• Maxillofacial Plastic and Reconstructive Surgery
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• 제22권1호
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• pp.98-104
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• 2000

Expansion in the scope and technique of head and neck tumor resection during the past two decades has paralleled precise tumor localization with advanced radiographic imaging and the availability of microvascular free tissue transfer. Especially, the defect reconstruction utilizing free flap results in improvement of patient survival due to decrease of local recurrence by wide resection of cancer. The rectus abdominis free flap has been used widely in reconstruction of the breast and extremities. However, the report of cases on its applications in the head and neck, based on the deep inferior epigastric artery and vein, is rare. This flap is one of the most versatile soft-tissue flaps. The deep inferior epigastric artery and vein are long and large-diameter vessels that are ideal for microvascular anastomosis. The skin area that can be transferred is probably the largest of all flaps presently in use. The versatility of the donor site is due to the ability to transfer large areas of skin with various thickness and amounts of underlying muscle. This article is to report reconstruction of midface defects utilizing the rectus abdominis free flap in 2 patients with maxillary squamous cell carcinoma and discuss briefly considerations in flap design and orbital exenteration, and healing of irradiated recipient site by hyperbaric oxygen therapy with literature review.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제17권2호
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• pp.109-129
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• 1995

Many patients with malignancies of the head and neck undergo radiation therapy, either as the only method of treatment or in combination with surgery. Radiation therapy has great effect in the case of fairly advanced malignancies which can't be operated radically. But the complication of radiation therapy arise because of damage to the peri- and operated area. It is fully known that irradiated tissue shows retarded healing process in the skin, mucosa and especially vascuslar tissue. The purpose of this study was to observe the healing process of irradiated free or island flap after operation. As Experimental Models, Femoral arterial and venous anastomosis (Group 1), Epigastric-island flap (Group 2) and free Epigastric falp(Group 3) with irradiated postoperative 24 hrs were made on 30 rats/group. As Control Model(Group 4), Free Epigastric flap was not irradiated after operation was chosen on 30 rats. The amount of irradiation was single fraction of 20 Gy using as linear megavoltage accelerator. Difference between Experimental and Control group was evaluated by the method of clinical examination, histopatholoical findings, biochemical analysis and DNA activity at postoperative 1, 3, 7, 14 and 28 days. The results were as follows, 1. Skin color and new epithelization in group 2 and 3 was similar to control group clinically. 2. Postoperarive patency of femoral artery and vien showed 5% and 22% of ischemity. 3. The externa, media and intima of irradiated femoral artery and vein were similar to control group histopathlogically. 4. Granulation and collagen tissue accumulation of irradiated groups were more active due to degenerative and fibrotic changes than control group at postoperative 7 days histopathologically. 5. The hydroxyproline content of all experimental groups were reduced till 14 days and the group 2 was most prominent at postoperative 7 and 28 days(p<0.05). 6. DNA activities of all groups were reduced till 3 days, but begun to recover at 7 days and more activities in control group than irradiated group(p<0.05). Based on the above results, the clinical healing process of free flaps with irradiated postoperative 24 hrs little difference from control group without complications.

• Archives of Plastic Surgery
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• 제33권4호
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• pp.510-513
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• 2006

Purpose: The Rectus abdominis muscle free flap is utilized in various reconstruction surgeries due to easiness in harvesting, consistency of vascular pedicle and reduced donor site morbidity. But rarely, femoral nerve injury during rectus abdominis harvesting can be resulted. We report a case of femoral nerve injury after rectus muscle harvesting and discuss the injury mechanism with the follow-up process of this injury. Methods: To reconstruct the defect of middle cranial base after wide excision of cystic adenocarcinoma of the external ear, rectus muscle free flap was havested in usual manner. To achieve a long vessel, inferior epigastric artery was dissected to the dividing portion of femoral artery and cut. Results: One week after the surgery, the patient noted sensory decrease in the lower leg, weakness in muscle strength, and disabilities in extension of the knee joint resulting in immobilization. EMG and NCV results showed no response on stimulation of the femoral nerve of the left leg, due to the defects in femoral nerve superior to the inguinal ligament. With routine neurologic evaluations and physical therapy, on the 75th day after the operation, the patient showed improvement in pain, sensation and muscle strength, and was able to move with walking frame. In 6 months after the operation, recovery of the muscle strength of the knee joint was observed with normal flexion and extension movements. Conclusion: Rarely, during dissection of the inferior epigastric artery, injuries to the femoral nerve can be resulted, probably due to excessive traction or pressure from the blade of the traction device. Therefore, femoral nerve injury can be prevented by avoiding excessive traction during surgery.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제33권5호
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• pp.375-384
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• 2011

Purpose: The advent of microsurgical technique and instruments, particularly in the field of perforator flap and supermicrosurgery, which have expanded the scope of microsurgery. However, supermicroanastomosis without any compression, tension, or distortions must be achieved to reach successful outcomes. Small-caliber vessels, such as those with an internal diameter less than 0.2 mm, are susceptible to inadvertent twisting of the anastomosis. In this study, using the superficial inferior epigastric artery (SIEA)-based flap model in Sprague-Dawley (SD) rats, we evaluated the acceptable limits of twisting effects on supermicroanastomotic sites. Methods: A total of 20 supermicroanastomoses were performed using the SIEA-based flap model in 10 male SD rats, 10-weeks-of-age, weighing 300~350 g. Rats were divided into five groups of two with four flaps as follows: 1) sham, 2) control group with end to end SIEA arterial supermicroanastomosis, 3) experimental I (EA1) with $90^{\circ}$ twisting, 4) experimental II (EA2) with $180^{\circ}$ twisting, and 5) experimental III (EA3) with $270^{\circ}$ twisting of the supermicroanastomosis. Each SIEA was anastomosed using six 11-0 $Ethilon^{(R)}$ (Ethicon Inc. Co., NJ, USA) stitches except in the sham group where the SIEA was only clamped with Supermicro vascular $clamps^{(R)}$ (S&T, Neuhausen, Switzerland) for 20 minutes. Results: The anastomosed arterial patency showed no remarkable changes according to doppler waveforms measured with a Smardop 45 Doppler System (Hadeco Inc., Kawasaki, Japan). The pulsatility index (PI) was increased at postoperative day 10 in the EA2 and EA3 groups, and the resistance index (RI) showed no statistically significant difference between preoperative and postoperative values at 10 days. Histologic specimens from the EA3 group showed increased tunica media necrosis, convolution of the internal elastic lamina, densely packed platelets, fibrin, and erythrocytes. Flap viability and anastomosed vessel patency were not significantly affected by the degree of arterial twisting in this study, other than in the EA3 group where minor effects on arterial patency of the microanastomoses were encountered. Conclusion: It appears that minor twisting on small caliber arteries, used in supermicroanastomoses, can be tolerated. However, twisting should be avoided as much as possible, and more than $180^{\circ}$ twisting must be prevented in clinical practice.

• Archives of Plastic Surgery
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• 제44권3호
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• pp.238-242
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• 2017

The most common anatomic variant seen in donor kidneys for renal transplantation is the presence of multiple renal arteries, which can cause an increased risk of complications. Accessory renal arteries should be anastomosed to the proper source arteries to improve renal perfusion via the appropriate vascular reconstruction techniques. In microsurgery, 2 kinds of vascular augmentation methods, known as 'supercharging' and 'turbocharging,' have been introduced to ensure vascular perfusion in the transferred flap. Supercharging uses a distant source of the vessels, while turbocharging uses vascular sources within the same flap territory. These technical concepts can also be applied in renal transplantation, and in this report, we describe 2 patients who underwent procedures using supercharging and turbocharging. In one case, the ipsilateral deep inferior epigastric artery was transposed to the accessory renal artery (supercharging), and in the other case, the accessory renal artery was anastomosed to the corresponding main renal artery with a vascular graft (turbocharging). The transplanted kidneys showed good perfusion and proper function. No cases of renal failure, hypertension, rejection, or urologic complications were observed. These microsurgical techniques can be safely utilized for renal transplantation with donor kidneys that have multiple arteries with a lower complication rate and better outcome.

• Journal of Chest Surgery
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• 제35권7호
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• pp.553-555
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• 2002

경복부 접근법은 관상동맥우회술후 재수술시 정중 흉골절개에 동반될 수 있는 위험성을 피할 수 있다는 장점 때문에 선택적으로 적용될 수 있는 접근법 중의 하나이다. 관상동맥우회술 후 협심증이 재발한 59세 여자 환자에서 경복부 접근법을 통하여 심폐바이패스를 이용하지 않는 관상동맥우회술을 시행하였다. 검상돌기하 부위 에 경복부 절개술을 시행하고 개복한 후 이식혈관으로 우위 대망동맥을 준비하였으며, 우심실과 횡격막 사이의 유착을 박리한 뒤, 심폐바이패스를 이용하지 않고 심박동하에서 우위대망동맥을 우관상동맥에 문합하였다. 술후 1일째 시행한 관상동맥조영술에서 문합부위에 이상이 없음을 확인하였고, 합병증 없이 술 후 4일째 퇴원하였다. 정중 흉골절개가 아닌 경복부 접근법을 통해 심폐바이패스를 이용하지 않는 관상동맥 우회 재수술을 시행하고 만족할 만한 결과를 얻었기에 이 증례를 보고하는 바이다.

• 대한미세수술학회:학술대회논문집
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• 대한미세수술학회 1996년도 제16차 학술대회
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• pp.171.1-171.1
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• 1996

• Archives of Plastic Surgery
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• 제45권4호
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• pp.298-303
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• 2018

Flap thinning is a procedure for making a thick flap thinner. This procedure does more than simply fill in the defected area, and it is better for reconstructing the area both functionally and aesthetically. However, because flap thinning is a rather blind procedure, it may have harmful effects on flap vascularity. Therefore, the vasculature of a flap must be understood before performing flap thinning. This paper analyzes the basic anatomy underlying flap thinning based on the previous anatomic study that categorized flaps into 6 types by their vascular structures. This paper also reviews specific studies of frequently practiced flap procedures (deep inferior epigastric artery perforator flap, thoracodorsal artery perforator flap, and anterolateral thigh flap) and presents important precautions for flap thinning procedures. Finally, this paper briefly examines the axiality of the subdermal plexus, which needs to be taken into account when performing flap thinning.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제34권5호
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• pp.367-375
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• 2012

Midfacial reconstruction following resection of extensive malignant oral cavity tumors constitutes a challenging problems for reconstructive surgeons. Rectus abdominis muscle free flap (RAMFF) can be considered as the optimal reconstructive option in this case, because this flap has some advantages including consistent deep inferior epigastric artery anatomy, easy to dissect with well defined skin boundaries, acceptable donor site morbidity and the ability to perform simultaneous flap harvest with oral cancer ablation surgery. The rectus abdominis muscle forms an important part of the anterior abdominal wall and flexes the vertebral column, which is a long strap-like muscle divided transversely by three tendinous intersections, fibrous bands which are adherent to the anterior rectus sheath, which is thickly enclosed by the rectus sheath, except for the posterior part below the arcuate line that is usually located midway between the umbilicus and symphysis pubis. Below the arcuate line, this muscle lies in direct contact with the transversalis fascia and parietal peritoneum. For the better understanding of RAMFF as a routine reconstructive procedure in oral and maxillofacial surgery, the constant anatomical findings muse be learned and memorized by the young doctors in the course of the special curriculum periods for the Korean national board of oral and maxillofacial surgery. This review article will discuss the anatomical basis of RAMFF with Korean language.

• Archives of Reconstructive Microsurgery
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• 제19권1호
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• pp.56-60
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• 2010

Purpose: Breast reconstruction with abdominal flap has many advantages. However, it might cause abdominal complications such as bulging or hernia. SIEA (Superficial inferior epigastric artery) flap is the most advanced form of abdominal flap which has no adverse effect on abdominal fascia. We report 2 cases of breast reconstruction with SIEA flap with reference review. Methods: From Jun 2006 to Jan 2009, 110 patients underwent breast reconstruction with free abdominal flap. We tried to find the SIEA in every cases and adopted SIEP flap if the diameter was larger than 1mm and it had visible pulsation. 2 patients underwent breast reconstruction with SIEA flap. After design of abdominal flap SIEA was investigated with portable Doppler. SIEA was usually found 4-5 cm lateral to the midline. Flap was elevated with SIEA and SIEV to their maximal length at hiatus. Results: There were no complications, such as infection, hematoma, and necrosis of flap. In both cases, flaps survived completely with excellent vascularity and breast reconstruction was successful. In one case, there was skin necrosis of mastectomy flap, and it was healed by conservative management. Conclusion: With the SIEA flap, donor site morbidity can be minimized along with reduction of operation time. If there is reliable SIEA, SIEA flap would be the preferred skills. However, the limitation of the SIEA flap is difficulty in identifying the SIEA. The reason for less availability of the flap in Korea might include high prevalence of the Caesarian section scar and relatively higher level of the lower margin of the flap.