• Archives of Plastic Surgery
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• 제41권6호
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• pp.722-727
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• 2014

Background Perineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage. Methods We retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction. Results Flap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%). Conclusions Despite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.

• Archives of Plastic Surgery
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• 제37권2호
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• pp.143-147
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• 2010

Purpose: Nostril stenosis is an uncommon deformity that develops as a consequence of smallpox, chickenpox, tuberculosis, syphilis, congenital malformations etc. There have been several studies on the surgical techniques to treat it. However, it is difficult to maintain the result for a long time. The goal of this study is to evaluate the use of Wplasty, perialar flap as an operative techniques and expansion exercise using Foley catheter as a method to keep the patency of nostril. Methods: This is a retrospective review of the senior surgeon's (Y.L.) patients who underwent W-plasty and a perialar flap. Patients treated from 2005 to 2009 were reviewed and the postoperative results were evaluated. Average patient age was 24 years, ranged from 1 to 61 years, average follow-up period was 27.5 months, ranged from 3 to 77 months. The mild deformity was released with an incision and expansion by the ballooning of a Foley catheter and corrected by W-plasty only. However, a severe deformity required an additional procedure including perialar flap transposition. During the postoperative period, the patients maintained a nasal stent and exercise using a Foley catheter to prevent recurrence. Results: Five cases of nostril stenosis in four patients were treated using this technique. One case was corrected with W-plasty only, but four cases were more severe and were corrected with W-plasty and a perialar flap. There were no perioperative complications. The patients were satisfied with the results and retained a good shape during the follow-up periods. Conclusion: Nostril stenosis can be corrected with W-plasty and a perialar flap. A perialar flap is added if W-plasty is unable to correct the deformity. A postoperative nasal stent and expansion with a Foley catheter can help in preventing recurrences.

• Archives of Reconstructive Microsurgery
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• 제15권2호
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• pp.65-69
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• 2006

Purpose: We performed vastus lateralis (VL) muslce or myocutaneous flap for close of the trochanteric skin defect usually happened in paraplegia and report our 6 cases. Materials and Methods: Between March 2004 and August 2005 we performed 4 cases of VL muscule flap with skin graft and 2 cases of VL myocutaneous flap for close of the trochanteric skin defect in 6 paraplegia patients. There were 5 men and 1 woman and mean age was 52.2 years and mean diameters of skin defect was $8.3{\times}8.3\;cm$. The mean follow up period was 18 months. The survival of flap, complications, healing time and patient's satisfaction were evaluated. Results: All flaps were survived except 1 case of margin necrosis. In 2 cases, blood-serous discharges were continued after operation which might be due to dead space and treated with $2{\sim}3$ times debridement and delayed close. Mean time to heal the skin defect was 7.6 weeks. No infection and recurrence in follow up periods. Cosmetic results judged by patients are that 3 cases are good and 3 cases are fair. Conclusion: VL muscle and myocutaneous flap is good treatment method among the numerous methods in treatment-failed cases of trochanteric skin defects of paraplegia patients. This surgical procedure is simple, constant blood supply, good pliability, cosmetic results and also appliable to other skin defect of pelvis girdle like sacrum and ischium.

• Archives of Reconstructive Microsurgery
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• 제2권1호
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• pp.46-52
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• 1993

Soft-tissue deficits over the plantar forefoot, plantar heel, Achilles tendon, and distal parts of lower leg are often troublesome to cover with a simple graft or local flap due to limited mobility of surrounding skin and poor circulation in these area. Soft-tissue reconstruction in these regions should provide tissue components similar to the original lost tissue, supply durability and minimal protective pressure sensation and result in a donor site that is well tolerated and treated. We analysed 7 cases that were treated with the Instep flap due to soft-tissue defects over these regions from July of 1990 to July of 1993. All flaps were viable and successful at follow-up. 1. The age ranged from 9 years to 60 years, and 6 cases were male and 1 case female. 2. The sites of soft-tissue loss were the plantar forefoot(1 case), plantar heel(3 cases), Achilles tendon(2 cases), and distal parts of lower leg(1 case). 3. The causes of soft-tissue loss were simple soft-tissue crushing injury(1 case), crushing injury of the 1st toe(1 case) and posttraumatic infection and necrosis(5 cases). 4. The associated injury were open distal tibio-fibula, fracture(2 cases), medial malleolar fracture of the ankle(1 case), Achilles tendon rupture(2 case) and 1st metatarso-phalangeal disarticulation(1 case). 5. The size of flap was from $3{\times}4cm$ to $5{\times}10cm$(average $4{\times}5.6cm)$. 6. In 7 cases, we were not to find post-operative necrosis and infection, non-viability, limitation of ankle joint, and gait disturbance caused by the Instep flap surgery. 7. This study demonstrates that the Instep flap should be considered as another valuable technique in reconstruction of these regions.

• Archives of Plastic Surgery
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• 제36권3호
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• pp.254-261
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• 2009

Purpose: The objective of this study was to evaluate the heparin effect for a viability of random - pattern dorsal flap in hairless mouse. Methods: A caudally - based random dorsal flap, measuring $1.5{\times}5cm$, was designed and heparin was applied topically after microneeding. Twenty five male hairless mice were randomly divided into control (Group1, n=5); received only microneedling (Group 2, n=5), only heparin(Group3, n=5), microneedling with saline(Group 4, n=5), and microneedling with heparin group(group5,n=5) to the flap during 7 days. The number of the capillaries were compared between the experimental groups and control group with respect to neovascularization after heparin application using imaging analysis program under hematoxylin - eosin stain. The capillary blood flow was measured by laser Doppler flowmetry. After seven days each animal was evaluated for the percentage area of the flap survival. Mann - Whitnety U test and Kruskal - Wallis statistical analysis of survival relationships was performed. Results: It can be observed increased number of the blood vessels in the experimental groups however it was not statistically significant. Blood flow of the haparin with microneedling group maintained higher than other experimental groups. Treated microneeding and heparin mice were significantly better flap viability than in controls (flap survival 67% and $54.4mm^2$ respectively; p<.01). Positive correlation was shown between flap survival rate and laser Doppler flux value only at first day after surgery. Conclusion: Heparin has a beneficial effect on capillary flow and improve peripheral circulatory disturbances in random pattern flaps.

• Archives of Plastic Surgery
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• 제45권6호
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• pp.495-503
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• 2018

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.

• Archives of Plastic Surgery
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• 제38권6호
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• pp.803-807
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• 2011

Purpose: The safety of radiation therapy after breast reconstruction using transverse rectus abdominis myocutaneous (TRAM) flap is still being debated, and few studies exist on the outcome of irradiation after immediate TRAM breast reconstruction. Some authors presented satisfactory outcomes after adjuvant radiation therapy on reconstructed breast with pedicled TRAM flap, while others reported significant post radiation changes of the flap. Effect of radiation therapy on TRAM flap was evaluated to see whether adjuvant radiation therapy was tolerable. Methods: 1000 immediate TRAM breast reconstruction was done by a single surgeon from July, 2001 to December, 2009. Among them 105 patients required adjuvant radiation therapy because of advanced disease or locoregional recurrence. Fat necrosis, radiation fibrosis, mastectomy skin flap necrosis, need for secondary touch up procedures, patient satisfaction were evaluated. Results: The incidence of fat necrosis was 10.5% and significant radiation fibrosis occurred in only one patient. Delayed wound problem did not occur during or after irradiation. Secondary touch-up procedures were performed in 12.3%, the most common being fat graft (8.6%). Average patient satisfaction score was 8.62/10, which was not significantly different from the authors' previous report involving all the TRAM patients (8.50). Conclusion: Radiation therapy did not increase the complication rate significantly. Aesthetic result was affected but was tolerated in most cases. The fear of adjuvant radiation is not a negative factor in selecting immediate breast reconstruction with TRAM flap.

• Archives of Plastic Surgery
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• 제38권1호
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• pp.89-92
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• 2011

Purpose: Electrical burn of scalp is uncommon. Much more, chronically exposed dura in unstable burn scar is quite exceptional. Hence, we report a case of chronically exposed dura following electrical burn. Methods: A 63-year-old man presented with an about 40 years history of an ulcerative lesion arising from electrical burn scar with 'squeeze like sensation' around wound. Wound was about $6{\times}8$ cm. Area in the center was $3{\times}3$ cm nonviable dura without sequestrum. Tangential excision with an intraoperative neurosurgical consultation and transposition flap under general anesthesia was done. Intraoperative biopsy was done. The wound was diagnosed as chronic osteomyelitis, not Marjolin ulcer. Flap was taken successfully. But after 5 days, infectious discharge had been appeared during 2 weeks, despite irrigation and drainage. As flap was re-evaluated, we could see remnant necrotic dura. After that, latissimus dorsi muscle free flap with meshed split thickness skin graft was transferred without excision of necrotic dura. Results: Flap was taken successfully. Follow-up at 10 weeks has been uneventful, with good and stable coverage of the wound. Conclusion: It is true that complete excision of devitalized tissue with sagittal sinus obliteration is prerequisite to flap taken. But necrotic dura was tangentially excised instead of total dura excision, because, posterior two-thirds of the sagittal sinus was involved underneath. Muscle is rich in blood vessels and decrease the recipient-site bacterial count effectively. In this case, muscle flap with skin graft without total dura excision is an alternative treatment.

• Archives of Plastic Surgery
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• 제40권4호
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• pp.367-373
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• 2013

Background Breast-conserving surgery is widely accepted as an appropriate method in breast cancer, and the lateral thoracodorsal flap provides a simple, reliable technique, especially when a mass is located in the lateral breast. This study describes the usefulness of a lateral thoracodorsal flap after breast conserving surgery in laterally located breast cancer. Methods From September 2008 to February 2013, a lateral thoracodorsal flap was used in 20 patients with laterally located breast cancer treated at our institution. The technique involves a local medially based, wedge shaped, fasciocutaneous transposition flap from the lateral region of the thoracic area. Overall satisfaction and aesthetic satisfaction surveys were conducted with the patients during a 6-month postoperative follow-up period. Aesthetic results in terms of breast shape and symmetry were evaluated by plastic surgeons. Results The average specimen weight was 76.8 g. The locations of the masses were the upper lateral quadrant (n=15), the lower lateral quadrant (n=2), and the central lateral area (n=3). Complications developed in four of the cases, partial flap necrosis in one, wound dehiscence in one, and fat necrosis in two. The majority of the patients were satisfied with their cosmetic outcomes. Conclusions Partial breast reconstruction using a lateral thoracodorsal flap is well matched with breast color and texture, and the surgery is less aggressive than other techniques with few complications. Therefore, the lateral thoracodorsal flap can be a useful, reliable technique in correcting breast deformity after breast conserving surgery, especially in laterally located breast cancer.

• Archives of Reconstructive Microsurgery
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• 제9권1호
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• pp.15-22
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• 2000

One hundred & seventy four consecutive free-flap transfers were reviewed to analyze distribution of the type of reconstructions, kinds of donor flaps as well incidence of complications. The role of emergent exploration and the effect of preoperative wound conditions in flap survival were evaluated. Free flap transfer for head and neck reconstruction was most common as 93 cases, followed by for upper extremity of 30 cases, for lower extremity 30 cases, 18 penile reconstructions and for trunk & breast 3 cases. Nine flaps exhibited signs of ciruclatory insufficiency between 5 hours and 7 days. Three were managed conservatively with ultimate partial necrosis of the flaps. Eight flaps required return to the operating room. On exploration, early arterial occlusion was revealed in 1 flap, late arterial occlusion in 2 flaps, early venous occlusion in 1 flap, late venous thrombosis in 2 flaps, prolonged venous spasm in 1 and hematoma in 1 flap. The average time from the first abnormal examination to exploration was 2.6 hours. There were no false-positive explorations. Four free flaps failed in spite of the correction of the cause of circulatory compromise. The remaining 4 flaps were salvaged following the correction the casuse. Recipient vessel problems such as irradiation and infection were the most common cause of circulatory crisis. Among the eight flaps requiring return to the operating room, single vein was anastomosed in three flaps and two veins in the remaining five. In the totally failed four flaps only single vein was anastomosed in three cases. The results of this study demonstrate the efficacy of clinical monitoring and the role of early exploration. Precautious selection of recipient vessels and two vein anastomosis are recommended for safe and better prognosis.