Ki Yong Hong

Preoperative TRAM Free Flap Volume Estimation for Breast Reconstruction in Lean Patients

To obtain pleasing symmetry in breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) free flap, a large amount of abdominal flap is elevated and remnant tissue is trimmed in most cases. However, elevation of abundant abdominal flap can cause excessive tension in donor site closure and increase the possibility of hypertrophic scarring especially in lean patients. The TRAM flap was divided into 4 zones in routine manner; the depth and dimension of the 4 zones were obtained using ultrasound and AutoCAD (Autodesk Inc., San Rafael, CA), respectively. The acquired numbers were then multiplied to obtain an estimate of volume of each zone and the each zone volume was added. To confirm the relation between the estimated volume and the actual volume, authors compared intraoperative actual TRAM flap volumes with preoperative estimated volumes in 30 consecutive TRAM free flap breast reconstructions. The estimated volumes and the actual elevated volumes of flap were found to be correlated by regression analysis (r = 0.9258, P < 0.01). According to this result, we could confirm the reliability of the preoperative volume estimation using our method. Afterward, the authors applied this method to 7 lean patients by estimation and revision of the design and obtained symmetric results with minimal donor site morbidity. Preoperative estimation of TRAM flap volume with ultrasound and AutoCAD (Autodesk Inc.) allow the authors to attain the precise volume desired for elevation. This method provides advantages in terms of minimal flap trimming, easier closure of donor sites, reduced scar widening and symmetry, especially in lean patients.

Reverse-Flow Intrinsic Fasciocutaneous Island Flaps in Foot Reconstruction

Reconstruction of soft tissue defects in the foot remains a challenge due to its specialized tissue for weightbearing and ambulation. Considering the principle of replacing “like with like,” adjacent soft tissues would be a best option for a donor site. Although several kinds of reverse-flow island flaps for the lower leg have been well described, intrinsic foot reverse flow flaps have been rarely reported. We describe 3 kinds of reverse-flow intrinsic fasciocutaneous flaps (RIFFs) for foot reconstruction. From September 2012 to August 2015, a retrospective study was done on case notes of all patients who had a RIFF for coverage of soft tissue defects within the foot following trauma or tumor ablation. A total of 7 patients were included in this study, with an average of 5 × 3.5 cm sized defects in the forefoot, second and third web space, and sole, which were reconstructed with RIFF. All flaps were well perfused and recovered excellent function of the foot with satisfactory aesthetics and minimal limitations in range of motion. However, one case showed a complication of venous congestion, due to remnant scar tissues, which resolved after medical leech application. Donor defects healed completely with split thickness skin grafting in all cases. Soft tissue defects within the foot were repaired successfully by RIFF. In spite of its technical challenges, it is a reliable one-stage procedure requiring no microsurgical anastomosis. Precise vascular evaluation of the reverse inflow has to be preceded for satisfactory outcome of RIFF.

Direct thrombectomy as a salvage technique in free flap breast reconstruction

Breast reconstruction with microvascular free tissue transfer has become a widely used method. Despite a high rate of success, a compromised flap necessitating re‐exploration can occur. Here, we introduce direct thrombectomy as a flap salvage technique, and compared the results with conventional thrombectomy.

Recurrent frontal osteoma overlying bone grafts

Osteoma is a benign slow-growing tumor that usually arises in the craniofacial region. Frontal osteomas are generally asymptomatic, rarely causing deformity or compressing adjacent structures. Clinically, osteoma is cured by surgical excision, and recurrence of osteoma is known to be rare. However, the authors report a first case of repeated recurrence of frontal osteoma overlying bone grafts. A 40-year-old woman presented with a bulging mass at left forehead. Previously, the patient had undergone two operations for excision of osteomas and reconstruction of defects with rib bone grafts (Figure 1). Histologic examination proved that the recurred mass was osteoma. She did not have any familial history related to cancer or bony diseases.