• Archives of Plastic Surgery
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• v.38 no.4
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• pp.421-426
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• 2011

Purpose: Although the sural nerve is the most commonly used donor for autologous nerve graft, its morbidity after harvesting is sparsely investigated. The sural nerve being a sensory nerve, complications such as sensory changes in its area and neuroma can be expected. This study was designed to evaluate the donor site morbidity after sural nerve harvesting. Methods: Among the 13 cases, who underwent sural nerve harvesting between January 2004 and August 2009, 11 patients with proper follow up were included in the study. The collected data included harvested graft length, actual length of the grafted nerve, anesthetic and paresthetic area, presence of Tinel sign and symptomatic neuroma, and scar quality. Results: In 7 patients, no anesthetic area could be detected. Of the patients with a follow up period of more than 2 years, all the patients showed no anesthetic area except two cases who had a very small area of sensory deficit ($225mm^2$) on the lateral heel area, and large deficit ($4,500mm^2$) on the lateral foot aspect. The patients with a short follow up period (1~2 m) demonstrated a large anesthetic skin area ($6.760mm^2$, $12,500mm^2$). Only one patient had a Tinel sign. This patient also showed a subcutaneous neuroma, which was visible, but did not complain of discomfort during daily activities. One patient had a hypertrophic scar in the retromalleolar area, whereas the two other scars on the calf were invisible. Conclusion: After a period of 2 years the size of anesthetic skin in the lateral retromalleolar area is nearly zero. It is hypothesized that the size of sensory skin deficit may be large immediately after the operation. This area decreases over time so that after 2 years the patient does not feel any discomfort from nerve harvesting.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.576-584
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• 2011

Purpose: The shape and location, the amount of the wound and the characteristics of the remaining tissues are known to influence wound contraction. The previous studies using small animals have not been an appropriate model because the wound healing mechanisms and skin structures are different from those of the human. The purpose of this study is to evaluate wound contraction according to the shape and location of the wound using a $Micropig^{(R)}$. Methods: Four $Micropigs^{(R)}$ (Medikinetics, Pyeongtaek, Korea) that were 10 months of age weighed 25 kg were used. Full thickness skin defects were made by clearing all the tissues above the fascial layer in the shape of square, a regular triangle and a circle of 9 $cm^2$ each on the back around the spine. Eight wounds were created on the back of each pig, 50 mm apart from each other. The randomly chosen wound shapes included 11 squares, 11 regular triangles, and 10 circles. Wound dressing was done every other day with polyurethane foam. The wound size was measured using a Visitrak $Digital^{(R)}$ (Smith & Nephew, Hull, UK) on every other day after surgery from day 2 to day 28. A biopsy was performed on day 3, and 1, 2, 3 and 4 weeks to investigate the degree of acute and chronic inflammation, the number of microvesssel and myofibroblast density using H & E stain and immunohistochemistry. The wound contraction rate was calculated to figure out the differences among each of the shapes and the locations. Results: The ultimate shape of the circle wound was oval, and that of the regular triangle and square were stellate. The maximum contraction rate was obtained on 8 to 10 days for all the shapes, which corresponds with the immunohistochemical finding that myofibroblast increases in the earlier 2 weeks whereas it decreases in the later 2 weeks. Epithelialization was seen in the wound margin on day 7 and afterwards. The final wound contraction rates were highest for the regular triangle shapes; however, there were no statistically significant differences. The wound contraction rates by locations showed statistically significant differences. The wound in the cephalic area presented more contractions than that of the wounds in the caudal area. Conclusion: The location of a wound is more important factor than the wound shape in wound contraction.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.383-390
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• 2011

Purpose: To correct the upper lip depression after the correction of unilateral cleft lip, autologous grafts such as bone, dermal, fascial grafts and fat injections or alloplastic implants are used. Transplanted bones, dermis and fascia have a tendency to be absorbed and have donor morbidity. Fat injections are absorbed inconsistently and alloplastic implants have problems such as foreign body reactions, protrusions and infections. Authors corrected the upper lip depression using conchal cartilage graft in unilateral cleft lip deformity and the results was analysed with photos. Methods: 26-unilateral cleft lip and 2-microform cleft lip cases, totally 28 cases were performed. Their mean age was 21.89 years. The male and female cases were 12 and 16, respectively. Under anesthesia (general: 18 cases and local: 10 cases), cavum conchae (n=8), cymba conchae (n=16) and whole conchae (n=4) were harvested. Transversely cut the margin of the obtained cartilage, we cut out the most bent portion and put a partial-thickness incision on concave surface in cases of excessive convexity. Then, we performed the onlay graft of the conchal cartilage via scar revision site in unilateral cleft lip and via the reconstruction site of the cupid bow in microform cleft lip. The augmentation of the upper lip was evaluated with photos. Adapting the baseline connecting between the both cheilions as a horizontal standard line, we measured the highest point among the tangents between the upper lip and nose (point a), the lowest point (point c), the middle point between a and c (point b) and the vertical line from the alare (point d) to the horizontal standard line. To assess the postoperative symmetry, we compared cleft side upper lip contour index (%) A,B,C,D=(a,b,c,d)-ch ${\times}$ 100/(ch-ch) and non-cleft side upper lip contour index (%) A',B',C',D'= (a',b',c',d')-ch ${\times}$ 100 / (ch-ch).h) Results: After the surgery, no complication was found except in one case which double layers graft performed in the cleft lip deformity, the lateral portion was protruded. The upper lip contour index, the difference of A and A' were-0.83%, and thus the mild depression was persisted. Difference of B and B', C and C', D and D' were 0.83%, 1.07%, 0.90%. There were statistically significant difference, and thus the depression of upper lip were improved generally. Conclusion: Authors performed the onlay graft of the conchal cartilage in unilateral cleft lip deformity and found that the depression of the upper lip was well corrected except the uppermost part when photogrammetrically analyzed.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.408-414
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• 2011

Purpose: To correct breast ptosis, reduction mammoplasty and mastopexy have been developed in a way that minimizes complications. Recently, as the mean age of breast cancer occurrence is decreasing, the need for breast reconstruction in patients with breast cancer is rising. If mastopexy is performed with breast reconstruction at the same time, the size of the normal breast and the new one is not quite different. We decided to apply Z-plasty, which is a widely-used technique in plastic surgery to lengthen or change the direction of tension of the tissue. Methods: From March 2008 to December 2009, we performed breast reconstruction in 6 patients with breast cancer and scar contracture. After breast reconstruction, mastopexy with Z-plasty was applied to correct the asymmetry. The new nipple-areolar complex is placed on the line connecting the midclavicle and the current nipple. The inferior border of the new areola corresponds with the inferior border of the original areola, and the superior border about 2 cm upward the original superior border. We drew two oblique lines connecting the medial end of the incision line lower to the nipple-areola complex and the lateral end of the inframammary fold for Z-plasty. The excess tissue between these two lines was removed and the new triangular flaps were put together. Results: The average age of patients was 42.6 years, aged from 36.1 to 48.1 The weight of removed tissue was between 54g and 95 g, with the mean of 74 g. The average distance from the midclavicle to the nipple was 24 cm before surgery, and 21 cm after the surgery. The average operation time per patient (1 mastopexy) was 45 minutes, and the patients were satisfied with the size and shape. Conclusion: Applying Z-plasty for the mastopexy on the normal breast ptosis is a relatively simple way to achieve symmetry in patients who need breast reconstruction.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.695-698
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• 2011

Purpose: Since spinal tuberculosis is increasing in prevalence, it appears that a repair of spinal soft tissue defect as a complication of spinal tuberculosis can be a meaningful work. We report this convenient and practical reconstructive surgery which use bilateral latissimus dorsi musculocutaneous advancement flap. Methods: Before the operation, $13{\times}9.5$ cm sized skin and soft tissue defect was located on the dorsal part of a patient from T11 to L3. And dura was exposed on L2. Under the general endotrachel anesthesia, the patient was placed in prone position. After massive saline irrigation, dissection of the bilateral latissimus dorsi musculocutaneous flaps was begun just upper to the paraspinous muscles (at T11 level) by seperating the paraspinous muscles from overlying latissimus dorsi muscles. The plane between the paraspinous muscles fascia and the posterior edge of the latissimus dorsi muscle was ill-defined in the area of deformity, but it could be identified to find attachment of thoracolumbar fascia. The seperation between latissimus dorsi and external oblique muscle was identified, and submuscular plane of dissection was developed between the two muscles. The detachment from thoracolumbar fascia was done. These dissections was facilitated to advance the flap. The posterior perforating vasculature of the latissimus dorsi muscle was divided when encountered approximately 6 cm lateral to midline. Seperating the origin of the latissimus dorsi muscle from rib was done. The dissection was continued on the deep surface of the latissimus dorsi muscle until bilateral latissimus dorsi musculocutaneous flaps were enough to advance for closure. Once this dissection was completely bilateraly, the bipedicled erector spinae muscle was advanced to the midline and was repaired 3-0 nylon to cover the exposed vertebrae. And two musculocutaneous units were advanced to the midline for closure. Three 400 cc hemovacs were inserted beneath bilateral latissimus dorsi musculocutaneous flaps and above exposed vertebra. The flap was sutured with 3-0 & 4-0 nylon & 4-0 vicryl. Results: The patient was kept in prone and lateral position. Suture site was stitched out on POD14 without wound dehiscence. According to observative findings, suture site was stable on POD55 without wound problem. Conclusion: Bilateral latissimus dorsi musculocutaneous advancement flap was one of the useful methods in repairing of large spinal soft tissue defect resulting from spinal tuberculosis.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.376-382
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• 2011

Purpose: In patients with unilateral cleft lip and nose deformity, alar retraction is commonly seen on the non-cleft side after cleft side is corrected. Spacer graft was used to drag down the inferior border of the alar cartilage of the non-cleft side so as to match the cleft side. By performing spacer graft and septal extension graft together, symmetry and cosmetic improvements were achieved. Methods: Seven unilateral cleft lip and nose deformity patients underwent surgery for alar retraction correction. The median age was 24 years (ranged from 15 to 34 years), and the median follow-up period was 7.4 months (ranged from 6 to 12 months). The perpendicular length from the longitudinal axis of the nostril to the alar rim, the nasolabial angle and the ala-labial angle were measured in the lateral view photo. The longest perpendicular length from the cephalic border of the alar rim to the parallel line of the alar base was measured in the frontal view photo. Results: Improvement in alar retraction was seen after the surgery. There were no specific complications during the follow-up and the symmetry of both nostrils was satisfactory. No increase in the nasolabial angle or exposure of the nostrils was seen after the tip projection via tip plasty. Conclusion: The fundamental factor in correcting alar retraction with secondary cleft lip and nose deformity is repositioning the alar rim with spacer graft, which seems to be more physiologic than other methods. The method combining spacer graft with septal extension graft will bring symmetry as well as more cosmetic improvement in correction of alar retraction with secondary cleft lip and nose deformity.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.369-375
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• 2011

Purpose: Many hemostatic agents and dressings have been tested with variable degree of success. Chitosan has a positive charge, it attracts red blood cells, which have a negative charge. Our goal is to test the efficacy of new developed chitosan-based hemostatic materials in providing durable hemostasis in a high-flow arterial wound model. Methods: We compared each group with SD rats motality tests and in vitro blood compatibility test by blood clotting index (BCI). We devided the SD rats into 6 groups (N =15) by type of hemostatic agents. A: 100% nonwoven chitosan (degree of the deacetylation: 90%). B: 50% N-acetylation on nonwoven of chitosan gel (degree of the deacetylation: 50%). C: 60% N-acetylation on nonwoven of chitosan ge (degree of the deacetylation: 40%)l. D: Cutanplast$^{(R)}$. E: HemCon$^{(R)}$ F: Gauze. In vivo test, a proximal arterial injury was created in unilateral femoral arteries of 90 anesthetized SD rats. Each materials was made same size and thickness then applied to the injury site for 3 minutes. In vitro test, we compared each group with BCI in human blood. Results: In vivo test, group A showed lower motality rate of 46% than any other groups, Group B and C showed lower motality rate of 60% than group D and E's motality rate of 66%. In vitro test, BCI of group A ($30.6{\pm}1.2$) and B ($29.3{\pm}1.0$) were showed nearly about group D ($29.1{\pm}1.8$) and E ($27.4{\pm}1.6$). Group C ($37.1{\pm}2.0$) showed higher BCI than group A and B, it means group C decreased blood clotting. Conclusion: In conclusion, this study suggests a newly developed chitosan-based hemostatic materials induced durable hemostasis and increased blood clotting, and are considered as effective biologic hemostatic agents.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.594-601
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• 2011

Purpose: The frontal sinuses are a pair of triangularly shaped, air-filled chambers lined by mucoperiosteum and located between the inner and outer tables of the frontal bone. Until recently, our understanding of gender variations in craniofacial anatomy has been chiefly built upon anthropometric studies, which typically employ facial surface measurements or plain film radiography. The aim of this study i to determine the sizes of the frontal sinus in both sexes in Koreans. Methods: 95 Korean subjects who underwent maxillofacial 3-Dimensional computed tomography (CT) between January 2009 and December 2009 were enrolled. Frontal sinus dimensions and forehead measurements were taken at midline and at 10, 20, and 30 mm to the left and right of midline using sagittal, coronal, and axial images. The data was analyzed for significant differences between measurements made at the selected points in the frontal sinus, for left to right variations, for gender variations, and for racial differences. Results: The mean thickness of the anterior table ranged from 2.31 to 3.23 mm. Mean anteroposterior depth of the frontal sinus ranged from 7.38 to 9.45 mm and did not vary significantly at any distance from midline. Frontal sinus height was greatest at midline (mean=29.24 mm) and progressively lessened at lateral distances. Mean total width at the level of the supraorbital ridge was 53.66 mm. For all measurements, no significant left to right variation was noted. Comparing the sexes, males were found to have greater dimensions in most frontal sinus measurements, though these differences were only found to be significant at or close to midline. The male forehead was marked by more acute nasofrontal angle ($133.3^{\circ}$ versus $141.6^{\circ}$) and a steeper posterior forehead inclination ($14.9^{\circ}$ versus $7.7^{\circ}$). Conclusion: Using CT imaging, forehead and frontal sinus dimensions have been described. Generally, males had larger overall frontal sinus dimensions. And Korean had similar sized frontal sinus to Caucasian in height and width. But in AP distance Korean had lesser measurement. The result of this study may be helpful in the comprehension of normal size of frontal sinus in Korean.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.602-608
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• 2011

Purpose: Nasal bone fracture is the most common type of facial bone fracture and most of nasal bone fracture is combined with septal fracture frequently. Nasal septum is important to support the distal nose and to maintain the nasal airway. But nasal septal fractures are usually unrecognized and untreated at the time of operation. Recently, various materials were using for nasal packing after closed reduction, however these materials are not focused on the correction of nasal bone and nasal septal fracture and many patients are suffered from nasal packing materials. Thus, the purpose of this study is to compare routine packing materials and rolled silastic sheet with respect to postoperative effect of correction of nasal bone fracture and discomfort of nasal packing materials. Methods: We examined 320 patients treated nasal bone fracture from January 2008 to December 2010. For Group I (n=92), $Merocel^{(R)}$ was used for nasal packing, for Group II (n=152) vaseline gauze was used, and Rolled silastic sheet (RSS) with vaseline gauze packing (VGP) was used for Group III (n=76). Under the general anesthesia, all patients were operated by closed reduction and nasal packing was done using three kinds of packing materials. At the time of postoperative 7 days, packing material was removed and studied for pt's satisfaction and postop. complications. Results: In patients with RSS with VGP, the complaints (nasal obstruction, foreign compressive sensation and discomfort during food ingestion) of keeping the nasal packing were decreased ($p$ <0.05) and the postoperative complication (deviation) were decreased comparing to vaseline gauze packing and $Merocel^{(R)}$ packing, however, these differences were not statistically significant ($p$ >0.05). Conclusion: Postoperative nasal packing with RSS with VGP was more comfortable to the patients and it was more effective method to correct the nasal bone fracture and nasal septal fracture.

• Archives of Plastic Surgery
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• v.37 no.4
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• pp.396-399
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• 2010

Purpose: In hand injury, pedicle is usually damaged by avulsion injury or crushing injury. Because of postoperative pedicle obliteration, it is often hard to save the injured hand and fingers, even after successful replantation. The author introduces three cases of extensive hand injury, and successful results after applicatoin of multiple venous grafts to these patients. Methods: In all cases there was no circulation in any finger. In the first case, some vessels were extracted, so venous graft was applied to two sites of severely damaged venous sites. In the second case, venous grafts were applied to all four digital arteries of all fingers except thumb which got severely crushed, and two sites of dorsal veins. In the third case, venous graft was applied to all four digital arteries of all five fingers, and two sites of dorsal veins and palmar veins each. Results: In all cases, survival of hands and fingers was successful. In the second case, however, amputation in thumb and little finger at DIP joint level was inevitable, because of its severe damage, and the large dorsal defect on index finger was filled with DIEP free flap. Thumb was reconstructed with toe-to-thumb free flap, and additional debulking procedures and contracture release is furtherly needed. In the first case, additional surgery was done, as FDP tendon got re-ruptured, but in long term follow-up, satisfactory range of motion was attained. In the third case, FTSG on dorsal skin region was planned. as flap on dorsal area got partial necrosis. Conclusion: In hand injury, there are many structures to be repaired, but sometimes venous graft is avoided for its long operating time. Even though the length of damaged vessel is enough for anastomosis, the endothelium is often damaged (zone of injury). In extensive hand injury, successful reconstruction would be possible with active venous graft to all vessels suspicious for damage.