• Archives of Hand and Microsurgery
• /
• v.23 no.4
• /
• pp.296-300
• /
• 2018

Penile shaft reconstruction requires adequate soft tissue characteristics as well as constant vascular pedicles when considering a perforator flap. The free flap technique using various donor sites and regional conventional and perforator flaps have been utilized for penile shaft reconstruction. Still, the free flap techniques include challenging surgical procedures in addition to postoperative management. The regional flap can be applied to limited defects due to the size and shape. We performed the bilateral superficial external pudendal artery (SEPA) perforator flaps in order to reconstruct a circumferential penile shaft defect. The circumferential wound has noted necrotic tissue involving superficial (Dartos) fascia. We underwent debridement, preserving deep (Buck's) fascia and corpus spongiosum. Thereafter, the soft tissue defect was covered with bilateral SEPA perforator flaps. The patient has been observed for 27 months, showing penile resilience without deformity or wound-related problems.

• Archives of Plastic Surgery
• /
• v.44 no.3
• /
• pp.243-247
• /
• 2017

Reconstruction of the lower limb presents a complex problem after skin cancer surgery, as proximity of skin and bone present vascular and technical challenges. Studies on vascular anatomy have confirmed that the vascular plane on the lower limb lies deep to the deep fascia. Yet, many flaps are routinely raised superficial to this plane and therefore flap failure rates in the lower limb are high. Fascio-cutaneous flaps based on perforators offer a better cosmetic alternative to skin grafts. In this paper, we detail use of a thermal imaging camera to identify perforator 'compartments' that can help in designing such flaps.

• Archives of Plastic Surgery
• /
• v.48 no.3
• /
• pp.282-286
• /
• 2021

Recent reports have described several cases of double muscle transfers to restore natural, symmetrical smiles in patients with long-standing facial paralysis. However, these complex procedures sometimes result in cheek bulkiness owing to the double muscle transfer. We present the case of a 67-year-old woman with long-standing facial paralysis, who underwent two-stage facial reanimation using two superficial subslips of the serratus anterior muscle innervated by the masseteric and contralateral facial nerves via a sural nerve graft. Each muscle subslip was transferred to the upper lip and oral commissures, which were oriented in different directions. Furthermore, a horizontal fascia lata graft was added at the lower lip to prevent deformities such as lower lip elongation and deviation. Voluntary contraction was noted at roughly 4 months, and a spontaneous smile without biting was noted 8 months postoperatively. At 18 months after surgery, the patient demonstrated a spontaneous symmetrical smile with adequate excursion of the lower lip, upper lip, and oral commissure, without cheek bulkiness. Dual-innervated muscle transfer using two multivector superficial subslips of the serratus anterior muscle may be a good option for long-standing facial paralysis, as it can achieve a symmetrical smile that can be performed voluntarily and spontaneously.

• Archives of Reconstructive Microsurgery
• /
• v.22 no.2
• /
• pp.43-47
• /
• 2013

Purpose: Un-healing and centrally located defect on back area, it is sometimes a challenge for the reconstructive surgeon. Although skin grafts are considered as the first choice for reconstruction of large skin defect on the back region, it is not always helpful but vascularized flaps provide a superior functional and aesthetic outcome. The present study was designed to investigate the clinical anatomy of the lumbar artery perforator flap to reconstruct back ulcer. Materials and Methods: Clinical anatomy study was undertaken using computed tomographic angiographic analysis. We identified the courses of lumbar arteries and its perforators, measured pedicle length by layers. The location of the perforator vessel was charted against anatomical landmarks. Results: The pedicle lengths of the third and fourth lumbar artery perforator reached a mean of 27.8 mm and 37.1 mm respectively from superficial fascia to deep fascia. The fourth perforator was more laterally located than the third perforator and less than 1 cm above the iliac crest. A case in which the fourth lumbar artery perforator was used as flap pedicle is described. Conclusion: For the reconstruction of central defect on the back area, the lumbar artery perforator flap coverage may be a good alternative option. Computed tomographic angiography can easily identify the course and location of lumbar artery perforators and can be helpful to elevate the flap successfully.

• Archives of Plastic Surgery
• /
• v.47 no.4
• /
• pp.340-346
• /
• 2020

Background Adipofascial flaps covered with a skin graft address the challenges involved in reconstructing dorsal foot defects. The purpose of this study was to describe a large adipofascial flap based on the perforators of the dorsalis pedis artery for large foot defects. Methods Twelve patients aged 5-18 years with large soft tissue defects of the dorsal foot due to trauma were treated with an extended dorsalis pedis adipofascial flap from May 2016 to December 2018. The flap was elevated from the non-injured half of the dorsum of the foot. Its length was increased by fascial extension from the medial or lateral foot fascia to the plantar fascia to cover the defect. All perforators of the dorsalis pedis artery were preserved to increase flap viability. The dorsalis pedis artery and its branches were kept intact. Results The right foot was affected in 10 patients, and the left foot in two patients. All flaps survived, providing an adequate contour and durable coverage with a thin flap. Follow-up lasted up to 2 years, and patients were satisfied with the results. They were able to wear shoes. Donor-site morbidity was negligible. Two cases each of partial skin graft loss and superficial necrosis at the tip of the donor cutaneous flap occurred and were healed by a dressing. Conclusions The hinged multiperforator-based extended dorsalis pedis adipofascial flap described herein is a suitable method for reconstructing dorsal foot defects, as it provides optimal functional and aesthetic outcomes with minimal donor site morbidity.

• Archives of Craniofacial Surgery
• /
• v.20 no.5
• /
• pp.319-323
• /
• 2019

Cochlear implant extrusion, which is a common complication of cochlear implants, is generally repaired by a well visualized soft-tissue flap. A 61-year-old female patient with a medical history of schizophrenia who had a skin ulcer that caused cochlear implant extrusion, but that would be a stronger statement was referred to our department for removal of the implant and reconstruction of the resultant scalp defect. Accordingly, the broad defect was covered via rotation of a temporoparietal fascia flap (TPFF) using the superficial temporal artery, with the pedicle in the preauricular region as the pivot point. Coverage of TPFF was achieved with a split-thickness skin graft using the scalp as the donor site, which led to a quick recovery after the operation and satisfactory results in terms of aesthetics. This case suggests that a TPFF might be used as a flexible flap with low donor site morbidity for reconstructing cases of cochlear implant extrusion accompanied by a large full-layer scalp defect.

• Archives of Craniofacial Surgery
• /
• v.23 no.1
• /
• pp.39-42
• /
• 2022

The reconstruction of total lower eyelid defects is challenging to plastic surgeons due to the complicated anatomical structure of the eyelid. In addition, in the setting of cancer excision, the resection is deep, which requires some volume augmentation. However, in some cases, free tissue transfer is not applicable. We report a case of using a temporoparietal fascia flap (TPFF) for reconstructing a total lower eyelid defect. A large erythematous mass in an 83-year-old woman was diagnosed as squamous cell carcinoma by biopsy. After wide excision, the defect size was about 8×6 cm. The lower eyelid structures including the tarsus were removed. The TPFF including the superficial temporal artery was elevated and inset to the defect area. After the flap inset, a split-thickness skin graft with an acellular dermal matrix was performed on the fascial flap. There were no wound problems such as infection, dehiscence, or necrosis. After the patient's discharge, partial skin graft loss and ectropion occurred. The complications resolved spontaneously during the postoperative period. We report a case of reconstructing a lower eyelid defect using a TPFF. A TPFF can be applied to patients with large defects for whom free tissue transfer surgery is not appropriate as in this case.

• Archives of Craniofacial Surgery
• /
• v.20 no.3
• /
• pp.176-180
• /
• 2019

Background: Parotidectomy is the treatment of choice in many parotid tumors. Due to the extensive nature of the procedure, unfavorable complications such as gustatory sweating, surgical site depression are common. Various techniques using fascia, muscle or AlloDerm have been developed but debate still remains regarding its availability and affordability. We applied a newly developed acellular dermal matrix (Insuregraf) to the parotidectomy field to act as a physical barrier and to provide adequate filling effect for prevention of functional and aesthetic complications. Methods: From March 2010 to March 2017, 30 patients with parotid tumors underwent superficial parotidectomy. Twenty patients underwent only superficial parotidectomy. Ten patients had Insuregraf applied to the surgical site after superficial parotidectomy. We evaluated the incidence of Frey's syndrome, surgical site depression, and patient satisfaction rate in both groups. Results: The incidence of Frey's syndrome was lower in the Insuregraf group (0 vs. 2). Surgical site depression was also lower in the Insuregraf group (2 vs. 20). Satisfaction score for facial contour in Insuregraf group was 9.2 out of 10, which was comparable to 6.2 out of 10 in the control group. Conclusion: Application of Insuregraf after superficial parotidectomy is an effective surgical procedure to prevent complications such as Frey's syndrome and surgical site depression. This technique is affordable and safe with no immune reactions. Above all this surgical method should be considered as an option for patients who are concerned about the contour of the face after surgery.

• Archives of Plastic Surgery
• /
• v.37 no.5
• /
• pp.535-546
• /
• 2010

Purpose: The subcutaneous fat tissue is separated into 2 layers by the subcutaneous fascia: the superficial and deep fat layers. The two fat layers have different structures according to the body regions. The purpose of this study is to evaluate the distribution and pattern of the two fat layers in the human body by computed tomography (CT) and histological analysis according to age, sex, anatomical region, and body mass index (BMI). Methods: This study included 200 males and 200 females who underwent 64-channel dynamic CT in our hospital. The patients were divided into 5 groups according to 10 years of their ages separately in either male or female gender. The thickness of the superficial and deep fat layers was measured in the abdominal, pelvic, and femoral regions, and we analyzed the values. Statistical analyses were performed using SPSS software. The $3{\times}3$-cm whole fat layers were harvested from the same sites of 3 cadavers for histological examination, and one cadaver was dissected for gross evaluation. Results: The total thickness of subcutaneous fat tissue was greater in females than in males, and the ratio of the superficial fat layer to the whole fat layer was higher in females. The superficial fat layer became thinner with increasing age in males. As BMI increased, the total fat layer became thicker, and the superficial fat layer became thicker than the deep fat layer. On histological examination, the superficial fat layer had small adipose lobules and showed a densely distributed pattern in the abdominal region, whereas in the femoral region, it had large adipose lobules and showed a sparsely distributed pattern. There were no significant differences in the histological findings of the deep fat layer between the 3 body regions. Conclusion: Significant differences in histological findings of the two fat layers were found in relation to age, sex, anatomical region, and BMI. The superficial fat layer became thinner with increasing age in males, but it was constant in females. As BMI increased, the total thickness of subcutaneous fat tissue became greater, and the superficial fat layer became thicker than the deep fat layer. Our measurements can be used to understand the characteristics of the fat layers in relation to age, sex, anatomical region, and BMI.

• Applied Microscopy
• /
• v.36 no.3
• /
• pp.183-194
• /
• 2006

The threadlike structures of fascia were examined by tight and electron microscopy. In order to distinguish its tissue organization, we used staining methods including hematoxylin-eosin, Masson's trichrome, Van Gieson's collagen fiber stain and Kluver-Barrera's luxol fast blue for nerve stain. Under the light microscope, the threadlike structures were composed of many collagen fibers and nerve. In higher magnification, they looked like as the bundle of tubular structures. Many myoid cell-spindle nuclei were observed in the tissue, which were taken from the fascia. It was identical with Bonghan duct known as one of meridian network theory. In the early 1960's the North Korean Bong-Han Kim showed the anatomical structures of the acupuncture points, and explained the meridian system as the concrete duct network system. According to Bonghan theory the Bonghan ducts spread throughout the body Because it is believed that the duct could have the role of signal pathway, the theory was reinvestigated in these days. All of the threadlike structures isolated from fascia shows the abundance of collagen fibers. The electron microscope examination (TEM) could confirm the well arranged collagen fiber and nerve. This investigation reveals that superficial Bohghan duct are nerve fiber parallel running with collagen fibers. We conjectured that the intermingled structure of collagen fiber, blood vessel and nerve fiber might have the role of meridian system. And the more, regardless of histological research, the study on collagen fiber as response transmitter in acupuncture treatment are in need.