Tai Suk Roh

The effect of botulinum toxin A on skin flap survival in rats.

This study examines the role of botulinum toxin type A (BoTA) in preventing the collapse of the peripheral vessels in the cutaneous flap and in increasing the survival of the flap. Because BoTA cleaves the SNAP‐25 protein, the release of vasoconstriction cotransmitters as well as acetylcholine would be blocked. Dorsal skin flaps in rats were elevated and returned to the original position. In the BoTA and the control group, either BoTA or saline was injected into the entire flap. The flap survival rate measurement and a histopathological examination were performed 1 week after flap elevation. The cutaneous blood flow was measured in three different areas of each flap, serially. In BoTA group, there was a significant increase in the survival rate (93.79 ± 6.06%, p=0.042). In the control group, the blood flow was decreased significantly immediately after flap elevation. The blood flow was high in all areas in the BoTA group in a week, and also most of the vessels maintained their shape without collapsing. In conclusion, pretreatment with BoTA increases the dorsal skin flap survival in rats by increased perfusion, and further studies should be performed to determine the possible mechanism by which BoTA attenuates the sympathetic vasoconstriction effect in skin flaps.

Ischemic oculomotor nerve palsy and skin necrosis caused by vascular embolization after hyaluronic acid filler injection: a case report.

AbstractHyaluronic acid filler injection is widely used for soft tissue augmentation. However, there can be disastrous complications by direct vascular embolization. We present a case of ischemic oculomotor nerve palsy and skin necrosis after hyaluronic acid filler injection on glabellar.Blepharoptosis, exotropia and diplopia developed suddenly after the injection, and skin necrosis gradually occurred. Symptoms and signs of oculomotor nerve palsy continuously improved with steroid therapy. Skin defects healed with minimal scars through intensive wound care.Percutaneous filler injection of periorbital areas should be performed carefully by experienced surgeons, and the possibility of embolization should be considered promptly if symptoms develop.

Inferior gluteal artery perforator flap: a viable alternative for ischial pressure sores

The ischial area is by far the most common site for pressure sores in wheelchair-bound paraplegic patients, because most of the pressure of the body is exerted on this area in the seated position. Even after a series of successful pressure sore treatments, the site is very prone to relapse from the simplest everyday tasks. Therefore, it is crucial to preserve the main pedicle during primary surgery. Several surgical procedures, such as myocutaneous flap and perforator flap, have been introduced for the treatment of pressure sores. During a 4-year time period at our institute, we found favourable clinical results using the inferior gluteal artery perforator (IGAP) procedure for ischial sore treatment. A total of 23 patients (20 males and three females) received IGAP flap surgery in our hospital from January 2003 to January 2007. Surgery was performed on the same site again in 10 (43%) patients who had originally relapsed after undergoing the conventional method of pressure sore surgery. The average age of patients was 47.4 years (range 26-71 years). Most of the patients were paraplegic (16 cases, 70%) and others were either quadriplegic (four cases, 17%) or ambulatory (three cases, 13%). Based on hospital records and clinical photographs, we attempted to assess the feasibility and practicability of the IGAP flap procedure through comparative analysis of several parameters including the size of the defective area, treatment modalities, relapses, complications, and postoperative treatments. The average follow-up duration for 23 subjects was 25.4 months (range 5-42 months). All flaps survived without major complications. Partial flap necrosis developed in one case but secondary healing was achieved and the final outcome was not impaired. Most of the cases healed well during the follow-up period. Postoperative complications such as wound dehiscence and fistula developed in some subjects, but all healed well with a secondary treatment. A total of five cases relapsed after surgery due to tissue deficit and these were treated with bursectomy and muscle transposition flap to fill the dead space. We propose that the IGAP flap should be considered a viable alternative to other methods of ischial pressure sore surgery owing to its many advantages, which include the ability to preserve peripheral muscle tissue, the variability of flap designs, relatively good durability, and the low donor site morbidity rate.

The Use of Matriderm and Autologous Skin Graft in the Treatment of Full Thickness Skin Defects

Background For patients with full thickness skin defects, autologous Split-thickness skin grafts (STSG) are generally regarded as the mainstay of treatment. However, skin grafts have some limitations, including undesirable outcomes resulting from scars, poor elasticity, and limitations in joint movement due to contractures. In this study, we present outcomes of Matriderm grafts used for various skin tissue defects whether it improves on these drawbacks. Methods From January 2010 to March 2012, a retrospective review of patients who had undergone autologous STSG with Matriderm was performed. We assessed graft survival to evaluate the effectiveness of Matriderm. We also evaluated skin quality using a Cutometer, Corneometer, Tewameter, or Mexameter, approximately 12 months after surgery. Results A total of 31 patients underwent STSG with Matriderm during the study period. The success rate of skin grafting was 96.7%. The elasticity value of the portion on which Matriderm was applied was 0.765 (range, 0.635-0.800), the value of the trans-epidermal water loss (TEWL) was 10.0 (range, 8.15-11.00) g/hr/m2, and the humidification value was 24.0 (range, 15.5-30.0). The levels of erythema and melanin were 352.0 arbitrary unit (AU) (range, 299.25-402.75 AU) and 211.0 AU (range, 158.25-297.00 AU), respectively. When comparing the values of elasticity and TEWL of the skin treated with Matriderm to the values of the surrounding skin, there was no statistically significant difference between the groups. Conclusions The results of this study demonstrate that a dermal substitute (Matriderm) with STSG was adopted stably and with minimal complications. Furthermore, comparing Matriderm grafted skin to normal skin using Cutometer, Matriderm proved valuable in restoring skin elasticity and the skin barrier.

Radial forearm‐palmaris longus tenocutaneous free flap; implication in the repair of the moderate‐sized postoncologic soft palate defect

Moderate resection of the soft palate results in suboptimal outcomes in terms of postoperative velopharyngeal function. We propose the radial forearm tenocutaneous free flap incorporating the palmaris longus tendon for reconstruction of the levator sling in these cases.

Hypopharyngeal reconstruction using remnant narrow pharyngeal wall as omega-shaped radial forearm free flap.

Purpose: There have been numerous attempts to use pharyngoesophageal reconstruction to restore swallowing function. Much controversy exist over reconstruction after total or partial pharyngectomy, and there is also debate over whether to continue with the reconstructive procedure with a narrow strip of remnant mucosa or complete it after total pharyngectomy. We analyzed the utility of omega-shaped radial forearm free flap (RFFF) using the narrow remnant posterior pharyngeal wall. Methods: Patients in group 1 (n = 12) had a narrow remnant pharyngeal wall with a width of less than 3 cm. Those in group 2 (n = 35) had a remnant pharynx with a width larger than 3 cm. The incidence of fistula, stricture, and swallowing difficulty were evaluated. Swallowing difficulty was graded using a 7-point visual analog scale. All circumferential hypopharyngeal reconstruction with tubed RFFF, pectoralis major flap, and jejunal free flap were also compared with group 1. Results: All flaps survived, and 1 fistula (8%) was detected in group 1. Compared with tubed RFFF (46%) and tubed pectoralis major flap (57%), this is a relatively low rate of fistula formation. In group 1, normal diet was possible in 92% of patients, but 1 patient can tolerate a liquid diet only. In group 2, normal diet was possible in 80% of patients. As for swallowing difficulty, the median visual analog scale score for both groups 1 and 2 was 6 points. When comparing different flaps, stricture and fistula rate was 0 and 8% in group 1, 15 and 46% in tubed RFFF, 43 and 57% in tubed pectoralis major flap, and 33 and 5% in jejunal flap, respectively. Conclusions: We performed all surgeries taking care not to transgress the wide excision principle with the remnant hypopharyngeal wall. For remnant lesions greater than 3 cm, patch-type RFFF was performed, whereas for those less than 3 cm, omega-shaped RFFF was done. We achieved fairly good results in both groups without total resection of the narrow remnant hypopharyngeal wall.

Volume and distances of the maxillary sinus in craniofacial deformities with midfacial hypoplasia

Objective: Craniofacial deformities (CFDs) frequently accompany midfacial hypoplasia. The authors evaluated characteristics of maxillary sinuses that had CFDs with variable degrees of midfacial hypoplasia. Study Design: Cross-sectional survey with chart review. Setting: Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. Subjects and Methods: We investigated 40 patients with CFDs having midfacial hypoplasia. Study group 1 (SG 1) consisted of eight patients with Crouzon syndrome (16 maxillary sinuses). Study group 2 (SG 2) consisted of 10 patients with midfacial hypoplasia after palatoplasty (20 maxillary sinuses). Study group 3 (SG 3) consisted of 22 patients with Pruzansky grade I hemifacial microsomia (22 maxillary sinuses on the affected sides). Data on volume and three-dimensional distances (height, width, and depth) from computed tomography were collected and compared with each corresponding control group. Correlation coefficient between volume and the three distances was also calculated. Results: The volume, height, width, and depth of the maxillary sinus were significantly decreased in SG 1 (P < 0.01). In SG 2, only the depth was significantly decreased (P < 0.05). In SG 3, there were no significant differences in any parameters. A multiple-regression analysis between the volume and the three distances showed a statistically significant relationship for width in SG 1, width and height in SG 2, and all distances in SG 3. Conclusion: There were differences in the structure of the maxillary sinuses among patients with different CFDs.

Pectoralis major–rectus abdominis bipedicled muscle flap in the treatment of poststernotomy mediastinitis

OBJECTIVES Although the incidence of infected sternotomy wounds after median sternotomy for cardiovascular surgery is relatively low (0.5% to 5%), it is associated with significant morbidity and a long period of treatment. Today, muscle flaps, such as the pectoralis major or the rectus abdominis, are widely accepted as a mainstay of reconstructive options. Each method carries unavoidable limitations and setbacks of its own. To overcome the disadvantages of the pectoralis muscle and rectus abdominis muscle flaps, we designed and performed a pectoralis major-rectus abdominis muscle bipedicled flap for the coverage of sternal defects. METHODS The pectoralis major-rectus abdominis bipedicled flap was elevated as a single unit, preserving the thoracoepigastric fascia in continuity with the rectus muscle and its anterior fascia. The method was used in 27 patients with postoperative mediastinitis during a 5-year period. RESULTS The bipedicled flap could fill the defect with sufficient volume, not only in the upper two thirds but also in the lower one third of the sternum. Recurrent uncontrolled infection developed in 11% of all cases, and upper abdominal fascial attenuation was observed in 1 patient. There were no surgical intervention-related complications or deaths. CONCLUSIONS We conclude that pectoralis major-rectus abdominis bipedicled flap is a practical and efficacious method in the reconstruction of the anterior chest wall defect caused by poststernotomy mediastinitis. It not only provides sufficient volume to fill the entire mediastinum but also affords resolution of the infected wound with favorable outcomes comparable with those of other methods.

Evaluation of the Efficacy of Microsurgical Practice Through Time Factor Added Protocol: Microsurgical Training Using Nonvital Material

Purpose: The evaluation of microsurgical technique is often done in an attempt to enhance the skills of surgeons. However, it varies depending on the institution or supervisors. According to some of the research done so far, there are many institutes that enable surgeons to train themselves with enough time but are confronted with some other limiting factors. We have added the time factor and conducted our study on the evaluation of microsurgical techniques. The purpose of this study was to decide whether using a nonvital pig leg saves microsurgical training time and improves microsurgical skill and how effective this method is in an objective assessment. Materials and Methods: For 3 pig legs, the full procedure time was calculated 3 times and the anastomosis duration was measured 5 times for a total of 8 trainees. The authors made evaluations conforming to the following protocol. The full procedure time was defined as the time period between when students entered and left the laboratory, including the time for preparation and cleaning up. The anastomosis time included just one anastomosis at the time of vessel cutting. An objective evaluation of vessel anastomosis was performed using a 5-point global rating scale in 6 categories. For suture errors, we calculated the number of broken sutures, broken knots, and broken or damaged needles. After anastomosis, leakage was tested using an infusion pump. For an objective analysis, the study was limited to arterial end-to-end anastomosis and all the parameters were measured by a single trainer. Results: For the full procedure time, 129.0 (13.8) minutes was needed for the first trial, whereas the third trial took 72.4 (11.1) minutes (P < 0.05). For the anastomosis time, the first trial took 47.1 (14.7) minutes, whereas the fifth took 18.0 (2.1) minutes. There was a statistical significance, except between the third and fourth trials. Improvement in the global rating scale was noted with increased procedure frequency. The mean total score (30 points is perfect) was 8.9 (1.5) at the first trial, which improved to 25.0 (0.9). As for the suture errors, 7.5 (1.3) errors were noted on the first trial, which was reduced to 1.6 (0.7) on the fifth trial. Conclusions: The authors carried out microsurgical training using a protocol that added the time factor to the conventional evaluation studies. Microsurgical practice with pig legs statistically saves time and improves the skill in 3 full procedures including 5 practice end-to-end arterial anastomoses. This is an effective and economic method of developing the basic techniques performed during anastomosis procedures.

Reconstruction of Ankle and Heel Defects with Peroneal Artery Perforator-Based Pedicled Flaps.

Background The reconstruction of ankle and heel defects remains a significant problem for plastic surgeons. The following options exist for reconstructing such defects: local random flaps, reverse flow island flaps, and free flaps. However, each of these methods has certain drawbacks. Peroneal artery perforators have many advantages; in particular, they are predictable and reliable for ankle and heel reconstructions. In this study, we report our clinical experience with peroneal artery perforator-based pedicled flaps in ankle and heel reconstructions. Methods From July 2005 to October 2012, 12 patients underwent the reconstruction of soft tissue defects in the ankle and heel using a peroneal artery perforator-based pedicled flap. These 12 cases were classified according to the anatomical area involved. The cause of the wound, comorbidities, flap size, operative results, and complications were analyzed through retrospective chart review. Results The mean age of the patients was 52.4 years. The size of the flaps ranged from 5×4 to 20×8 cm2. The defects were classified into two groups based on whether they occurred in the Achilles tendon (n=9) or heel pad (n=3). In all 12 patients, complete flap survival was achieved without significant complications; however, two patients experienced minor wound dehiscence. Nevertheless, these wounds healed in response to subsequent debridement and conservative management. No patient had any functional deficits of the lower extremities. Conclusions Peroneal artery perforator-based pedicled flaps were found to be a useful option for the reconstruction of soft tissue defects of the ankle and heel.