• Archives of Craniofacial Surgery
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• v.20 no.3
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• pp.170-175
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• 2019

Background: Cryptotia is a congenital anomaly in which the upper part of the retroauricular sulcus is absent and buried underneath the temporal skin. Various surgical techniques have been reported for the correction of cryptotia following Kubo's V-Y plasty in 1933. Conventional methods using a local skin flap, skin grafting, tissue expansion, Z-plasty, and any of these combined approaches can result in skin deficiency of the upper auricle. The aim of this study was to develop a new method that improves cosmetic results and has fewer complications. Methods: This study involved four patients in whom five cryptotia deformities were corrected using V-Y plasty and Z-plasty. After elevation of the flap, acellular dermal matrix (ADM; MegaDerm) that was over 5 mm in thickness was applied to the cephalo-auricular angle and positioned to enhance the projection of the ear. Lastly, the flap was transposed to complete the repair. Results: Between January 2014 and February 2018, cryptotia correction with ADM graft was performed in four patients. None of the patients developed a recurrence of cryptotia, and there were no postoperative complications such as wound infection, seroma formation, and dehiscence. In addition, the procedures resulted in a favorable cosmetic appearance. Conclusion: Based on these findings, i.e., no recurrence and a favorable cosmetic result, when using an ADM graft, it is suggested that this technique could be an alternative method of cryptotia correction. It could also lessen donor-site morbidity when compared to autologous cartilage grafting and be more cost-effective than using cartilage from a cadaver.

• Archives of Plastic Surgery
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• v.46 no.3
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• pp.214-220
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• 2019

Background Microvascular anastomosis patency is adversely affected by local and systemic factors. Impaired intimal recovery and endothelial mechanisms promoting thrombus formation at the anastomotic site are common etiological factors of reduced anastomosis patency. Epigallocatechin gallate (EGCG) is a catechin derivative belonging to the flavonoid subgroup and is present in green tea (Camellia sinensis). This study investigated the effects of EGCG on the structure of vessel tips used in microvascular anastomoses and evaluated its effects on thrombus formation at an anastomotic site. Methods Thirty-six adult male Wistar albino rats were used in the study. The right femoral artery was cut and reanastomosed. The rats were divided into two groups (18 per group) and were systemically administered either EGCG or saline. Each group were then subdivided into three groups, each with six rats. Axial histological sections were taken from segments 1 cm proximal and 1 cm distal to the microvascular anastomosis site on days 5, 10, and 14. Results Thrombus formation was significantly different between the EGCG and control groups on day 5 (P=0.015) but not on days 10 or 14. The mean luminal diameter was significantly greater in the EGCG group on days 5 (P=0.002), 10 (P=0.026), and 14 (P=0.002). Intimal thickening was significantly higher on days 5 (P=0.041) and 10 (P=0.02). Conclusions EGCG showed vasodilatory effects and led to reduced early thrombus formation after microvascular repair. Similar studies on venous anastomoses and random or axial pedunculated skin flaps would also contribute valuable findings relevant to this topic.

• Archives of Plastic Surgery
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• v.46 no.1
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• pp.69-74
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• 2019

Background Local symptoms and signs of snake envenomation mimic the clinical features of compartment syndrome. It is important to measure the intracompartmental pressure to diagnose compartment syndrome. In this study, we present our experiences of confirming compartment syndrome and performing fasciotomy in snakebite patients based on high intracompartmental pressure findings. Methods The medical records of patients who visited the trauma center of Wonju Severance Christian Hospital from January 2010 to December 2015 for the management of venomous snakebite were retrospectively reviewed. Starting in 2014, fasciotomy was performed in patients with an intracompartmental pressure of more than 40 mmHg in addition to the clinical symptoms of compartment syndrome. Results A total of 158 patients with snakebite came to the hospital within 48 hours for treatment. Most patients (110 patients) were bitten at the upper extremities (69.6%). Since 2014, 33 out of 59 patients were suspected to have compartment syndrome, and their intracompartmental pressures were measured. Seventeen of those patients had a high intracompartmental pressure (average, 49.6 mmHg; range, 37-88 mmHg), and fasciotomy was performed. Conclusions In this study, as many as 10.8% of all cases were in need of fasciotomy when compartment syndrome was diagnosed by measuring the intracompartmental pressure. Previously, it was reported that fasciotomy was not required in many cases of compartment syndrome originating from snakebite. However, some patients may develop very severe compartment syndrome, requiring fasciotomy.

• Archives of Plastic Surgery
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• v.46 no.2
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• pp.129-134
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• 2019

Background Nipple-areolar complex (NAC) reconstruction is the final stage of breast reconstruction. Ideal reconstruction of the NAC requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there is no gold standard technique. The technique devised by the authors is very versatile, with excellent results, and it enables 1-step reconstruction with optimal results in terms of shape and nipple projection. Methods Our technique consists of a combination of modified local flaps and a full-thickness skin graft. Patients were observed for 18 months to estimate the amount of retraction. This procedure was performed in 40 patients, four of them bilaterally. The duration of the follow-up was 30 months. Complications occurred in 10% of patients, and included infections (5%), ischemia (2.5%), and hematoma (2.5%). Results No cases of total nipple necrosis were reported. The NAC shape remained optimal in all cases, with a very small reduction of the vertical and horizontal diameters of the areola, which maintained its designed round shape well, and negligible retraction in the diameter and projection of the nipple. Conclusions The oval technique represents a major step forward, involving a combination of existing techniques, such as the C-V flap and the cutaneous graft, to achieve excellent results regarding areola shape and nipple projection, significantly reducing the cases of nipple ischemia. These results were substantially obtained through subcutaneous equatorial sutures, skin grafting, and flattening of the apexes of the flap.

• Archives of Craniofacial Surgery
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• v.20 no.2
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• pp.84-88
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• 2019

Background: Epidermal cysts are benign, slow growing cysts that often develop on the head, neck, chest, and back of adults. The most common method of surgical excision involves the use of a scalpel and often leaves a scar proportional to the size of the cyst. Therefore, minimally invasive techniques are required. Among these techniques, the $CO_2$ laser-based technique is minimally invasive and has lower complication rate, shorter recovery times, and lesser scarring. This paper aimed to compare the results and postoperative complications associated with a $CO_2$ laser-based excision against conventional surgical excision for epidermal cysts. Methods: We surveyed 120 patients, aged 16 to 65 years, with epidermal cysts on the face measuring 0.5 to 2.2 cm in diameter. Twelve months later, we compared the scar length, recurrence rate, patient satisfaction, and complications between patients treated with $CO_2$ laser excision versus surgical excision. Results: The mean scar length (12 months postoperative) after $CO_2$ laser excision was $0.30{\pm}0.15cm$, and that following surgical excision was $1.23{\pm}0.43cm$ (p= 0.001). The procedure time (time from incision after local anesthesia to the end of repair) was $16.15{\pm}5.96minutes$ for $CO_2$ laser excision versus $22.38{\pm}6.05minutes$ for surgical excision (p= 0.001). The recurrence rates in the surgical excision group and $CO_2$ laser excision group were 3.3% and 8.3%, respectively; this difference was not statistically significant (p= 0.648). Conclusion: The cosmetic outcome of $CO_2$ laser excision is excellent. For epidermal cysts measuring 2.2 cm or smaller, $CO_2$ laser excision is recommended, especially when aesthetic outcome is considered important.

• Archives of Craniofacial Surgery
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• v.21 no.6
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• pp.357-362
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• 2020

Background: Full-thickness skin grafts (FTSGs) have been widely used after facial skin cancer resection, for correcting defects that are too wide to be reconstructed using a local flap or if structural deformation is expected. The preauricular, posterior auricular, supraclavicular, conchal bowl, nasolabial fold, and upper eyelid skin areas are known as the main donor sites for facial FTSG. Herein, we aimed to describe the effectiveness of using infraclavicular skin as the donor site for specific cases. Methods: We performed FTSG using the infraclavicular skin as the donor site in older Asian adults following skin cancer resection. Outcomes were observed for > 6 months postoperatively. The Manchester Scar Scale was used for an objective evaluation of satisfaction following surgery and scarring. Results: We analyzed the data of 17 patients. During follow-up, the donor and recipient sites of all patients healed without complications. Upon evaluation, the average Manchester Scar Scale scores for the recipient and donor sites were 7.4 points and 5.7 points, respectively. Conclusion: In general, conventional donor sites, such as the preauricular, posterior auricular, and supraclavicular sites, are widely used for facial FTSG because they achieve good cosmetic results. However, the infraclavicular skin may be a useful donor for facial FTSG in cases where the duration of time spent under anesthesia must be minimized due to a patient's advanced age or underlying health conditions, or when the recipient site is relatively thick area, such as the nose, forehead, or cheek.

• Archives of Craniofacial Surgery
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• v.23 no.1
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• pp.17-22
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• 2022

Background: Reconstruction of large facial defects is challenging as both functional and cosmetic results must be considered. Reconstruction with forehead flaps on the face is advantageous; nonetheless, reconstruction of large defects with forehead flaps alone results in extensive scarring on the donor site. In our study, the results of reconstruction using a combination of forehead flaps and other techniques for large facial defects were evaluated. Methods: A total of 63 patients underwent reconstructive surgery using forehead flaps between February 2005 and June 2020 at our institution. Reconstruction of a large defect with forehead flaps alone has limitations; because of this, 22 patients underwent a combination of procedures and were selected as the subjects of this study. This study was retrospectively conducted by reviewing the patients' medical records. Additional procedures included orbicularis oculi musculocutaneous (OOMC) V-Y advancement flap, cheek advancement flap, nasolabial V-Y advancement flap, grafting, and simultaneous application of two different techniques. Flap survival, complications, and recurrence of skin cancer were analyzed. Patient satisfaction was evaluated using questionnaires. Results: Along with reconstructive surgery using forehead flaps, nasolabial V-Y advancement flap was performed in nine patients, local advancement flap in three, OOMC V-Y advancement flap in two, grafting in five, and two different techniques in three patients. No patient developed flap loss; however, cancer recurred in two patients. The overall patient satisfaction was high. Conclusion: Reconstruction with a combination of forehead flaps and other techniques for large facial defects can be considered as both functionally and cosmetically reliable.

• Archives of Plastic Surgery
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• v.49 no.3
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• pp.397-404
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• 2022

Background Excessive use of corticosteroids therapy along with gross immunocompromised conditions in the novel coronavirus disease 2019 (COVID-19) pandemic has raised the risks of contracting opportunistic fungal infections. Here, we describe our experience with the implementation of a surgical protocol to treat and reconstruct rhino-orbital-cerebral mucormycosis. Methods A retrospective review of our prospectively maintained database was conducted on consecutive patients diagnosed with mucormycosis undergoing immediate reconstruction utilizing our "Mucormycosis Management Protocol." All patients included in this study underwent reconstruction after recovering from COVID-19. Wide local excision was performed in all cases removing all suspected and edematous tissue. Reconstruction was done primarily after clear margins were achieved on clinical assessment under a cover of injectable liposomal amphotericin B. Results Fourteen patients were included. The average age was 43.6 years and follow-up was 24.3 days. Thirteen patients had been admitted for inpatient care of COVID-19. Steroid therapy was implemented for 2 weeks in 11 patients and for 3 weeks in 3 patients. Eight patients (57.1%) had a maxillectomy and mucosal lining resection with/without skin excision, and six patients (42.8%) underwent maxillectomy and wide tissue excision (maxillectomy and partial zygomatic resection, orbital exenteration, orbital floor resection, nose debridement, or skull base debridement). Anterolateral thigh (ALT) flaps were used to cover defects in all patients. All flaps survived. No major or minor complications occurred. No recurrence of mucormycosis was noted. Conclusion The approach presented in this study indicates that immediate reconstruction is safe and reliable in cases when appropriate tissue resection is accomplished. Further studies are required to verify the external validity of these findings.

• Archives of Plastic Surgery
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• v.49 no.5
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• pp.617-632
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• 2022

Tracheoesophageal puncture (TEP) and voice prosthesis insertion following laryngectomy may fail to form an adequate seal. When spontaneous closure of the fistula tract does not occur after conservative measures, surgical closure is required. The purpose of this study was to summarize the available evidence on surgical methods for TEP site closure. A comprehensive search across PubMed, Web of Science, SCOPUS, and Cochrane was performed to identify studies describing surgical techniques, outcomes, and complications for TEP closure. We evaluated the rate of unsuccessful TEP closure after surgical management. A meta-analysis with a random-effect method was performed. Thirty-four studies reporting on 144 patients satisfied inclusion criteria. The overall incidence of an unsuccessful TEP surgical closure was 6% (95% confidence interval [CI] 1-13%). Subgroup analysis showed an unsuccessful TEP closure rate for silicone button of 8% (95% CI < 1-43%), 7% (95% CI < 1-34%) for dermal graft interposition, < 1% (95% CI < 1-37%) for radial forearm free flap, < 1% (95% CI < 1-52%) for ligation of the fistula, 17% (95% CI < 1-64%) for interposition of a deltopectoral flap, 9% (95% CI < 1-28%) for primary closure, and 2% (95% CI < 1-20%) for interposition of a sternocleidomastoid muscle flap. Critical assessment of the reconstructive modality should take into consideration previous history of surgery or radiotherapy. Nonirradiated fields and small defects may benefit from fistula excision and tracheal and esophageal multilayer closure. In cases of previous radiotherapy, local flaps or free tissue transfer yield high successful TEP closure rates. Depending on the defect size, sternocleidomastoid muscle flap or fasciocutaneous free flaps are optimal alternatives.

• Archives of Plastic Surgery
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• v.48 no.4
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• pp.440-447
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• 2021

Background Brown adipose tissue (BAT) is a potential target for anti-obesity treatments. Previous studies have shown that BAT activation causes an acute metabolic boost and reduces adiposity. Furthermore, BAT and BAT-derived cell transplantation reportedly help treat obesity by regulating glucose and fatty acid metabolism. However, since BAT transplantation leads to whole-body weight loss, we speculated that earlier approaches cause a generalized and unnecessary fat tissue loss, including in breast and hip tissues. Methods We transplanted white adipose tissue-derived or BAT-derived preadipocytes prepared from C57BL/6 mice into one side of the inguinal fat pads of an obese mouse model (db/db mice) to examine whether it would cause fat loss at the peri-transplant site (n=5 each). The same volume of phosphate-buffered saline was injected as a control on the other side. Six weeks after transplantation, the inguinal fat pad was excised and weighed. We also measured the concentrations of glucose, triglycerides, fatty acids, and total cholesterol in the peripheral blood. Results BAT-derived preadipocytes showed abundant mitochondria and high levels of mitochondrial membrane uncoupling protein 1 expression, both in vivo and in vitro, with a remarkable reduction in weight of the inguinal fat pad after transplantation (0.17±0.12 g, P=0.043). Only free fatty acid levels tended to decrease in the BAT-transplanted group, but the difference was not significant (P=0.11). Conclusions Our results suggest that brown adipocytes drive fat degradation around the transplantation site. Thus, local transplantation of BAT-derived preadipocytes may be useful for treating obesity, as well as in cosmetic treatments.