• Journal of Trauma and Injury
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• v.21 no.2
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• pp.140-143
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• 2008

Degloving injuries result from the tangential force against the skin surface, with resultant separation of the skin and the subcutaneous tissue from the rigid underlying muscle and fascia. These injuries are associated with extensive soft tissue loss and occasionally with exposure of bone, and they require reconstructive modality for resurfacing and successful rehabilitation that considers the vascular anatomy and the timing of the operation. A 19-year-old male patient was transferred to our facility with degloving injury extending from the lower third of the right thigh to the malleolar area. The tibial bone was exposed to a size of $2{\times}3.5cm^2$ on the upper third of the lower leg at the posttraumatic third day. The exposed soft tissue was healthy, and the patient did not have any other associated disease. At the posttraumatic sixth day, one-stage resurfacing was performed with a medial gastrocnemius muscle flap transposition for the denuded bone and a split-thickness skin graft for the entire raw surface. The transposed gastrocnemius muscle attained its anatomical shape quickly, and the operating time was relatively short. No transfusion was needed. This early reconstruction prevented the accumulation of chronic granulation tissue, which leads to contracture of the wound and joint. The early correction of the gastrocnemius muscle flap transposition made early rehabilitation possible, and the patient recovered a nearly full range of motion at the injured knee joint. The leg contour was almost symmetric at one month postoperatively.

• Archives of Reconstructive Microsurgery
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• v.5 no.1
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• pp.24-34
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• 1996

There are many kinds of free flaps for management of extensive soft tissue defect of extremities in orthopaedic field. Free vascularized scapular flap is one of the most useful and relatively easy to application. This flap has been utilize clinically from early eighties by many microsurgical pioneers. Authors performed 102 cases of this flap from 1984 to 1995. We have to consider about the surgical anatomy of the flap, technique of the donor harvesting procedures, vascular varieties and anatomical abnormalities and success rate and the weak points of the procedure. This flap nourished by cutaneous branches from circumflex scapular vessels emerges from the lateral aspect of the subscapular artery 2.5-5cm from its lateral origin passing through the triangular space(bounded by subscapularis, teres minor, teres major, long head of triceps). The terminal cutaneous branch runs posteriorly around the lateral border of the scapular and divided into two major branches, those transeverse horizontally and obliquely to the fascial plane of overlying skin of the scapular body. We can utilize these arteries for scapular and parascapular flap. The vascular pedicle ranged from 5 to 10 cm long depends on the dissection, usually two venae comitantes accompanied circumflex scapular artery and its major branches. The diameter of the circumflex scapular artery is more than 1mm in adult, rare vascular variation. Surgical techniques : The scapular flap can be dissected conveniently with prone or lateral decubitus position, prone position is more easier in my experience. There are two kinds of surgical approaches, most of the surgeon prefer elevation of the flap from its outer border towards its base which known easier and quicker, but I prefer elevation of the flap from its outer border because of the lowering the possibilities of damage to vasculature in the flap itself which runs just underneath the subcutaneous tissue of the flap and provide more quicker elevation of the flap with blunt finger dissection after secure pedicle dissection and confirmed the course from the base of the pedicle. There are minimal donor site morbidity with direct skin closure if the flap size is not so larger than 10cm width. This flap has versatility in the design of the flap shape and size, if we need more longer and larger one, we can use parascapular flap or both. Even more, the flap can be used with latissimus dorsi musculocutaneous flap and serratus anterior flap which have common vascular pedicle from subscapular artery, some instance can combined with osteocutaneous flap if we include the lateral border of the scapular bone or parts of the ribs with serratus anterior. The most important shortcoming of the scapular free flap is non sensating, there are no reasonable sensory nerves to the flap to anastomose with recipient site nerve. Results : Among our 102 cases, overall success rate was 89%, most of the causes of the failure was recipient site vascular problems such as damaged recipient arterial conditions, and there were two cases of vascular anomalies in our series. Patients ages from 3 years old to 62 years old. Six cases of combined flap with latissimus dorsi, 4 cases of osteocutaneous flap for bone reconstruction, 62 parascapular flap was performed - we prefer parascapular flap to scapular. Statistical analysis of the size of the flap has less meaningful because of the flap has great versatility in size. In the length of the pedicle depends on the recipient site condition, we can adjust the pedicle length. The longest vascular pedicle was 14 cm in length from the axillary artery to the enter point cutaneous tissue. In conclusion, scapular free flap is one of the most useful modalities to manage the large intractable soft tissue defect. It has almost constant vascular pedicle with rare anatomical variation, easy to dissect great versatility in size and shape, low donor morbidity, thin and hairless skin.

• Journal of Periodontal and Implant Science
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• v.29 no.4
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• pp.893-914
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• 1999

Tooth mobility may be the decisive factor that determines whether dental treatment of any kind is undertaken. Although tooth mobility in isolation says little in itself, the finding of increased tooth mobility is of both diagnostic and prognostic importance. Only the detection of an increase or decrease in mobility makes an evaluation possible. Thus prior to treatment, we must understand the pathologic process causing the observed the tooth mobility and decide whether the pattern and degree of observed tooth mobility is reversible or irreversible. And then it must be decided whether retention and treatment or extraction and replacement. The purpose of this study was to compare tooth mobility at different time period during root planing and flap operation and to relate changes in mobility to each treatment method. Twenty-one patients (287 teeth) with chronic adult periodontitis were treated with root planing(control group) and flap operation(experimental group), and each group was divided 3 subgroups based upon initial probing pocket depth (1-3mm, 4-6mm, 7mm and more). Tooth mobility was measured with $Periotest^{(R)}$ at the day of operation, 4 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 8 weeks, 12 weeks after each treatment. Tooth mobility, attachment loss, radiographic bone loss, and bleeding on probing were measured at the day of operation, 4 weeks, 8 weeks and 12 weeks after treatment. 1. In group initial probing depth was 1-3mm, tooth mobility had no significant difference after root planing and flap operation. 2 . In group initial probing depth was 4-6mm, 7mm and more, tooth mobility had decreased in 12 weeks after root planing(p<0.01). And the mobility had increased after flap operation(p<0.01) and was at peak in 1 week, and decreased at initial level in 4 weeks, below the initial level in 12 weeks(p<0.01). 3. In 1 week, significant difference in tooth mobility between control and experimental group was found(p<0.01) but, in 12 weeks no difference between two groups was found. 4. Change of immediate tooth mobility after treatment was more larger in deep pocket than in shallow one. In group with the same probing pocket depth, the change of tooth mobility in molar group was greater than that of premolar group. 5. Tooth mobility before treatment was more strongly correlated with radiographic bone loss (r=0.5325) than probing depth, attachment loss and bleeding on probing, in 12 weeks after treatment, was more strongly correlated with attachment loss($r^2$=0.4761) than probing depth and bleeding on probing. Evaluation of the treatment effect and the prognosis after root planing and flap operation were meaningful on tooth initial probing depth 4mm and more. After flap operation, evaluation of the prognosis should be performed at least in 4 weeks and in 12 weeks after treatment, no difference in tooth mobility between two groups was observed. Radiographic bone loss and attachment loss were good clinical indicators to evaluate tooth mobility.

• The korean journal of orthodontics
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• v.24 no.3 s.46
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• pp.673-693
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• 1994

Most adults, unlike growing children, have some periodontal problems which can influence the outcome of the orthodontic treatment. In cases where periodontal disease progression resulted in marked reduction of periodontium, orthodontic treatment could result in the worsening of the periodontal conditions, and therefore orthodontic treatment planning in such adult patients requires special considerations for the periodontal problems. This study investigates the effects of horizontal orthodontic tooth movement on the changes in the mesial, distal and furcation areas of the disease affected periodontium of adult dogs with advanced bone loss. Six adult dogs with healthy periodontium were selected, and mandibular 2nd premolars were extracted. In the mandibular 3rd premolars, angular bony defects in the mesial and distal sides, and horizontal bony defects in the furcation areas were created. Those that received the flap operation and plaque control were designated as the control, those that had horizontal tooth movement without plaque control after the flap operation as Experimental group I, those that had horizontal tooth movement under plaque control without the flap operation as Experimental group II, and those that had horizontal tooth movement under plaque control after the flap operation as Experimental group III. The control group was sacrificed 2 months postoperatively, and the experimental groups were sacrificed 5 months after the initiation of tooth movement. Specimens were histologically analyzed under light microscope. The results were as follows; 1. After the horizontal tooth movements, Experimental group I and II showed angular bony defects in the mesial sides of the roots and the distal side of the furcation areas, which correspond to the pressure sides. 2. After the horizontal tooth movements, Experimental group I and II showed decreased level of alveolar bone crest in the distal sides of the roots, which correspond to the tension sides. 3. Long junctional epithelium in the control group has not been replaced by periodontal connective tissue after the horizontal tooth movements. 4. Limited formation of new bone was observed in the angular bony defects in the mesial and distal aspects of the roots in the control group. 5. Inflammatory cell infiltration in the connective tissue was most severe in the Experimental group I, followed by Experimental group II, III, and the control group in that order. These results seem to indicate that plaque control was the most influencing factor in the alteration of the periodontal tissue after the horizontal tooth movements in the periodontal tissue with alveolar bone defects.

• Journal of Periodontal and Implant Science
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• v.43 no.4
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• pp.153-159
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• 2013

Purpose: The level of the implant above the marginal bone and flap design have an effect on the bone resorption during the healing period. The aim of this study is to detect the relationship between the level of the implant at the implant placement and the bone level at the healing period in the mesial and distal side of implants placed with flapless (FL) and full-thickness flap (FT) methods. Methods: Twenty-two nonsubmerged implants were placed with the FL and FT technique. Periapical radiographs were taken of the patient at implant placement, and at 6 and 12 weeks. By using computer software, bone level measurements were taken from the shoulder of the healing cap to the first bone implant contact in the mesial and distal side of the implant surface. Results: At 6 weeks, the correlation between the crestal bone level at the implant placement and crestal bone level of the FT mesially was significant (Pearson correlation coefficient=0.675, P<0.023). At 12 weeks, in the FT mesially, the correlation was nonsignificant (Spearman correlation coefficient=0.297, P<0.346). At 6 weeks in the FT distally, the correlation was nonsignificant (Pearson correlation coefficient=0.512, P<0.107). At 12 weeks in the FT distally, the correlation was significant (Spearman correlation coefficient=0.730, P<0.011). At 6 weeks in the FL mesially, the correlation was nonsignificant (Spearman correlation coefficient=0.083, P<0.809). At 12 weeks in the FL mesially, the correlation was nonsignificant (Spearman correlation coefficient= 0.062, P<0.856). At 6 weeks in the FL distally, the correlation was nonsignificant (Spearman correlation coefficient=0.197, P<0.562). At 12 weeks in the FL distally, the correlation was significant (Pearson correlation coefficient=0.692, P<0.018). Conclusions: A larger sample size is recommended to verify the conclusions in this preliminary study. The bone level during the healing period in the FT was more positively correlated with the implant level at implant placement than in the FL.

• Archives of Reconstructive Microsurgery
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• v.6 no.1
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• pp.87-95
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• 1997

Traumatic injury to the hand often leads to soft tissue defects with exposed tendons, bones, or joints. Though many new flap have been introduced, the choice of flap that would be best for the patient depends on such factors as the site, size, and degree of wounds. Additionally the selected surgical method should be yielded cosmetic and functional superiority by the one-staged reconstruction. In our experience, small to medium sized soft tissue defect with bone and tendon exposure of hand can be resurfaced with an arterialized venous free flap from the volar aspect of distal forearm. Wide and deep defects of the hand can be covered with a sensory cutaneous free flap such as the medial plantar free flap, dorsalis pedis free flap, and radial forearm free flap. Specialized flap such as wrap-around flap, toe-to-finger transfer, onychocutaneous free flap can be used for the recontruction of defect on the thumb and finger. Based on the above considerations and our clinical experience of 60 free flap cases of the hand, the various methods for the proper repair of soft tissue defects of the hand are described. And we obtained satisfactory functional and cosmetic results with 95% success rate of free flap.

• Archives of Plastic Surgery
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• v.35 no.2
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• pp.174-180
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• 2008

Purpose: While radiotherapy remains an essential part of the multidisciplinary treatment of cancers, it may cause unwanted consequences such as tissue break down and chronic non-healing wounds as a result of hypoxia, hypovascularity, and hypocellularity. The conservative treatment of osteoradionecrosis was effective only in the early stages or has a limited result. The surgical treatment of osteoradionecrosis includes various local fasciocutaneous flaps, local myocutaneous flaps and different kinds of free flaps with cancellous bone graft or alloplastic material after removal of all devitalized tissue. This study reviews recent cases of osteoradionecrosis in Severance hospital and investigates the use of various flaps for reconstruction of osteoradionecrosis. Methods: From 2000 to 2006, a total of 29 patients, nine men and twenty women with a mean age of 60.4 years were identified and included in the study. Fasciocutaneous flaps were used on 7 patients and myocutaneous flaps were used on the remaining patients. Mean follow-up period was 10.4 months. Results: In the fasciocutaneous flap group, we noted two complications including total flap failure and a partial flap necrosis. In the myocutaneous flap group, four complications were noted including a partial flap necrosis and 3 cases of wound dehiscence. Considering the complications noted in this study, the natural history of progression to flap necrosis appeared to follow the following sequence of events: marginal flap necrosis, infection, wound dehiscence, flap floating and partial flap necrosis, serially. Conclusion: Successful surgical treatment of osteoradionecrosis includes wide radical debridement and reconstruction with a well vascularized flap like myocutaneous flap or fasciocutaneous flap.

• Journal of Periodontal and Implant Science
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• v.27 no.1
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• pp.179-189
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• 1997

Teeth mobility is an important part of a periodontal examination, because it represents a function of the persisting height of the alveolar bone and the width of the periodontal ligament. The purpose of this study was to evaluate clinical difference in teeth mobility after treatment with the modified Widman flap and the undisplaced flap in humans. Twenty males with moderate periodontal disease were selected. The severity of periodontal disease was evaluated with sulcular bleeding index, pocket depth and attachment level and tooth mobility was measured with Periotest(Siemens Co., Germany) at the initial examination, 1, 2, 4, 6, 8 and 12 weeks following the modified Widman flap and the undisplaced flap operation using the split-mouth technique. The relation of mobility to clinical parameters was statistically analyzed by multiple regression and the change of teeth mobility according to healing process by independent t-test using SPSS program. The results were as follows: 1. There was a strong relationship between the Periotest value(PTV) and attachment level. 2. The change of teeth mobility in both flap procedures was increased significantly at 1 week post-op. and was decreased to preoperative level at 4 weeks post-op, in modified Widman flap and at 6 weeks post-op. in undisplaced flap. 3. The change of teeth mobility in premolar teeth group in undisplaced flap compared to modified Widman flap was generally increased but these changes were not statistically significant. The changes of teeth mobility in molar teeth group in undisplaced flap was increased significantly at 2 weeks post-op.. 4. The change of teeth mobility following undisplaced flap was increased significantly compared to that of modified Widman flap at 2 weeks post-op.

• Archives of Plastic Surgery
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• v.45 no.1
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• pp.45-50
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• 2018

Background Free muscle flaps are a mainstay for reconstruction of distal third leg wounds and for large lower extremity wounds with exposed bone. However a major problem is the significant postoperative flap swelling, which may take months to resolve. We studied the efficacy and safety of immediate application of a vacuum assisted closure (VAC) dressing after a free muscle flap to the lower extremity. Methods Over a 19 months period, all consecutive free muscle flaps for lower extremity reconstruction at a Level I trauma center were evaluated prospectively for postoperative flap thickness, complications and flap survival. Immediate application of a VAC dressing was performed in 9 patients, while the flap was left exposed for monitoring in 8 patients. Results There was no statistically significant difference in flap survival between both cohorts. Mean flap thickness at postoperative day 5 for the VAC group was $6.4{\pm}6.4mm$, while flap thickness for the exposed flap group was $29.6{\pm}13.5mm$. Flap thickness was significantly decreased at postoperative day 5 for the VAC dressing group. Conclusions Immediate application of VAC dressing following free muscle flaps to the lower extremity does not compromise flap survival or outcomes and results in decreased flap thickness and a better aesthetic outcome.

• Archives of Plastic Surgery
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• v.49 no.6
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• pp.760-763
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• 2022

The dorsal metacarpal artery perforator flap is a flap that rises from the hand dorsum. Owing to its reliability and versatility, this flap is used as a workhorse for finger defect. However, to cover the radial-volar defect of the proximal interphalangeal joint (PIPJ) of the index finger, a longer flap is required than before. Here, we introduce the oblique extended reverse first dorsal metacarpal artery (FDMA) perforator flap to cover the radial-volar aspect defect of the index finger. A 45-year-old man got injured to the radial-volar defect of PIPJ of the left index finger caused by thermal press machine. The wound was 2 × 1 cm in size, and the joint and bone were exposed. We used FDMA perforator from anastomosis with palmar metacarpal artery at metacarpal neck. Since the defect was extended to the volar side, the flap was elevated by oblique extension to the fourth metacarpal base level. The fascia was included to the flap, and the flap was rotated counterclockwise. Finally, PIPJ was fully covered by the flap. Donor site was primarily closed. After 12 months of operation, the flap was stable without complication and limitation of range of motion. The oblique extended reverse FDMA perforator flap is a reliable method for covering the radial-volar defect of the PIPJ of the index finger. This flap, which also has an aesthetic advantage, will be a good choice for hand surgeons who want to cover the PIPJ defect of the index finger using a nonmicrosurgical option.