Reaching New Heights: A Comprehensive Study of Hand Transplantations in Korea after Institutionalization of Hand Transplantation Law.

PURPOSE: With the revision of the Organ and Transplantation Act in 2018, the hand has become legal as an area of transplantable organs in Korea. In January 2021, the first hand allotransplantation since legalization was successfully performed, and we have performed a total of three successful hand transplantation since then. By comparing and incorporating our experiences, this study aimed to provide a comprehensive reconstructive solution for hand amputation in Korea. MATERIALS AND METHODS: Recipients were selected through a structured preoperative evaluation, and hand transplantations were performed at the distal forearm level. Postoperatively, patients were treated with three-drug immunosuppressive regimen, and functional outcomes were monitored. RESULTS: The hand transplantations were performed without intraoperative complications. All patients had partial skin necrosis and underwent additional surgical procedures in 2 months after transplantation. After additional operations, no further severe complications were observed. Also, patients developed acute rejection within 3 months of surgery, but all resolved within 2 weeks after steroid pulse therapy. Motor and sensory function improved dramatically, and patients were very satisfied with the appearance and function of their transplanted hands. CONCLUSION: Hand transplantation is a viable reconstructive option, and patients have shown positive functional and psychological outcomes. Although this study has limitations, such as the small number of patients and short follow-up period, we should focus on continued recovery of hand function, and be careful not to develop side effects from immunosuppressive drugs. Through the present study, we will continue to strive for a bright future regarding hand transplantation in Korea.

A bipedicled keystone perforator island flap: Pedicle division technique with enhanced advancement potential for chronic wound coverage.

Since the first description of the keystone perforator island flap (KPIF) in 2003, several modifications have been suggested to enhance its coverage ability. However, locoregional flaps have limited its use in chronic wounds due to decreased elasticity around the defect. We investigated the use of a bipedicled KPIF (bKPIF), which covers a defect while completely elevating the median part of the flap from the fascia. A retrospective chart review of 20 consecutive patients who underwent classical type I KPIF (n = 10) or bKPIF (n = 10) reconstruction from June 2020 to December 2022 was performed. Baseline characteristics, indications, operative details, healing time, and complications were analyzed and compared between the two groups. The average defect size was 30 cm2 in type I KPIF and 36.6 cm2 in bKPIF, and an average flap size of 86.5 cm2 was covered in type I KPIF, larger than bKPIF at 73.8 cm2. The flap/defect ratio was significantly lower in the bKPIF group (p < 0.02), with an average of only 55% pedicular area. The average advancement distance in the bKPIF group was 1.85 cm (standard deviation 0.78) greater than that in the type 1 KPIF group. There was no significant difference between the groups in terms of operation time, complete healing time, and complications. All ten bKPIFs were successful without any flap necrosis. Even though the mean pedicular area in the bKPIF group was nearly half compared with that in the type I KPIF group, it was sufficient to perfuse the entire flap without any major complications. This novel technique using bKPIF has potential clinical relevance, as evidenced by the enhanced ability to cover chronic defects with severe scarring. Lateralizing the hotspots to the bilateral corners of the flap is the mechanism that facilitates this potential.

One Year Experience of the Hand Allotransplantation First Performed after Korea Organ Transplantation Act (KOTA) Amendment.

The revision of the Korea Organ Transplantation Act (KOTA) in 2018 included hand/arm among the organs that can be transplanted. The first hand transplantation since the revision of KOTA took place in January 2021. A 62-year-old male patient experienced hand amputation on July 13, 2018, by a catapult injury. The patient first visited our institute 3 months after the injury. After serial interviews and an overall evaluation, the patient was registered on the hand transplantation waiting list in January 2020. On January 9, 2021, the patient underwent hand transplantation at the right distal forearm level. The total operation time was 17 hours 15 minutes, and the cold ischemic time was 4 hours 9 minutes. Postoperative immunosuppression was administered based on the protocol used for kidney transplantation. Two acute rejection episodes occurred, on postoperative days 33 and 41. Both rejection episodes were reversible with rescue therapy of a higher tacrolimus trough level, steroid pulse therapy, and topical immunosuppressants. Controlled passive range of motion exercise was started on postoperative day 10. Dynamic splint was applied on postoperative day 18. At 1 year, graft maintenance and functional improvement were satisfactory, and the patient showed a Disabilities of Arm, Shoulder and Hand score of 25.8. We successfully performed the first hand transplantation surgery under the KOTA amendment. It came from the organic and effective cooperation of plastic, orthopaedic, and transplantation departments and we believe it will guarantee the future ongoing success.

Breast Tissue Restoration after the Partial Mastectomy Using Polycaprolactone Scaffold.

As breast conserving surgery increases in the surgical treatment of breast cancer, partial mastectomy is also increasing. Polycaprolactone (PCL) is a polymer that is used as an artifact in various parts of the human body based on the biocompatibility and mechanical properties of PCL. Here, we hypothesized that a PCL scaffold can be utilized for the restoration of breast tissue after a partial mastectomy. To demonstrate the hypothesis, a PCL scaffold was fabricated by 3D printing and three types of spherical PCL scaffold including PCL scaffold, PCL scaffold with collagen, and the PCL scaffold with breast tissue fragment were implanted in the rat breast defect model. After 6 months of implantation, the restoration of breast tissue was observed in the PCL scaffold and the expression of collagen in the PCL scaffold with collagen was seen. The expression of TNF-α was significantly increased in the PCL scaffold, but the expression of IL-6 showed no significant difference in all groups. Through this, it showed the possibility of using it as a method to conveniently repair tissue defects after partial mastectomy of the human body.

Methodology in Conventional Head and Neck Reconstruction Following Robotic Cancer Surgery: A Bridgehead Robotic Head and Neck Reconstruction.

PURPOSE: Robotic head and neck surgery is widespread nowadays. However, in the reconstruction field, the use of robotic operations is not. This article aimed to examine methodologies for conventional head and neck reconstruction after robotic tumor surgery in an effort to obtain further options for future reconstruction manipulations. MATERIALS AND METHODS: A retrospective review of all patients who received head and neck robot surgery and conventional reconstructive surgery between October 2016 and September 2021. RESULTS: In total, 53 cases were performed. 67.9% of the tumors were greater than 4 cm. Regarding defect size, 47.2% of the lesions were greater than 8 cm. In terms of TNM stage, stage 3 disease was recorded in 26.4% and stage 4 in 52.8%. To make a deep and narrow field wider, we changed the patient's posture in pre-op field, additional dissection was done. We used radial forearm flap mostly (62.2%). CONCLUSION: Conventional head and neck reconstruction after robotic ENT cancer surgery is possible. One key step is to secure additional space in the deep and narrow space left after robotic surgery. For this, we opted for a radial forearm flap mostly. This can be performed as a bridgehead to perform robotic head and neck reconstruction.

Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers.

INTRODUCTION: Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique. MATERIALS AND METHODS: From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated. RESULTS: The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m2; p = 0.183). CONCLUSION: The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.

The effect of light-emitting diode (590/830 nm)-based low-level laser therapy on posttraumatic edema of facial bone fracture patients.

PURPOSE: Posttraumatic edema in facial bone fracture patients may interfere with the operation field and delay the schedule. Thus, swiftly reducing the edema alleviates patient discomfort and advances the operation date. Ice packing and compression bandages are often used for such a purpose, but such methods are often inconvenient for the face. In this study, we aim to analyze the effect of light-emitting diode (LED) (590/830 nm)-based low-level laser therapy (LLLT) in posttraumatic edema in facial bone fracture patients. MATERIALS AND METHODS: We conducted a prospective cohort study of 40 patients who were admitted to a single institution for facial bone fracture. The patients were divided into two groups of 20 each, treated either with LLLT or with sham treatment light. We used an LLLT device that consists of planar LED-based arrays with double wavelengths 590 nm and 830 nm. The patients were treated with either true or sham light from posttraumatic day 1-5, twice a day. After each treatment, the volume of a patient's face was measured with a 3-dimensional camera. We analyzed and compared the changes in facial edema. The Wilcoxon rank sum test was conducted for statistical comparison of the two groups, and significance was set to the level of p < 0.05. RESULTS: The sex ratio and mean age of the two groups were of little difference. The fracture sites included the nasal bone, orbital wall, zygomaticomaxillary bone, mandible, and frontal sinus. Mechanisms of injury included fall, assault, traffic accident, sports, and gunshot. The total operation rate of both groups was equal to 85%. Our analysis showed a 16.5% reduction of edema in the LLLT group and 7.3% in the sham light group. The edema reduction was statistically significantly greater in the LLLT group than in the sham light group (p < 0.047). CONCLUSION: LED-based LLLT is recently receiving attention worldwide for its cost-effectiveness and large coverage area compared to traditional laser therapy. Recent studies support its effectiveness in various areas such as wound healing, skin rejuvenation, and pain alleviation. In this study, we treated facial bone fracture patients with LED-based LLLT, and showed its effectiveness in reducing posttraumatic edema.

Patient Satisfaction with Implant Based Breast Reconstruction Associated with Implant Volume and Mastectomy Specimen Weight Ratio.

PURPOSE: Breast volume assessment is one of the most important steps during implant-based breast reconstruction because it is critical in selecting implant size. According to previous studies, there is a close relationship between the mastectomy specimen weight and resected breast volume. The aim of this study was to evaluate long-term patient satisfaction with implant-based breast reconstruction guided by the ratio of implant volume to mastectomy specimen weight. In doing so, we describe the ideal ratio for patient satisfaction. METHODS: A total of 84 patients who underwent implant-based breast reconstruction for breast cancer were included in this study. The patients were grouped by the ratio of implant size to mastectomy specimen weight (group 1, <65%; group 2, 65%-75%; and group 3, >75%). Outcome analysis was performed using a questionnaire of patient satisfaction and the desired implant size. RESULTS: Patient satisfaction scores concerning the postoperative body image, size, and position of the reconstructed breast were significantly higher in group 2. The average ratio of the ideal implant volume to mastectomy specimen weight for each group was 71.9% (range, 54.5%-96.7%), with the differences across the three groups being not significant (p=0.244). CONCLUSION: Since there is an increase in breast reconstruction, selecting the appropriate breast implant is undoubtedly important. Our novel technique using the ratio of implant volume to mastectomy specimen weight provides physicians a firm guide to intraoperative selection of the proper implant in reconstructive breast surgery.

Variance of the pectoralis major in relation to the inframammary fold and the pectoralis minor and its application to breast surgery.

Understanding the anatomy of the muscles and other structures of the chest is of great importance in breast surgery. We have conducted the first analysis of the overall variations and relationships among the pectoralis major (PM), inframammary fold (IMF), and pectoralis minor (Pm). We studied 30 patients and 10 cadavers, leading to a total of 50 breasts. Preoperatively, the breast width was measured, and the costal origin of the lowest IMF point was marked. Intraoperatively, we recorded the costal origins of the PM and IMF, PM width, the distance between the PM and IMF, and the relationship and distance between the PM and Pm. Among the patients, PMs originated from the sixth rib in 80% and above the IMF in 66.67%. The mean distances between the PM and IMF were 10.5 mm in the patients and 16 mm in the cadavers. The mean PM/breast width ratio was 0.82 in the patients and 0.85 in the cadavers. The PM and Pm mostly crossed on the fourth or fifth rib, and the average angles between the two muscles were 23.5° and 21.4° in the patients and cadavers, respectively. This study is the first to analyze the anatomical variations of the PM, IMF, and Pm simultaneously. We also examined the differences between Western and Asian populations. Understanding the anatomy is undoubtedly crucial for breast surgery, and here we provide a firm guide to the variations to be expected during operations, which can lead to successful outcomes. Clin. Anat. 30:357-361, 2017. © 2017 Wiley Periodicals, Inc.

Facial Flap Repositioning in Posttraumatic Facial Asymmetry.

Perfect facial and body symmetry is an important aesthetic concept which is very difficult, if not impossible, to achieve. Yet, facial asymmetries are commonly encountered by plastic and reconstructive surgeons. Here, we present a case of posttraumatic facial asymmetry successfully treated with a unique concept of facial flap repositioning. A 25-year-old male patient visited our department with severe posttraumatic facial asymmetry. There was deviated nasal bone and implant to the right, and the actual facial appearance asymmetry was much more severe compared to the computed tomography, generally shifted to the right. After corrective rhinoplasty, we approached through intraoral incision, and much adhesion from previous surgeries was noted. We meticulously elevated the facial flap of both sides, mainly involving the cheeks. The elevated facial flap was shifted to the left, and after finding the appropriate location, we sutured the middle portion of the flap to the periosteum of anterior nasal spine for fixation. We successfully freed the deviated facial tissues and repositioned it to improve symmetry in a single stage operation. We conclude that facial flap repositioning is an effective technique for patients with multiple operation history, and such method can successfully apply to other body parts with decreased tissue laxity.

A retrospective analysis of ruptured breast implants.

BACKGROUND: Rupture is an important complication of breast implants. Before cohesive gel silicone implants, rupture rates of both saline and silicone breast implants were over 10%. Through an analysis of ruptured implants, we can determine the various factors related to ruptured implants. METHODS: We performed a retrospective review of 72 implants that were removed for implant rupture between 2005 and 2014 at a single institution. The following data were collected: type of implants (saline or silicone), duration of implantation, type of implant shell, degree of capsular contracture, associated symptoms, cause of rupture, diagnostic tools, and management. RESULTS: Forty-five Saline implants and 27 silicone implants were used. Rupture was diagnosed at a mean of 5.6 and 12 years after insertion of saline and silicone implants, respectively. There was no association between shell type and risk of rupture. Spontaneous was the most common reason for the rupture. Rupture management was implant change (39 case), microfat graft (2 case), removal only (14 case), and follow-up loss (17 case). CONCLUSIONS: Saline implants have a shorter average duration of rupture, but diagnosis is easier and safer, leading to fewer complications. Previous-generation silicone implants required frequent follow-up observation, and it is recommended that they be changed to a cohesive gel implant before hidden rupture occurs.