Sug-Won Kim

Simultaneous reconstruction of the Achilles tendon and soft-tissue defect using only a latissimus dorsi muscle free flap.

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenging problem. These patients need not only soft tissue but also dynamic and functional reconstruction. Four cases of major defects of the Achilles tendon and overlying soft tissue after trauma are presented. In each case, the tendon and the overlying soft tissues were reconstructed using only a latissimus dorsi muscle free flap and overlying split-thickness skin graft. In conventional methods, evolved in the reconstruction of the Achilles tendon and soft tissue, the size of the defect was a limit. However, this technique can be used to reconstruct an extensive defect, including distal calf muscle to the plantar metatarsal area. In one case, the flap was harvested in a myocutaneous unit, and the skin portion was deepithelialized for the coverage and enough padding on the bony exposure area in reverse position. The purpose of the present study was to reevaluate the potential of denervated muscle flap for a force-bearing conduit as an alternative reconstructive method of the Achilles tendon. The denervated latissimus dorsi muscle in this study eventually experienced the process of atrophy and fibrosis but maintained its original length. Although there remained some atrophic muscle fibers, a fibrosis of the muscle fibers formed a tendon-like fibrous band, and so the action of the posterior calf muscle could be transmitted through the tendon-like fibrotic change of the denervated latissimus dorsi muscle. The advantages of this technique are that (1) it is a single procedure, (2) it is adaptable to a wide range of defect sizes, (3) it allows faster wound healing supported by well-vascularized tissues, (4) it produces satisfactory function of the ankle joint and a padding effect, and (5) it produces good contour of the posterior calf to the sole and an acceptable donor-site morbidity.A two-part investigation was undertaken to determine whether a four- or a five-flap Z-plasty gives the greatest increase in length (deepening) over the same radius of a web. In part A, flaps were designed on a model of a webspace made from a plastic frame and Speedo fabric; four types of flaps, three different central limb lengths, and three trials for each length gave a total of 36 observations. In part B, flaps were designed on the natural axillary webs of the pig; three Yorkshire pigs with one type of flap per axillary web gave a total of 12 observations. In part A, the stereometric elongation (percent deepening) produced by the five-flap Z-plasty was similar to that of a single 60-degree Z-plasty (4-cm central limb; five-flap versus a single Z procedure, 72.5 ± 4.3 versus 75.0 ± 2.5 percent). The 90-degree four-flap procedure gave a 1.59 times greater deepening than the five-flap procedure (4-cm central limb; 90-degree four flap technique, 114.2 ± 1.4 percent). The 120-degree four-flap technique gave 2.0 and 1.26 times greater deepening than the five-flap and 90-degree four-flap procedures, respectively (4-cm central limb; 120-degree four-flap technique, 144.2 ± 1.4 percent). In part B, the 90-degree four-flap Z-plasty again produced a significantly greater lengthening (1.57 times) than the five-flap procedure (132.7 ± 6.4 versus 84.0 ± 4.0 percent; p < 0.05), and the percentage of elongation of the 120-degree four-flap procedure was 1.27 times greater than that of the 90-degree four-flap technique (167.3 ± 7.0 versus 131.3 ± 2.3 percent; p < 0.05). In conclusion, the four-flap Z-plasty produced greater webspace deepening than that of the five-flap Z-plasty. The 120-degree four-flap procedure gave the greatest percentage of elongation, but it was more difficult to design and close than the 90-degree four-flap Z-plasty.

Coverage of difficult wounds around the knee joint with prefabricated, distally based sartorius muscle flaps.

The coverage of soft-tissue defects around the knee joint presents a difficult challenge to the reconstructive surgeon. Various reconstructive choices are available depending on the location, size, and depth of the defect relative to the knee joint. However, the knee joint frequently accompanies injuries to the lower leg that may limit the use of muscle flaps, especially the gastrocnemius muscle. The use of a free flap is preferred for reconstruction involving obliteration of large-cavity defects, but the isolation of recipient pedicle can be difficult because of the extent of injury zone and in cases of chronic infection around the knee. To provide muscle bulk with a reliable vascular supply, the distally based, prefabricated sartorius muscle flap was used as a last resort to reconstruct difficult wounds with chronic osteomyelitis around the knee joint in 6 patients from June 1995 to May 2001. This method is a two-stage procedure. First, the sartorius muscle is prefabricated by denervation and vascular delay. Silicone sheets are used to increase the vascularity and dimension of the flap. Second, after 3 weeks, the muscle is transposed based on a distal pedicle to reconstruct the soft-tissue defect around the knee. The prefabricated sartorius muscle can provide efficient bulk to obliterate the dead space and to cover moderate-size soft-tissue defects around the knee joint. This method can be considered to reconstruct the soft tissue around the knee joint when local muscle flaps and free flaps are not feasible.

Unilateral multilayered musculocutaneous V-Y advancement flap for the treatment of pressure sore.

&NA; We have devised a modified technique using the gluteus maximus musculocutaneous flap as multilayered sliding V‐Y advancement to cover pressure sores on the sacral area. Nine patients with relatively large (average 7 × 7 cm) sacral grade IV pressure sores underwent unilateral multilayered V‐Y advancement flap. All patients were followed for a minimum of 8 weeks. The mean postoperative follow‐up was 32.3 months, with a range of 24 to 39 months. Using this technique, the success of surgery, i.e., the percentage of sores that healed, was 100 percent in our patients. The advantages of this technique include sufficient advancement of the flap, coverage of large ulcer defects using only a unilateral musculocutaneous flap, and preservation of the contralateral gluteus maximus muscle for future use. (Plast. Reconstr. Surg. 100: 340, 1997.)

Reconstruction of composite metacarpal defects using a fibula free flap.

Vascularized bone flaps provide reliable replacement for bony deficits in the extremities and face. Vascularized bone heals faster, with less bony absorption or atrophy, and is more reliable than nonvascularized bone in settings of scar, infection, or irradiation. The free fibula flap, introduced by Taylor et al.1 in 1975, has been used extensively for skeletal reconstruction of extremities2 and mandible.3,4 We report the use of the free fibular flap to reconstruct two complex hand injuries with metacarpal and soft-tissue deficits.

Effect of botulinum toxin type A injection into human masseter muscle on stimulated parotid saliva flow rate

Botulinum toxin type A (BTX-A) injection into the masseter muscles is used to treat masseteric hypertrophy. No serious side effects of BTX-A have been reported, but patients sometimes complain of xerostomia. The aim of this study was to evaluate the effect of injecting BTX-A into the masseter for the treatment of masseteric hypertrophy on the flow of saliva from the parotid gland. 34 volunteers enrolled in this study. A total of 25 units of BTX-A was injected into each side bilaterally at two points at the center of the lower third of the masseter muscle. Saliva was collected from the parotid gland over a period of 10 min to determine the flow rate for 18 weeks after injection. The flow rate was calculated by dividing the amount in milliliters by the collection time in minutes. There were no significant changes in the stimulated parotid saliva flow at 4, 8, 12 or 18 weeks compared with the baseline. Within this limited study, it can be concluded that BTX-A injection into the masseter does not cause any significant decrease in the production of saliva from the parotid gland.

A vascularized osteocutaneous fibular free flap for reconstruction of a complex injury of the foot

The foot plays a vital role in standing and gait. Its function results from harmonious interaction of bones, joints, and soft tissue. An imbalance or a defect in these structures can result in problems. The cuneiform bone of the foot consists of three bones: medial, intermediate, and lateral. Its structure plays an important role in maintaining the skeletal arch and it supports the bodys weight. A defect or dislocation can disrupt the distribution of the weight-bearing complex of the foot and can lead to difficult gait.

Changes in masticatory function after injection of botulinum toxin type A to masticatory muscles.

This study examined changes in masticatory function after botulinum toxin type A (BTX-A) injection using objective and subjective tests during 12xa0weeks. Also, we compared differences in masticatory function between group in which only masseter muscle (M group) was injected and group in which masseter and temporal muscle (M-T group) were injected. Forty subjects were assigned into two groups; M group (nxa0=xa020) and the M-T group (nxa0=xa020). The Meditoxin(®) was used as BTX-A injection. The mixing ability index (MAI) was used as the objective indicator, and visual analogue scale (VAS) and food intake ability (FIA) index were used as subjective indicators. Overall, the masticatory function drastically declined after 4xa0weeks and gradually recovered with time. Compared with the pre-injection state, the masticatory function decreased by 89·2% (MAI), 12·2% (FIA) and 32·2% (VAS) 4xa0weeks after the injection (Pxa0<xa00·05). When the results between M group and M-T group were compared, scores of VAS and FIA were significantly different 4xa0weeks after the injection (Pxa0<xa00·05), but the MAI score showed no significant difference between two groups. In conclusion, this study showed that masticatory function was significantly decreased after BTX-A injection into the masticatory muscle after 4 and 8xa0weeks from injection. However, masticatory efficiency measured using MAI could completely recover after 12xa0weeks. Furthermore, after 8xa0weeks from the injection, the masticatory function measured after injection into only the masseter muscle was similar to that measured after injection into both masseter and temporal muscle.