Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap

BACKGROUND: In immediate breast reconstruction using an extended latissimus dorsi musculocutaneous (eLDMC) flap, the volume of the flap decreases, which causes a secondary deformity of the breast shape. Since little research has investigated this decrease in muscle volume, the authors conducted an objective study to characterize the decrease in muscle volume after breast reconstruction using an eLDMC flap. METHODS: Research was conducted from October 2011 to November 2016. The subjects included 23 patients who underwent mastectomy due to breast cancer, received immediate reconstruction using an eLDMC flap without any adjuvant chemotherapy or radiotherapy, and received a computed tomography (CT) scan from days 7 to 10 after surgery and 6 to 8 months postoperatively. In 10 patients, an additional CT scan was conducted 18 months postoperatively. Axial CT scans were utilized to measure the volumetric change of the latissimus dorsi muscle during the follow-up period. RESULTS: In the 23 patients, an average decrease of 54.5% was observed in the latissimus dorsi muscle volume between the images obtained immediately postoperatively and the scans obtained 6 to 8 months after surgery. Ten patients showed an average additional decrease of 11.9% from 6–8 months to 18 months after surgery. CONCLUSIONS: We studied changes in the volume of the latissimus dorsi muscle after surgery using an eLDMC flap performed after a mastectomy without adjuvant chemotherapy or radiotherapy. In this study, we found that immediate breast reconstruction using a latissimus dorsi muscle flap led to a decrease in muscle volume of up to 50%.

Hip Flexion during Intraoperative Insetting of a Perforator Flap for Reconstruction of an Ischial Sore

PURPOSE: Perforator flap-using ischial sore reconstruction is performed in a prone position. But after the surgery, recurrence frequently occurs in a sitting position. In this sense, we introduce modified flap insetting method which closely resembles patient's sitting position to lessen the flap tension surgically. MATERIALS AND METHODS: Authors tried to check a skin tension difference between prone position and sitting position in normal people group and to find out the importance of performing flap insetting in hip flexion position. Healthy volunteers were collected (n=20) and designed the same length of 4 divided sections around the ischium. Lengths of each section were measured when hip joint was flexed to 90 degree and when both hip and knee joints were flexed to 90 degree and the statistical evaluation was performed. Twenty cases with ischial sore underwent reconstructive surgery using perforator flap under hip flexion position and followed-up for any recurrences. RESULTS: There was a meaningful difference between the joint flexed skin length and that of the neutral position. Flap showed sufficient thickness over 12 months. CONCLUSION: It seems that recurrence could be reduced when the reconstructed flap could sufficiently cover in a sitting position regarding its significant length difference in normal people group.

Considerations for Postoperative Results of Pressure Sores around Buttock Region by Musculocutaneous Flaps and Perforator Flaps

PURPOSE: Perforator flaps have been widely used for reconstruction of pressure sores because they have many benefits, especially reducing tension. Otherwise in order to prevent recurrence of a pressure sore, sufficient thickness of a flap is desirable, so a musculocutaneous flap is also useful for reconstruction of a pressure sore. Therefore, the authors considered about the postoperative results of reconstruction of pressure sores between using perforator flaps and musculocutaneous flaps. METHODS: In this study, 33 patients(46 flaps) who underwent reconstructive operation of pressure sores from January 2007 to February 2011 were reviewed. Patients operated by using perforator flaps were 18(18 flaps), and musculocutaneous flaps were 17(28 flaps). We studied postoperative complications and recurrence. RESULTS: We experienced five patients(10 flaps) with complications or recurrences who were operated using musculocutaneous flaps and one patient using a perforator flap. One case using a perforator flap stemmed from dehiscence caused by a urinary fistula occurring in two months after the surgery. Among ten cases using musculocutaneous flaps, one case was caused by total necrosis of flap, five cases by partial necrosis of flap and dehiscence, and four cases by recurrences during follow-up period. CONCLUSION: Even if more cases were required, it can be more considerable to operate using the perforator flap rather than the musculocutaneous flap to reduce the complication or recurrence of pressure sore.

The Result and Attentiveness of Reconstructive Surgery by Anterolateral Thigh Perforator Free Flap

PURPOSE: Anterolateral thigh(ALT) perforator free flap is commonly used because of its various benefits. The author reports important factors of preoperative and perioperative ALT perforator free flap and causes of failure. METHODS: 84 patients who were treated with ALT perforator free flap from December 2004 to 2008, and February 2010 to April 2010 were studied. 61 patients were male and 23 were female. The mean age of patients was 51.1. The main cause was neoplasm and the main reconstructive areas were head and neck area. The size of flap was various from 3 x 4 to 12 x 18cm. 6 patients received split thickness skin graft at donor site. Preoperative angiography was checked to all patients. RESULTS: Among the 84 patients, partial necrosis of flaps occurred in 4 patients because of atherosclerosis, varicose vein, or inattention of patient, etc. And total flap necrosis in 5 patients because of abnormal vessels of recipient area or delay of operation, etc. One case of serous cyst was found as the complication of donor area. Two cases of skin graft on donor site were done because of suspected muscle compartment syndrome, 4 cases of that because of large flap. Septocutaneous perforators were found in 7 cases. The author couldn't find reliable perforator in 3 cases, ipsilateral anteromedial thigh perforator and contralateral ALT perforator and latissimus dorsi musculocutaneous free flap were done instead of ALT. There was no case which needed reoperation because of the impairment of blood supply, and 3 cases were revised by leech because of the burn injury by a lamp or venous congestion. CONCLUSION: Although ALT perforator free flap is widely used with its various merits, many factors such as preoperative condition of donor or recipient area, morphology of defect and operating time need to consider to prevent flap necrosis. And operators should need careful technique because septocutaneous perforator is uncommon, and musculocutaneous perforator is common but difficult to dissect.

A Retrospective Analysis of Six Cases of Angiosarcoma

PURPOSE: Angiosarcoma is a rare and aggressive malignant soft tissue tumor. Due to a lack of the established optimal treatment modalities, however, an extensive resection followed by an early detection has been reported to be the best treatment of choice. We analyzed the clinical course of six patients, hence attempted to contribute to making a treatment plan for patients with angiosarcoma. METHODS: Six patients who have been surgically treated between 2005 and 2010 are included. Through a retrospective analysis of the medical records, we evaluated the pattern of disease detection, a past history, time span between the detection and the primary surgery, surgical treatment modalities, time span between the primary surgery and the recurrence/metastasis, the sites of metastasis and the secondary treatment modalities. RESULTS: The mean age of patients was 70.5 years; all male; and the sites were the scalp. Four patients underwent the reconstruction using a local flap with a skin graft and two patients using a free flap. The mean period elapsed until the primary operation since the identification was 7.3 months and until a recurrence or a metastasis occurred following the primary operation was 12 months. Four patients had pulmonary metastasis. As a secondary therapy, four patients underwent the radiotherapy and one was treated with the chemotherapy. At the present, five patients died and one undergoes a monitoring of the clinical course. CONCLUSION: It would be mandatory to shorten the length of hospital stay and to return patients to their daily lives as the earliest as possible using relatively simpler surgical methods, thus attempting to give them opportunity to resume their previous normal life.

Correction of High Fold without Skin Excision

PURPOSE: Double-eyelid operation is one of the most common cosmetic operations among Korean patients. In such operations, however, the complexity of and individual differences in the patients' anatomical structures may cause various complications, such as asymmetry, retraction of the eyelid, and the occurrence of a high fold. A high fold occurs frequently, and its correction is not very simple. Many methods have been developed to correct it, and among these, the operation involving the excision of the skin between the previous double-eyelid line and the new double-eyelid line is usually selected by plastic surgeons. In many cases, however, patients have insufficient eyelid skins for this operation. In this study, the authors introduce an operation procedure for high-fold correction that does not involve skin excision METHODS: From June 2005 to June 2009, 246 cases were treated with this procedure. After the incision of the new double-eyelid line, dissection was done between the previous scar tissue and the levator aponeurosis. Then the orbital septum, orbital fat or the retro-orbicularis oculi fat was slid down and sutured with a tarsal plate. Such sutures were repeated at four to five points, including the lateral and medial limbus, to prevent the reattachment of the previous scar and to create a new double-eyelid line at the end of the orbital septum. RESULTS: Most of the high-fold patients were satisfied with the procedure described above. Their previous scar was hidden under the new double-eyelid line after the operation. In the six cases, the scar was visible in the patients who had a very high and deep inner line. As such, scar revision was undertaken three months after the operation. It is known that scar revision is also required after an operation involving skin excision in the case of a very high inner-eyelid line. CONCLUSION: This method is an appropriate procedure for high-fold correction for patients who have insufficient upper-eyelid skin.

The Reconstruction of the Extensive Inferior Blow-out Fracture Through Endoscopic Transnasal and Subciliary Approaches

PURPOSE: Inferior blow-out fracture is the common facial fracture. Unsatisfactory functional and aesthetic outcomes are frequent when it is treated inappropriately. If fractures are extended and reach the posterior end of orbital floor, enophthalmos frequently followed as complication. The PURPOSE of this study was to evaluate reduction technique of extensive inferior blow-out fracture with ballooning of foley catheter through endoscopic transnasal approach and implantation of Medpor(R) through subciliary approach. METHODS: A retrospective study was performed on 14 patients with extensive inferior blow-out fracture who underwent ballooning of foley catheter through endoscopic transnasal approach with implantation of Medpor(R) through subciliary approach. Patients were operated from May 2005 to November 2007. Data for 14 patients were acquired from patient's charts. Preoperative and postoperative data for enophthalmos, diplopia, limitation of extraocular motion were reviewed. Preoperative and postoperative CT scan were also checked. The patients were followed up from 4 to 18 months. RESULTS: The enophthalmos was corrected in all patients. Among 7 patients with diplopia preoperatively, diplopia was resolved in three patients postoperatively. The diplopia persisted in four patients and two of them also had limitation of extraocular motion postoperatively. The limitation of extraocular motion occurred in seven patients preoperatively. But five patients recovered after operation immediately. These symptoms were resolved about three months after the operation. CONCLUSION: The ballooning of foley catheter through endoscopic transnasal approach with implantation of Medpor(R) through subciliary approach can be considered one of the appropriate technique for extensive inferior blow- out fracture.

The Reconstruction of the Extensive Inferior Blow-out Fracture Through Endoscopic Transnasal and Subciliary Approaches

PURPOSE: Inferior blow-out fracture is the common facial fracture. Unsatisfactory functional and aesthetic outcomes are frequent when it is treated inappropriately. If fractures are extended and reach the posterior end of orbital floor, enophthalmos frequently followed as complication. The PURPOSE of this study was to evaluate reduction technique of extensive inferior blow-out fracture with ballooning of foley catheter through endoscopic transnasal approach and implantation of Medpor(R) through subciliary approach. METHODS: A retrospective study was performed on 14 patients with extensive inferior blow-out fracture who underwent ballooning of foley catheter through endoscopic transnasal approach with implantation of Medpor(R) through subciliary approach. Patients were operated from May 2005 to November 2007. Data for 14 patients were acquired from patient's charts. Preoperative and postoperative data for enophthalmos, diplopia, limitation of extraocular motion were reviewed. Preoperative and postoperative CT scan were also checked. The patients were followed up from 4 to 18 months. RESULTS: The enophthalmos was corrected in all patients. Among 7 patients with diplopia preoperatively, diplopia was resolved in three patients postoperatively. The diplopia persisted in four patients and two of them also had limitation of extraocular motion postoperatively. The limitation of extraocular motion occurred in seven patients preoperatively. But five patients recovered after operation immediately. These symptoms were resolved about three months after the operation. CONCLUSION: The ballooning of foley catheter through endoscopic transnasal approach with implantation of Medpor(R) through subciliary approach can be considered one of the appropriate technique for extensive inferior blow- out fracture.

Clinical Experiences of Arteriovenous Fistula on The Face

PURPOSE: Arteriovenous fistula is one of high flow vascular malformations. Recently, arteriovenous fistula has been regarded as one of the type of arteriovenous malformations. The patients were diagnosed as arteriovenous malformation Schobinger clinical stage II. Even though arteriovenous fistula rarely occurs on head and neck, treatment of that is difficult due to frequent recurrence. In treating the arteriovenous fistula, chemical embolization, surgical excision and other treatment modalities were used, but the results were not satisfactory. The authors experienced three cases of arteriovenous fistula and treated them with surgical excision. METHODS: In cases, warmth, enlargement, pulsation, thrill, and bruit were found. For the accurate evaluation before the operation, angiography and MRI were checked in advance. Incision was made on the site of pulsation. The artery and vein connected to the arteriovenous fistula were dissected widely, individually ligated, and divided. And then the entire mass was totally removed. RESULTS: All surgical sites were healed well without complications and there was no evidence of recurrence in all cases up to for 2 years of follow-up examination. CONCLUSION: The arteriovenous fistula on face is a very rare disease and has difficulties in treatment. The authors experienced three cases of arteriovenous fistula with complete surgical removal and no recurrence was found in all cases.