Suk Joon Oh

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.

Prevention and treatment of wide scar and alopecia in the scalp: wedge excision and double relaxation suture.

The visible linear scar of the scalp is a cosmetically serious complication of a scalp incision in scalp surgery, forehead lift, and craniofacial surgery, especially on the temporal scalp. Its causes are cicatrical alopecia and scar widening. To solve this problem, we performed the wedge excision of the scalp and the double relaxation suture of the galea in 2 patients undergoing facial surgery through the coronal approach and in 15 patients with scalp alopecia ranging from 0.5 to 3.0 cm in width. The wedge excision using the beveling incision at an angle of 30 degrees to the hair follicles preserves the deep hair follicles of the flap margins and allows the hair to grow into the scar, eventually preventing cicatricial alopecia and camouflaging the linear scar. The double relaxation suture of the trimmed galea with nonabsorbable suture with or without the relaxation incision minimizes skin tension for a long time, eventually preventing scar widening. This procedure was followed by the superficial skin suture for maintaining the skin sutures for a long time and avoiding the injury of the superficial hair follicles. In all patients, we observed an excellent cosmetic result of unnoticed scar line without complications during the follow-up period of 10 weeks to 6 months.

Weight-bearing plantar reconstruction using versatile medial plantar sensate flap

The medial plantar flap serves as an ideal tissue reserve for reconstructing the weight-bearing plantar areas as these areas require a sensate and glabrous skin. Furthermore, the flap provides tissue that is structurally similar to the plantar foot as it is also composed of thick glabrous plantar skin, shock-absorbing fibro-fatty subcutaneous tissue and plantar fascia. During the past 25 years, 20 patients (10 men, 10 women) with skin and soft-tissue defects over the weight-bearing plantar foot were treated. They ranged in age from 20 to 70 years (mean, 31.5 years). The causes of the defects were trauma (n=14) and malignant tumour (n=6); the defects were localised at the heel (n=16) and plantar forefoot (n=4). The medial plantar flap was transposed to the defects in three different ways: proximally pedicled sensorial island flaps (n =8), distally pedicled sensate island flaps based on the lateral plantar vessel (n =3) and neurovascular free flaps (n =9). Flap size varied from a width of 4-8cm and a length of 6-12cm. The mean size of the medial plantar flap was 49.5cm(2) (range, 28-96cm(2)). The follow-up period ranged from 6 to 80 months (mean, 19.9 months). Partial flap loss was observed in two proximally pedicled sensorial island flaps and one distally pedicled sensate island flap. Two free flaps restored normal sensation within 5 years of surgery. Minor skin graft loss at the donor site was observed in seven patients. However, no revision or re-grafting was performed. Hyperkeratosis was observed in one case. All patients achieved normal gait within 3 months after surgery and none noticed recurred ulceration. Durable, sensate coverage of the defects was achieved in all patients. We advocate variable sensate medial plantar flaps for the reconstruction of moderate-size defects of the weight-bearing plantar subunits.

Fist position for skin grafting on the dorsal hand : I. Analysis of length of the dorsal hand surface in hand positions

In skin grafting for reconstruction of burns and contracture deformities of the dorsal hand, the hand is kept in a proper position to provide the greatest amount of skin and to avoid the secondary functional deformity. The safe position has been commonly used for immobilizing the hand, but this is to protect the hand function rather than to provide maximal surface for skin grafting. Split-thickness skin graft contracts up to 30 to 50 percent of the original size owing to secondary contraction. If insufficient skin is grafted, contracture deformity of the dorsal hand may occur. To graft the greatest amount of skin on the dorsal hand, the hand should be kept preoperatively in a position flexing all joints of the wrist, metacarpophalangeal joints, and interphalangeal joints and maximally stretching the dorsal hand (a fist position). We studied the surface length of the dorsal hand between the wrist, the metacarpophalangeal joint, and the eponychium in the anatomic, safe, and fist positions of the right hand in 60 adults. Difference of total length between the anatomic and safe positions was not statistically significant (p > 0.05). The total length in a fist position was significantly increased in comparison with the other two positions (p < 0.05). In a fist position compared with the safe position, the increase in length of the dorsal surface of the proximal hand was 11 to 20 percent except in the thumb, and the increase in length of the dorsal surface of the finger was 12 to 17 percent. The increase in total length of a fist position was about 9 mm (7 to 8 percent) in the thumb and 20 to 32 mm (14 to 18 percent) in the index to little fingers. It suggests that the safe position fails to provide an increased dorsal hand surface area for skin grafting compared with the anatomic position. The greatest amount of skin can be grafted in a fist position. Hand immobilization in a fist position for 7 to 9 days after skin grafting has not resulted in irrevocable joint stiffness in our experience. If injury of the deep structures is not present, the hand should be immobilized in a fist position before skin grafting on the dorsal hand.

Combined AlloDerm® and thin skin grafting for the treatment of postburn dyspigmented scar contracture of the upper extremity

Postburn dyspigmented scar contractures of the upper extremity often require aesthetic improvement. The ideal reconstruction of this deformity remains a challenge because the various available skin grafts and flaps result in skin colour mismatches, prominent marginal scars and donor morbidity. Postburn scar contractures and dyspigmented areas of the upper extremity can be improved by a combination of dermabrasion and Alloderm(®) graft over scar-releasing defect. Their raw surfaces are subsequently re-surfaced with thin split-thickness skin graft (0.005-0007 inches thick). Twenty-seven patients with wide dyspigmented scar contractures of the upper extremity underwent the combined techniques described by us. The median patient age at burn incidents was 3 years and at operation was 24 years. Median thin skin graft area was 180cm(2), and the median AlloDerm(®) graft area was 40cm(2). Thin skin and AlloDerm(®) grafts took root completely in all patients without re-grafting. Follow-up periods ranged from 30 to 67 months (average 47.6 months). Re-pigmentation was achieved in all cases and all scar contractures were adequately released and treated with an AlloDerm(®) graft. Paired differences between preoperative and postoperative parameters as determined by the Vancouver Scar Scale (VSS) were significant. Focal hypertrophic scar and reddish-coloured graft sites gradually improved over 3-4 years postoperatively. Graft margin and donor scars were inconspicuous. Our described combined technique was found to treat these deformities effectively. We suggest that the use of Alloderm(®) and thin skin grafting be considered in patients concerned about this type of cosmetic disfigurement.

A review of microvascular ear replantation.

Microvascular ear replantation is a significant challenge because of the small size of the vessels and the fact that traumatic amputations are frequently avulsed. The zone of trauma is therefore extended and the primary repair of the injured vessel is rendered unlikely. The purpose of this study is to review the literature of ear replantation. A review of the relevant literature that has been published since 1980 revealed 47 cases reported in 37 publications. We present 5 cases from our own experience and analyze a total 52 cases of microvascular ear replantation. The patients age, sex, degree of amputation, cause of injury, ischemic time, method of arterial and venous anastomosis, complications, any additional outflow used, postoperative medications, the requirement for transfusions, and the number of hospital admission days are described. Successful microvascular ear replantations require anastomosis of the vessels if possible. Rather than a vein graft, primary repair of the vessels, or at least pedicled repair of the artery, should be considered to ensure flap survival. In addition, vein repair should be considered if possible to ensure the secure drainage of blood from the replant. With secure circulation, the replant can survive, resulting in a very satisfactory outcome.

Surgical treatment of dermatomal capillary malformations in the adult face.

Background Facial capillary malformations (CMs) rarely recede; they often become darker and raised in proportion to their growth. These malformations may hypertrophy in adulthood, resulting in increased disfigurement and dysfunction. Laser treatment is considered a first-line therapy for focal CMs, but thick wide lesions, which are accompanied by hypertrophy and have a well-circumscribed nodularity, may be treated with surgical excision and reconstruction. Methods We retrospectively reviewed the records of 25 consecutive patients who had undergone complete or partial excisions of facial capillary malformations in our unit. After the excisions, the defects that encompassed their facial aesthetic units were subsequently covered by various methods, including primary closures, local flaps, expanded flaps, split-thickness skin grafts, and full thickness skin grafts. Results The data demonstrated satisfactory results and reliability. Our patients were treated without significant complications, and all of the patients were moderately or fully satisfied with the outcome of their surgeries. Conclusions Among the many reconstructive options for adult patients with facial capillary malformations, thick split-thickness skin grafts can be a good choice for the coverage of widely excised wounds.

Reconstruction of a Perineoscrotal Defect Using Bilateral Medial Thigh Fasciocutaneous Flaps

There are many reasons for skin defects of the perineoscrotal area. These defects can result from severe infection with gangrene and loss of the covering skin. Traumatic avulsions of the scrotal and penile skin are commonly caused by clothing being caught in revolving machinery, automobile versus pedestrian accidents, falls, rare bull-horn avulsion injuries, the excision of scrotal skin diseases and genital burns [1]. n nPressure sores of the ischial region have been treated with muscles and skin of the medial part of the thigh. Hirshowitz and Peretz [2] introduced superomedial thigh flaps in the reconstruction of the scrotum and vulva in 1982. We present two cases using medial thigh fasciocutaneous flaps in the reconstruction of wide skin defects of the perineoscrotal area. The operations were performed under general anesthesia and in the lithotomy position. We first used a Doppler sonogram to mark the external pudendal, superficial femoral, and medial circumflex femoral arteries at the area 5 cm lateral to the pubic tubercle. Then, a triangular flap was designed. A line was drawn extending from the pubic tubercle to the insertion area of the semitendinosus tendon. The anterior border of the flap may lie a centimeter or so anterior to this line. A triangular flap 9 cm in width can be safely elevated distally 20 cm along that border [3]. n nDissection begins distally to identify the deep fascia, which must be included with the flap. To preserve the main pedicles, surgeons must not dissect near a line 5 cm lateral to pubic tubercle. After avoiding the loss of septocutaneous perforators in the dissection, the flap, including the fascia, was raised from the distal aspect, advanced cephalad and rotated medially toward the inguinal canal using the pedicles of the three arteries as a pivot point. Superficial subcutaneous tissues and veins may be included in the pedicle if they do not prevent flap mobilization [4]. Then, the distal end of the flap was rotated toward the anus, and the posterior end of the flap was rotated toward the penis. After coverage of the defect with bilateral flaps, donor site closure could be achieved by primary intention. n nA 46-year-old man had a wide perineoscrotal defect due to Fourniers gangrene. He had undergone a colostomy due to anal sphincter dysfunction. The size of the defect was 17×12 cm and included perineal and scrotal skin (Fig. 1). The defect was covered with a bilateral medial thigh fasciocutaneous flap. The size of each flap was 18×7 cm, and primary closure was performed to close the donor site (Fig. 2). The colostomy failed on postoperative day 2. The wound became infected due to fecal contamination and dehisced with partial loss of the perianal flap. On postoperative day 20, the wound was revised under local anesthesia with debridement and primary closure. There was no further flap loss, wound dehiscence, or scar contracture as of 6 months postoperatively (Fig. 3). n n n nFig. 1 n nPreoperative photograph of case 1. The defect size was 17×12 cm. Both the testes and anal sphincter were exposed. n n n n n nFig. 2 n nIntraoperative photograph of case 1. The defect was covered with a bilateral medial thigh fasciocutaneous flap. n n n n n nFig. 3 n nPostoperative photograph of case 1 after 6 months. There is no severe scar contracture as can result from a skin graft, and the contour of the reconstructed scrotum looks similar to a normal scrotum. n n n nA 54-year-old man had a perineal defect due to trauma. He had hepatocellular cell carcinoma, which impaired his coagulation function. The size of the defect was 10×9 cm (Fig. 4). The defect area was mainly the lower two-thirds of his scrotum and included perineal skin. The defect was covered with bilateral medial thigh fasciocutaneous flaps and remnant scrotum. The size of each flap was 5×6 cm. The wound healed without problems such as hematoma. There were no significant complications or operative site problems as of 3 months postoperatively (Fig. 5). Reconstruction of the perineoscrotal area after complete loss of the overlying skin is a challenging problem for reconstructive surgeons [1]. The fasciocutaneous flap provides durable skin and a large area of soft tissue coverage for reconstructing scrotal and perineal defects. With this thin flap coverage, it produces an acceptable cosmetic effect. n n n nFig. 4 n nPreoperative photograph of case 2. The defect size was 10×9 cm. The lower two-thirds of both testes were exposed. n n n n n nFig. 5 n nPostoperative photograph of case 2 after 3 months. There is no severe scar, as can result from a skin graft, and the contour of the scrotum is exposed naturally due to the thin flaps and remnant scrotal skin. n n n nIn our cases, the defect areas included both the scrotum and perineum. As mentioned above, surgeons should consider not only the extent of coverage but also aesthetic and functional aspects in cases of scrotal reconstruction. n nThe medial thigh fasciocutaneous flap is an axial pattern flap that consists of perforators of three arteries: the external pudendal, superficial femoral, and medial circumflex femoral arteries. The presence of axial vessels from the medial femoral circumflex artery and vein has been demonstrated by transillumination at the time of surgery and by cadaveric study [2,3,5]. Because of the longitudinal axial interconnections of these three vessels above the deep fascia of the medial thigh, preservation of only the proximal afferents of each pedicle allows for safe elevation of this large, longitudinally-oriented medial thigh fasciocutaneous flap [3]. With this anatomical understanding, the flap can be medially rotated approximately 90 degrees at the lithotomy position, while preserving the axial vessels, to cover the defect. We thought bilateral flaps could maintain the scrotal shape aesthetically better than other unilateral flaps. Compared to other cases of unilateral flap coverage, the midline scar after bilateral flap insertion can substitute for the perineal raphe aesthetically. With thin fasciocutaneous flap coverage, the contour of the reconstructed scrotum looks similar to a normal scrotum. n nAfter flap elevation, the donor site can be closed by primary intention without excessive tension. Aesthetically, the inner part of the thigh is relatively unexposed. n nIn conclusion, bilateral medial thigh fasciocutaneous flap is a safe and effective procedure in perineoscrotal reconstruction without donor site morbidity for both small and large defects.

Ilizarov distraction and vascularized fibular osteocutaneous graft for postosteomyelitis skeletal deformity of the forearm.

The reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. This paper reports on the treatment of bone defects caused by osteomyelitis of the radius using an Ilizarov distraction technique and a vascularized fibular graft. A 25-year-old man first presented with a right radial defect caused by osteomyelitis when he was 3 years old. His right forearm was shortened and angulated with a dislocation of the distal radio-ulnar joint. The defect in the radial shaft was noted on a radiograph. The reconstruction of his radial bone defect was performed in three separate operations. A two-stage Ilizarov application was performed. Ten months after this operation, the radial bone defect was reconstructed with a vascularized fibular osteocutaneous graft. The right radius was shortened by 10 mm due to the angulation in the distal fixation of the graft 14 years after surgery. Although limited motions of the right thumb extension and wrist supination were noted, other hand functions were adequately restored. The Ilizarov technique is an effective method for correcting distal radio-ulnar joint dislocations and shortened, angulated ulnar bones. The specific features of the vascularized fibular graft make it suitable for the bone reconstruction of large defects in the radius.

Combined rotation and advancement flap reconstruction for a defect of the upper lip: 2 cases.

Many types of upper lip reconstruction have been introduced to treat defects after a tumor excision or trauma. The authors treated two cases of upper lip defects. A 35-year-old woman presented with a squamous cell carcinoma of the left upper lip that had invaded the corner of the mouth. After resecting the tumor, the defect was 3.7×3.5 cm in size. A 52-year-old woman presented with a dog bite of the right upper lip. The defect measured 4.0×2.2 cm in size. The two cases were reconstructed by combined rotation and advancement of a cheek flap. This technique produced a good functional outcome that allowed for oral competence and created an opening of adequate size. A combination of rotation and an advancement flap can be used to treat upper lip defects in a single-stage procedure. This approach produces a good functional and cosmetic outcome.