeding with a spoon, cup, or syringe (G2, N = 40). Complication rates, postoperative sedative use, oral intake for the first 6 days, and relative weight gain at 1 and 2 months were compared. There were no significant complications such as bleeding or respiratory problem. The overall complication rate including wound dehiscence and oronasal fistula was similar in G1 and G2 (11.9% versus 12.5%, P = 1.000) as was postoperative sedative use and mean daily oral intake for the first 5 days. Mean intake on the sixth day was significantly higher in G1. There were no significant between-group differences in relative weight gain after 1 and 2 months. In conclusion, bottle-feeding had no adverse effect on the early postoperative course after palatoplasty including complication rate, oral intake, and weight gain. These findings suggest that an unrestricted feeding regimen is appropriate immediately after palatoplasty.

Outcome of Management of Local Recurrence after Immediate Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Background No consensus has been reached regarding the outcome of management of local recurrence after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. This study demonstrated the presentation, management, and outcomes of local recurrence after immediate TRAM breast reconstruction. Methods A comparison was conducted among 1,000 consecutive patients who underwent immediate breast reconstruction with a pedicled TRAM flap (TRAM group) and 3,183 consecutive patients who underwent only modified radical mastectomy without reconstruction (MRM group) from January 2001 to December 2009. The presentation, treatment, and outcome including aesthetics and overall survival rate were analyzed. Results Local recurrences occurred in 18 (1.8%) patients (TRAM-LR group) who underwent TRAM breast reconstruction and 38 (1.2%) patients (MRM-LR group) who underwent MRM only (P=0.1712). Wide excision was indicated in almost all the local recurrence cases. Skin graft was required in 4 patients in the MRM-LR group, whereas only one patient required a skin graft to preserve the mound shape in the TRAM-LR group. The breast mound was maintained in all 17 patients that survived in the TRAM-LR group even after wide excision. The overall survival rate was 94.4% in the TRAM-LR group and 65.8% in the MRM-LR group (P=0.276). Conclusions Local recurrence after immediate TRAM flap breast reconstruction could be detected without delay and managed effectively by multiple modalities without reducing overall survival rates. Breast mound reconstruction with soft autologous tissue allowed for primary closure in most of the cases. In all of the patients who survived, the contour of their reconstructed breast remained.