Seung-Kyu Han

The timing of neovascularization in fingertip replantation by external bleeding.

&NA; To overcome venous congestion in fingertip replantation with no venous anastomosis, the authors have used a salvage procedure that consists of continuous external bleeding through a stab incision on the paraungual area and dripping a heparinized saline solution at the incision site to maintain external bleeding. Because this method requires continuous bleeding for a certain period of time, it may be a great burden on the patient; therefore, it is most important to minimize the duration of bleeding. Many authors have studied the timing of the new venous channel formation of the flap. However, to our knowledge, a study on fingertip replantations has not yet been performed. From June of 1985 to November of 1999, the authors performed fingertip replantations on 144 fingers of 137 patients using our salvage procedure at Korea University Guro Hospital. Among the 144 fingers, 101 fingers of 96 patients were successfully transplanted, including those with partial necrosis. The authors reviewed the medical records of these 101 fingers retrospectively; they compared and analyzed the necessary duration of external bleeding according to sex, age, level of injury, cause of amputation, and the type of injury. The average period of the salvage procedure was 7.6 days. Regarding age, the shortest period (5.5 days) was required for patients younger than 10 years. On the basis of the types of injuries, the duration of bleeding was shortest for the guillotine injury group (5.9 days) compared with crush (8.2 days) or avulsion (8.0 days) injuries. Sex and level of injury did not make much difference in the duration of the procedure. (Plast. Reconstr. Surg. 110: 1042, 2002.)

Anthropometric Study of Alar Cartilage in Asians

Measurements of 52 alar cartilages in 26 Koreans were obtained for an anthropometric study during primary open-approach rhinoplasties. The lateral crura were found most commonly to be concave, exhibited in 40% of the male patients and in 50% of the female patients. The medial crura were most often straight, found in 56% of the male patients and in 46% of the female patients. The average length, width, and thickness of the lateral crura were 19.7 mm, 10.5 mm, and 0.55 mm, respectively, in men; and 16.8 mm, 9.8 mm, and 0.54 mm, respectively, in women. The lengths of the columellar and footplate segments of the medial crura were 10.0 mm and 7.8 mm in men, and were 8.0 mm and 6.3 mm in women. These data suggest that the alar cartilage in Asians, contrary to popular myth, is not markedly smaller than that of whites. However, differences were found in the configuration of the cartilage and the length of the footplate of the medial crus.

Randomised controlled clinical trial for autologous fibroblast-hyaluronic acid complex in treating diabetic foot ulcers

OBJECTIVE Diabetic foot ulcers (DFUs) often pose a treatment problem. Bioengineered skin substitutes have been reported to result in accelerated diabetic wound healing. The purpose of this clinical trial was to evaluate the efficacy and safety of the autologous fibroblast-hyaluronic acid complex for treating DFUs. METHOD A stratified, randomised, controlled, multicentre study was carried out. Patients with DFUs were allocated to either a treatment group with grafting of an autologous fibroblast-hyaluronic acid complex or a control group with non-adherent foam dressing. Except for application of the fibroblast complex, treatment of the study ulcers was identical for patients in both groups. The maximum follow-up period for each patient was 12 weeks. RESULTS Complete ulcer healing was achieved in 84% (26/31 patients) of the treatment group and 34% (11/32 patients) of the control group (p<0.05). The times required for complete healing were 36.4 ± 17.6 and 48.4 ± 13.1 days in the treatment and control groups, respectively (p<0.05). No adverse events related to treatment occurred. CONCLUSION These results indicate that autologous fibroblast-hyaluronic acid complex may offer a safe and effective treatment for DFUs.

Is the foot elevation the optimal position for wound healing of a diabetic foot

In managing diabetic foot ulcers, foot elevation has generally been recommended to reduce oedema and prevent other sequential problems. However, foot elevation may decrease tissue oxygenation of the foot more than the dependent position since the dependent position is known to increase blood flow within the arterial system. In addition, diabetic foot ulcers, which have peripheral vascular insufficiency, generally have less oedema than other wounds. Therefore, we argue that foot elevation may not be helpful for healing of vascularly compromised diabetic foot ulcers since adequate tissue oxygenation is an essential factor in diabetic wound healing. The purpose of this study was to evaluate the influence of foot height on tissue oxygenation and to determine the optimal foot position to accelerate wound healing of diabetic foot ulcers. This study included 122 cases (73 males and 47 females; two males had bilateral disease) of diabetic foot ulcer patients aged 40-93 years. Trans-cutaneous partial oxygen tension (TcpO(2)) values of diabetic feet were measured before and after foot elevation (n=21). Elevation was achieved by placing a foot over four cushions. We also measured foot TcpO(2) values before and after lowering the feet (n=122). Feet were lowered to the patients tibial height, approximately 30-35 cm, beside a bed handrail. Due to the large number of lowering measurements, we divided them into five sub-groups according to initial TcpO(2.) Tissue oxygenation values were compared. Foot-elevation-lowered TcpO(2) values before and after elevation were 32.5+/-22.2 and 23.8+/-23.1 mmHg (p<0.01), respectively. Foot-lowering-augmented TcpO(2) values before and after lowering were 44.6+/-23.8 and 58.0+/-25.9 mmHg (p<0.01), respectively. The lower the initial TcpO(2) level, the more the TcpO(2) level increased. The foot lowering, rather than elevation, significantly augments TcpO(2) and may stimulate healing of diabetic foot ulcers.

Extended incision in open-approach rhinoplasty for asians.

The purpose of this study was to introduce an extended incision in open-approach rhinoplasty for obtaining greater satisfaction in aesthetic rhinoplasty for Asians. This incision is the same as for the usual open rhinoplasty incision, but it is extended along the caudal border of the footplates of the medial crura onto the floor of the nasal vestibule to access the footplates of the medial crura more easily. This simple extended incision enabled the authors to achieve further tip projection because the pressure of the skin flap on the tip was reduced. By approximating the lateral curves of the medial crural footplates, the width and the length of the columella were narrowed and lengthened, respectively. The columella was also advanced caudally; thus, the shape of the nostrils could also be elongated. In addition, a cartilage graft or an implant insertion for alar base augmentation could be performed through this extended incision without an additional incision. Another advantage was that in correction of caudal septal deviation, displaced septal cartilage could be repositioned by suturing to the periosteum or soft tissue around the anterior nasal spine without drilling into it through an intraoral incision. Fifty-one consecutive patients who underwent this extended open-approach rhinoplasty between August of 1999 and September of 2000 were included in this study. A total of 40 patients had an adequate follow-up time of over 6 months. Patient satisfaction and postoperative complications were recorded. The majority of the patients (35 of 40) were satisfied with the results of the procedure. Two patients had complications of nostril-scar contracture requiring close follow-up. There were no cases of implant extrusion, displacement, or infection. No patients experienced transcolumellar or extended-incision scarring. Although further studies and longer follow-up are needed to determine the value of this incision, the authors believe that the addition of the extended incision in open-approach rhinoplasty is safe and reliable for effecting better results for Asians.

Reconstruction of extensive abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh flap: A case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator‐based pedicled anterolateral thigh (ALT) flap is presented. A 30‐year‐old man presented with recurrent desmoid‐type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full‐thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator‐based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator‐based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects.

Influence of the pedicle orientation and length on viability of unipedicled venous island flaps

The use of unipedicled venous flaps has been limited due to their unconventional perfusion patterns and inconsistent survival. Further information regarding the optimal conditions required for unipedicled venous flap coverage is needed to increase flap survival. The purpose of this study was to investigate the effect of the pedicle orientation and length on the viability of unipedicled venous flaps based on a review of our clinical experience. Thirty‐one skin and soft tissue hand defects of 29 patients were treated with unipedicled venous flaps. Sixteen defects were treated with proximally pedicled flaps and 15 were treated with distally pedicled flaps. Five of the 16 proximally pedicled flaps and eight of the 15 distally pedicled flaps had pedicle lengths ≥ 5 cm. All proximally pedicled flaps survived, and distally pedicled flaps with pedicle lengths <5 cm (n = 7) also survived. Distally pedicled flaps with pedicle lengths ≥5 cm (n = 8) developed congestion within 1–2 days after surgery, and external bleeding was applied. Four of the eight flaps survived completely, and partial necrosis developed in the other four. The results demonstrate that proximally pedicled venous flaps of the hand can survive regardless of pedicle length. Distally pedicled venous flaps can also survive completely when pedicle length is <5 cm. Distally pedicled venous flaps with pedicle lengths ≥5 cm should be used with caution.

Basics of Wound Healing

We all experience our fair share of wounds during the course of our lives. We get pricked by thorns, scratched by sharp objects, sunburned at the beach, and scalded by hot water. Accidents can lead to our skin being peeled or sliced off, and many of us may undergo surgical procedures which inevitably result in surgical wounds on our bodies. Selecting an appropriate wound healing strategy is crucial for successful wound healing in that it can minimize the risk of complications, enhance the speed of wound healing, and minimize scar formation after the wound has fully healed. During the past few decades, various technologies have been developed for optimal wound healing. In order to understand new techniques, procedure, and materials in wound healing, medical professionals should have a basic knowledge of wound healing. In this chapter, clinically useful anatomy of the skin, terminology and documentation for wounds, basic wound healing process, and conventional wound healing methods will be briefly described prior to the main topics of this book.

A prospective randomized study comparing fibrin sealant versus suture for conjunctival wound closure in orbital wall fracture surgery

The purpose of this randomized prospective study was to compare the clinical outcomes of orbital wall fracture surgery involving transconjunctival wound closure with fibrin sealant to the outcomes achieved with a conventional suture method. All surgeries were performed using the same technique, except that the conjunctival closure was achieved using either a buried 6-0 Vicryl suture (n=10) or fibrin sealant (n=10). The time to conjunctival closure and time required for complete wound healing were investigated. Postoperative discomfort in the two groups was compared at day 1, day 3, week 1, and week 4. Postoperative subconjunctival haemorrhage and peri-orbital ecchymosis were observed. The mean conjunctival closure time was significantly shorter in the fibrin group than in the suture group. All conjunctival wounds healed by the end of the first week. On postoperative days 1 and 3, the discomfort scores were significantly lower in the fibrin group. Subconjunctival haemorrhage and peri-orbital ecchymosis were less frequent in the fibrin group. Fibrin sealant proved to be as effective as sutures for conjunctival wound closure. Fibrin sealant allows a more comfortable early postoperative course and may be an excellent alternative for conjunctival wound closure in orbital wall fracture surgery.

Interactive Wound Dressings

The ideal dressing material should provide a moist environment to the wound while shielding it from bacterial invasion. The traditional gauze dressing cannot maintain a moisturized environment or absorb excess exudates, and gauze fibers are too widely spaced to effectively block out bacterial invasion. Recently, various interactive (or advanced) dressing materials have been developed to promote cell activity or to minimize scar formation and are currently in active use. One can choose from film, hydrocolloid, hydrogel, foam, hydrofiber, biologic, and composite dressings to suit one’s needs according to the condition of the wound. In this chapter, information of interactive wound dressings including classification, function, and selection is presented. In addition, advantages, action mechanisms, and precautions of silver- and iodine-based antimicrobial dressings are described. In particular, feature of a new polyurethane foam dressing impregnated with 3 % povidone-iodine, which has been recently developed to overcome the limitations of current silver-containing foam dressings, is demonstrated.