• Investigative Magnetic Resonance Imaging
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• v.17 no.1
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• pp.55-58
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• 2013

Persistent proatlantal artery (PPA) is a rare embryologically remnant carotico-vertebrobasilar anastomoses. There are two types of PPA according to embryological considerations, origin and anatomic course. Type I PPA usually originate from internal carotid artery and not traversing transverse foramen. Type II PPA traverses from external carotid artery to C1 transverse foramen. The PPA is usually found incidentally without clinical symptoms, but can be related to several clinically significant vascular lesions, such as hypoplastic vertebral artery, intracranial arteriovenous malformation and in a case of carotid endarterectomy or external carotid artery embolization. So, thorough understanding of this anomaly is needed and we report a case of type II PPA diagnosed by MR angiography.

• Archives of Plastic Surgery
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• v.35 no.2
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• pp.159-164
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• 2008

Purpose: Microvascular free tissue transfer has become a reliable technique for the reconstruction of complex wounds. Occasionally, unexpected intraoperative thrombosis and/or spasm of recipient artery might be annoying problems even for the technically competent microvascular surgeons. If such problems are not treated properly, they will inevitably cause to flap failure. Methods: From January 2006 to February 2007, soft tissue reconstructions by free tissue transfers were performed on 21 patients having complex defects in the lower extremity. Although segmental revision and various pharmacologic agents were repeatedly applied, arterial occlusions were not managed in 6 cases. For removal of thrombi and release of spasm, Fogarty No. 2 or No. 3 catheters were inserted into the lumen to the proximal recipient artery. Its balloon was then inflated after passing through a resistant area. Next, the catheter was gently withdrawn backward. Results: After the Fogarty catheter was inserted two or three times, the pulsatile arterial flow was restored. When the catheter was inserted into the lumen, a feeling of resistance existed in a 5-10cm more proximal portion that could not be easily accessed from the vascular end. After the reestablishment of blood flow, successful anastomoses were achieved and immediate rethrombosis or spasm did not occur. No long-term sequelae associated with balloon trauma to the arterial wall were observed. Conclusion: The use of the Fogarty catheter can be an effective method in treating pedicle thrombosis and spasm. This is a very simple and rapid technique that offers microvascular surgeons another option to increase the success rate of microvascular anastomosis in free tissue transfers.

• Archives of Plastic Surgery
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• v.40 no.5
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• pp.575-583
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• 2013

Background The aim of lower-extremity reconstruction has focused on wound coverage and functional recovery. However, there are limitations in the use of a local flap in cases of extensive defects of the lower-extremities. Therefore, free flap is a useful option in lower-extremity reconstruction. Methods We performed a retrospective review of 49 patients (52 cases) who underwent lower-extremity reconstruction at our institution during a 10-year period. In these patients, we evaluated causes and sites of defects, types of flaps, recipient vessels, types of anastomosis, survival rate, and complications. Results There were 42 men and 10 women with a mean age of 32.7 years (range, 3-72 years). The sites of defects included the dorsum of the foot (19), pretibial area (17), ankle (7), heel (5) and other sites (4). The types of free flap included latissimus dorsi muscle flap (10), scapular fascial flap (6), anterolateral thigh flap (6), and other flaps (30). There were four cases of vascular complications, out of which two flaps survived after intervention. The overall survival of the flaps was 96.2% (50/52). There were 19 cases of other complications at recipient sites such as partial graft loss (8), partial flap necrosis (6) and infection (5). However, these complications were not notable and were resolved with skin grafts. Conclusions The free flap is an effective method of lower-extremity reconstruction. Good outcomes can be achieved with complete debridement and the selection of appropriate recipient vessels and flaps according to the recipient site.

• Archives of Reconstructive Microsurgery
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• v.17 no.2
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• pp.94-100
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• 2008

In the past decade, there has been increasing breast reconstructions after mastectomy, and the abdomen has been the gold standard for donor site. TRAM (transverse rectus abdominis myocutaneous), MSTRAM (muscle sparing transverse rectus abdominis myocutaneous), DIEP (deep inferior epigastric artery perforator), SIEA (superficial inferior epigastric artery) flap has been widely used nowadays. Among them, DIEP free flap spares the whole rectus abdominis muscle and anterior rectus sheath resulting in decreased donor site morbidity. Between March of 2006 and February of 2008, six patients had undergone immediate breast reconstructions using DIEP free flap. The mean age of patients was 48.5 years. All patients had unilateral breast reconstructions. We dissected two perforators which were included in the unilateral pedicle. Thoracodorsal artery and its venae comitantes were chosen as recipient vessels. For venous anastomosis, we used the GEM Microvascular Anastomotic Coupler System (Synovis Micro Companies Alliance, Inc., Birmingham, Ala.) in four cases. All flaps were survived completely except one who showed fatty abdomen in old age. She showed repetitive vascular spasm intraoperatively. None of the patients had abdominal hernia, bulge or weakness. We believe that DIEP free flap provides a reliable method for autologous breast reconstruction if the patients are selected appropriately and performed by a skillful surgeon.

• Archives of Reconstructive Microsurgery
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• v.24 no.1
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• pp.7-12
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• 2015

Purpose: The rectus abdominis musculocutaneous (RAM) flap has contributed to the efficient reconstruction of soft tissue defects. The flap has the advantage of easy dissection, minimal donor site morbidity, and the constant vascular anatomy with long pedicle. Authors used the free RAM flap to reconstruct multi-located soft tissue defects while still considering functionality and aesthetics. We present the long-term outcomes and versatility of free RAM flaps. Materials and Methods: From 1994 to 2004, all patients who underwent soft tissue reconstruction with free RAM flap were reviewed retrospectively. The site of the reconstruction, vessels of anastomosis, type of RAM flap, and outcomes, including flap success rate, hospital stay after flap transfer, conduction of secondary procedure, flap complications, and donor-site complications were analyzed. Results: Twenty-one patients underwent 24 free RAM flaps in site of breast, face, upper extremity and lower extremity. Mean follow-up period was 36.1 months (range, 3~156 months). The overall success rate was 92% with only a loss of 2 flaps. Minor complications related to transferred flaps were necrosis of 2 partial flaps, hematoma formation in 3 cases, and a wound infection in 1 case. Donor site morbidity was not observed. Debulking surgery was performed in 4 patients, and scar revision was performed in 3 patients. Conclusion: Free RAM flap is a workhorse flap for general soft-tissue reconstruction with minimal donor site morbidity with aesthetically good results. Thus, the free RAM flaps are versatile, and sturdy for any sites of soft-tissue where reconstruction could be performed.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.30 no.4
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• pp.353-358
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• 2008

Purpose: The purpose of this clinical retrospective study was to evaluate our experience of radial forearm free flap for reconstruction of the oral cavity. Material and methods: From 1997 to 2006, 50 radial forearm free flaps were employed for head and neck reconstruction in 50 patients at department of oral and maxillofacial surgery, Yonsei University, Korea. Data were obtained from chart review, and clinical follow-up. Results: Patients' age ranged from 26 to 82 years (mean 53.2). There were 39 men and 11 women. 43 of the 50(86%) patients had squamous cell carcinoma. The total flap survival were 47(94%), complication rate were revealed for 15(30%). Conclusion: In the reconstruction of soft tissue within the oral cavity, several free flaps have been used. Because of its constant anatomy, long pedicle allows a hypothetic vascular anastomosis in the contralateral neck, contourability for various type of oral defects, pliability and can be used simultaneous reconstruction in intraoral and extra oral defects, the radial forearm free flap constitutes one of the best choice of intraoral soft tissue reconstruction.

• Archives of Plastic Surgery
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• v.46 no.5
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• pp.426-432
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• 2019

Background The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma. Methods This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved. Results Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years. Conclusions Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.

• Journal of Chest Surgery
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• v.54 no.3
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• pp.191-199
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• 2021

Background: Tracheal replacement is a challenge for thoracic surgeons due to stenosis in the trachea-prosthesis anastomosis. We propose that stenosis occurs due to fibrosis as a result of an abnormal healing process, characterized by an increased expression of wound healing growth factors (vascular endothelial growth factor [VEGF], survivin, and CD31), which promote angiogenesis and decrease apoptosis. We analyzed the immunoreactivity of VEGF, survivin, CD31, and caspase-3 in the development of fibrotic stenosis in prosthetic tracheal replacement. Methods: Fourteen dogs were operated on: group I (n=7) received a 6-ring cervical tracheal segment autograft, while in group II (n=7), a 6-ring segment of the cervical trachea was resected and tracheal continuity was restored with a Dacron prosthesis. The follow-up was 3 months. Immunoreactivity studies for VEGF, survivin, CD31, and caspase-3 were performed. A statistical analysis was done using the Wilcoxon signed rank test. Results: Four animals in group I were euthanized on the 10th postoperative day due to autograft necrosis. Three animals completed the study without anastomotic stenosis. Moderate expression of VEGF (p=0.038), survivin (p=0.038), and CD31 (p=0.038) was found. All group II animals developed stenosis in the trachea-prosthesis anastomotic sites. Microscopy showed abundant collagen and neovascularization vessels. Statistically significant immunoreactive expression of VEGF (p=0.015), survivin (p=0.017), and CD31 (p=0.011) was observed. No expression of caspase-3 was found. Conclusion: We found a strong correlation between fibrosis in trachea-prosthesis anastomoses and excessive angiogenesis, moderate to intense VEGF, CD31, and survivin expression, and null apoptotic activity. These factors led to uncontrolled collagen production.

• Journal of Chest Surgery
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• v.36 no.3
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• pp.142-149
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• 2003

To know the feasibility of the coronary artery bypass graft (CABG) for multivessel coronary artery disease with purely bilateral internal thoracic arteries (ITAs), we analyzed the short-term clinical results and the coronary angiography of the patients. Material and Method: From March 2001 to June 2002, four hundred and five patients underwent CABG. Purely bilateral ITAs were used in 159 patients (39.3%). We analyzed these patients retrospectively The mean age of these patients was $61.2{\pm}8.5$ (range: 30 ~80) years and there were 123 male patients. The preoperative risk factors were as follows: diabetes in 54 patients (34.0%), history of acute myocardiac infarction within 4 weeks in 29 (18.2%), and emergency operation in 6 (3.8%). Off-pump CABG was carried out in 128 patients (80.5%). Associated procedures were mitral valvuloplasty (5), aortic valve replacement (3), Dor procedure (1), and so on. Result: The mean number of distal anastomoses was $3.1{\pm}0.9$ (range: 2~6), the mean duration of hospital stay was $8.4{\pm}4.5$ days. There was one (0.6%) operative death. Except for one early death, no other patients suffered from low cardiac output. The other postoperative complications were occurred as follows: reoperation due to bleeding in 3 patients, perioperative myocardiac infarction in 1, transient cardiac arrest in 2, transient cognitive dysfunction in 7, and transient ischemic attack in 1, and deep sternal wound infection in 1 patient. Recently, early postoperative angiography was performed in 19 patients who had triple vessel disease. The total number of distal anastomosis was 78 (mean $4.1{\pm}0.8$/patient). All distal anastomosis sites were patent, but competition flow was observed at the bypass sites where the native coronary artery stenosis was not significant. Conclusion: The CABG with purely bilateral ITAs for triple vessel disease was performed safely. The early patency rate was relatively good in small number of patients. However the long-term patency rate and the functional study to evaluate the sites where competition flow was observed should be followed.

• Journal of Chest Surgery
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• v.41 no.1
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• pp.1-11
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• 2008

Background: The Damus-Kaye-Stansel (DKS) procedure is a proximal MPA-ascending aorta anastomosis used to relieve systemic ventricular outflow tract obstructions (SVOTO) and pulmonary hypertension. The purpose of this study was to review the indications and outcomes of the DKS procedure, including the DKS pathway and semilunar valve function. Material and Method: A retrospective review of 28 patients who underwent a DKS procedure between May 1994 and April 2006 was performed. The median age at operation was 5.3 months ($13\;days{\sim}38.1\;months$) and body weight was 5.0 kg ($2.9{\sim}13.5\;kg$). Preoperative pressure gradients were $25.3{\pm}15.7\;mmHg$ ($10{\sim}60\;mmHg$). Eighteen patients underwent a preliminary pulmonary artery banding as an initial palliation. Preoperative main diagnoses were double outlet right ventricle in 9 patients, double inlet left ventricle with ventriculoarterial discordance in 6,. another functional univentricular heart in 5, Criss-cross heart in 4, complete atrioventricular septal defect in 3, and hypoplastic left heart variant in 1. DKS techniques included end-to-side anastomosis with patch augmentation in 14 patients, classical end-to-side anastomosis in 6, Lamberti method (double-barrel) in 3, and others in 5. The bidirectional cavopulmonary shunt and Fontan procedure were concomitantly performed in 6 and 2 patients, respectively. Result: There were 4 hospital deaths (14.3%), and 3 late deaths (12.5%) with a follow-up duration of $62.7{\pm}38.9$ months ($3.3{\sim}128.1$ months). Kaplan-Meier estimated actuarial survival was $71.9%{\pm}9.3%$ at 10 years. Multivariate analysis showed right ventricle type single ventricle (hazard ratio=13.960, p=0.004) and the DKS procedure as initial operation (hazard ratio=6.767, p=0.042) as significant mortality risk factors. Four patients underwent staged biventricular repair and 13 received Fontan completion. No SVOTO was detected after the procedure by either cardiac catheterization or echocardiography except in one patient. There was no semiulnar valve regurgitation (>Gr II) or semilunar valve-related reoperation, but one patient (3.6%) who underwent classical end-to-side anastomosis needed reoperation for pulmonary artery stenosis caused by compression of the enlarged DKS pathway. The freedom from reoperation for the DKS pathway and semilunar valve was 87.5% at 10 years after operation. Conclusion: The DKS procedure can improve the management of SVOTO, and facilitate the selected patients who are high risk for biventricular repair just after birth to undergo successful staged biventricular repair. Preliminary pulmonary artery banding is a safe and effective procedure that improves the likelihood of successful DKS by decreasing pulmonary vascular resistance. The long-term outcome of the DKS procedure for semilunar valve function, DKS pathway, and relief of SVOTO is satisfactory.