• Archives of Plastic Surgery
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• v.38 no.4
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• pp.539-542
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• 2011

Purpose: Despite the increasing number of patients with HIV (human immunodeficiency virus) infection, surgical experience with these patients remains limited in aesthetic and reconstructive surgery. The authors performed breast reconsruction with free TRAM (Transverse Rectus Abdominis Muculocutaneous) flap in HIV infected patient firstly in Korea. Methods: A 53-years-old female with HIV positive underwent delayed breast reconstruction with free TRAM flap and 6 months lateral nipple reconstruction was performed. All procedures were performed according to the HIV infection control guidelines provided by the Korea Centers for Disease Control and Prevention. Results: There were no complications such as infection, hematoma and flap loss and symmetry of breast was achieved. Conclusion: When the operation is performed in line with the guidelines of HIV infection control, breast reconstruction with free flap is possible and can obtain successful results.

• Archives of Reconstructive Microsurgery
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• v.14 no.2
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• pp.125-130
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• 2005

The purpose of this study is to introduce a sensory restoration in reconstructed breast with free TRAM flap to evaluate recovery aspect and recovery quantity. 144 patients underwent breast reconstruction with free TRAM flap by authors and were followed up at the out patient clinique. We discovered that sensory of operated breast was recoverd. We divide the breast into 5 region (upper medial, lower medial, upper lateral, lower lateral, nipple areolar complex) for examining the sensory restoration. Sense of upper medial region & upper lateral region is recovered more quickly than other region. Touch sensation was recovered more quickly than pain sensation, temperature sensation, vibratory sensation. After about 1 year all protective sensation was recovered in all patient. We discovered that severe postop scar and irradiation of breast is related to delayed sensory recovery, age and size of flap is not related to sensory recovery.

• Archives of Plastic Surgery
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• v.34 no.5
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• pp.569-573
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• 2007

Purpose: The selection of the recipient vessels in breast reconstruction has a great influence on the surgical result and the shape of the reconstructed breast. We would like to introduce the criteria for the selection of recipient vessels in delayed reconstruction of the breast. Methods: We studied 56 patients with delayed breast reconstruction using free TRAM flaps from April 1994 to December 2006. The thoracodorsal and the ipsilateral internal mammary vessels were used as recipients in 25 patients each, the opposite internal mammary vessels in 3 patients, the thoracoacromial vessels in 2 patients, and the transverse cervical artery with the cephalic vein in 1 patient. The survival rate of the flaps, the vessel diameter, the length of the pedicles, and the convenience of vessel dissection were studied. Results: The diameter of the recipient vessel did not influence the anastomosis. The operation time, the survival rate of flap, the postoperative complications showed no significant difference according to the recipient vessel. Dissection of the thoracodorsal vessels was tedious due to scar formation from the prior operation. Dissection of the internal mammary vessels proved to be relatively easy, and the required length of the pedicle was shorter than any other site, but the need for removal of rib cartilage makes this procedure inconvenient. Conclusion: The first choice of the recipient vessel in immediate breast reconstruction is the thoracodorsal vessels, but in cases of delayed reconstruction the internal mammary vessels are favored as the first choice, because the thoracodorsal vessels have a high unusability rate. If the ipsilateral internal mammary vessels prove to be useless, the contralateral vessels can be used. The thoracoacromial vessels are useful, when the mastectomy scar is located in the upper portion. The transverse cervical artery and the cephalic vein can serve as the last resort, if all other vessels are unreliable.

• Archives of Plastic Surgery
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• v.33 no.6
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• pp.737-741
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• 2006

Purpose: This study was to evaluate the expression pattern of CD 18(leukocyte adhesion glycoprotein) in ischemia-reperfusion injury of TRAM flap of rats. Through this study, we can obtain more information about ischemia-reperfusion injury. We want to develop specific medicine to improve the survival rate of TRAM flap in the future. Methods: A TRAM flap supplied by a single pedicle superior epigastric artery and vein was elevated on 60 Sprauge-Dawley rats. The rats were divide into 6 groups (each group n=10); Group O: sham, no ischemia-reperfusion injury, Group I: 2 hour reperfusion after 4 hour ischemia, Group II: 4 hour reperfusion after 4 hour ischemia, Group III: 8 hour reperfusion after 4 hour ischemia, Group IV: 12 hour reperfusion after 4 hour ischemia, and Group V: 24 hour reperfusion after 4 hour ischemia. This study consisted of gross examination for flap survival and flow cytometry study of CD18 on neutrophils. Results: The gross measurement of the flap showed different survival rate in group I(71%), II(68%), III(37%), IV(34%) and V(34%). All experimental groups showed an increase in the expression of CD18 compared to group O. The expression of CD18 was rapidly increased in ascending order in group I, II and III. But, the expression of CD18 was maintained in group IV and V. Conclusion: The results can be implemented in the study to develop drugs which are capable of reducing ischemia-reperfusion injury in microsurgical breast reconstruction.

• Archives of Plastic Surgery
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• v.32 no.4
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• pp.403-407
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• 2005

Following a transverse rectus abdominis musculocutaneous(TRAM) flap breast reconstruction, denervated state of the flap causes the flap skin prone to thermal injury, calling for special attention. During the last 5 years, 69 breast reconstruction with 72 free TRAM flaps, were performed. Four out of thesse 69 patients sustained burn injury. Heat sources were a warm bag(n=2), heating pad(n=1) and warming light (n=1). The thermal injuries occured from 2 days to 3 months following the reconstruction. Three patients healed with conservative treatment, but one patient required debridement and skin graft. Initially 3 out of 4 patients with the burn had shown superficial 2nd degree burn with small blebs or bullae. However all 4 patients healed with scars. Mechanism of burn injuries of the denervated flap are known to be resulting from; 1) loss of behavioral protection due to denervation of flap with flap elevation and transfer, 2) loss of autonomic thermoregulatory control with heat dissipation on skin flap vasculature contributing to susceptibility of burn injury. 3) changes of immunologic and normal inflammatory response increasing thromboxane, and a fall in substance P & NGF (nerve growth factor). Including the abdominal flap donor site, sensory recovery of the reconstructed breast varies individually from 6 month even to 5 years postoperatively. During this period, wound healing is delayed, resulting in easier scarring compared to that observed in the sensate skin. Patients should be carefully informed and warned of possible burn injuries and taught to avoid exposure to heat source at least until 3 years postoperatively.

• Archives of Plastic Surgery
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• v.33 no.5
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• pp.570-576
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• 2006

Purpose: Skin-sparing mastectomy(SSM) with immediate breast reconstruction is becoming a proved option for early-stage breast cancer patients. Recently, skin-sparing mastectomy with preserving the nipple-areolar complex is becoming popular procedure. Methods: During a 13-month period, from April 2004 to January 2005, 101 cases of immediate breast reconstructions with pedicled TRAM flap were performed after 40 cases of nipple-areolar sparing mastectomies, 57 cases of skin-sparing mastectomies and 4 cases of modified radical mastectomies. Results: During the 11 months follow up period, necrosis of mastectomy skin flap occurred in 17.5%(n=10) after skin-sparing mastectomy and necrosis of mastectomy skin flap and nipple-areolar necrosis occurred in 30%(n=12) after nipple-areolar sparing mastectomy. These complications were healed after simple dressing without any surgical procedure. Conclusion: Nipple-areolar sparing mastectomy and immediate breast reconstruction with TRAM flap is good option for early breast cancer patients and some modifications are needed to reduce skin necrosis.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.531-534
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• 2011

Purpose: The rectus abdominis myocutaneous flap is currently the most commonly used donor site of immediate and delayed breast reconstruction surgery, for its versatility and ease of handling, as well as sufficient blood supply. Despite many advantages of rectus abdominis flap, morbidity of donor site is considered as inevitable shortcoming. The authors recently faced a devastating complication, small bowel obstruction that led to strangulation, after delayed breast reconstruction with free transverses rectus abdominis myocutaneous (TRAM) flap. And we would like to report it, because abdominal pain after TRAM flap is a common symptom and can be overlooked easily. Methods: A 56-year-old female patient who had history of receiving total abdominal hysterectomy 20 years ago underwent delayed breast reconstruction with TRAM flap transfer. She complained abdominal discomfort and pain from third postoperative day, postoperative small bowel obstruction that arose from strangulated bowel and prompt emergency operation was done. Results: After resection of the strangulated bowel and reanastomosis, quickly her symptoms were relieved, and there were no further problems during her hospital stay. 7 days after her emergency operation she was discharged. Conclusion: In patients with previous abdominal surgical history, prolonged ileus can lead to bowel strangulation, so surgeons should always consider the possibility, and must be aware of abdominal symptoms in patients who receive free TRAM flap operations.

• Journal of Korean Society of Coastal and Ocean Engineers
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• v.19 no.5
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• pp.492-501
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• 2007

Coastal disasters have become one of the most important issues in every coastal country. In Korea, coastal disasters such as storm surge, sea level rise and extreme weather have placed many coastal regions in danger of being exposed or damaged during subsequent storms and gradual shoreline retreat. A storm surge is an onshore gush of water associated with a tow pressure weather system, typically in typhoon season. However, it is very difficult to predict storm surge height and inundation due to the irregularity of the course and intensity of a typhoon. To provide a new scheme of typhoon damage prediction model, the scenario which changes the central pressure, the maximum wind radius, the track and the proceeding speed by corresponding previous typhoon database, was composed. The virtual typhoon scenario database was constructed with individual scenario simulation and evaluation, in which it extracted the result from the scenario database of information of the hereafter typhoon and information due to climate change. This virtual typhoon scenario database will apply damage prediction information about a typhoon. This study performed construction and analysis of the simulation system with the storm surge/coastal inundation model at Masan coastal areas, and applied method for predicting using the scenario of the storm surge.

• Archives of Plastic Surgery
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• v.32 no.1
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• pp.76-84
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• 2005

Immediate breast reconstruction in breast cancer patients is universalized and now with a wide variety of methods to choose from, we can select a breast reconstruction method according to the patient's condition. Among these methods, immediate breast reconstruction with TRAM free flap is the most commonly used. Nipple reconstruction is usually performed as a secondary procedure, reconstructed. Nipple is reconstructed with contralateral nipple composite graft or with local flap. Areola is reconstructed with skin graft and tattooing. Therefore, to reconstruct complete breast, two or more staged operations are needed and are troublesome to both the surgeon and the patient. If we could reconstruct breast mound and nipple at same time, we would reduce the operative stages and heighten the patient's satisfaction. The author performed delayed or immediate breast reconstruction with TRAM free flap and nipple reconstruction at the same time. If the TRAM flap was to situate in the whole of the breast or at the center of the breast mound, nipple was reconstructed with a local flap from the TRAM flap. If the TRAM flap was not situated in center of breast mound, nipple was reconstructed with a local flap from remnant breast skin. Immediate nipple reconstructions in breast reconstruction consisted total of 22 cases. Among these, delayed breast reconstruction were 5 cases and immediate breast reconstruction were 17 cases. According to patient's condition and mastectomy method, nipple reconstruction method was selected; nipple reconstruction with contralateral nipple composite graft(3 cases); nipple reconstruction with remnant breast skin(6 cases); nipple reconstruction from flap margin(10 cases); nipple reconstruction with prefabricated nipple on flap(3 cases). Malposition of the reconstructed nipple was the most common and serious complication(6 cases). The other complications were atrophy of the nipple(1 case), and necrosis(1 case). Reconstruction of the breast and nipple at the same time can reduce the need of a secondary operation and use remnant skin or redundant flap tissue maximally. On the other hand, it must be considered that position and shape of nipple could be deformed, because the nipple reconstruction is performed before the shape of reconstructed breast settles completely. Prudent attention is needed, because the danger of complication is higher than delayed nipple reconstruction.