• Archives of Plastic Surgery
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• 제35권1호
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• pp.20-27
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• 2008

Purpose: The anterolateral thigh flap has many advantages over other conventional free flaps. But the anterolateral thigh flap has yet to enter widespread use because perforating arteries exhibit a wide range of anatomic variations and are difficult to dissect when small. The aim of this study is to identify the vascular variability of perforating arteries and pedicle in the anterolateral thigh free flap. Methods: We studied 12 cadavers and dissected 23 thighs. An anterolateral thigh flap ($12{\times}12cm$) was designed and centered at the midpoint of the line drawn from anterior superior iliac spine to the superolateral border of the patella. After we identifed the perforating arteries we dissected up to their origin from lateral circumflex femoral artery along descending branch of lateral circumflex femoral artery. We then investigated the number and the position of perforating arteries, length and diameter of vascular pedicle and pattern of lateral circumflex femoral arterial system. Results: On average $2.3{\pm}1.1$ perforating arteries per thigh were identified. The musculocutaneous perforators were 63.1%. In those perforators five perforators were arose from transverse branch of lateral circumflex femoral artery and two were arose from rectus femoral artery. Most of the perforators were near the intermuscular septum between rectus femoris muscle and vastus lateralis muscle. The length and diameter of pedicle were $11.9{\pm}3.5cm$ and $3.1{\pm}0.8mm$ on average. Conclusion: This study will be helpful for the success in anterolateral thigh free flap.

• Archives of Plastic Surgery
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• 제35권4호
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• pp.483-486
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• 2008

Purpose: Fingertip injuries are the most common hand injuries and may lead to significant disability. Knowledge of fingertip anatomy is mandatory to treat these injuries effectively. All surgical techniques used for coverage of fingertip injuries must be based on the nature of the injury and the patient's age. Many authors have studied the method of fingertip reconstruction because goals of these treatments should include maintaining length, sensibility, motions, and appearance. The purpose of this study is to evaluate the effect of digital artery perforator flap for fingertip reconstruction without aesthetic and functional problems. Methods: From November 2006 to March 2007, the authors performed fingertip reconstruction on 3 fingers of 3 patients, aged between 41 to 54 years (average age, 47 years) using digital artery perforator flap. Results: All fingers recovered successfully and there were no necrosis of the flap. We followed up 3 cases more than 5 months. Light touch and temperature sensation could be detected in all flaps and the static two-point discrimination test was 8 mm. Conclusion: This flap is an alternative choice for coverage of fingertip defects. This method also takes short time to procedure and to recovery. The digital artery perforator flap has never been reported in Korea, however it is considered as a useful method for treatment of fingertip injury.

• Archives of Plastic Surgery
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• 제35권4호
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• pp.450-454
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• 2008

Purpose: From May 2000 to January 2008, We experienced the 10 cases of the thenar free flap for the coverage of the large volar soft tissue defect in the finger. Methods: The pedicles of the flap were the superficial palmar artery of radial artery and subcutaneous vein, and we anastomosed them to the digital artery and subcutaneous vein of the finger. Results: The average size of the flaps was $12cm^2$ and it was large enough to cover the entire color soft tissue defect of a phalanx or the defect of the neighbored phalanges. All of donor wounds were closed primarily. Conclusion: The color and skin texture of the flap was matched with the volar skin of the finger functionally and cosmetically and the debulking of the flap was not necessary. Other advantages were constant anatomic pedicle of the flap, minimal donor site morbidity, one operation field. We consider that the thenar free flap is another reliable and useful method for the reconstructing of the large volar defect of the finger especially at the situation of emergency.

• Archives of Plastic Surgery
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• 제35권4호
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• pp.446-449
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• 2008

Purpose: Pilonidal sinus is a frequent disease that occurs mostly in hairy young men, defined as chronic inflammation and infection of the postsacral sinuses. Wide excision of the affected area is the treatment of choice. Many techniques have been described to cover the defect. However none appears to be the ideal procedure to prevent infection, recurrence, and delayed wound healing. We present the results of an alternative technique that we performed by using partial deepithelized gluteal transposition flap for reconstruction of the defect following wide excision. Methods: From October 2004 to September 2007, we performed the partial deepithelized gluteal transposition flap method on 6 patients. We modified the transposition flap techniques by deepithelialising the medial parts of the flap and burying them under the opposing edge of the flap. The results were compared with previous studies and evaluated regarding duration of surgery, size of defect, hospitalization periods, and complications. Results: All the flaps were healed well with no partial or complete loss of the flap. Hospitalization and immobilization periods were acceptably shortened. Recurrence was not seen. The aesthetic outcome was also satisfactory and all patients were satisfied with the results. Conclusion: The main advantage of our techniques is using healthy tissues to obliterate the dead space, to provide an extra-cushion, and to prevent deep dehiscence. We believe that the partial deepithelized gluteal transposition flap is a good alternative method for treatment of pilonidal sinus.

• Archives of Plastic Surgery
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• 제36권6호
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• pp.750-754
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• 2009

Purpose: The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free abdominal flap breast reconstructions. Recently, the internal mammary vessels have been recommended as the first - choice recipient vessels for microvascular breast reconstruction. To approach the internal mammary vessel, 3rd or 4th rib cartilage excision is needed, but this method has some demerits - vessel injury, post operative pain and post operative chest hollowness. So, authors propose the approach method to the internal mammary vessel through intercostal space without rib cartilage resection. Methods: From November, 2008 to May, 2009, 13 patients underwent free abdominal flap breast reconstruction with approach to the internal mammary vessel through intercostal space without rib cartilage resection. Results: The mean patient age was 41.8 years, and the mean height was 159.3 cm. 11 patients underwent immediate breast reconstruction. Free DIEP flap reconstruction was performed in 7 patients, Free TRAM flap was performed in 5 patients, and Free SIEA flap was performed in 1 patient. Except 1 case, approach to the internal mammary vessel was took through 3rd intercostal space, and all width of intercostal space exceeded 1 cm. Conclusion: In the authors' experience, use of approach to the internal mammary vessels without rib cartilage resection method is safe and reliable to overcome demerits of rib cartilage resection method.

• Archives of Plastic Surgery
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• 제36권2호
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• pp.140-146
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• 2009

Purpose: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. In a free transverse rectus abdominis myocutaneous(TRAM) or deep inferior epigastric artery perforator(DIEP) flap, a preoperative evaluation of the precise location of perforating vessels and vascular run - off systems is required. The objective of this report is to demonstrate the usefulness of multidetector computed tomography(MDCT) in the preoperative planning of patients undergoing breast reconstruction with abdominal flap. Methods: From June 2006 to January 2008, 28 patients underwent MDCT evaluation before breast reconstruction. All subjects were females with an age range of 30 to 55 years. The CT scan was performed using a 64 - slice MDCT scanner(Brilliance 64; Philips Medical Systems, Best, Netherlands). Results: One perforator or two major perforators were marked on image in good relation with a hand - held Doppler examination and intraoperative findings. All vascular run - off systems were cleared before operation. Conclusion: Preoperative evaluation of perforator arteries with MDCT angiography is beneficial in patients undergoing breast reconstruction. This technique provides a noninvasive approach of the vascular anatomy of the entire anterior abdominal wall.

• Archives of Plastic Surgery
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• 제36권6호
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• pp.707-713
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• 2009

Purpose: The deep inferior epigastric perforator(DIEP) free flap is well known as an ideal donor site for the breast reconstruction. The flap can provide huge amount of fat tissue for breast and buttock contour, while it is also very useful as a thin skin flap to reconstruct the upper and lower extremities. We used a DIEP free flap in various site reconstructions besides the breast and would like to reinsure the usefulness of this flap. Methods: Twenty nine consecutive patients who underwent DIEP free flap surgery from 2001 January to 2007 December were reviewed. The case constituted seven male patients and twenty two female patients. There were sixteen breast reconstructions, five face reconstructions, five lower extremity reconstructions, two upper extremity reconstructions, and one buttock contour reconstruction. All clinical data were based on the patient's medical records. Results: All DIEP free flaps survived without major complications. There was no hematoma, seroma, or partial necrosis. The donor sites were closed primarily with linear scar on lower abdomen. The thinnest part of flap was 0.7 cm in thickness. The size of the largest flap was $38{\times}13cm$. The flaps were used in various types of skin and adipose tissue, adipose tissue only, and skin only according to the requirement of recipient site. Conclusion: The DIEP free flap was enough to provide a thin and huge flap for both breast and extremity reconstructions. It was able to provide versatile designs with sufficient adipose tissue. So we use it for 3 - dimentional face and buttock contour reconstructions. The DIEP free flap is a valuable reconstructive donor for face, upper and lower extremity in addition to breast without compromising the integrity of abdominal wall.

• Archives of Plastic Surgery
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• 제36권6호
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• pp.714-719
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• 2009

Purpose: Recurrent ischial pressure sore is troublesome for adequate soft tissue coverage, because usually its pocket has a very large deep space and adjacent donor tissue have been scarred in the previous surgery. However, the conventional reconstructive methods are very difficult to overcome them. Modified gluteus maximus myocutaneous V - Y advancement flap from buttock can be successfully used in these circumstances. Methods: From February 2007 to October 2008, modified gluteus maximus myocutaneous V - Y advancement flaps were perfomed in 10 paraplegic patients with recurrent ischial pressure sore. The myocutaneous flap based on the inferior gluteal artery was designed in V - shaped pattern toward the superolateral aspect of buttock and was elevated from adjacent tissue. Furthermore, when additional muscular bulk was required to obliterate dead space, the flap dissection was extended to the inferolateral aspect which can included the adequate amount of the gluteal muscle. After the advanced flap was located in sore pocket, donor defect was repaired primarily. Results: The patients' mean age was 46.9 and the average follow - up period was 12.4 months. The immediate postoperative course was uneventful. But, two patients were treated through readvancement of previous flap due to wound dehiscence or recurrence after 6 months. The long - term results were satisfied in proper soft tissue bulk and low recurrence rate. Conclusions: The modified gluteus maximus myocutaneous V - Y advancement flap may be a reliable method in reconstruction of recurrent ischial pressure sore, which were surrounded by scarred tissue because of its repetitive surgeries and were required to provide sufficient volume of soft tissue to fill the large pocket.

• Archives of Plastic Surgery
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• 제36권6호
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• pp.788-791
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• 2009

Purpose: Reconstruction of full - thickness defects of the nasal ala has always been a challenge. Local flaps can be used easily, and good result can be achieved when it is indicated. But local flaps often result in facial scars and bulky ala that require secondary revisions. Composite auricular chondrocutaneous graft may matches nasal alae well in terms of contour, color and texture, however, the size of composite graft is limited. We performed free vascularized helical root flaps for reconstruction of nasal ala. Methods: Bilateral ala were excised and the defects were reconstructed with a chondrocutaneous free helical root flap. Each side of ala was reconstructed in 3 months interval. Superficial temporal vessels of vascularized helical root flap were anastomosed to facial vessels. Great saphenous vein was used for interpositional vascular graft. Results: Flaps were survived successfully. The contour, texture and color match were satisfactory. Functional problem of nasal obstruction caused by scar stenosis of nostrils was also resolved. Conclusion: The free vascularized helical root flap is a reliable method in reconstruction of nasal alar defects. The donor deformity was minimal.

• Archives of Plastic Surgery
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• 제36권6호
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• pp.720-726
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• 2009

Purpose: Fasciocutaneous flap with random pattern flap has limitation in mobility and length - width ratio. This characteristic is more pronounced in lower extremity which has relatively poor vascularity. Perforator based flap in lower extremity reconstruction has various advantages as a axial flap, allowing abundant blood supply and widening of mobility range. So if it is not a case of wide defect, free flap can be replaced by perforator based flap. Methods: From April 2007 to March 2009, 18 cases of perforator flap were performed. 8 had defect in upper 1/3 of calf, 6 in middle 1/3, and 4 in lower 1/3. In 10 cases island flap were used, 3 case had transposition flap, 2 cases used advancement flap, 2 case had propeller flap and 1 case had rotation flap. Results: 17 cases survived without flap necrosis. Partial flap necrosis occurred in 1 case, so secondary split thickness skin graft was done. Chronic wound with pseudomonas infection occurred in 1 case, but it was completely cured with conservative treatment. Conclusion: Perforator based flap is useful in lower extremity reconstruction because of relative freedom in changing the size and thickness of the flap depending on the recipient site, good mobility, and abundant vascularity. And donor site morbidity can be minimized. Lower extremity reconstruction using perforator based flap is a good method because it can minimize the complication and obtain effective result.