• Archives of Plastic Surgery
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• v.32 no.2
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• pp.175-182
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• 2005

Skull base tumors have been determined inoperable because it is difficult to accurately diagnose the extent of the involvement and to approach and excise the tumor safely. However, recently, the advent of sophisticated diagnostic tools such as computed tomography and magnetic resonance imaging as well as the craniofacial and neurosurgical advanced techniques enabled an accurate determination of operative plans and safe approach for tumor excision. Resection of these tumors may sometimes result in massive and complex extirpation defects that are not amenable to local tissue closure. The purpose of this study is to analyze experiences of skull base reconstruction and to evaluate long term survival rate and complications. All cranial base reconstructions performed from July 1993 to September 2000 at Department of Plastic and Reconstructive Surgery of the Seoul National University Hospital were observed. The medical records were reviewed and analysed to assess the location of defects, reconstruction method, existence of the dural repair, history of preoperative radiotherapy and chemotherapy, complications and causes of death of the expired patients. There were 12 cases in region II, 8 cases in region I and 1 case in region III according to the Irish classification of skull base. Cranioplasty was performed in 4 patients with a bone graft and microvascular free tissue transfer was selected in 17 patients to reconstruct the cranial base and/or mid-facial defects. Among them, 11 cases were reconstructed with a rectus abdominis musculocutaneous free flap, 2 with a latissimus dorsi muscluocutaneous free flap, 1 with a fibular osteocutaneous free flap, 2 with a scapular osteocutaneous free flap, and 1 with a forearm fasciocutaneous free flap, respectively. During over 3 years follow-up, 5 patients were expired and 8 lesions were relapsed. Infection(3 cases) and partial flap loss(2 cases) were the main complications and multiorgan failure(3 cases) by cancer metastasis and sepsis(2 cases) were causes of death. Statistically 4-years survival rate was 68%. A large complex defects were successfully reconstructed by one-stage operation and, the functional results were also satisfactory with acceptable survival rates.

• Archives of Plastic Surgery
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• v.38 no.3
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• pp.326-328
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• 2011

Purpose: The anatomical anomaly of the rectus abdominis muscle and it's fascia is very rare. No case of the absence of the linea alba below the umbilicus has yet been reported. During breast reconstruction with pedicled TRAM flap, we experienced one case of absence of linea alba. Methods: The patient was a 38-years old female who underwent immediate breast reconstruction with pedicled TRAM flap after Right modified radical mastectomy in June 2010. While the TRAM flap was being elevated, bilateral twitching of the rectus abdominis muscle occurred when electrocautery was applied, and we found the absence of the linea alba below the umbilicus. Results: When the rectus abdominis muscle was exposed, the linea alba below the umbilicus was not observed, and the bilateral rectus abdominis muscle was indistinguishably fused in a gross observation. In addition, bilateral twitching of rectus abdominis muscle was simultaneously observed as one muscle unit when electrocautery was applied. As with both rectus abdominis muscles was bluntly dissected with scissors, the scanty fatty tissues were observed between the both rectus muscles, and the bilateral rectus abdominis muscle was easily separated. The flap was transposed into the corresponding defect to make breast mound. Midline fascia was fixed to the posterior rectus sheath to reconstruct smilar anatomic linea alba. Abdominal defect was reinforced by suturing between remaining anterior rectus sheath. Conclusion: As the unexpected anatomical anomaly may affect the operation outcome, surgeons should be careful when they unexpectedly encounter the anatomical anomaly during an operation. Here, we report a rare case of absence of the linea alba seen at the time of pedicled TRAM flap elevation for breast reconstruction.

• Archives of Plastic Surgery
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• v.35 no.1
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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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• v.44 no.6
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• pp.530-538
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• 2017

Background A pharyngocutaneous fistula is a common and difficult-to-manage complication after head and neck reconstruction. It can lead to serious complications such as flap failure, carotid artery rupture, and pharyngeal stricture, and may require additional surgery. Previous radiotherapy, a low serum albumin level, and a higher T stage have been proposed as contributing factors. We aimed to clarify the risk factors for pharyngocutaneous fistula in patients who underwent flap reconstruction and to describe our experiences in treating pharyngocutaneous fistula. Methods Squamous cell carcinoma cases that underwent flap reconstruction after cancer resection from 1995 to 2013 were analyzed retrospectively. We investigated several significant clinical risk factors. The treatment modality was selected according to the size of the fistula and the state of the surrounding tissue, with options including conservative management, direct closure, flap surgery, and pharyngostoma formation. Results A total of 127 cases (18 with fistulae) were analyzed. A higher T stage (P=0.048) and tube-type reconstruction (P=0.007) increased fistula incidence; other factors did not show statistical significance (P>0.05). Two cases were treated with conservative management, 1 case with direct closure, 4 cases with immediate reconstruction using a pectoralis major musculocutaneous flap, and 11 cases with direct closure (4 cases) or additional flap surgery (7 cases) after pharyngostoma formation. Conclusions Pharyngocutaneous fistula requires global management from prevention to treatment. In cases of advanced-stage cancer and tube-type reconstruction, a more cautious approach should be employed. Once it occurs, an accurate diagnosis of the fistula and a thorough assessment of the surrounding tissue are necessary, and aggressive treatment should be implemented in order to ensure satisfactory long-term results.

• Archives of Plastic Surgery
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• v.36 no.5
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• pp.555-558
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• 2009

Purpose: The high success rate of free flap transfers is well documented in previous literature, and is possible due to the early detection of vascular compromise and timely reoperation. We specifically analyzed the operative results of immediate and delayed reconstruction with free transverse rectus abdominis musculocutaneous(TRAM) flap respectively in order to reveal its distinctive features on timing and causes of vascular compromise. Methods: The senior author operated on 158 patients, 161 cases of free TRAM flap for breast reconstruction. 51 patients underwent delayed reconstruction, whilst immediate reconstruction was performed in the other 107 patients. All patients were monitored every 3 hours for the first 3 days. We reviewed medical records of all patients, and tested statistical significance with the Fisher's test. Results: Reoperation was performed in 20 cases, but the cases include hematoma with bleeding focus and arterial anastomosis site rupture due to abrupt arm abduction. We performed reoperation in 15 cases of suspicious vascular compromise. Flap compromise was noticed mostly within 24 hours, but not longer than 72 hours. Venous compromise was dominant by 11 cases (73.3%). There was difference in the timing of flap compromise between immediate and delayed reconstruction. All the cases of delayed reconstruction did not show signs of vascular compromise after 12 hours postoperatively. On the other hand, cases of vascular compromise were observed until 72 hours postoperatively in cases of immediate reconstruction. Conclusion: Delayed reconstruction showed vascular compromise within 12 hours postoperatively, while immediate reconstruction showed compromised until the 3rd postoperative day. If more aggressive monitoring is maintained during this period, we believe salvage of flaps may be increased with more efficiency.

• Archives of Plastic Surgery
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• v.47 no.3
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• pp.267-271
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• 2020

The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for breast reconstruction. However, it has the disadvantage of frequent seroma formation at the donor site, and late seroma has also been reported. The authors report histological findings after the surgical treatment of a late, repeatedly recurrent seroma at 10 years after breast reconstruction with LDMCF. In 2008, a 66-year-old female patient underwent immediate breast reconstruction with LDMCF. In 2015, a late seroma was found at the donor site. After aspiration and drainage, the seroma recurred again in 2018. Total surgical excision of the seroma was performed and bloody-appearing fluid was identified in the capsule. The excised tissue was biopsied. Histological examination revealed no evidence of blood in the fluid, and multinucleated giant cells with amorphous eosinophilic proteinaceous material were identified. The cyst was suggestive of chronic granulomatous inflammation. There was no recurrence at 8 months postoperatively. The patient described herein underwent surgical treatment of late seroma that recurred after immediate breast reconstruction with LDMCF, and histological findings were identified. These results may be helpful for other future studies regarding late seroma after breast reconstruction with LDMCF.

• Archives of Plastic Surgery
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• v.49 no.4
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• pp.494-500
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• 2022

Background Seroma formation is the most common donor site complication following autologous breast reconstruction, along with hematoma. Seroma may lead to patient discomfort and may prolong hospital stay or delay adjuvant treatment. The aim of this study was to compare seroma rates between the deep inferior epigastric perforator (DIEP), transverse musculocutaneous gracilis (TMG), and superior gluteal artery perforator (SGAP) donor sites. Methods The authors conducted a retrospective single-center cohort study consisting of chart review of all patients who underwent microsurgical breast reconstruction from April 2018 to June 2020. The primary outcome studied was frequency of seroma formation at the different donor sites. The secondary outcome evaluated potential prognostic properties associated with seroma formation. Third, the number of donor site seroma evacuations was compared between the three donor sites. Results Overall, 242 breast reconstructions were performed in 189 patients. Demographic data were found statistically comparable between the three flap cohorts, except for body mass index (BMI). Frequency of seroma formation was highest at the SGAP donor site (75.0%), followed by the TMG (65.0%), and DIEP (28.6%) donor sites. No association was found between seroma formation and BMI, age at surgery, smoking status, diabetes mellitus, neoadjuvant chemotherapy, or DIEP laterality. The mean number of seroma evacuations was significantly higher in the SGAP and the TMG group compared with the DIEP group. Conclusion This study provides a single center's experience regarding seroma formation at the donor site after microsurgical breast reconstruction. The observed rate of donor site seroma formation was comparably high, especially in the TMG and SGAP group, necessitating an adaption of the surgical protocol.

• Archives of Reconstructive Microsurgery
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• v.11 no.1
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• pp.11-18
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• 2002

Large soft tissue defects around the knee joint are known to significantly diminish joint function. Severe soft tissue defects on the anterior aspect of the knee joint especially bring on significant joint motion limitation. Although simple split skin grafts can cover the skin defect, the progressing scar contracture of the grafted skin causes joint stiffness. One of the best solutions of large soft tissue defects around the knee joint is covering the defect with a good quality skin flap. Separated flaps with one vascular pedicle are good candidates for covering anterior and posterior aspects of the joint for example. Authors performed 12 cases of combined scapular and latissimus dorsi free flaps from 1984 to 2000. Among them, we experienced 5 cases of knee joint defect covering using the double free flap for coverage of the soft tissue defect with preservation of the knee joint function and satisfactory results. The system of flaps based on the subscapular artery and vein provides a variety of composite free flaps. The possible flaps that can be harvested based on this single vascular pedicle include the scapular and parascapular skin flap, the serratus anterior and latissimus dorsi muscular flap, the lateral scapular bone flap, the latissimus dorsi-rib flap, and the serratus anterior-rib flap. This combined flap is available for multiple tissue defects or complex defects because it can be incorporated with skin, muscle and bone flaps. A main advantage is the independent vascular pedicles of each component, which allow freedom in orientation of each components. Consequently it can be freely applied to any form of three dimensional defects on the upper and lower extremities. The combination of scapular cutaneous flap and latissimus dorsi musculocutaneous flap can be resurfaced for massive cutaneous defects on the extremities. We report the use of the combined scapular and latissimus dorsi free flap in five patients to reconstruct massive defects on the extremities with resultant improved joint function. There was no flap failure and minimal complications and disadvantages. The anatomy of this flap is reviewed and the indication and advantages are discussed. All of the five flaps survived and there was no scar contracture affecting the joint motion.

• Archives of Plastic Surgery
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• v.44 no.2
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• pp.136-143
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• 2017

Background The goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps. Methods The authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients. Results We identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from $2.0cm{\times}4.5cm$ to $8.0cm{\times}8.0cm$. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures. Conclusions The peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

• Archives of Reconstructive Microsurgery
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• v.13 no.1
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• pp.24-28
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• 2004

The vascularity of a skin island in fibula osteocutaneous free flap often depends on musculocutaneous perforators that find their origin in the proximal peroneal artery. But a potential drawback has been reported on the unreliability of the skin paddle. The perforating vessels to the skin paddle of the fibula osteocutaneous free flap were rarely derived from a common tibio-fibula trunk, an anterior tibial artery and a posterior tibial artery. Previous studies have emphasized total loss of the overlying skin paddle, if the expected perforating vessels are not present. We report here on our experience that the skin paddle of the fibula osteocutaneous free flap was vascularized not by a peroneal artery but a direct branch of the posterior tibial artery. There were no intraseptal nor intramuscular pedicles in the posterior crural septum which connected to the overlying skin island. Therefore, we performed microsurgical anastomoses between distal peroneal vessels of the fibula and the perforating branches of the posterior tibial vessels of the skin paddle. The anastomosed skin paddle was salvaged with a peroneal flow through vascular anastomosis and was transferred to the bone and intraoral soft tissue defects with the fibula graft. The patient had no evidence of vascular compromise in the postoperative period and showed good healing of the intraoral skin flap.