• Archives of Plastic Surgery
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• v.32 no.4
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• pp.421-427
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• 2005

Although the incidence of mediastinal wound infection in patient undergoing median sternotomy for cardiovascular surgery is relatively low(less than 1%), it is not only a devastating and potentially life-threatening complication but also associated morbidity, mortality and cost are unacceptably high. During the past few decades various methods had been applied for the treatment of postoperative mediastinitis. Currently, chest wall reconstruction by using muscle flaps-especially pectoralis major muscle and rectus abdominis muscle are commonly selected for the reconstruction after wide debridement has become widely accepted. We performed bilateral pectoralis major-rectus abdominis muscles in-continuity bipedicle flap to overcome the limit of each flap for reconstruction of sternal defects in 17 patients. We analyzed the results of the surgery. Recurrent infection developed in 17.6% of cases and abdominal herniation was observed in one patient. There was no postoperative hematoma or death. We conclude that this flap is very valuable in reconstruction of the anterior chest wall defect caused by post-sternotomy infection because it provides sufficient volume to fill the entire mediastinum, and the complication rate compares favorably to that of other methods.

• Archives of Craniofacial Surgery
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• v.18 no.2
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• pp.112-116
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• 2017

The ideal scalp reconstruction involves closure of the defect with similar hair-bearing local tissue in a single step. Various reconstructions can be used including primary closure, secondary healing, skin grafts, local flaps, and microvascular tissue transfer. A 53-year-old female patient suffered glioblastoma, which had recurred for the second time. The neuro-surgeons performed radial debridement and an additional resection of the tumor, followed by reconstruction using a serratus anterior muscle flap with a split-thickness skin graft. Unfortunately, the flap became completely useless and a bilateral rotation flap was used to cover the defect. Two month later, seroma with infection was found due to recurrence of the tumor. Additional surgery was performed using multiple perforator based island flap. The patient was discharged two weeks after surgery without any complications, but two months later, the patient died. Radical surgical resection of tumor is the most important curative option, followed by functional and aesthetic reconstruction. We describe a patient with a highly malignant tumor that required multiple resections and subsequent reconstruction. Repeated recurrences of the tumor led to the failure of reconstruction and our strategy inevitably changed, from reconstruction to palliative treatment involving fast and stable wound closure for the patient's comfort.

• Archives of Plastic Surgery
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• v.32 no.4
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• pp.408-415
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• 2005

Following a transverse rectus abdominis musculocutaneous(TRAM) flap breast reconstruction, denervated state of the flap causes the flap skin prone to thermal injury, calling for special attention. During the last 5 years, 69 breast reconstruction with 72 free TRAM flaps, were performed. Four out of thesse 69 patients sustained burn injury. Heat sources were a warm bag(n=2), heating pad(n=1) and warming light (n=1). The thermal injuries occured from 2 days to 3 months following the reconstruction. Three patients healed with conservative treatment, but one patient required debridement and skin graft. Initially 3 out of 4 patients with the burn had shown superficial 2nd degree burn with small blebs or bullae. However all 4 patients healed with scars. Mechanism of burn injuries of the denervated flap are known to be resulting from; 1) loss of behavioral protection due to denervation of flap with flap elevation and transfer, 2) loss of autonomic thermoregulatory control with heat dissipation on skin flap vasculature contributing to susceptibility of burn injury. 3) changes of immunologic and normal inflammatory response increasing thromboxane, and a fall in substance P & NGF (nerve growth factor). Including the abdominal flap donor site, sensory recovery of the reconstructed breast varies individually from 6 month even to 5 years postoperatively. During this period, wound healing is delayed, resulting in easier scarring compared to that observed in the sensate skin. Patients should be carefully informed and warned of possible burn injuries and taught to avoid exposure to heat source at least until 3 years postoperatively.

• Archives of Plastic Surgery
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• v.37 no.6
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• pp.775-778
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• 2010

Purpose: Reconstruction of soft tissue defects with osteomyelitis in the lower third of the leg represents a challenge to plastic surgeons. Moreover, it is more arduous in multimorbid patients. One excellent option for reconstruction of these defects is to use a delayed distally based sural flap. Methods: We successfully used delayed distally based sural flap with a two-step procedure. During the first operation, radical debridement and elevation of flap were performed. The raised flap was fixed again at the donor site. The delay period ranged from seven to ten days. Between August 2008 and July 2009, we underwent operations for five patients using this technique. The size of flap varied from $10{\times}6\;cm$ to $12{\times}14\;cm$. Results: All flaps successfully survived. Partial skin loss of the grafted site was seen in two patients but no further surgical procedure was required for wound healing. Complaints of hypoesthesia on the lateral part of the foot was observed. In a three month follow-up period, hypoesthesia was resolved spontaneously. Conclusion: Delayed procedure improves the viability of distally based sural flap in high risk, critically multimorbid patients. We recommend that, if a two-stage operative approach is required, the delayed procedure should be considered.

• The Journal of Internal Korean Medicine
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• v.41 no.3
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• pp.478-486
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• 2020

Objectives: Pressure injury is a common symptom of end-stage cancer, which impact quality of life. This case study reports on use of traditional Korean medicine in an end-stage cancer patient with pressure injury after debridement and local flap. Methods: A pressure injury with debridement and a local flap was treated using herbal medicine, a carbon arc, acupuncture, dressing, and cooperation in plastic surgery. Pressure injury was followed up with photographs. Results: On the 22^nd day of treatment (26 days after the debridement and local flap), redness, swelling, and the condition of pressure injury were all improved. Moreover, the condition of the pressure injury was good without dressing. Conclusions: These results show that traditional Korean medicine may have a positive effect on a pressure injury and improve the quality of life of cancer patients. However, further study is needed to confirm these findings.

• Archives of Plastic Surgery
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• v.32 no.4
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• pp.403-407
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• 2005

Following a transverse rectus abdominis musculocutaneous(TRAM) flap breast reconstruction, denervated state of the flap causes the flap skin prone to thermal injury, calling for special attention. During the last 5 years, 69 breast reconstruction with 72 free TRAM flaps, were performed. Four out of thesse 69 patients sustained burn injury. Heat sources were a warm bag(n=2), heating pad(n=1) and warming light (n=1). The thermal injuries occured from 2 days to 3 months following the reconstruction. Three patients healed with conservative treatment, but one patient required debridement and skin graft. Initially 3 out of 4 patients with the burn had shown superficial 2nd degree burn with small blebs or bullae. However all 4 patients healed with scars. Mechanism of burn injuries of the denervated flap are known to be resulting from; 1) loss of behavioral protection due to denervation of flap with flap elevation and transfer, 2) loss of autonomic thermoregulatory control with heat dissipation on skin flap vasculature contributing to susceptibility of burn injury. 3) changes of immunologic and normal inflammatory response increasing thromboxane, and a fall in substance P & NGF (nerve growth factor). Including the abdominal flap donor site, sensory recovery of the reconstructed breast varies individually from 6 month even to 5 years postoperatively. During this period, wound healing is delayed, resulting in easier scarring compared to that observed in the sensate skin. Patients should be carefully informed and warned of possible burn injuries and taught to avoid exposure to heat source at least until 3 years postoperatively.

• Journal of Dental Anesthesia and Pain Medicine
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• v.19 no.1
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• pp.45-54
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• 2019

Background: Profound anesthesia with adequate duration is required in periodontal flap surgery, which involves the manipulation of both hard and soft tissues. The anterior middle superior alveolar (AMSA) injection may be an alternative to multiple injections required for this purpose in the maxilla. The present study aimed to assess the effectiveness of AMSA injection using computer-controlled local anesthetic delivery (CCLAD) system to anesthetize buccal hard tissue (BHT), buccal soft tissue (BST), palatal hard tissue (PHT), and palatal soft tissue (PST) around the maxillary teeth. Methods: Thirty-five patients who were indicated for open flap debridement in a whole maxillary quadrant were given AMSA injection using the CCLAD. The effectiveness of anesthesia was evaluated using subjective and objective parameters around each tooth. Supraperiosteal infiltrations were administered to complete the surgery wherever the AMSA injection was ineffective. Results: The AMSA injection was more effective on the palatal tissues than on the buccal tissues, as 94.14% of PST and 87.89% of PHT sites were anesthetized compared to 49.22% and 43.75% of BHT and BST sites, respectively. There was no significant difference in the frequency of anesthesia around the anterior and posterior teeth. The PHT was significantly more anesthetized (P = 0.003) in males than in females. Conclusions: The AMSA injection using CCLAD is highly effective on palatal tissues and could be used as a first-line anesthesia for periodontal flap surgery. However, its effect on buccal tissues is less predictable, with supraperiosteal infiltration often required to supplement the AMSA injection.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.415-420
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• 2011

Purpose: The reconstruction of a soft tissue defect of the heel pad can be challenging. One vital issue is the restoration of the ability of the heel to bear the load of the body weight. Many surgeons prefer to use local flaps or free tissue transfer rather than a skin graft. In this study, we evaluated the criteria for choosing a proper flap for heel pad reconstruction. Methods: In this study, 23 cases of heel pad reconstruction were performed by using the flap technique. The etiologies of the heel defects included pressure sores, trauma, or wide excision of a malignant tumor. During the operation, the location, size and depth of the heel pad defect determined which flap was chosen. When the defect size was relatively small and the defect depth was limited to the subcutaneous layer, a local flap was used. A free flap was selected when the defect was so large and deep that almost entire heel pad had to be replaced. Results: There was only one complication of poor graft acceptance, involving partial flap necrosis. This patient experienced complete recovery after debridement of the necrotic tissue and a split thickness skin graft. None of the other transferred tissues had complications. During the follow-up period, the patients were reported satisfactory with both aesthetic and functional results. Conclusion: The heel pad reconstructive method is determined by the size and soft-tissue requirements of the defect. The proper choice of the donor flap allows to achieve satisfactory surgical outcomes in aesthetic and functional viewpoints with fewer complications.

• Archives of Plastic Surgery
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• v.50 no.2
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• pp.171-176
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• 2023

Background Human bite wounds in emergency department need evaluation in regard of reconstruction. These are due to occlusive bite injuries over face. Most commonly, human bites over face involve ear and nose, and may lead to avulsion injury. Defects over nose can be reconstructed immediately after debridement or delayed till the wound heals and scar becomes supple. Thorough wash and lavage with broadspectrum antibiotic cover has utmost importance in preventing cartilage infection. Methods We report 20 cases of human bite injuries over nose who presented to us in emergency department between 2018 and 2020. At the time of presentation the wound was assessed for closure. If not possible, patient was planned for delayed reconstruction after 3 months. In case delayed reconstruction was planned, the skin and nasal mucosa were approximated at first presentation. The patients underwent paramedian forehead flap after recreation of defect with conchal cartilage graft. Second stage of flap detachment and insetting was done after 3 weeks. After three weeks of second stage, third stage of flap thinning was done. Patients were followed for 3-6 months and subjective satisfaction was noted. Results Nineteen patients underwent delayed staged reconstruction with paramedian forehead flap and one underwent primary wound closure. The flap survival was 100%. The patient satisfaction was excellent in most cases. Conclusion We recommend delayed reconstruction for human bite nasal injuries. For reconstruction, paramedian forehead flap with conchal cartilage graft, if required, provides excellent reconstructive option with good contour and color match and minimal donor site scar.

• Archives of Reconstructive Microsurgery
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• v.15 no.2
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• pp.58-64
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• 2006

Purpose: Management of soft-tissue defect after open tibial fractures includes immediate and repeated debridement, skeletal stabilization, and early soft-tissue coverage with muscle flaps. The purpose of this study was to evaluate the outcome of the free rectus abdominis muscle flap (RA flap) for treatment of open fractures of the tibia and to discuss its advantages compared with the latissimus dorsi muscle flap (LD flap) in poly trauma patients. Materials and Methods: We performed a retrospective review of 5 patients who had a severe (Gustilo IIIb or IIIc) open fracture of the tibia treated with RA flap from May 2003 to March 2006. All were men, and the mean age was 46.6 years (range, $28{\sim}68$). Three patients had combined injuries such as pelvic bone fractures, multiple rib fractures with hemothorax, and contralateral tibial fracture. All patients received RA flap within 7 days after trauma except two with established chronic osteomyelitis. Results: All flaps survived, and there was no marginal flap necrosis. During the follow-up period, there was no evidence of persistent or recurrent osteomyelitis. The size of RA flap ranged from $8{\sim}20\;cm$ in length and $6{\sim}10\;cm$ in width. The average time required for RA flap elevation was 32 minutes, which is shorter than LD flap. Flap elevation could be done in supine position which is essential in poly trauma patients. Conclusion: Although a wide variety of options are available, RA flap is regarded as an optimal method for coverage of soft-tissue defect of the open tibial fracture in poly trauma patients. LD flap is reserved for large sized soft-tissue defect which cannot be covered by RA flap.