Seung Han Song

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.

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.

Hydroxyapatite synthesis using EDTA.

AbstractBone comprises structure of the body and consisted of inorganic substances. It exists in an organic structure in the body. Even though it is firm and has self-healing mechanism, it can be damaged by trauma, cancer, or bone diseases. Allograft can be an alternative solution for autologous bone graft. Hydroxyapatite (Ca10(PO4)6(OH)2), an excellent candidate for allograft, can be applied to bone defect area. There are several methods to produce hydroxyapatite; however, economical cost and being time consuming make the production difficult. In this study, we synthesized hydroxyapatite with EDTA. Freeze-dried bone allograft (Hans Biomed) was used as the control group. Synthesized hydroxyapatite was a rod-shaped, white powdery substance with 2- to 5-&mgr;m length and 0.5- to 1-&mgr;m width. X-ray diffraction showed the highest sharp peak at 32°C and high peaks at 25.8°C, 39.8°C, 46.8°C, 49.5°C, and 64.0°C, indicating a similar substance to the freeze-dried bone allograft. After 3 days, the cell growth of synthesized hydroxyapatite showed 1.5-fold more than did the bone allograft. Cellular and media alkaline phosphate activity increased similar to the bone allograft. In this study, we came up with a new method to produce the hydroxyapatite. It is a convenient method that can be held in room temperature and low pressure. Also, the product can be manufactured in large quantity. It can be also transformed into scaffold structure, which will perform a stronger configuration. The manufacturing method will help the bony defect patients and make future medical products.

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.

Proper Choice of Vessels for Supermicrosurgery Training: An Experimental Animal study

Background Reconstruction using supermicrosurgery, a technique of microneurovascular anastomosis for smaller vessels (< 0.8 mm), has become popular. Experimental animal studies for supermicrosurgery training have been reported; however, there have been few studies performed according to vessel diameter and pedicle length. In this study, the external diameters of four vessels (femoral, superficial epigastric, axillary, and common thoracic) and pedicle length of two flaps (superficial epigastric and common thoracic‐long thoracic) were measured. Methods The inguinal and pectoral regions of Sprague‐Dawley rats (n = 19) were dissected anatomically, and the external diameters of the four vessels were measured (right and left, artery and vein measured separately). After elevating the superficial epigastric and common thoracic‐long thoracic flaps, the pedicle length of the flaps was also measured. Results Among the 16 vessels examined, the external diameters of 11 and 5 vessels were above and below 0.8 mm, respectively. The external diameters of the superficial epigastric vessel and common thoracic vessel (both arteries and veins) were below 0.8 mm. The external diameters of the femoral and axillary vessels (veins) were above 0.8 mm. The length of the common thoracic‐long thoracic pedicle was approximately10 mm longer than that of the superficial epigastric pedicle. Conclusions The external diameters of the superficial epigastric vessel and common thoracic vessel are small enough for supermicrosurgery training. The pedicle lengths of both the superficial epigastric and common thoracic‐long thoracic flaps are sufficient to perform free flap experiments. Supermicrosurgical free flaps using these two vessels and a study of the physiology and pharmacology of the flaps will likely be possible in the future.

Open reduction of zygoma fractures with the extended transconjunctival approach and T-bar screw reduction

Background Zygomaticomaxillary complex (ZMC) fractures mostly occur in the form of tripod fractures. The surgical field is accessed using a combination of three classic approaches. However, the subciliary incision may have unfavorable aesthetic results. Herein, the authors report the advantages of the extended transconjunctival approach (ETA) combined with T-bar screw reduction in minimizing scarring and complications for the treatment of ZMC fractures. Methods A total of 26 patients underwent ZMC reduction through the ETA and intraoral approach. A skin incision measuring roughly 5 to 8 mm in length was placed following the lateral canthal skin crease. After releasing the inferior crus of the lateral canthal tendon for canthotomy, the medial periosteum of the lateral orbital rim was preserved for canthal reattachment. A limited subperiosteal dissection and partial relaxing incision of the orbicularis oculi were performed to expose the fracture line of the inferior orbital rim and zygomaticofrontal suture. Reduction was performed using a T-bar screw through the transconjunctivalincision and an elevator through the intraoral incision. Results The aesthetic and functional results were excellent. Successful reduction was achieved and the skin incision was less than 8 mm in 20 cases (76.9%). Only six patients had an additional skin incision (less than 5 mm) to achieve reduction. No cases of ectropion, entropion, or excessive scarring were noted. Conclusions The ETA using a T-bar screw is a useful method for maximizing aesthetic results in ZMC fractures, with the advantages of minimal scarring, faster recovery, and maintenance of pretarsal fullness.

Aesthetic Lateral Canthoplasty Using Tarso-Conjunctival Advancement Technique.

Abstract Reduced horizontal length of the palpebral fissure is a distinctive characteristic of Asian eyelids, and aesthetic lateral canthal lengthening techniques have been performed for a refinement. The aim of this study is to describe a novel lateral canthoplasty using tarso-conjunctival advancement with a lid margin splitting procedure on the upper eyelids and to report the postoperative results. From December 2011 to June 2014, patients who underwent lateral canthoplasty using the tarso-conjunctival advancement procedure for aesthetic purposes were reviewed retrospectively. The predictor variables were grouped into demographic and operative categories. The primary outcome variables were the distances from the mid-pupillary line to the lateral canthus and the horizontal length of the palpebral aperture (distance from the medial to lateral canthus). Data analyses were performed using descriptive and univariate statistics. Patients who showed increment in objective measurements were considered significant. Aesthetic appearance was also evaluated based on pre- and postoperative clinical photographs. A total of 45 patients were enrolled in this study. Both the distance from the mid-pupil to the lateral canthus (&Dgr;Dpupil-lateral; 2.78 ± 0.54 mm, P <0.05) and the palpebral aperture horizontal length (&Dgr;Dmedial-lateral 2.93 ± 0.81 mm, P <0.05) increased significantly from pre- to postoperative state. All the patients demonstrated satisfactory results aesthetically during the follow-up. The tarso-conjunctival advancement technique for lateral canthoplasty produced satisfactory aesthetic results with an enlarged palpebral aperture. Future research is required to fully delineate the risk of possible complications, including injury to the eyelashes and meibomian glands.

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