• Archives of Plastic Surgery
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• v.35 no.6
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• pp.663-668
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• 2008

Purpose: Pedicled transverse rectus abdominis myocutaneous(TRAM) flap has been a gold standard for breast reconstruction and one of surgical techniques preferred by many surgeons. The authors examined the course of deep epigastric artery focusing on distance from margins of rectus abdominis to pedicle and location of choke vessels to get minimal muscles during pedicled TRAM flap operation. Methods: Eleven rectus abdominis muscle from nine cadavers were used in this study. Rectus abdominis was separated from the cadavers, deep inferior and superior epigastric artery were isolated and then 8 anatomical landmarks in medial and lateral margins of rectus abdominis were designated. Distance to a pedicle meeting first horizontally was measured and vertical location from umbilicus to choke vessel was determined. In addition, 32 rectus abdominis images of 16 women(average age: 37.2 years old) from 64 channel abdomen dynamic computerized tomography were also examined with the same anatomical landmarks with those of cadavers. Results: Average distance from four landmarks on lateral margin of rectus abdominis to pedicle was 1.9 - 3.4cm and 1.8 - 3.8 cm on medial margin. Choke vessel was located between middle and inferior tendinous intersection in all cases and average distance between two tendinous intersection was 6.7 - 7.0 cm on medial margin and 6.2 cm on lateral margin. Location of inferior tendinous intersection was on umbilicus or superior of it in all cases and its average distance from umbilicus was 1.8 - 5.6 cm on medial margin and 2.7 - 6.2 cm on lateral margin. Conclusion: Distance from medial and lateral margins of rectus abdominis muscle to pedicle was the shortest in inferior tendinous intersection and that was averagely 1.8 cm on medial margin and 1.9 cm in average on lateral margin. All choke vessels were located between middle and inferior tendinous intersection.

• Archives of Plastic Surgery
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• v.36 no.5
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• pp.583-590
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• 2009

Purpose: In the cases of a vascular compromised condition in an injured lower extremity, soft tissue coverage with free tissue transfer presents a challenging problem to the reconstructive surgeon. For this reason, cross - leg flaps are still used in unusual circumstances. Advances in surgical technique has made the cross - leg free flap possible although it may require long operation time along with significant donor site morbidity. Therefore, a pedicled cross - leg muscle flap may be an alternative treatment modality when local flap or free flap is not possible. Methods: Twelve patients(9 males and 3 females) underwent the operation between October of 2001 and December of 2008. The patients' age ranged from 6 to 82 years. The unusual defects included the regions such as the knee, popliteal fossa, distal third of the tibia, dorsal foot, and the heel. Indications for the cross - leg gastrocnemius flap are inadequate recipient vessels for free flap(in eight cases), extensive soft tissue injuries(in three cases) and free flap failure(in one case). The muscle flap was elevated from contralateral leg and transferred to the soft tissue defect on the lower leg while both legs were immobilized with two connected external fixator systems. Delay procedure was performed 2 weeks postoperatively, and detachment was done after the establishment of the adequate circulation. The average period from the initial flap surgery to detachment was 32 days (3 to 6 weeks). Mean follow - up period was 4 years. Results: Stable coverage was achieved in all twelve patients without any flap complications. Donor site had minimal scarring without any functional and cosmetic problems. No severe complications such as deep vein thrombosis or flap necrosis were noted although mild to moderate contracture of the knee and ankle joint developed due to external fixation requiring 3 to 4 weeks of physical treatment. All patients were able to walk without crutches 3 months postoperatively. Conclusion: Although pedicled cross - leg flaps may not substitute free flap surgery, it may be an alternative method of treatment when free flap is not feasible. Using this modification of the gastrocnemius flap we managed to close successfully soft tissue defects in twelve patients without using free tissue transfers.

• Archives of Plastic Surgery
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• v.39 no.2
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• pp.130-136
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• 2012

Background : Complex elbow injuries with associated nerve, muscle, or joint injury commonly develop post-inury stiffness. In order to preserve function, joint congruency, elbow stability and durable wound coverage must be achieved in a timely manner. Methods : A retrospective review of patients who underwent orthopaedic fixation followed by free anterolateral thigh (ALT) flap soft tissue coverage was performed. Five patients were identified and included in this study. Results : We present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from $4{\times}9cm$ ($36cm^2$) to $15{\times}30cm$ ($450cm^2$) and were located either posteriorly (n=4) or anteriorly (n=1). Associated injuries included open fractures (n=3) and motor nerve transection (n=2). Wound coverage was achieved in a mean duration of 18.8 days (range, 11 to 42 day). There were no flap failures and no major complications. The mean postoperative active elbow motion was $102^{\circ}$ (range, $45^{\circ}$ to $140^{\circ}$). Conclusions : In our small series we have highlighted the safety and utility of using the free ALT flap in complex elbow injuries. The ALT flap has many advantages which include abundant skin and subcutaneous tissue; vascularised vastus lateralis muscle that was used in our series to obliterate dead space, provide a vascular bed for nerve grafts and combat infection; and, access to fascia lata grafts for reconstruction of the triceps tendon.

• Archives of Plastic Surgery
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• v.39 no.2
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• pp.126-129
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• 2012

Background : Facial capillary malformations (CMs) rarely recede; they often become darker and raised in proportion to their growth. These malformations may hypertrophy in adulthood, resulting in increased disfigurement and dysfunction. Laser treatment is considered a first-line therapy for focal CMs, but thick wide lesions, which are accompanied by hypertrophy and have a well-circumscribed nodularity, may be treated with surgical excision and reconstruction. Methods : We retrospectively reviewed the records of 25 consecutive patients who had undergone complete or partial excisions of facial capillary malformations in our unit. After the excisions, the defects that encompassed their facial aesthetic units were subsequently covered by various methods, including primary closures, local flaps, expanded flaps, split-thickness skin grafts, and full thickness skin grafts. Results : The data demonstrated satisfactory results and reliability. Our patients were treated without significant complications, and all of the patients were moderately or fully satisfied with the outcome of their surgeries. Conclusions : Among the many reconstructive options for adult patients with facial capillary malformations, thick split-thickness skin grafts can be a good choice for the coverage of widely excised wounds.

• Journal of Chest Surgery
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• v.39 no.12 s.269
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• pp.927-930
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• 2006

Hybrid procedure was performed for a thirteen-day-old girl with a functionally single ventricle, who weighed 2.2 kg and had been prematurely born at $32^{+5}$ weeks of gestation. She underwent bilateral pulmonary artery banding using 3.5 mm Gore-Tex graft, ductal stenting using balloon expandable stent, and reverse Blalock-Taussig shunt with 3.5 mm Gore-Tex vascular graft. After discharge, she was followed up for 4 months, and underwent 2nd stage operation(extensive arch reconstruction with Damus-Kaye-Stansel anastomosis, atrial septectomy, bilateral pulmonary artery angioplasty, bidirectional cavopulmonary shunt). She has been followed up for 4 months after the 2nd operation with an excellent clinical condition.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.41
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• pp.3.1-3.9
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• 2019

Background: The infratemporal fossa (ITF) is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. Due to its difficult approach, surgical intervention at the ITF has remained a heavy burden to surgeons. The aim of this article is to review basic skull base approaches and ITF structures and to avoid severe complications based on the accurate surgical knowledge. Methods: A search of the recent literature using MEDLINE (PubMed), Embase, Cochrane Library, and other online tools was executed using the following keyword combinations: infratemporal fossa, subtemporal fossa, transzygomatic approach, orbitozygomatic approach, transmaxillary approach, facial translocation approach, midface degloving, zygomatico-transmandibular approach, and lateral skull base. Aside from our Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial, there have been very few randomized controlled trials. The search data for this review are summarized based on the authors' diverse clinical experiences. Results: We divided our results based on representative skull base approaches and the anatomy of the ITF. Basic approaches to the ITF include endoscopic endonasal, transzygomatic, orbitozygomatic, zygomatico-transmandibular, transmaxillary, facial translocation, and the midfacial degloving approach. The borders and inner structures of the ITF (with basic lateral skull base dissection schemes) are summarized, and the modified zygomatico-transmandibular approach (ZTMA) is described in detail. Conclusions: An anatomical basic knowledge would be required for the appropriate management of the ITF pathology for diverse specialized doctors, including maxillofacial, plastic, and vascular surgeons. The ITF approach, in conjunction with the application of microsurgical techniques and improved perioperative care, has permitted significant advances and successful curative outcomes for patients having malignancy in ITF.

• Archives of Plastic Surgery
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• v.44 no.2
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• pp.124-135
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• 2017

Background In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. Methods A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. Results A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. Conclusions Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.

• Korean Journal of Head & Neck Oncology
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• v.12 no.2
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• pp.224-229
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• 1996

Head and neck arteriovenous malformation usually forms huge mass, cause profuse bleeding or potenially compromise the airway. This bleeding is vulnerable to be uncontrollable and life­threatening. Sometimes it has a high mortality. Although surgical resection is possible in some cases, the morbidity such as a defects of soft tissue is very high and its reconstruction is very difficult. The authors report an 11 year old female patient in whom occlusion of arteriovenous malformation with glue after transcutaneous embolization made a satisfactory results. At the beginning, she was transferred for massive oral bleeding. The bleeding was persistent and it was not possible to remove the packing in spite of many times of embolizations through feeding arteries. The massive bleeding trom the left upper alveolar mucosa compromised the airway and tracheotomy was done. Whenever the hypovolemic shock was occurred in a short time, blood transfusion and cardiopulmonary resucitation were done. To embolize the vascular mass of arteriovenous malformation, as a final trial before operation, the spinal needle was administered through the left upper gingiva under the fluoroscopy. The glue was injected on the target. The bleeding was stopped and we have noticed the absence of nidus on follow-up angiography after 3 weeks. We experienced that some cases of arteriovenous malformation in head & neck revealing the bleeding could be treated with transcutaneous embolization instead of surgical resection.

• Archives of Reconstructive Microsurgery
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• v.1 no.1
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• pp.31-38
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• 1992

The management of giant cell tumor involving juxta-articular portion has always been a difficult problem. In certain some giant cell tumors with bony destruction, a wide segmental resection may be needed for preventing to recur. But a main problem is preserving of bony continuity in bony defect as well as preservation of joint function. The traditional bone grafts have high incidence in recurrence rate, delayed union, bony resorption, stress fracture despite long immobilization and stiffness of adjuscent joint. We have attemped to overcome these problems by using a microvascular technique to transfer the fibula with peroneal vascular pedicle as a living bone graft. From Apr. 1984 to Nov. 1990, we performed the reconstruction of wide bone defect after segmental resection of giant cell tumor in 4 cases, using Vascularized Fibular Graft, which occur at the distal radius in 3 cases and at the proximal tibia in 1 case. An average follow-up was 2 years 8 months, average bone defect after wide segmental resection of lesion was 11.4cm. These all cases revealed good bony union in average 6.5months, and we got the wide range of motion of adjacent joint without recurrence and serious complications.

• Archives of Plastic Surgery
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• v.33 no.4
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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.