Sung Won Jung

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]. Pressure 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]. Dissection 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. A 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). Fig. 1 Preoperative photograph of case 1. The defect size was 17×12 cm. Both the testes and anal sphincter were exposed. Fig. 2 Intraoperative photograph of case 1. The defect was covered with a bilateral medial thigh fasciocutaneous flap. Fig. 3 Postoperative 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. A 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. Fig. 4 Preoperative photograph of case 2. The defect size was 10×9 cm. The lower two-thirds of both testes were exposed. Fig. 5 Postoperative 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. In 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. The 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. After flap elevation, the donor site can be closed by primary intention without excessive tension. Aesthetically, the inner part of the thigh is relatively unexposed. In 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.

Postoperative Changes in Isolated Medial Orbital Wall Fractures Based on Computed Tomography

Abstract The treatment has been improved on the accurate reduction of blow-out fracture for many decades. But still, it has been limited to reduce completely when surgeons are approaching by conventional technique. The authors analyzed the postoperative results using computed tomography (CT) scans after conventional open reduction of isolated medial wall fracture. Thirty-seven patients with isolated medial wall fracture were reviewed. All patients underwent preoperative, immediate, and postoperative CT scans. Two surgeons have performed the surgery by conventional open reduction with transcaruncular approach and absorbable mesh insertion. The authors evaluated changing orbital volume and distance, comparing the immediate and 6 months postoperative outcomes with preoperative outcome. The differences between immediate postoperative and 6 months postoperatively data were statistically evaluated. The authors used the distant value to minimize bias of CT view selection. Significant differences from the 2 kinds of data were observed (P < 0.05 for volume, P < 0.01 for distance, Paired t test). Bone remodeling process after conventional open reduction of orbital wall has not been fully understood. Most popular technique is conventional open reduction and mesh insertion but it is not easy for surgeons to reduce fractured bones completely. The authors analyzed the bone remodeling after incomplete reduction. These results suggest that the decreased measurements might be caused from the scar contracture with fibrosis. This research is very limited to explain the change while bone remodeling is progressed. Further research should be continued to discover the understanding of the process.

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.

Preoperative Use of Radiopaque Materials on Fractured Zygomatic Arch.

Fractures of the zygoma are relatively frequent and their management has been extensively described. Above all, isolated zygomatic arch fractures comprise about 10% of all zygomatic fractures. Temporal approach is common surgical method, Gillies approach, but it has the limitation of blinded surgical approach. So, the mobile intraoperative fluoroscan is used famously for more suitable reduction, but it needs an additional man to control the machine and increases irradiation doses. The authors got the simple idea, but so helpful tool, and it has been performed since 2012. The authors have gotten good surgical results, so introduce this idea that favors the surgery on isolated zygomatic arch fracture.

Multiple Epidermal Cysts in the Volar Skin of the Thumb.

Epidermal cysts most commonly occur in hair-bearing areas, such as the scalp, face, neck, trunk, and scrotum, where many pilosebaceous glands are present [1,2]. Epidermal cysts do not commonly develop in the palmoplantar skin due to the absence of pilosebaceous glands. The etiology of epidermal cysts on the palms and soles may not involve inflammation of the hair follicle, but the traumatic implantation of epidermal elements [1,3]. In this report, we describe a case of multiple epidermal cysts that developed in the volar skin of the thumb. A 53-year-old man visited our outpatient plastic surgery clinic, presenting with a slow-growing protruding mass on the left thumb (Fig. 1). He was a carpenter by occupation, and the mass developed after recurrent mechanical trauma by hammering for several decades. The 2.5×2-cm mass was located on the volar side of the distal phalanx of the left thumb. Upon physical examination, the mass was movable, without tenderness, redness, or a sense of warmth. We performed a simple X-ray of the hand to evaluate potential bony abnormalities and ultrasonography to determine the characteristics of the mass. The simple X-ray showed a normal bony appearance without bony erosion due to mass effect. We also found three subcutaneous low echoic masses on ultrasonography (Fig. 2). The overlying skin was incised horizontally and four masses were resected (Fig. 3). Mild adhesion was noted between the masses and the surrounding tissue, which was completely resected. The light microscopic examination of hematoxylin-eosin-stained sections was performed for all masses, which were diagnosed as epidermal cysts by a pathologist (Fig. 4). The wound was closed directly and followed up for two weeks. No complications, such as dehiscence, necrosis, hematoma, tingling sensation or hypoesthesia, or motility dysfunction occurred. Fig. 1 A 2.5×2-cm protruding subcutaneous mass on the left thumb without an abnormal skin lesion. Fig. 2 Three lobulated heterogeneous hypoechoic masses were seen on ultrasonography. The size of the largest mass was 1.3×0.6×1.2 cm and the other two small masses measured 0.5×0.5 cm each. Fig. 3 During the operation, a total of four masses were removed without any remnants. Fig. 4 A postoperative biopsy showed keratin material (KM) surrounded by stratified squamous epithelium (SE) and a granular cell layer adjacent to the keratin-containing cyst lumen. The result was compatible with an epidermal cyst. H&E stain. (A) ×40. ... Epidermal cysts usually result from inflammation around pilosebaceous follicles [4]. However, no pilosebaceous follicles are present in the skin of the palm and the sole of the foot. Epidermal cysts in the palmoplantar skin have been assumed to result from the implantation of epidermal fragments due to a penetrating injury or another form of epidermal trauma [1,5]. Recently, some palmoplantar epidermal cysts have been reported to be caused by human papilloma virus (HPV) infection [4,5]. The pathophysiology of the epidermal cyst in this patient was presumed to be the implantation of an epidermal fragment, since the patient in this case had a history of recurrent occupational mechanical trauma [1,3]. We did not test for HPV infection because the patient did not present any symptoms or signs thereof. Epidermal cysts in the palmoplantar skin are easily confused with warts or calluses. Surgeons should be aware of the possibility of epidermal cysts in palmoplantar skin and be able to diagnose them correctly and design an appropriate treatment strategy.

Modified Dovetail-Plasty in Scar Revision

AbstractScar revision is one of the fundamental techniques in the field of plastic and reconstructive surgery. Local flaps, such as a Z-plasty, W-plasty, or geometric broken-line closure, have been used for scar revision. Camouflaging a scar during scar revision for marginal scars from skin grafts and flaps, trapdoor scars, and linear scars is difficult. We describe our experience with the use of modified dovetail-plasty for scar revision in these difficult areas. Our study group consisted of 28 cases among 22 patients (9 males and 13 females) with a mean age of 33.6 years (range, 6–61 years). The conspicuous scars were located on the face (50%) and extremities (50%). The authors designed Y-shaped incision lines to relax the skin tension lines on one side of the excision line and trapezoid incision lines on the other side. There were 16 follow-up operations performed over 6 months after the initial operation among a total of 22 patients. There were scar depressions (2 patients) and a hypertrophic scar (1 patient) at the interval area between the dovetail flaps. A diffuse hypertrophic scar occurred in 1 patient with a dorsal foot scar. The overall success rates of the procedure as assessed by the surgeons were as follows: excellent (75%), good (12.4%), fair (6.3%), and poor (6.3%). This new local flap can achieve an inconspicuous scar using a blurred scar line and reducing tension. The authors recommend a modified dovetail-plasty for the revision of trapdoor scars and scars under excessive tension.

Retained large glass fragments for over 40 years in the maxillofacial region

Foreign body (FB) impaction in the maxillofacial area could be caused by knives, glass fragments, and vegetative materials. We present the rare case of a 62-year-old man with a large glass FB in the left cheek retained for over 40 years. He had traffic accident over 40 years ago and glass fragments impacted on his left cheek. Glass fragments were retained around the zygomatic arch with dimpled scar and unclear serous discharge, but other facial motor or sensory dysfunction was not observed. We confirmed three glass fragments with radiologic examination including plain radiograph and computed tomographic image. Under general anesthesia, impacted glass fragments were removed through the direct incision on the dimpled scar and the additional incision on the left lateral canthal area. Remnant FBs were not seen on an intraoperative C-arm radiograph. After 2 days of irrigation for inflammation control, the dimpled wound was sutured. The wound was healed without major complication and the original dimpled scar was much improved.