Hyunsuk Suh

A New Plane of Elevation: The Superficial Fascial Plane for Perforator Flap Elevation

BACKGROUND The aim for microsurgical reconstruction has broadened from achieving functional to also providing good esthetic outcomes. The perforator flaps are widely used for this goal. However, perforator flaps can still be bulky especially to resurface the skin defect. We hypothesized that elevation from the superficial fascial plane can obtain a thin and viable flap. METHOD In this retrospective study, we report consecutive perforator flaps elevated at the superficial fascial plane from November 2007 to July 2013. Total of 304 flaps which were 196 superficial circumflex iliac perforator (SCIP) flaps, 81 anterolateral thigh (ALT) flaps, and 27 gluteal artery perforator (GAP) flaps were reviewed. RESULT The patient group composed of 189 male and 115 female patients with an average age of 35.8 years. The average body mass index was 23.5 kg/m(2) (range, 15.91-34.57 kg/m(2)). All 304 flaps were successfully elevated with this approach with at least one viable perforator. The thickness averaged approximately 6 mm for ALT flap (range, 4-11 mm), 5 mm for SCIP flap (range, 3-12 mm), and 8.5 mm for GAP flap (range, 5-11 mm). Complete survival was noted in 282 flaps, partial loss of flaps requiring secondary procedures in 6 cases, partial loss healing secondarily in 8 cases, and total loss in 9 cases. During the average follow-up of 34 months, secondary debulking procedures were required in six flaps. CONCLUSION This new approach of elevation on the superficial fascia is reliable, provides a viable tissue, and is able to obtain a thin flap achieving good functional and esthetic outcome.

Negative Pressure Wound Therapy on Closed Surgical Wounds With Dead Space: Animal Study Using a Swine Model.

BackgroundClosed incisional wound surgery frequently leaves dead space under the repaired skin, which results in delayed healing. The purpose of this study was to evaluate the effect of negative pressure wound therapy (NPWT) on incisional wounds with dead space after primary closure by evaluating the fluid volume through the suction drain, blood flow of the skin, tensile strength, and histology of the wounds. MethodsBilateral 25-cm-long incisional wounds with dead space were created on the back of 6 pigs by partially removing the back muscle and then suturing the skin with nylon sutures. NPWT (experimental group) or gauze dressing (control group) was applied over the closed incision for 7 days. Analysis of the wound included monitoring the amount of closed suction drain, blood perfusion unit, tensile strength of the repaired skin, and histology of the incision site. ResultsThe drainage amount was significantly reduced in the experimental group (49.8 mL) compared to the control group (86.2 mL) (P = 0.046). Skin perfusion was increased in the experimental group with statistical significance compared to the control group (P = 0.0175). Collagen staining was increased in the experimental group. The tensile strength of the incision site was significantly higher in the experimental group (24.6 N at 7 days, 61.67 N at 21 days) compared to the control group (18.26 N at 7 days, 50.05 N at 21 days) (P = 0.02). ConclusionThis study explains some of the mechanism for using NPWT in closed incision wounds with dead space. It demonstrates that NPWT significantly reduces drainage amount, increases skin perfusion, increases tensile strength, and has the tendency to promote collagen synthesis for closed wound with dead space indicating enhanced healing.

A Magnetic Resonance-based Seed Localization Method for I-125 Prostate Implants

This study was performed to develop and evaluate a semi-automatic seed localization algorithm from magnetic resonance (MR) images for interstitial prostate brachytherapy. The computerized tomography (CT) and MR images (3 mm-slice thickness) of six patients who had received real-time MR imaging-guided interstitial prostate brachytherapy were obtained. An automatic seed localization method was performed on CT images to obtain seed coordinates, and an algorithm for seed localization from MR images of the prostate was developed and tested. The resultant seed distributions from MR images were then compared to CT-derived distribution by matching the same seeds and calculating percent volume receiving 100% of the prescribed dose and the extent of the volume in 3-dimensions. The semiautomatic seed localization method made it possible to extract more than 90% of the seeds with either less than 8% of noises or 3% of missing seeds. The mean volume difference obtained from CT and MR receiving 100% of the prescribed dose was less than 3%. The maximum extent of the volume receiving the prescribed dose were 0.3, 0.6, and 0.2 cm in x, y, and z directions, respectively. These results indicate that the algorithm is very useful in identifying seeds from MR image for post-implant dosimety.

Effects of Incisional Negative-pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study.

Background: Prolonged hematoma or seroma after primary closure is a causative element in wound complications. This study evaluated the effects of negative-pressure wound therapy on primary closed wounds after superficial circumflex iliac artery perforator flap harvest. Methods: This study was a prospective, randomized, clinical trial comparing conventional dressing against a single application of negative-pressure wound therapy for 5 days after primary closure. A total of 100 patients who had superficial circumflex iliac artery perforator flap harvest were enrolled. Results: There was no statistical difference between the incisional negative-pressure wound therapy and conventional dressing groups in the distribution of risk factors. Significant findings were noted for duration and amount of closed suction drainage: 6.12 ± 4.99 days (median, 4 days; range, 3 to 8 days) and 100.47 ± 140.69 cc (median, 42 cc) for wounds treated with conventional dressing versus 3.34 ± 1.35 days (median, 3 days; range, 2 to 4 days) and 23.28 ±18.36 cc (median, 20 cc) for wounds in treatment group (p = 0.0077 and p = 0.0004), respectively. After closure, an increase in skin perfusion were noted on day 5 in the treatment group (p = 0.0223). There was one case of wound dehiscence in the conventional dressing group. Conclusion: The incisional negative-pressure wound therapy has a positive effect over primary closed surgical defects by significantly reducing the amount of fluid collected by closed suction drains, allowing earlier removal of drains and enhancing the skin perfusion on the repaired skin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Prognostic value of human apurinic/apyrimidinic endonuclease 1 (APE1) expression in breast cancer.

Human apurinic/apyrimidinic endonuclease 1 (APE1) is an essential protein for DNA base excision repair (BER) and redox regulation. The ability of cancer cells to recognize DNA damage and initiate DNA repair is an important mechanism for therapeutic resistance. Several recent studies have suggested that APE1 expression levels and/or subcellular dysregulation may be used to indicate the sensitivity of tumors to radiotherapy or chemotherapy. In this study, we assessed the prognostic significance of APE1 and differences in APE1 expression levels according to breast cancer molecular subtypes. We analyzed formalin-fixed, paraffin-embedded tumor tissue sections from 243 cases diagnosed as invasive breast cancer at Ewha Womans University Medical Center between January 2003 and December 2008. Immunohistochemistry was performed and the nuclear level of APE1 was scored by taking into account the percentage of positive cells. Medical records were reviewed to investigate clinicopathologic characteristics. We found that nuclear APE1 high-level expression (proportion ≥50%) in breast cancer showed a tendency towards unfavorable prognosis regarding disease-free survival (p = 0.093). However, there was no significant difference in overall survival between low and high-level expression groups (p = 0.294). Interestingly, within the Ki-67 low-level expression group, APE1 low-level expression was significantly associated with poor overall survival (p = 0.007). A significant positive correlation was observed between APE1 nuclear expression and estrogen receptor status (75.7% vs. 59.7%, p = 0.022). Also, the luminal A subtype was the most commonly observed breast cancer subtype in the APE1 high-level expression group (61.6% vs. 45.2%, p = 0.000). This study suggests that APE1 expression may be associated with breast cancer prognosis. In particular, its role as a prognostic factor would be significant for breast cancers with a low Ki-67 proliferation index. It is proposed that nuclear APE1 may be a novel target in breast cancer with a low proliferation rate to obtain better outcome.

Free-style Deepithelialized Propeller Flaps: An Ideal Local Flap to Obliterate Wounds with Dead Space

Background: The reconstruction of the posterior trunk, especially with large dead spaces, remains challenging. Regional muscle flaps may lack adequate volume and reach. The purpose of this report was to evaluate the efficacy of deepithelialized free-style perforator-based propeller flaps to obliterate defects with large dead space. Methods: A total of 7 patients with defects on the posterior trunk with large dead spaces were evaluated. After complete debridement or resection, all flaps were designed on a single perforator adjacent to the defect, deepithelialized, and then rotated in a propeller fashion. Flaps were further modified in some cases such as folding the flap after deepithelialization to increase bulk and to obliterate the dead space. Results: The flap dimension ranged from 10 × 5 × 1 to 15 × 8 × 2.5 cm based on a single perforator. The rotation arch of the flap ranged from 90 to 180 degrees. Uneventful healing was noted in all cases. One case showed latent redness and swelling at 7 months after falling down, which resolved with medication. During the average follow-up of 28 months, there were no other flap and donor site complications. Conclusion: The deepithelialized propeller flap can be used efficiently to obliterate dead spaces in the posterior trunk and retains advantages such as having a good vascular supply, adequate bulk, sufficient reach without tension, and minimal donor site morbidity.

Reconstruction using a perforator free flap after malignant melanoma resection of the ankle and foot

Surgical excision with adequate margin is the treatment of choice to provide best chance for survival. However, tumors located on distal lower extremity may require reconstruction to salvage the limb which may affect prognosis and quality of life. This retrospective study aimed to evaluate the effect of free flap on overall outcomes of patients with primary malignant melanoma located on the foot and ankle.

One Stage Allogenic Acellular Dermal Matrices (ADM) and Split-Thickness Skin Graft with Negative Pressure Wound Therapy

After first success of epidermal autotransplantation onto a granulating wound in 1869, skin graft become a standard option for closing defect that cannot be closed primarily. [1] Skin graft can be used in various clinical situations. For the reconstruction of traumatic wounds, burn wound, soft tissue defect or skin defect after cancer ablation surgery or after removal of pigmented skin lesion, diabetic wounds and after scar contracture release and pigmented scar removal, skin graft are widely used around the world.