• Archives of Plastic Surgery
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• v.34 no.6
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• pp.753-758
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• 2007

Purpose: Penoscrotal extramammary Paget's disease is a rare cutaneous malignancy that primarily affects the elderly. To prevent local recurrence, adequate surgical excision with its intraoperative frozen section, proper reconstruction, and careful follow-ups are required. The present study describes the treatment of patients with penoscrotal extramammary Paget's disease, focusing on the reconstruction after the ablation of lesion. Methods: Nine patients were selected who had undergone a local pedicle flap procedure due to the large defects after ablation of extramammary Paget's disease of the penoscrotal area, during the period of 1999 to 2005. Wide excision combined with intraoperative frozen sectioning was performed, and the penoscrotal wound was reconstructed with a local skin flap. Three flaps were chosen depending on the size of the defect. If the defect size was small and the scrotal tissue was adequate, scrotal flap(n=5) was enough for its reconstruction. However, as there were large defects with insufficient remnant scrotal tissue, a groin flap(n=2) or an anterolateral thigh flap(n=2) were performed. Results: There were no complications with the postoperative wound. Furthermore, no local recurrence was noted during two to six years of follow-up period (mean average 3.7 years). Conclusion: For the resurfacing the penoscrotum at large defects after ablation of extramammary Paget's disease, we performed reconstruction with a local flap. In the aspect of both function and cosmetic concerns, the results were satisfactory.　

• Archives of Plastic Surgery
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• v.41 no.6
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• pp.693-701
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• 2014

Background A thin perforator flap is one of the best methods for covering defects. This study aimed to revisit and further test the rapidly advancing field of flap thinning techniques. Methods We performed two cadaveric studies to test the known flap thinning methods, and then applied these methods to a clinical series. In the first study, five cadavers were used to observe the anatomical relation of the perforator with the subdermal plexuses and the subcutaneous fat layer by injecting a colored latex solution. The second study was done on four cadavers independently from the first study. Last, a clinical series was performed on 15 patients. Results The areolar fat lobules of 10 anterolateral thigh perforator (ALT), seven deep inferior epigastric artery perforator (DIEAP), and six thoracodorsal artery perforator (TAP) flaps were dissected to reduce the flap thickness guided by the colored vascular pattern. On average, the ALT, DIEAP, and TAP flaps were reduced to $32.76%{\pm}9.76%$, $37.01%{\pm}9.21%$, and $35.42%{\pm}9.41%$, respectively. In the second study, the areolar fat lobules were directly dissected in six ALT, six TAP, and four MSAP flaps, and an average reduction in flap thickness of $53.41%{\pm}5.64%$, $52.30%{\pm}2.88%$, and $47.87%{\pm}6.41%$, respectively, was found. In the clinical series, 13 out of the 15 cases yielded satisfactory outcomes with an average thickness reduction of $37.91%{\pm}7.15%$. Conclusions These multiple studies showed that the deep fat layer could be safely removed to obtain a thin yet viable perforator flap. This evidence suggests that the macroscopic flap thinning technique can achieve thin flaps. Surgeons should consider this technique before embracing the latest technique of supermicrosurgery.

• Archives of Plastic Surgery
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• v.38 no.1
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• pp.113-116
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• 2011

Purpose: Many fingertip injuries are associated with nail injury and it is hard to repair to original shape due to its unique characteristic. Mucosal graft is used for a defect of the nail bed injury. Hereby, we introduce a DAP flap and buccal mucosal graft, with which we could reduce the defect size of the injured fingertip and donor site morbidity at the same time, without any need for harvesting additional skin from other part of hand. Also, mucosal graft makes good cosmetic and functional outcome of nail. Methods: This method was performed in a 56-year-old man with fingertip injury on dorsal side of left thumb due to electrical saw. First, DAP flap was performed on the injured finger to reduce the size of the defect of fingertip and cover the bone exposure. Second, nail bed part of the DAP flap was de-epithelized and buccal mucosal graft was done from left side of intraoral cavity wall. Results: Flap and graft survived without any necrosis but some nail bed could not be covered with flap due to insufficient flap size. All wounds healed well and did not present any severe adversary symptoms. Conclusion: DAP flap with mucosal graft is an effective method that we can easily apply in reconstruction of fingertip injury. We suggest that the combination of the two procedures makes good functional and cosmetic outcome compared to the usual manner, especially in cases of nail bed injury without distal phalanx bone defect.

• Archives of Reconstructive Microsurgery
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• v.23 no.2
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• pp.76-81
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• 2014

Purpose: Anteromedial surface of the leg is susceptible to trauma, which frequently induces soft tissue defect. When the size of a soft tissue defect is small to moderate, a local muscle flap is an easy and reliable alternative to a free flap. The authors performed medial hemisoleus flaps for reconstruction of soft tissue defects on the anteromedial surface of legs. The aim of this study was to evaluate clinical outcomes and effectiveness of the medial hemisoleus flap. Materials and Methods: Twelve patients underwent the medial hemisoleus flap for reconstruction of a soft tissue defect on the anteromedial surface of the leg from February 2009 to December 2013. There were eight males and four females with a mean age of 47.8 years (15 to 69 years). The mean size of defects was $4.7{\times}4.2cm$ ($2{\times}2$ to $9{\times}6cm$). Flap survival and postoperative complications were evaluated. Results: Mean follow-up period was 39.6 months (7 to 64 months) and all flaps survived. There were two cases of negligible necrosis of distal margin of the flap, which were healed after debridement. All patients were capable of full weight bearing ambulation at the last follow-up. Conclusion: The medial hemisoleus flap is a simple, reliable procedure for treatment of a small to moderate sized soft tissue defect on the anteromedial surface of the leg.

• Archives of Plastic Surgery
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• v.40 no.6
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• pp.754-760
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• 2013

Background Classical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes. Methods Between December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation. Results Eight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from $1cm{\times}1.5cm$ to $3cm{\times}6cm$. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results. Conclusions The facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.

• Archives of Plastic Surgery
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• v.36 no.4
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• pp.393-396
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• 2009

Purpose: Low - molecular - weight dextran is one of the most frequently used antithrombotic agents in microvascular surgery, but there is controversy if it has the real benefit in the clinical aspects. The purpose of this study was to evaluate the effect associated with postoperative use of low - molecular - weight dextran in breast reconstruction by free TRAM flap patients. Methods: From January 2002 to October 2008, we reconstructed 88 cases of postmastectomy deformity using the free TRAM flap. The 88 cases were divided into two groups : a group with no use of dextran(66 patients, control group, Group A) and a postoperative low - molecular weight dextran loaded group(22 patients, Group B). We assessed number of flap survival, rate of complication like hematoma or seroma, total amount of drainage from operative wound, duration of drainage, and amount of transfusion in each group. Results: There was no total flap loss and every flap was survived. Total amount of drainage for post - operative 5 days were 857 ml in group A and 1101 ml in group B. Drain was kept for average of 7.3 days in group A and 8.7 days in group B. Packed red cell transfusions were made in average of 3.3 units for group A and 3.0 units for group B. Group B showed significantly higher values in former 2 comparative parameters than group A. Conclusion: There was no definitive advantage of anticoagulants in elective free - flap surgery in terms of success rate. However, groups with using anticoagulants had the increased bleeding tendency in immediate postoperative period. The routine use of anticoagulants in elective free - flap surgery should be reconsidered with postoperatively less bleeding and early recovery.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.714-719
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• 2009

Purpose: Recurrent ischial pressure sore is troublesome for adequate soft tissue coverage, because usually its pocket has a very large deep space and adjacent donor tissue have been scarred in the previous surgery. However, the conventional reconstructive methods are very difficult to overcome them. Modified gluteus maximus myocutaneous V - Y advancement flap from buttock can be successfully used in these circumstances. Methods: From February 2007 to October 2008, modified gluteus maximus myocutaneous V - Y advancement flaps were perfomed in 10 paraplegic patients with recurrent ischial pressure sore. The myocutaneous flap based on the inferior gluteal artery was designed in V - shaped pattern toward the superolateral aspect of buttock and was elevated from adjacent tissue. Furthermore, when additional muscular bulk was required to obliterate dead space, the flap dissection was extended to the inferolateral aspect which can included the adequate amount of the gluteal muscle. After the advanced flap was located in sore pocket, donor defect was repaired primarily. Results: The patients' mean age was 46.9 and the average follow - up period was 12.4 months. The immediate postoperative course was uneventful. But, two patients were treated through readvancement of previous flap due to wound dehiscence or recurrence after 6 months. The long - term results were satisfied in proper soft tissue bulk and low recurrence rate. Conclusions: The modified gluteus maximus myocutaneous V - Y advancement flap may be a reliable method in reconstruction of recurrent ischial pressure sore, which were surrounded by scarred tissue because of its repetitive surgeries and were required to provide sufficient volume of soft tissue to fill the large pocket.

• 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.18 no.1
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• pp.35-39
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• 2009

Purpose: Various techniques have been attempted for design of the flaps. However, there are some disadvantages. They have thin, pliable, and two dimensional methods. The aim of this study is to report usefulness of polyurethane foam dressing materials for three dimensional design of the digital island flap. Methods: From June of 2007 to september of 2008, 10 patients received digital island flap surgery for soft tissue defect of the finger. After minimal debridement of the wound, size and shape of the defect were measured using polyurethane foam. We used Medifoam-$5^{(R)}$ And then, designed this inset the wound. The flap was designed on the donor site with a arterial pedicle as the central axis according to size and shape. A full thickness skin graft from the groin is applied on the flap donor defect and secured with a tieover bolster dressing. Results: Reviewing sizes of the flaps, the length and width of flaps ranged from 1.5 to 3.3 cm and 1.0 to 2.5 cm. The PACS(Picture Archiving Communication System) program allows identification of the donor depth of finger. The distance for the soft tissue ranged from 4.3 mm to 6.7 mm. Mean depth of donor site was 5.3${\pm}$0.6 mm. Also, the thickness of Medifoam-$5^{(R)}$ ranged nearly 5 mm. On flap insetting, full-thickness skin graft was necessary. We did not experience any problems in the recipient site size either, regardless of the extended flaps. Conclusion: Polyurethane foam has many advantages over the more conventional templates. Refinements in flap design and surgical technique resulted in favorable functional and cosmetic results. Especially, for beginner, Polyurethane foam dressing material is a simple and safe tool and therefore is an excellent choice for design of the island flap.

• Archives of Craniofacial Surgery
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• v.18 no.3
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• pp.162-165
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• 2017

Background: It is controversial issue that heparin decreases thrombosis for microsurgical anastomosis, and its effective role is under discussion. This study is for proving whether low-dose heparin is preventing thrombosis in free flap reconstruction. Methods: Through chart reviews of 134 patients, using low-dose heparin for free tissue transfer from 2011 to 2016, retrospective analysis was performed. 33 patients received low-dose heparin therapy after surgery. And 101 patients received no-heparin therapy. Complications included flap necrosis, hematoma formation, dehiscence and infection. Results: In no-heparin therapy group, comparing the flap necrosis revealed 16 cases (15.84%). And, flap necrosis was 6 cases (18.18%) in low-dose heparin therapy group. The statistical analysis of flap necrosis rate showed no significant difference (p=0.75). The results showed that there was no significant difference of flap necrosis rate between two groups. Conclusion: In this study, patients in the low-dose heparin group had no significantly lower rates of flap failure compared with no-heparin group. This suggests that low-dose heparin may not prevent thrombosis and subsequent flap failure to a significant extent.