Nakheon Kang

Medpor implant fixation using fibrin glue in blowout fracture surgery.

Abstract The Medpor implant is (Prous polyethylene, Porex Surgical Inc, Newnan, GA, USA) widely used to reconstruct orbital wall defects. However, this implant is commonly associated with numerous complications, including implant displacement. Therefore, the authors have hypothesized that fixation of the Medpor implant with fibrin glue (Tisseel, Baxter Healthcare, Norfolk, UK), compared to other fixation methods, may be more stable and could provide better results than other fixation methods. In this study, 485 patients who had been treated for blowout fractures from 2008 to 2012 were evaluated. Medpor implants fixed using Tisseel were used to reconstruct bone defects of the orbital wall. The patients’ hospital records and radiologic images were reviewed according to sex, fracture site, and postoperative complications. According to retrospective chart review and radiologic evaluation, the complication rate was low and included diplopia (7%; 33 patients), enophthalmos (4%; 17 patients), and extraocular movement limitation (3%; 13 patients). This study suggests that Medpor implant fixation using Tisseel is a simpler, more secure, and more suitable for reconstruction of the fractured orbital wall compared with other methods.

Medpor Implant Fixation Using Fibrin Glue in the Treatment of Medial Orbital Wall Fracture.

AbstractThe optimal treatment modalities are determined based on the symptoms and degree of the bone defects in patients with medial orbital wall blowout fracture. Most of the patients in this series underwent implant surgery. However, there are many patients whose implants were not fixed during surgery. Therefore, some patients who had implant migration occurred had been reported.We have therefore used methods for applying fibrin glue (Tisseel, Baxter Healthcare, Norfolk, United Kingdom) for the fixation of implant. Between 2007 and 2013, a total of 168 patients underwent porous polyethylene orbital implant (Medpor) surgery with the application of Tisseel. All the patients underwent surgical treatments via a transcaruncular approach, for which the Medpor was used. Postoperative complications include 6 cases of the limitation of extraoccular movement, 10 cases of diplopia, and 7 cases of enophthalmos. However, there were no specific complications caused by Tisseel. All the patients were satisfied with the treatment outcomes.In this study, we report the usefulness of Tisseel in the fixation of the medial orbital wall fracture using the Medpor implant with a review of literatures.

The Vascular System of the Superior Auricular Artery: Anatomical Study and Clinical Application

BACKGROUND The retroauricular flap has many advantages for facial reconstruction, but it is difficult to perform reconstruction of the upper part of the auricle and its surroundings. METHODS We investigated the relationship between the superior auricular artery and its surrounding structures through anatomic studies with seven fresh cadavers and applied the findings clinically. From February 2008 to December 2009, we performed 12 cases with the superior auricular artery island flap to reconstruct defects in the upper region of the auricle and its surroundings. RESULTS We found that the superior auricular artery is a reliable pedicle for the retroauricular flap. All wounds of the patients were successfully closed, with the exception of one minor complication. The aesthetic outcomes of the donor and recipient sites were satisfactory. CONCLUSIONS The superior auricular artery island flap has several advantages. Therefore, we suggest that the superior auricular artery island flap can be another choice for reconstructing soft tissue defects at the upper region of the auricle and its surrounding area. The authors have indicated no significant interest with commercial supporters.

Fixation of fractured anterior wall of maxillary sinus using fibrin glue in a zygomaticomaxillary complex fracture.

BackgroundZygomaticomaxillary complex (ZMC) fracture occurs commonly, and restorations of facial shape and symmetry by 3-dimensional reduction and ridged fixation are important. A severe ZMC fracture is accompanied by fractures to the anterior wall of maxillary sinus; thus, various complications can occur without appropriate restoration by surgery. MethodOf the patients with ZMC fracture from January 2008 to December 2012, 328 patients underwent surgery. Among them, 234 patients with severe fractures to the anterior wall of the maxillary sinus underwent restoration using fibrin glue (Tisseel; Baxter Healthcare, Norfolk, UK). ResultsThere were no major side effects in any of the 234 patients in whom Tisseel was used, and the bone fragments were fixed well in their original places according to postoperative CT findings. ConclusionGrafted bone fragments can be maintained in their original places by fibrin clot layers with Tisseel. Using Tisseel, operation time is reduced, and the bleeding tendency is decreased by reduced shearing force with surrounding tissues and the hemostatic reaction of fibrin. Therefore, it can be concluded that using Tisseel is one effective method for the restoration of fractures on the anterior wall of the maxillary sinus.

Management of Alveolar Cleft

The alveolar cleft has not received as much attention as labial or palatal clefts, and the management of this cleft remains controversial. The management of alveolar cleft is varied, according to the timing of operation, surgical approach, and the choice of graft material. Gingivoperiosteoplasty does not yet have a clear concensus among surgeons. Primary bone graft is associated with maxillary retrusion, and because of this, secondary bone graft is the most widely adopted. However, a number of surgeons employ presurgical palatal appliance prior to primary alveolar bone graft and have found ways to minimize flap dissection, which is reported to decrease the rate of facial growth attenuation and crossbite. In this article, the authors wish to review the literature regarding various advantages and disadvantages of these approaches.

Reconstruction of the Head and Neck Region Using Lower Trapezius Musculocutaneous Flaps

Background Recent literature has indicated that free flaps are currently considered the preferred choice for head and neck reconstruction. However, head and neck cancer patients are frequently treated with chemoradiotherapy, which is often associated with a poor general and local condition, and thus, such patients are ineligible for free flap reconstruction. Therefore, other reconstruction modalities should be considered. Methods We used lower trapezius musculocutaneous (LTMC) flap based on the dorsal scapular artery to reconstruct head and neck defects that arose from head and neck cancer in 8 patients. All of the patients had undergone preoperative chemoradiotherapy. Results There were no complications except one case of partial flap necrosis; it was treated with secondary intention. Healing in the remaining patients was uneventful without hematoma, seroma, or infection. The donor sites were closed primarily. Conclusions The LTMC flap is the preferred flap for a simple, reliable, large flap with a wide arc of rotation and minor donor-site morbidity. The authors recommend this versatile island flap as an alternative to microvascular free tissue transfer for the reconstruction of defects in the head and neck region, for patients that have undergone preoperative chemoradiotherapy.

Septal harvesting instruments in rhinoplasty.

BackgroundSeptal cartilage is the best graft material for reconstructing the nasal dorsum, columella, and tip. It is the tissue of choice in primary and secondary rhinoplasties, provided that it can be shaped into a desired contour. Because the amount of cartilage obtained with the cutting method using a swivel knife and septal cartilage scissors is insufficient, new instruments and separation methods are needed to compensate for this shortcoming.MethodsThis article presents two new instruments: the spatula suction dissector and the J & D knife. Using the spatula suction dissector, the septal cartilage was separated from the mucoperichondrium. Then, suspending the hook of the J & D knife on the septal caudal border, a 10-mm marginal incision perpendicular to the cartilage edge is made. The spatula suction dissector and/or D knife can effectively separate the tongue-and-groove articulation.ResultsThe spatula suction dissector, J & D knife, and separation techniques make it possible to harvest sufficient amounts of cartilage in one piece without leaving any behind during rhinoplasty.ConclusionThere was a need for improved instrumentation to obtain sufficient cartilage than what is currently available. New instruments that made it easier, faster, and safer to harvest the cartilage are presented.

Histological, Physical Studies after Xenograft of Porcine Ear Cartilage

Background Because of the relatively similar size of organs to human and the physiological and structural similarities, the use of porcine as xenograft donors is progressing very actively. In this study, we analyzed the characteristics of porcine ear cartilage and evaluated its suitability as graft material in reconstructive and cosmetic surgery. Methods The auricular cartilage was harvested from two pigs, and subjected to histological examination by immunohistochemical staining. To determine the collagen content, samples were treated with collagenase and weight changes were measured. After sterilization by irradiation, the samples were grafted into rats and stained with Hematoxylin and Eosin and Masson Trichrome to observe inflammation and xenograft rejection. Results In IHC staining, extracellular matrices were mainly stained with type II collagen (20.69%), keratin sulfate (10.20%), chondroitin sulfate (2.62%), and hyaluronic acid (0.84%). After collagenase treatment, the weight decreased by 68.3%, indicating that about 70% of the porcine ear cartilage was composed of collagen. Upon xenograft of the sterilized cartilages in rats, inflammatory cells were observed for up to 2 months. However, they gradually decreased, and inflammation and reject-response were rarely observed at 5 months. Conclusion The porcine ear cartilage was covered with perichondrium and cellular constituents were found to be composed of chondrocytes and chondroblasts. In addition, the extracellular matrices were mainly composed of collagen. Upon xenograft of irradiated cartilage into rats, there was no specific inflammatory reaction around the transplanted cartilage. These findings suggest that porcine ear cartilage could be a useful alternative implant material for human cosmetic surgery.

Recurrent Chondroid Syringoma of the Alar Rim

Chondroid synringoma (CS), pleomorphic adenoma of skin, is a benign tumor found in the head and neck region. CS was first reported in 1859 by Billorth for the salivary gland tumor. The usual presentation is an slowly growing, asymptomatic mass. A 53-year-old female with a history of chondroid synringoma had presented with multiple firm, nodular masses found in the left nostril area. The lesion had been excised 8 years prior and was diagnosed histopathologically, but had gradually recurred. Excision of the mass located in subcutaneous layer revealed four whitish, firm tumors surrounded with capsular tissue. Neither recurrence nor complications occurred during the 18 months follow-up period. In the head and neck region, chondroid syringoma should always be considered in differential diagnosis of soft tissue masses despite its rare incidence. For that reason, excisional biopsy with clear margin is the optimal diagnostic as well as therapeutic choice. We report a case of recurred chondroid syringoma on the nose in female patient.

The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects.

The reconstruction of laryngopharyngectomy defects requires the creation of a tubular passage that connects the pharyngeal remnant to the cervical esophagus. Tubed fasciocutaneous flaps (e.g., from the anterolateral thigh or radial forearm) are most commonly used, because they permit good postoperative speech and result in low systemic morbidity. However, if a fasciocutaneous flap is unavailable due to a lack of perforators or an obese thigh, the next choice is a jejunal flap. The most common method of securing visceral graft anastomoses was previously one or two layers of hand sewing. However, circular mechanical staplers have been commonly used by general surgeons for enteric anastomosis and lead to similar or lower anastomotic leakage and stricture rates than hand sewing [1,2]. Stapled anastomoses may also reduce the mean operating time by reducing the time required for anastomosis, and also probably reduce blood loss and the likelihood of intraoperative contamination [3]. The ischemic time seems to be a very important factor affecting the likelihood of postoperative complications, especially for free flaps. In particular, the intestine is more vulnerable to ischemia than the skin and bone [4]. In this report, the use of circular mechanical stapling for jejunoesophageal anastomosis was reviewed to assess whether it is a good alternative to hand-sewn anastomoses in the reconstruction area. Jejunal free flap surgery was performed in six patients with a total laryngopharyngectomy defect between March 2009 and January 2013. Total laryngopharyngectomy was performed to treat hypopharyngeal cancer in four cases and to treat glottis cancer in two cases. All patient specimens were diagnosed as squamous cell carcinoma by a pathologist. A single general surgeon harvested the jejunal flap segment in all six cases. A distal jejunoesophageal anastomosis was performed using a 25-mm end-to-end anastomosis (EEA) circular mechanical stapler (Covidien, Mansfield, MA, USA) in all cases. The anastomosis process for the flap was as follows. First, traction sutures were placed in the cervical esophagus to dilate the esophageal lumen. Purse-string sutures were placed at the end of the esophagus prior to stapling. The jejunal flap was pierced with a sharp trocar end, seated in position within the stapler cartridge, and the safety lock was then removed (Fig. 1). Stapling was performed by triggering. After confirming anastomosis of the entire tubular margin, the device was gently removed via the flap lumen (Fig. 2). Proximal flap anastomosis was performed using hand-sewn sutures in an interrupted fashion. At this point, the conduit was trimmed to eliminate redundancy. The suturing was performed with a double layer of interrupted (Covidien, Mansfield, MA, USA) (Fig. 3). We then performed revascularization of the pedicle vessels. We recorded the duration of stapler usage in each case. Two to three months after surgery, patients were assessed for anastomotic leakage or stricture by barium esophagography and endoscopy. Fig. 1 Diagram of the anastomosis process. (A) Diagram showing the proximal esophagus with the trocar in place and retraction (purse-string) sutures for dilating and sizing the esophageal lumen. (B) The pierced jejunum is seated within the stapler cartridge. ... Fig. 2 Diagram of the stapling process. (A) Firing the stapler. After firing, the end-to-end anastomosis device is removed gently via the jejunal flap lumen. (B) Inset, jejunum flap. Fig. 3 A case of total laryngopharyngeal defect reconstruction. (A) Preoperative photograph. (B) The trocar and purse-string sutures are placed on the end of the esophagus prior to stapling