• Archives of Plastic Surgery
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• 제37권6호
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• pp.721-725
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• 2010

Purpose: The survival of composite graft is dependent on three steps, (1) plasmatic imbibitions, (2) inosculation, and (3) neovascularization. Among the many trials to increase the survival rate of composite graft, prostaglandin E1 (PGE1) has beneficial effects on the microcirculatory level with vasodilating, antithrombotic, anti-inflammatory and neoangiogenic properties. Lipo-PGE1 which is lipid microspheres containing PGE1 had developed to compensate the systemic and local side effects of PGE1. This study was proposed to determine whether Lipo-PGE1 administration enhanced the survival of composite graft through neovascularization quantitatively in a rabbit ear model. Methods: Fourteen New Zealand White Rabbits each weighing 3~4 kg were divided in two groups: (1) intravenous Lipo-PGE1 injection group and (2) control group. A $2{\times}1\;cm$ sized, full-thickness rectangular composite graft was harvested in each auricle. Then, the graft was reaaproximated in situ using a 5-0 nylon suture. For the experimental group, $3{\mu}g$/kg/day of Lipo-PGE1 ($5{\mu}g$/mL) was administered intravenously through the marginal vein of the ear for 14 days. The control group was received no pharmacologic treatment. On the 14th postoperative day, composite graft of the ear was harvested and immunochemistry staining used Monoclonal mouse anti-CD 31 antibody was performed. Neoangiogenesis was quantified by counting the vessels that showed luminal structures surrounded by the brown color-stained epithelium and counted from 10 random high-power fields (400x) by independent blinded observer. Statistical analysis (Wilcoxon Signed Ranks test for nonparametric data) was performed using SPSS v12.0, with values of p<0.05 considered significant. Results: The mean number of the microvessels was $15.48{\pm}8.65$ in the experimental group and $9.82{\pm}7.25$ in the control group (p=0.028). Conclusion: The use of Lipo-PGE1 facilitated the neoangiogenesis, resulted in the improvement of the survival rate of graft. On the basis of this results, we could support wider application of Lipo-PGE1 for more effective therapeutic angiogenesis and successful survival in various cases of composite graft in the human.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.385-390
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• 2010

Purpose: The purpose of this study is to demonstrate the usefulness of the high resolutional ultrasonographic features in patients with foreign body. Methods: From September 2007 to August 2009, we retrospectively reviewed high resolutional ultrasonogram using 5~12 MHz linear transducer of 13 patients presenting with inflammation after foreign body injection. They were referred for complications after foreign body injection. Injected foreign bodies were 4 silicone, 4 paraffin, 2 artecoll, and 3 unknown. We treated them with foreign body removal (7), foreign body removal and corrective plastic surgery (4), and conservative treatment with antibiotics and steroid injection (2). Results: High resolutional ultrasonography well demonstrated the existence of foreign body and it's overall size, location within the tissue layer, and vascularity. Comparison between preoperative and postoperative ultrasonographic findings was useful not only to evaluate the prognosis but also to plan the treatment. These ultrasonographic findings aided in precise assessment of the contour and location of the foreign body and led to an accurate surgery. We were able to acquire various information in order to set a detailed plan for the operation which in turn, led to a precise, successful surgery. After the treatment, complication did not occur in 12 patients, except 1 patient. But this patient was also treated after reoperation. Postoperative high resolutional ultrasonography shows almost foreign body removed and inflammation disappeared. Conclusion: Considering the usefulness of highresolution ultrasonography in foreign body injection, highresolution ultrasonography would be necessary for both the patient and the doctor. Preoperative and postoperative high resolutional ultrasonography is highly accurate, safe, inexpensive and easy. It can be a useful modality in foreign body after plastic surgery.

• Archives of Plastic Surgery
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• 제37권6호
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• pp.831-834
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• 2010

Purpose: Congenital absence of the vagina is a rare case. It occurs as a result of Mullerian duct aplasia or complete androgen insensitivity syndrome. The reconstructive modality includes skin graft, use of intestine and various methods of flap. We report a patient who underwent vulvoperineal fasciocutaneous flap to reconstruct congenital absence of the vagina, while the external genitalia and ovaries are normal. Methods: A 26-year-old woman presented with vaginal agenesis. Under general anesthesia, a U-shaped incision was made between the urethral meatus and the anus. The new vaginal pocket was created up to the level of the peritoneal reflection between the urinary structures and the rectum. Next, the vulvoperineal fasciocutaneous flaps were designed in a rectangular fashion. Flap elevation was begun at the lateral margin which the adductor longus fascia was incised and elevated, and the superficial perineal neurovascular pedicle was invested by the fascial layer. The medial border was then elevated. A subcutaneous tunnel was created beneath the inferior of the labia to rotate the flaps. The left vulvoperineal flap was rotated counterclockwise and the right was rotated clockwise. The neovaginal pouch was formed by approximating the medial and lateral borders. The tubed neovagina was then transposed into the cavity. Results: In 3 weeks, the vaginal canal remained supple After 6 weeks, the physical examination showed normalappearing labia majora and perineum with an adequate vaginal depth. A year after the operation, the patient had a 7 cm vagina of sufficient width with no evidence of contractures nor fibrous scar formation. The patient was sexually active without difficulty. Conclusion: Although many methods were described for reconstruction of vaginal absence, there is not a method yet to be approved as a perfect solution. We used the vulvoperineal fasciocutaneous flap to reconstruct a neovagina. This method had a following merits: a single-stage procedure, excellent flap reliability, the potential for normal function, minimal donor site morbidity and no need for subsequent dilatation, stents, or obturators. We thought that this operation has a good anatomic and functional results for reconstruction of the vagina.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.380-384
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• 2010

Purpose: Distinguishing different types of implants and assessing the position and size of implants by radiologic exam after orbital wall reconstruction is important in determining the surgery outcome and forecasting prognosis. We observed time-dependent density changes in three types of implants (porous polyethylene, resorbing plate and titanium mesh plate) by performing facial bone CT after orbital wall reconstructions. Methods: A total of 32 patients, who had underwent orbital wall fracture surgery from October 2006 to March 2009 and received facial bone CT as outpatients at 1 postoperative year were included in the study. Follow-up facial bone CT was performed on the patients pre- operatively, 1 month post-operatively, and 1 year post-operatively to observe the status of the orbital implants. Medpor $^{(R)}$ (Porex Surgical, Inc., Newnan, Ga.) was used as porous polyethylene and followed-up in 14 cases; for resorbing plate, Synthes mesh plate (Synthes, Oberdorf, Switzerland) was used in the reconstruction, and followed-up in 11 cases; and titanium mesh plate usage was followed-up in 7 cases. Computed tomographic scan (CT) and water's view were done for radiography, and hounsfield unit (HU) was used to compare density of those facial bone CT. Wilcoxon signed rank test was applied to statistically verify measurement difference in each group of hounsfield units. Results: Facial bone CT examination performed in 1 month post-operative showed that the density of porous polyethylene, resorbing plate and titanium mesh plate were -42.07, 105.67 and 539.48 on average, respectively. Among the three types of implants, titanium mesh plate showed the highest density due to its radiopaque feature. Following up the density of three types of implants in CT during 1 year after the orbital wall fracture surgery, the density of porous polyethylene increased in 10.52 House Field Units and the resorbing plate was decreased in 26.87 HouseField Units. There were no significant differences between densities in 1 month post-operatively and 1 year post-operatively in each group ($p{\geq}0.05$). Conclusion: We performed facial bone CT on patients with orbital fractures during follow-up period, distinguishing the types of implants by the different concentration of implant density, and the densities showed little change even at 1 year post-operative. To observe how implant densities change in facial bone CT, further studies with longer follow-up periods should be carried out.

• Archives of Plastic Surgery
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• 제37권6호
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• pp.823-826
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• 2010

Purpose: Meningomyelocele is the most common type of neural tube defect disease. Early surgical treatment is recommended to prevent central nervous system infection. Several reconstruction methods were reported previously regarding surgical wound defect closure following meningomyelocele excision. In this article, we report two successful patients using the bilateral fasciocutaneous sliding V-Y advancement flap as a covering for meningomyelocele defects. Methods: Two patients with meningomyelocele were evaluated. Both patients were male and received their operations on the 1st and 4th day of life. After neurosurgeons completed their part of the operation, the V-Y advancement flap was used to close the defect. Initially a bilateral V-shape incision design was made on the skin such that the base of the V-flap measures identical to the size of the wound defect. An incision was made down to the fascia in order to allow the V-flaps to slide into the defect. Subfascial dissection was performed up to 1/3 to 1/4 the length of the V-flap from the wound while minimizing injury to the perforating vessels. Results: Both patients were treated successfully and there was no evidence of complication in 2 months follow up. Conclusion: Several reconstruction methods such as local flaps, skin graft and myocutaneous flaps were reported regarding meningomyelocele surgical wound defect closure. Bilateral fasciocutaneous sliding V-Y advancement flap is an easy method without involving the underlying muscles or a secondary skin graft in a short operation time. Therefore we recommend this treatment option for reconstruction of the wound defect following meningomyelocele excision.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.481-484
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• 2010

Purpose: Congenital dermoid cysts develop during the fusion of the embryo when the ectodermal tissue gets trapped in the line of fusion. Dermoid cysts of the head are rare lesions comprised of epidermal and mesodermal elements. Furthermore, dermoid cysts in the occipital area are extremely rare. Only a few cases of dermoid cysts in the posterior scalp have been reported. Especially, A bilateral, synchronous presentation in this location has not been reported previously in the literature. Methods: All 5 cases had a gradually enlarging mass of the posterior aspect of the scalp. The cysts were mobile, noncompressible, and non-tender, without evidence of an associated sinus tract, skin dimpling, discoloration, or communication with adjacent structures. The CT scan displayed a hypodense cystic lesions about -87 to +24 HU (Housefield units, average +3.2 HU) with hypodense capsule and no postcontrast enhancement. All tumors were found just under the skin, and were well encapsulated, so they were completely removed the mass with adjacent periosteum. Results: On gross findings, all tumors were oval-or round-shaped, and when the cystic tumor was cut open it presented a greasy and caseous substance. Histologically, all specimens contain desquamated squamous epithelium and keratin in the lumen and are encapsulated and lined by keratinized stratified squamous epithelium. And, all cases of posterior mass are the presence of adnexal structures. Conclusion: Appropriate diagnosis requires not only an index of suspicion for this rare tumor a very careful history and search for skin changes. Especially, CT can reveal the exact location of the cyst, its relationship with the adjacent structures. We think that occipital dermoids divide into superficial and deep type. In our cases, because they did not have intra-cranial involvement or fistula formation, they are superficial type. This report describes the clinical and operative aspects of the superficial dermoid cysts and provides a review of the literatures.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.415-420
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• 2010

Purpose: Heterotopic calcification is a pathological event in which deposits of calcium salts build up, usually in the joint area or soft tissues. It can occur under many conditions and in some rare cases may develop in burn scars. In particular, ulcerations in burn scars accompanied by heterotopic calcification are difficult to treat through conservative treatment. This study reports methods for accurate diagnosis and adequate treatment of ulceration in burn scars accompanied by heterotopic calcification. Methods: Fourteen patients who visited our hospital from March 2008 to January 2010 were subjected to this study. Their sex, age, modes of burn, degree, TBSA (%), ulcerated area, the time of occurrence of the ulcerations in the burn scars were investigated. In addition, radiological examination and biopsy was performed to diagnose heterotopic calcification. Results: Among the 14 cases, 6 were male and 8 were female. The average age of the patients was 48.2 (27 - 69 yrs). As for the mode of burn, 11 were flame burns and 3 were scalding burns. The average time of occurrence of the ulcerations in the burn scars was 4.5 months. The ulcerated areas were situated in the legs in 12 cases, arms in 1 case, and torso in 1 case. The diagnosis was confirmed through X-ray and biopsy, and skin graft was performed after wide excision. Conclusion: Diagnosis of the ulceration in burn scars accompanied by heterotopic calcification is possible through radiological and pathologic studies. Surgical treatment is the most reliable method of treatment, and we chose to perform skin graft after wide excision. Also, we learned that the complete removal of the calcified tissue and the inflammatory fibrotic tissues is crucial in preventing recurrence. Also, in contrast to Marjolin's ulcer, heterotopic calcification had a small size, little or no granulation tissue, and lacked fungating type ulceration. Therefore, favorable prognosis could be achieved through adequate treatment.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.400-408
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• 2010

Purpose: Complete septal extension grafts have been widely used in rhinoplasty for effective projection of the short retruded columella in Asian patients. Autologous septal cartilages and porous high-density polyethylene sheets are frequently used as septal extension grafts. This study was conducted to compare the postoperative results of porous polyethylene sheets and septal cartilages used for correction of unilateral cleft lip nasal deformities by using photogrammetric analysis. Methods: This study investigated a total of 49 patients with cleft lip nasal deformities who underwent corrective surgery, and were followed up for at least 6 months. Septal cartilages were used in 39 patients, and porous polyethylene sheets were used in 10 patients. In all patients, through the open rhinoplasty, complete septal extension grafts were sutured to the caudal margin of the septal cartilage, and the alar cartilage was sutured with suspension. The cleft side alar cartilage was overcorrected by approximately 3 - 5 mm. Postoperative outcomes were evaluated by using photogrammetric analysis. Five indices and 4 angles were measured on their photographs taken before and after the surgery. In patients with unilateral cleft lip nasal deformities, symmetry was also evaluated by means of columellar length index. Results: The postoperative values obtained in photogrammetric analysis showed improvements in comparison with the preoperative ones. The polyethylene group produced more improved outcomes than the septal cartilage group but also resulted in more complications at the same time. Conclusion: The results of this study indicates that complete septal extension grafts are efficient for the correction of unilateral cleft lip nasal deformities. However, since postoperative complications occur more frequently in the polyethylene group than in the septal cartilage group, caution is advised in using porous high-density polyethylene sheets in patients with cleft lip nasal deformities.

• Archives of Plastic Surgery
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• 제37권6호
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• pp.783-787
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• 2010

Purpose: There are many articles describing about Guyon canal compression syndrome. Until recently, most of these articles have been presented about the symptoms of ulnar nerve compression, but there have been no reports about ulnar artery compression. In this article, besides the nerve compression symptoms in the Guyon's canal, we represented the symptoms and treatments based on the ulnar artery obstruction. Methods: Guyon canal is composed of the hamate and pisiform, and the ligaments which connect them. The course of the ulnar nerve and artery, which passes through this narrow canal, is affected by the anatomical structure of the base of the canal. Out of 14 patients (21 cases) were retrospectively reviewed in this study from 2006 to 2009. Of 14 patients, there were 5 men and 9 women with ages between 21 to 61 years old. The symptoms had volar sensory loss of ulnar sided digits, with muscular atrophy of hypothenar muscles. Prior to surgery, most of these patients had vascular disorders which was diagnosed definitively by angiography and electromyogram. Results: The release of Guyon canal and interposition graft of the obstructed arteries was carried out to 11 patients (15 cases) who had artery (vascular) occlusive disorder, and. 12 cases had sympathectomy and interposition graft after resection of obstructed ulnar artery. Six cases had release of carpal tunnel performed simultaneously. There were no major complications after surgery. The circulation of the ulnar artery was improved along with the patients' symptoms. Conclusion: The pre-existing articles about Guyon canal compression syndrome were mainly focused on ulnar nerve compression. This study, which was carried out by our department, showed that most of these patients had ulnar artery obstruction or stenosis simultaneously with ulnar nerve compression. The vascular disorder was corrected by interposition graft after the resection of the site of ulnar artery occlusion. And to conclude, When we resolve the ulnar nerve compression, the proper diagnosis & treatment of impaired ulnar artery circulation should be carried out concomitantly.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.340-345
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• 2010

Purpose: Recently, bioceramics have become popular as a substitute graft material for reconstruction of bony defect after trauma or tumor surgery. Among the bioceramic materials, hydroxyapatite (HA) is favored due to its biocompatibility. HA scaffold is composed of the interconnected reticular framework, macropores and micropores. Macropores play an important role in cell migration, nutrients supply and vascular ingrowth. On the other hand, a number of micropores less than $10{\mu}m$ form an irregular surface on HA scaffolds, which prevents the osteoblast from adhering and proliferating on the surface of HA scaffold. Methods: In this study, three different groups were designed for comparison. In the first group (group A), conventional method was used, in which HA pellet was applied without surface pretreatment. The second group (group B) was given a HA pellet that has been coated with crystalline HA solution prior to application. In the third group (group C), the same method was used as the second group, where the pretreated HA pellet was heated ($1250^{\circ}C$, 1 hour) before application. Osteoblast-like cells ($2{\times}10^4$/mL) were scattered onto every pellet, then they were incubated in 5% $CO_2$ incubator at $37^{\circ}C$ for twelve days. During the first three days, osteoblast cells were counted using the hemocytometer daily. ALP activity was measured on the 3, 6, 9 and 12 culture days using the spectrophotometer. Results: Under SEM, group A showed a surface with numerous micropores, and group B revealed more rough crystal surface. Group C revealed a fused crystal appearance and flattened smooth surface. In proliferation and ALP activity of osteoblast cells, group C showed better results compared to group B. Group A which lacks pretreatment of the surface showed less osteoblast proliferation and ALP activity than group C, but showed better results than group B. Conclusion: We found that crystallized HA with heat treatment method enhances the osteoblasts proliferation and differentiation on the surface of HA pellets.