• Archives of Reconstructive Microsurgery
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• 제11권1호
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• pp.53-62
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• 2002

Several investigators have reported clinical experience of medial plantar septo-cutaneous flap for reconstruction for soft tissue defect of the hand and digits. Jayme and Hamilton first described the anatomy of superficial branch of medial division of the medial plantar artery used in this flap through cadavaric study in 1997. But, they had a few cases for this flap and there was no anatomic study in Korean. We experienced the reliability of medial plantar septo-cutaneous flap for reconstruction for soft tissue defect of hand and digits through an anatomic study (20 fresh specimens dissected) and clinical application (17 patients). An anatomic study revealed that there were differences in diameter and length of the vessels between Korean and Caucasian. The diameter of vessels in Korean is larger than Caucasian one in each area. Based on this anatomic knowledge, we could harvest this flap safely, and have performed reconstruction on 17 patients with soft tissue defects of hand and digits using a thin, flexible medial plantar septo-cutaneous flap similar to the volar aspect of the hand and digits in anatomical characteristics of the skin and subcutaneous tissue covering. The vessels used for this flap were superficial branches of medial division of the medial plantar artery and vena comitants, or the subcutaneous veins. The mean size of the flap was $2.82cm{\times}4.15cm$. All the flaps survived without significant complications. A medial plantar septo-cutaneous flap possesses several advantages : (1) It is very thin in comparison with other standard free flap; (2) it has two draining venous pathways; (3) it provides a good color and texture match for hand and finger; (4) a good recovery of protective sensation is achievable.

• Archives of Reconstructive Microsurgery
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• 제11권1호
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• pp.29-35
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• 2002

Free flap reconstruction of the foot has become one of the standard procedures at the present time, but choice of a free flap for the soft tissue defect of the foot according to location and size remains controversial. We evaluated the results of free flap reconstruction for the soft tissue defects of the foot. Twenty seven free flaps to the foot were performed between May 1986 and December 2000 in the department of Orthopedic Surgery. Patient age ranged from 3 to 60 years. Male to female distribution was 20:7. Mean follow-up period was 30.5 months which ranged from 12 months to 60 months. The indications for a specific flap depended on the location and extension of the foot defect. In weight-bearing area and amputation stump, the authors chose the sensate (reinnervated) dorsalis pedis flaps (n=7) and sensate radial forearm flaps (n=2). In nonweight-bearing area including dorsum of the foot and area around Achilles tendon, we performed nonsensate (non-reinnervated) free flap reconstructions which included dorsalis pedis flaps (n=5), groin flap (n=1), radial forearm flaps (n=6), scapular flaps (n=4), latissimus dorsi flaps (n=2). Twenty-six flaps transferred successfully (96.3%). The sensate flaps which were performed in weight-bearing area and amputation stumps survived in all cases and recovered protective sensation. Mean two-point discrimination was 26 mm at the last follow up. As a conclusion, the selection of a proper flap depends on the location and extension of the foot defect and patient's age. Fasciocutaneous flap including radial forearm flaps and dorsalis pedis flaps were the best choice in nonweight-bearing area. The sensate free flaps which are performed in the weight-bearing area and amputation stumps can produce better outcome than nonsensate free flap.

• Archives of Reconstructive Microsurgery
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• 제9권2호
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• pp.114-119
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• 2000

The soft tissue defects including the Achilles tendon are complex and very difficult to reconstruct. Recently, several free composite flaps including the tendon have been used to reconstruct large defects in this area in an one-stage effort. Our case presents a patient reconstructed with free composite dorsalis pedis flap along with the extensor digitorum longus and superficial peroneal nerve for extensive defects of the Achilles tendon and surrounding soft tissue. A 36-year-old-man sustained an open injury to the Achilles tendon. He was referred to our department with gross infection of the wound and complete rupture of the tendon associated with loss of skin following reduction of distal tibial bone fracture. After extensive debridement, $6{\times}8cm$ of skin loss and 8cm of tendon defect was noted. Corresponding to the size of the defect, the composite dorsalis pedis flap was raised as a neurosensory unit including the extensor digitorum longus to provide tendon repair and sensate skin for an one-stage reconstruction. One tendon slip was sutured to the soleus musculotendinous portion, the other two were sutured to the gastrocnemius musculotendinous portion with 2-0 Prolene. The superficial peroneal nerve was then coaptated to the medial sural cutaneous nerve. The anterior tibial artery and vein were anastomosed to the posterior tibial artery and accompanying vein in an end to end fashion. After 12 months of follow-up, 5 degrees of dorsiflexion due to the checkrein deformity and 58 degrees of plantar flexion was achieved. The patient was able to walk without crutches. Twopoint discrimination and moving two-point discrimination were more than 1mm at the transferred flap site. The donor site healed uneventfully. Of the various free composite flaps for the Achilles tendon reconstruction when skin coverage is also needed, we recommand the composite dorsalis pedis flap. The advantages such as to control infection, adequate restoration of ankle contour for normal foot wear, transfer of the long tendinous portion, and protective sensation makes this flap our first choice for reconstruction of soft tissue defect including the Achilles tendon.

• 대한후두음성언어의학회지
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• 제27권1호
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• pp.30-34
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• 2016

Background and Objectives : Microsurgical resection of intracordal cysts is technically difficult and challenging because the wall of cysts may be tightly attached to underlying vocal ligament and/or overlying epithelium, and therefore their thin wall will easily rupture during surgical dissection. We aimed to evaluate the voice outcomes of standard microflap subepithelial resection and the recurrence rate depending on the intraoperative rupturing of the cyst. Materials and Methods : Medical records of Samsung Medical Center, Seoul, Korea, were reviewed for sixty-four consecutive patients who received surgical resection of vocal cyst using microflap subepithelial dissection technique between the year 2004 and 2013. Meticulous dissection was performed to completely remove the cyst wall while preserving the mucosa and the lamina propria as much as possible. Voice outcomes and recurrence rates were compared according to the type, size and the intraoperative rupture of cyst. Results : Presence or absence of cyst rupture was clearly described in the operation records of 41 patients. Intraoperative rupture of the cyst occurred in 32 of 41 (78%) patients. The recurrence was detected in 5 of 64 (7.8%) total cases and 4 of 32 (12.5%) cases of ruptured cyst, but not in 9 cases of intact extirpation. Rupture was more common in case of mucous retention cyst compared with epidermoid cyst (p=0.036). Subjective and objective voice parameters were measured at before and 3 months after surgery, which improved regardless of the cyst rupture. Conclusion : Although complete microsurgical extirpation of intracordal cyst while keeping the cyst wall intact is technically difficult, meticulous dissection with maximal preservation of surrounding tissue may warrant the improvement of voice outcomes.

• Archives of Plastic Surgery
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• 제35권3호
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• pp.267-272
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• 2008

Purpose: Donor site seroma is the most common complication of extended latissimus dorsi flap for breast reconstruction. One of preventive treatments is to use the fibrin sealant in donor site before closure. Experimentally, it has been used successfully in the prevention of latissimus donor site seroma, but its clinical efficacy and results were very controversial. Thus, the purpose of this study is to evaluate the clinical efficacy and to determine the optimal dose of fibrin sealant. Methods: A retrospective study was done of patients operated under same surgical conditions by one operator with variable doses of fibrin sealant. The study group consisted of 60 consecutive patients who underwent breast reconstruction with extended latissimus flap reconstructions from January 2005 to December 2006. Patients were divided into 4 group by applied fibrin sealant amount(group 1=0 mL, group 2=1 mL, group 3=2 mL, group 4=4 mL). Retrospective data were obtained from total postoperative drainage amount, time from surgery to drain removal, and incidence and quantity of seroma formation in matched patients group. Results: Total drainage amount decreased relative to the amount of fibrin sealant. The seroma formation rate of 30% in the study group 4 was significantly less than group 1 rate of 71%(p<0.05). It was an improvement over the rates of as much as 79% described previously in the literature. Also, time from surgery to drain removal was shortened significantly in group 4 patients(p<0.05). Conclusion: The use of fibrin sealant in the extended latissimus dorsi flap donor site appears effective in preventing seroma. However, important factors to obtain lower seroma formation rates are proper techniques and proper amounts such as the authors suggested amount: $0.01mL/cm^2$ with spray type fibrin sealant.

• Archives of Plastic Surgery
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• 제37권5호
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• pp.712-716
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• 2010

Purpose: Extensive lumbosacral defects after removal of spinal tumors have a high risk of wound healing problems. Therefore it is an effective reconstructive strategy to provide preemptive soft tissue coverage at the time of initial spinal surgery, especially when there is an instrument exposure. For soft tissue reconstruction of a lumbosacral defect, a variation of the gluteal flap is the first-line choice. However, the musculocutaneous flap or muscle flap that is conventionally used, has many disadvantages. It damages gluteus muscle and causes functional disturbance in ambulation, has a short pedicle which limits areas of coverage, and can damage perforators, limiting further surgery that is usually necessary in spinal tumor patients. In this article, we present the superior gluteal artery perforator turn-over flap that reconstructs complex lumbosacral defects successfully, especially one that has instrument exposure, without damaging the ambulatory function of the patient. Methods: A 67 year old man presented with sacral sarcoma. Sacralectomy with L5 corpectomy was performed and resulted in a $15{\times}8\;cm$ sized complex soft tissue defect in the lumbosacral area. There was no defect in the skin. Sacral stabilization with alloplastic fibular bone graft and reconstruction plate was done and the instruments were exposed through the wound. A $18{\times}8\;cm$ sized superior gluteal artery perforator flap was designed based on the superior gluteal artery perforator and deepithelized. It was turned over 180 degrees into the lumbosacral dead space. Soft tissue from both sides of the wound was approximated over the flap and this provided in double padding over the instrument. Results: No complications such as hematoma, flap necrosis, or infection occurred. Until three months after the resection, functional disturbances in walking were not observed. The postoperative magnetic resonance imaging scan shows the flap volume was well maintained over the instrument. Conclusion: This superior gluteal artery perforator turn-over flap, a modification of the conventional superior gluteal artery perforator flap, is a simple method that enabled the successful reconstruction of a lumbosacral defect with instrument exposure without affecting ambulatory function.

• Archives of Plastic Surgery
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• 제37권5호
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• pp.519-525
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• 2010

Purpose: Of various effects of relaxin, we assumed that anti-fibrotic effects, neovascularization effects and vasodilatation effects of relaxin might enhance the survival rate of skin flap. In the current study, we used adenovirus expressing relaxin genes to examine whether these genes could enhance the survival rate of a skin flap. Methods: A total of 30 Sprangue-Dawley rats were divided into three groups: RLX group (10; relaxin virus injected group), CTR group (10; no gene coded virus injection group), and PBS group (10; PBS injected group). Each group was intradermally injected with the virus ($10^7$ PFU) and PBS 48 hours before and immediately before the flap elevation. A distally based flap $3{\times}9\;cm$ in size was elevated on the dorsal aspect of each rat. Following this, a flap was placed in the original location and then sutured using a #4-0 Nylon. A surviving area of the flap was measured and then compared on postoperative days 3, 7 and 10. Using a laser Doppler, the amount of blood flow was measured. On postoperative day 10, tissues were harvested for histologic examination and the number of blood vessels was counted. Results: There was a significant increase in the area of the flap survival in the RLX group on postoperative days 3 and 7. The Doppler measurement also showed significantly increased blood flow immediately after the operation and on postoperative days 7 and 10. The number of blood vessels was significantly greater in the RLX group in the tissue harvested on postoperative day 10. The VEGF concentration was significantly higher in the RLX group than others in the tissues harvested on postoperative day 10. Conclusion: Following an analysis of the effects of relaxin-secreting adenovirus on the survival of a flap, the surviving area of the flap and the blood flow also increased. A histopathology also showed an increase in the number of blood vessels and the concentration of VEGF.

• Archives of Plastic Surgery
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• 제37권2호
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• pp.129-136
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• 2010

Purpose: Anatomically, the foot is provided with insufficient blood supply and is relatively vulnerable to venous congestion compared to other parts of the body. Soft tissue defects are more difficult to manage and palliative treatments can cause hyperkeratosis or ulcer formation, which subsequently requires repeated surgeries. For weight bearing area such as the heel, not only is it important to provide wound coverage but also to restore the protective senses. In these cases, application of flaps for hind foot reconstruction is widely recognized as an effective treatment. In this study, we report the cases of soft tissue reconstruction for which various types of flaps were used to produce good results in both functional and cosmetic aspects. Methods: Data from 37 cases of hind foot operation utilizing flaps performed between from June 2000 to June 2008 were analyzed. Results: Burn related factors were the most common cause of defects, accounting for 19 cases. In addition, chronic ulceration was responsible for 8 cases and so forth. Types of flaps used for the operations, listed in descending order are radial forearm free flap (18), medial plantar island flap (6), rotation flap (5), sural island flap (3), anterolateral thigh free flap (2), lattisimus dorsi muscular flap (2), and contra lateral medial plantar free flap (1). 37 cases were successful, but 8 cases required skin graft due to partial necrosis in small areas. Conclusion : Hind foot reconstruction surgeries that utilize flaps are advantageous in protecting the internal structure, restoring functions, and achieving proper contour aesthetically. Generally, medial plantar skin is preferred because of the anatomical characteristics of the foot (e.g. fibrous septa, soft tissue for cushion). However alternative methods must be applied for defects larger than medial plantar skin and cases in which injuries exist in the flap donor / recipient site (scars in the vicinity of the wound, combined vascular injury). We used various types of flaps including radial forearm neurosensory free flap in order to reconstruct hind foot defects, and report good results in both functional and cosmetic aspects.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
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• 제31권5호
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• pp.409-416
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• 2005

Purpose of study: The temporomandibular joint (TMJ) occupies a key functional role in mastication and contributes to normal deglutition, speech as well as cosmesis. When a large amount of mandible including the condyle head is resected, it is very difficult to reconstruct it as a functional unit. In this retrospective study, we present the functional, radiographic and cosmetic results of reconstructed temporomandibular joint using free fibular flap. Patients and Methods: Total 12 patients (M:F = 6:6) who underwent condylar reconstruction with the fibular flap were interviewed and examined by radiographs and Bio-PAK$^{(R)}$. Mean follow up periods was $47.7{\pm}20.0$ months and the average age was $38.7{\pm}15.3$ years. Remodeling of condyle and function of TMJ were evaluated and facial contour was judged subjectively. Results: All flaps were viable and no immediate postoperative complication had happened. One patient showed decreased mouth opening, so interpositional gap arthroplasty was performed. The resorption rates of reconstructed fibular were minimal and the condyle heads were changed into domeshaped neocondyle after 2 years. All patients had normal diet and no speech difficulty was reported. Nine patients were satisfied with their facial contour but three patients complained about the depression of cheek. Conclusion: The reconstruction of TMJ with free fibular flap was reliable methods and very effective means of restoring mandibular function. The functional and morphologic results were excellent and showed little complications.

• Archives of Reconstructive Microsurgery
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• 제16권1호
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• pp.1-5
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• 2007

The purpose of this article to evaluate the availability of the rectus femoris flap in Korean subjects. Material and Methods is that Cadaveric dissections were done on 51 femoral triangles of 26 cadevers. We measured the length of the direct head of rectus femoris from anterior superior iliac spine to patella upper pole, ASIS to lateral border of femoral nerve, and entry point of femoral nerve and vessel branches to rectus. Usually, there were three terminal branches to rectus femoris from the femoral nerve. The entry point of the first branch was at the proximal $17.5{\sim}31.4%$ portion of the rectus femoris. The second and the third branch entered at the proximal $22.5{\sim}40.7%$ and $26.3{\sim}42.3%$, respectively. The vessel entry was at $20.2{\sim}37.3%$. The length from ASIS to femoral nerve was $3.5{\sim}8.5\;cm$. Among the 51 rectus femoris muscles, 44 had one nutrient artery, and 7 had 2 nutrient arteries. The nutrient artery originated from the descending branch of the lateral femoral circumflex artery in 18(40.9%) cases, directly from the lateral femoral circumflex artery in 8(18.0%) cases, and from proximal(6 cases, 13.6%) and distal(12 cases, 27.3%) portion of the deep femoral artery. The average length of the nutrient artery was 29.8 mm and the width was 2.14 mm. The point where it meets the main feeding artery of the rectus femoris was $9.0{\sim}15.0\;cm$ from the ASIS. In all cases, the main artery's entrance was proximal to the first nerve branch. Conclusion is that rectus femoris has available data for functional flap.