Clinical Experience of Three-dimensional Reconstruction Using Free TRAM Flap after Total Maxillectomy with Orbital Exenteration

PURPOSE: Extensive midface defect following total maxillectomy with orbital exenteration and cheek skin resection should be three dimensionally reconstructed with a large flap that have a sufficient volume of tissue and multiple skin islands. We describe our transverse rectus abdominis myocutaneous(TRAM) free flap with three skin islands which was successfully used in this situation. METHODS: A 58-year-old man was performed enbloc total maxillectomy including orbital contents and wide cheek skin because of invasive maxillary squamous cell carcinoma. He was immediately reconstructed with TRAM flap that was designed not vertical but transverse fashion for providing sufficient skin area. Also, deepithelialization procedure making for multiple skin islands was done in flap insetting period when appropriate modification according to the intraoperative situation was possible. Dead space was completely obliterated by bulky muscular tissue, and three skin islands were used for lining of lateral nasal wall, palatal surface, and cheek skin restoration. RESULTS: Postoperative course was satisfying. Maintaining of proper ipsilateral nasal airway, loss of rhinolalia and oronasal regurgitation of food particles, and restoration of cheek contour were successfully obtained. CONCLUSION: We report clinical experience of threedimensional reconstruction using free TRAM flap after total maxillectomy with orbital exenteration.

Stabilization of Unilateral Septal Extension Graft Using Pivot Locking Suture

Septal extension graft is valuable in elongating the nasal length which projects and rotates the tip. It is very effective for improving the nasal tip, therefore, it has widely been applied to correct short noses and drooping tips. In the field of Asian rhinoplasty, many operations are conducted using a septal extension graft, and variable techniques and methods have been introduced by several surgeons. However, there are difficulties in harvesting a sufficient amount of septum from Asian noses, therefore, appropriate designs and definite fixation of a graft are important factors. Furthermore, when applying the harvested septal cartilage to the L-strut, stability depends on the method and the location of the graft fixation. When the graft is unstable due to its pivot motion, the tip will be drooping, deviated and decreased in projection. We herein introduce a pivot locking suture that can firmly stabilize the septal extension graft and explain the factors related with septal stabilization. From September 2006 to February 2008, we performed unilateral septal extension graft for aesthetic purposes in 64 patients. After classic compression suture between L-strut and unilateral septal cartilage graft, pivot locking sutures were performed. Pivot locking suture fixed the meeting site of septal extension graft, and cephalic and caudal margin of L-strut using "figure of 8" suture. Then, we confirmed the stability with a vertical stability test and horizontal stability test. We could follow up with 20 patients. All patients were satisfied except 2 patients with the tip deviation. Therefore, we believe that pivot locking sutures together with classic compression sutures can overcome limitations of stability inherent with conventional methods, due to unstable septal extension graft cartilage.

Effects of Cross-Linking Agents on the Stability of Human Acellular Dermal Matrix

PURPOSE: Human acellular dermal matrix(ADM) is widely used in the treatment of congenital anomalies and soft tissue deficiencies. But it is rapidly degraded in the body and does not provide satisfactory results. There is a need to improve collagen fiber stability through various methods and ultimately regulate the speed of degradation. METHODS: The ADMs were added with various cross- linking agents called glutaraldehyde, dimethyl 3,3'-dithiobispropionimidate to produce cross-linked acellular dermal matrices. 1,4-butanediol diglycidyl ether solution was applied with a pH of 4.5 and 9.0, respectively. The stability of cross-linked dermal matrix was observed by measuring the shrinkage temperature and the degradation rates. The cross- and non-cross linked dermis were placed in the rat abdomen and obtained after 8, 12 and 16 weeks. RESULTS: The shrinkage temperature significantly increased and the degradation rate significantly decreased, compared to the control(p<0.05). All of cross- linked dermises were observed grossly in 16 weeks, but most of non-cross linked dermis were absorbed in 8 weeks. Histologically, the control group ADM was found to have been infiltrated with fibroblasts and most of dermal stroma were transformed into the host collagen fibers. However, infiltration of fibroblasts in the experiment was insignificant and the original collagen structure was intact. CONCLUSION: Collagen cross-linking increases the structural stability and decreases degradation of acellular dermis. Therefore, decrease in body absorption and increase in duration can be expected.

The Correction of Inverted Nipple Using Modified Purse-string Suture

PURPOSE: An inverted nipple presents both cosmetic and functional problems. It is a source of repeated irritation and inflammation, and interferes with nursing. In addition, its abnormal appearance may cause psychological distress. With consideration of its underlying pathophysiologic components and severity, a number of techniques have been introduced for correction of this anomaly. The diversity of techniques indicates the lack of a good, sustainable, and durable solution for this quite common problem. We report our method as an alternative solution for correcting of the inverted nipple. METHODS: From August 2003 to November 2007, 273 nipples in 147 patients were treated. 126 patients had bilateral inverted nipples. Patient age at the operation ranged from 21 to 63 years(mean age, 34 years). All nipples were congenital anomaly. 45 nipples were graded as grade I, 179 nipples as II, and 49 nipples as III. In the our study, we made some modification to the classic purse-string suture: (1) twice purse-string suture: (2) excision of diamond-shaped skin at the nipple neck: (3) buried suture of the breast parenchyma at the nipple base: (4) some timely release of retraction using Bovie's electrocautery dissection at inner surface of the nipple neck. RESULTS: The operation time averaged 15 minutes. The mean follow-up period ranged from 3 to 48 months, with an average of 8.4 months. There were no complications associated with the surgery, such as infection, hematoma, permanent sensory disturbance, or total nipple necrosis except temporary sensory loss in 9 cases, partial nipple necrosis in 7 cases, and recurred inversion in 15 cases. All patients except recurred inversion were satisfied with their results. CONCLUSION: We believe that our modified purse- string suture is a reliable, simple, safe, and effective method for correcting the inverted nipple.

Tissue Reaction and Morphologic Change of Gore-Tex Implant in the Rabbit Model

Various materials have been proposed for use in aesthetic and reconstructive augmentation of the face. Three basic types of material are currently available: autografts, homografts, and alloplasts. Alloplastic materials have been used widely for soft tissue augmentation. Many synthetic material have been developed for alloplasty; among these, the porous material, Gore-Tex(r)(ePTFE) allows minimal fibrous tissue ingrowth but the amount is sufficient to confer some stability of the implant in soft tissue over time. The purpose of this study is to evaluate the tissue reaction and size change of Gore-Tex in rabbits. A precise pockets were made in the plane below the panniculus carnosus and periosteum. The 25x5x3mm sized rectangular shape of Gore-Tex(r) was then inserted into the pocket. Tissue specimens including skin and implant were obtained in 1, 3, 6 months after implantation. The specimens were examined grossly and microscopically. Grossly, none of the implants were lost or extruded and there was no evidence of wound infection, hematoma, or seroma formation. Thickness of implants under periosteum decreased more than panniculus carnosus. Results of light microscopy revealed a mild inflammatory cell reaction in the early implant group(1 month) at the tissue-implant interface. Within the substance of the material, tissue ingrowth was not observed in the early implant group(1 month and 3 months), but was observed in the late implant group(6 months). In this study the Gore-Tex appears to be a safe and reliable substance for use in augmentation of bony and soft tissue structure of the face.

Comparative Observation of Barrier Sheet and Nonbarrier Sheet Medpor(R) Inserted on Orbital Floor in Rabbits

The purpose of this study was to determine the histopathologic change of Medpor(R) implant for the case of orbital floor reconstruction in the rabbit model. Two types of Medpor(R)(barrier sheet and nonbarrier sheet) were used for the reconstruction of orbital floor in 30 rabbits. In 1 month and 6 months postoperatively, the histopathologic changes were observed with light microscope and forced duction test was performed. None of the implants were lost or extruded and there was no evidence of wound infection, hematoma, or seroma formation. None of cases showed positive in force duction test. Orbital tissue ingrowth was not observed in the barrier sheet Medpor(R) implant group, however, it was observed in the nonbarrier sheet Medpor(R) implant group. This study supports that the barrier sheet Medpor(R) may more suitable than nonbarrier sheet Medpor(R) for reconstruction of the fractured orbital wall.

Intraoral Compressive Dressing for Prevention of Palatal Fistula after Cleft Palate Repair

The rate of postoperative cleft palate fistula is influenced by palatal repair methods. High incidence of cleft palate fistula is associated with pushback palatoplasty, because wide elevation of mucoperiosteal flaps can cause hematoma and exudate, which make flaps thinner so necrotise. Thus, the authors tried to reduce the wound disruption, hematoma, and dead space while performing pushback palatoplasty in complete cleft palate by applying compressive dressing over mucoperiosteal flaps. As a result, the incidence of cleft palate fistula was statistically reduced after compressive dressing. Three fistulas occurred in 14 patients treated by pushback palatoplasty without compressive dressing, but no fistula occurred in 25 patients treated by pushback palatoplasty with compressive dressing. By applying the compressive dressing after Pushback palatoplasty, it is expected not only reduced short-term complication, but also better results in the long-term follow up of maxillary growth and speech development.

A Study on Serum IgE Levels in Patients with Scabies / 대한피부과학회지

Serum IgE levels in 48 patients with scabies were measured by enzyme-linked immunosorbent a.ssay(ELISA) to evaluate the relationship between the scabies and serum IgE. A group of 44 healthy persons was taken as a controls. The results were summarized as follows: In children group(p 15 year-old) of the scabies, serum IgE level was 446 3 +267.2 IU/ml and significantly elevated than in controls, 126, 3 175, 4 IU/rnl, In adult group(over 16 year-old), serum IgE levels of the scabies and controls were 506. 4 + 581. 8 IU/ml, 435, 5+ 548, 8 lU/rnl respetively, and there was no significant difference between them. 2) There were no statistical correlations between the serum IgE levels and intensity of pruritus, duration of illness, number of skin lesions or number of circu1ating eosinophils in patients with scabies.