Yoonho Lee, M.D., Ph.D., 1949 to 2019

No abstract available.

Soft tissue reconstruction in wide Tessier number 3 cleft using the straight-line advanced release technique

Craniofacial cleft is a rare disease, and has multiple variations with a wide spectrum of severity. Among several classification systems of craniofacial clefts, the Tessier classification is the most widely used because of its simplicity and treatment-oriented approach. We report the case of a Tessier number 3 cleft with wide soft tissue and skeletal defect that resulted in direct communication among the orbital, maxillary sinus, nasal, and oral cavities. We performed soft tissue reconstruction using the straight-line advanced release technique that was devised for unilateral cleft lip repair. The extension of the lateral mucosal and medial mucosal flaps, the turn over flap from the outward turning lower eyelid, and wide dissection around the orbicularis oris muscle enabled successful soft tissue reconstruction without complications. Through this case, we have proved that the straight-line advanced release technique can be applied to severe craniofacial cleft repair as well as unilateral cleft lip repair.

Rat Hindlimb Allotransplantation with Short-term Immune Suppressants and Dendritic Cell Pretreatment

Prevention of acute rejection in composite tissue allotransplantation without continuous immunosuppression lacks reports in worldwide literature. Recently dendritic cells (DC) gained considerble attention as antigen presenting cells that are also capable of immunologic tolerance induction. This study assesses the effect of alloantigen-pulsed dendritic cells in induction of survival in a rat hindlimb allograft. We performed hindlimb allotransplantation between donor Sprague-Dawley and recipient Fischer344 rats. Recipient derived dendritic cells were harvested from rat whole blood and cultured with anti-inflammatory cytokine IL-10. Then donor-specific alloantigen pulsed dendritic cells were reinjected into subcutaneous tissue before limb transplantation. Groups: I) untreated (n=6), II) DC injected (n=6), III) Immunosuppressant (FK-506, 2 mg/Kg) injected (n=6), IV) DC and immunouppressant injected (n=6). Graft appearance challenges were assessed postoperatively. Observation of graft appearance, H-E staning, immunohistochemical (IHC) study, and confocal immunofluoreiscece were performed postoperatively. Donor antigen pulsed host dendritic cell combined with short-term immunosuppression showed minimal mononuclear cell infiltration, regulator T cell presence, and could prolong limb allograft survival.

Implementation Issues of Virtual Desktop Infrastructure and Its Case Study for a Physician's Round at Seoul National University Bundang Hospital / 대한의료정보학회지

OBJECTIVES: The cloud computing-based virtual desktop infrastructure (VDI) allows access to computing environments with no limitations in terms of time or place such that it can permit the rapid establishment of a mobile hospital environment. The objective of this study was to investigate the empirical issues to be considered when establishing a virtual mobile environment using VDI technology in a hospital setting and to examine the utility of the technology with an Apple iPad during a physician's rounds as a case study. METHODS: Empirical implementation issues were derived from a 910-bed tertiary national university hospital that recently launched a VDI system. During the physicians' rounds, we surveyed patient satisfaction levels with the VDI-based mobile consultation service with the iPad and the relationship between these levels of satisfaction and hospital revisits, hospital recommendations, and the hospital brand image. Thirty-five inpatients (including their next-of-kin) and seven physicians participated in the survey. RESULTS: Implementation issues pertaining to the VDI system arose with regard to the highly availability system architecture, wireless network infrastructure, and screen resolution of the system. Other issues were related to privacy and security, mobile device management, and user education. When the system was used in rounds, patients and their next-of-kin expressed high satisfaction levels, and a positive relationship was noted as regards patients' decisions to revisit the hospital and whether the use of the VDI system improved the brand image of the hospital. CONCLUSIONS: Mobile hospital environments have the potential to benefit both physicians and patients. The issues related to the implementation of VDI system discussed here should be examined in advance for its successful adoption and implementation.

Monitor Preference for Electronic Medical Record in Outpatient Clinic / 대한의료정보학회지

OBJECTIVES: The objective of this paper is to assess which wide type monitor configurations are preferred when physicians use an Electronic Medical Record (EMR) system in an outpatient clinic setting. METHODS: We selected three kinds of monitor configurations available for adoption at outpatient clinics with reference to monitor market trends. Fifteen attending physicians of the Seoul National University Bundang Hospital used each monitor configuration in their outpatient clinics. After completing the outpatient sessions, they selected the best monitor configuration for criteria described in five questionnaire items. We counted the number of votes and reviewed opinions of participants. RESULTS: The Wide Quad High Definition (WQHD) 27-inch single monitor configuration was most preferred for all questionnaire items. All participants answered that the WQHD 27-inch single monitor configuration was the best for desk space utilization. Eleven out of fifteen participants chose the WQHD 27-inch single monitor configuration as the most suitable monitor for outpatient practice. CONCLUSIONS: This study found that physicians preferred the WQHD 27-inch single monitor configuration in outpatient clinic settings. Healthcare organizations need to consider this finding when they purchase wide type monitors for EMR systems instead of the standard type monitor.

Comparing the Certification Criteria for CCHIT-Certified Ambulatory EHR with the SNUBH's EHR Functionalities / 대한의료정보학회지

OBJECTIVES: This study aims to investigate the suitability of electronic health record (EHR) systems in Korea for global certification and to propose functions for future global systems by comparing and analyzing the certification criteria for Certification Commission for Health Information Technology (CCHIT) Certified Ambulatory EHR with BESTCare, which is the EHR system at Seoul National University Bundang hospital. METHODS: Domain expert groups were formed to analyze the inclusion of BESTCare functions and the types of differences for each of the CCHIT Certified 2011 Ambulatory EHR Certification Criteria. The types of differences were divided into differences in functions (F), differences in business processes (B), and differences in government policies (P). RESULTS: Generally, the criteria that showed differences in functions pertained to the connection between the diagnosis/problem list and order, the alert and warning functions for medication-diagnosis interactions, and the reminder/instruction/notification messages related to the patient's immunization status; these absent functions were enhanced clinical decision support system (CDSS) functions related to patient safety and healthcare quality. Differences in government policies were found in the pharmacy's electronic prescription functions, while differences in business processes were found in the functions constrained by the local workflow or internal policy, which require some customization. CONCLUSIONS: Functions that differed between the CCHIT certification criteria and the BESTCare system in this study should be considered when developing a global EHR system. Such a system will need to be easily customizable to adapt to various government policies and local business processes. These functions should be considered when developing a global EHR system certified by CCHIT in the future.

Pitfalls and Security Measures for the Mobile EMR System in Medical Facilities / 대한의료정보학회지

OBJECTIVES: The goal of this paper is to examine the security measures that should be reviewed by medical facilities that are trying to implement mobile Electronic Medical Record (EMR) systems designed for hospitals. METHODS: The study of the security requirements for a mobile EMR system is divided into legal considerations and sectional security investigations. Legal considerations were examined with regard to remote medical services, patients' personal information and EMR, medical devices, the establishment of mobile systems, and mobile applications. For the 4 sectional security investigations, the mobile security level SL-3 from the Smartphone Security Standards of the National Intelligence Service (NIS) was used. RESULTS: From a compliance perspective, legal considerations for various laws and guidelines of mobile EMR were executed according to the model of the legal considerations. To correspond to the SL-3, separation of DMZ and wireless network is needed. Mobile access servers must be located in only the smartphone DMZ. Furthermore, security measures like 24-hour security control, WIPS, VPN, MDM, and ISMS for each section are needed to establish a secure mobile EMR system. CONCLUSIONS: This paper suggested a direction for applying regulatory measures to strengthen the security of a mobile EMR system in accordance with the standard security requirements presented by the Smartphone Security Guideline of the NIS. A future study on the materialization of these suggestions after their application at actual medical facilities can be used as an illustrative case to determine the degree to which theory and reality correspond with one another.

Pitfalls and Security Measures for the Mobile EMR System in Medical Facilities / 대한의료정보학회지

OBJECTIVES: The goal of this paper is to examine the security measures that should be reviewed by medical facilities that are trying to implement mobile Electronic Medical Record (EMR) systems designed for hospitals. METHODS: The study of the security requirements for a mobile EMR system is divided into legal considerations and sectional security investigations. Legal considerations were examined with regard to remote medical services, patients' personal information and EMR, medical devices, the establishment of mobile systems, and mobile applications. For the 4 sectional security investigations, the mobile security level SL-3 from the Smartphone Security Standards of the National Intelligence Service (NIS) was used. RESULTS: From a compliance perspective, legal considerations for various laws and guidelines of mobile EMR were executed according to the model of the legal considerations. To correspond to the SL-3, separation of DMZ and wireless network is needed. Mobile access servers must be located in only the smartphone DMZ. Furthermore, security measures like 24-hour security control, WIPS, VPN, MDM, and ISMS for each section are needed to establish a secure mobile EMR system. CONCLUSIONS: This paper suggested a direction for applying regulatory measures to strengthen the security of a mobile EMR system in accordance with the standard security requirements presented by the Smartphone Security Guideline of the NIS. A future study on the materialization of these suggestions after their application at actual medical facilities can be used as an illustrative case to determine the degree to which theory and reality correspond with one another.

Seoul National University Bundang Hospital's Electronic System for Total Care / 대한의료정보학회지

OBJECTIVES: Seoul National University Bundang Hospital, which is the first Stage 7 hospital outside of North America, has adopted and utilized an innovative and emerging information technology system to improve the efficiency and quality of patient care. The objective of this paper is to briefly introduce the major components of the SNUBH information system and to describe our progress toward a next-generation hospital information system (HIS). METHODS: SNUBH opened in 2003 as a fully digital hospital by successfully launching a new HIS named BESTCare, "Bundang hospital Electronic System for Total Care". Subsequently, the system has been continuously improved with new applications, including close-loop medication administration (CLMA), clinical data warehouse (CDW), health information exchange (HIE), and disaster recovery (DR), which have resulted in the achievement of Stage 7 status. RESULTS: The BESTCare system is an integrated system for a university hospital setting. BESTCare is mainly composed of three application domains: the core applications, an information infrastructure, and channel domains. The most critical and unique applications of the system, such as the electronic medical record (EMR), computerized physician order entry (CPOE), clinical decision support system (CDSS), CLMA, CDW, HIE, and DR applications, are described in detail. CONCLUSIONS: Beyond our achievement of Stage 7 hospital status, we are currently developing a next-generation HIS with new goals of implementing infrastructure that is flexible and innovative, implementing a patient-centered system, and strengthening the IT capability to maximize the hospital value.

Seoul National University Bundang Hospital's Electronic System for Total Care / 대한의료정보학회지

OBJECTIVES: Seoul National University Bundang Hospital, which is the first Stage 7 hospital outside of North America, has adopted and utilized an innovative and emerging information technology system to improve the efficiency and quality of patient care. The objective of this paper is to briefly introduce the major components of the SNUBH information system and to describe our progress toward a next-generation hospital information system (HIS). METHODS: SNUBH opened in 2003 as a fully digital hospital by successfully launching a new HIS named BESTCare, "Bundang hospital Electronic System for Total Care". Subsequently, the system has been continuously improved with new applications, including close-loop medication administration (CLMA), clinical data warehouse (CDW), health information exchange (HIE), and disaster recovery (DR), which have resulted in the achievement of Stage 7 status. RESULTS: The BESTCare system is an integrated system for a university hospital setting. BESTCare is mainly composed of three application domains: the core applications, an information infrastructure, and channel domains. The most critical and unique applications of the system, such as the electronic medical record (EMR), computerized physician order entry (CPOE), clinical decision support system (CDSS), CLMA, CDW, HIE, and DR applications, are described in detail. CONCLUSIONS: Beyond our achievement of Stage 7 hospital status, we are currently developing a next-generation HIS with new goals of implementing infrastructure that is flexible and innovative, implementing a patient-centered system, and strengthening the IT capability to maximize the hospital value.

Treatment of Metacarpal Bone Fracture Using Biodegradable Plates and Screws

PURPOSE: Metacarpal fractures are common hand injury that may require operative intervention to ensure adequate reduction and stabilization. Traditionally, titanium miniplate was used for rigid fixation of bone fractures. However, the use of permanent plate lends itself to multiple complications such as infection, exposure of the hardware, tendon adhesions, tendon rupture, prolonged pain, bony atrophy and osteoporosis (stress shielding), metal sensitization, and palpation under the skin. This study evaluated the usefulness and stability of biodegradable plates and screws for treatment of metacarpal bone fractures. METHODS: There was 17 patients who had surgery for metacarpal bone fracture from April 2007 to June 2010. All patients had open reduction and internal fixation. We used absorbable plates and screws (Inion CPS(R)) for internal fixation. Postoperative results were assessed with x-ray. Stability of plates and screws, healing process and its complications were observed by clinical and radiographic assessment. RESULTS: All patients were successfully reduced of bone fracture, and fixations with absorbable plates and screws were stable. The mean follow up period was 7.1 months. 2 patients complained postoperative pain, but they were relieved with analgesics. All patients experienced transient stiffness, but they were relieved with active assistive range of motion after removal of splint. No patients suffered complications which could be occurred by using metallic plate. CONCLUSION: There was no critical complications such as re-fracture or nonunion among patients. No patients suffered side effects related with metallic implants. Biodegradable implants can offer clinically stable and attractive alternative to metallic implants to stabilize metacarpal bone fractures in the hand.

Reconstruction of Soft Tissue Defect of Knee Joint Area Using Anterolateral Thigh Perforator Flap

Reconstruction of soft tissue defect of knee joint area has been remained a challenging task for plastic surgeons. The earlier the normal tissue saved and the necrotic tissue removed, the less the patients had complications and functional disability. But such defects are difficult to manage for its poor vascularity, rigid tissue distensibility, easy infectability and a relatively long healing period. The goal of flap coverage in the knee joint should not only be satisfactory wound coverage, but also acceptable appearance and minimal donor site morbidity. We have treated five cases using the anterolateral thigh perforator flaps for reconstruction successfully. In conclusion, we believe that in cases of knee joint area soft tissue defects, flaps like anterolateral thigh perforator flap should be considered as the first line of treatment.

Inguinal Soft Tissue Reconstruction Using Pedicled Anterolateral Thigh Flap: A Case Report

We present our experience of reconstruction of inguinal soft tissue defect following inguinal lymphadenectomy, because of penile squamous cell carcinoma. Malignant infiltration required wide resection, producing a defect requiring complex soft tissue reconstruction. We have used a pedicled anterolateral thigh flap as our first choice flap for this case. Patient achieved reasonable esthetic coverage. Complications were few and patient achieved durable long term coverage. We found this flap to be technically easy, reliable and effective.

Treatment of Velopharyngeal Insufficiency in Kabuki Syndrome: Case Report

PURPOSE: Kabuki syndrome is a multiple malformation syndrome that was first reported in Japan. It is characterized by distinctive Kabuki-like facial features, skeletal anomalies, dermatoglyphic abnormalities, short stature, and mental retardation. We report two cases of Kabuki syndrome with the surgical intervention and speech evaluation. METHODS: Both patients had velopharyngeal insufficiency and had a superior based pharyngeal flap operation. The preoperative and postoperative speech evaluations were performed by a speech language pathologist. RESULTS: In case 1, hypernasality was reduced in spontaneous speech, and the nasalance scores in syllable repetitions were reduced to be within normal ranges. In case 2, hypernasality in spontaneous speech was reduced from severe level to moderate level and the nasalance scores in syllable repetitions were also reduced to be within normal ranges. CONCLUSION: The goal of this article is to raise awareness among plastic surgeons who may encounter such patients with unique facial features. This study shows that pharyngeal flap operation can successfully correct the velopharyngeal insufficiency in Kabuki syndrome and post operative speech therapy plays a role in reinforcing surgical result.

Hand Resurfacing with Full Thickness Skin Graft from the Palm Ulnar Border

PURPOSE: Split-or full-thickness skin grafts are used to reconstruct palmar skin and soft tissue defects after trauma or to release burn scar contracture on the hand. Glabrous skin defects should be substituted with similar skin to preserve function and aesthetics. The authors report their experiences with a technique that uses a full-thickness graft taken from glabrous skin on the ulnar edge of the palm for the reconstruction of soft tissue defects of the hand. METHODS: During a three-year period from 2007 to 2010, 22 patients with burn scar contracture and 12 patients with post-traumatic skin defects on their hands were treated with full-thickness skin graft operations. The palmar skin and soft tissue defects after release of burn scar contracture or debridement of post-traumatic wounds were reconstructed with full-thickness skin grafts harvested from the ulnar border of their palms. All donor-site wounds were primarily closed. RESULTS: The followup periods ranged from 3 to 25 months. Contractures of the hand were corrected without recurrence, and the grafts showed relatively good contour and color match to the adjacent fields. There were no reported complications such as significant color change or hypertrophic scarring. The grafted skin showed an average 5.9mm static two-point discrimination obtained in fingertip reconstruction cases, indicating satisfactory reinnervation. CONCLUSION: Glabrous full-thickness grafts harvested from the palmar ulnar border is a very useful way of reconstructing soft tissue defects on hands, including fingertips, for function restoration, favorable aesthetic results, and low donor-site morbidity.

Soft Tissue Reconstruction Using Anterolateral Thigh Flap with Fascia Lata Component

PURPOSE: The anterolateral thigh flap is versatile flap for soft-tissue reconstruction for defects located at various sites of the body. This useful flap offers a thick and vascular fascia lata component with large amounts that can be soft tissue coverage for different reconstructive purposes. We present our clinical experience with the use of vascular fascia lata, combined with anterolateral thigh flap for various reconstructive goals. METHODS: From April 2008 to February 2011, we transferred anterolateral thigh flaps with fascia lata component to reconstruct soft-tissue defects for different purposes in 11 patients. The fascia lata component of the flap was used for tendon gliding surface in hand/forearm reconstruction in 4 patients, for reconstruction medial and lateral patellar synovial membrane and retinaculum in 2 patients, for reconstruction of plantar aponeurosis in the foot in 2 patients, for reconstruction of fascial and peritoneal defect in the abdominal wall in 2 patient, and for dural defect reconstruction in the scalp in the remaining one. RESULTS: Complete loss of the flap was not seen in all cases. Partial flap necrosis occurred in 2 patients. These complications were treated successfully with minimal surgical debridement and dressing. Infection occurred in 1 patient. In this case, intravenous antibiotics treatment was effective. CONCLUSION: Anterolateral thigh flap has thick vascular fascia with large amounts. This fascial component of the flap is useful for different reconstructive aims, such as for tendon, ligament, aponeurosis defects, abdominal wall or dura reconstruction. It should be considerated as an important advantage of the flap, together with other well-known advantages.

A Case Report of Nasopharyngeal Endoscopic Biofeedback Trial Therapy for Patients with Velopharyngeal Inadequecy

PURPOSE: The authors would like to introduce two patients who presented with velopharyngeal inadequacy. We emphasize the importance of nasaopharyngeal endoscopy in evaluating the velopharyngeal function and the usefulness of biofeedback trial therapy. METHODS: Two patients visited our clinic due to velopharyngeal inadequacy. Both of the patients showed hypernasality, nasal emission and compensatory articulation such as glottal stop. During oral examination and nasopharyngeal endoscopy both showed no evidence of structural deformities. One inconsistently showed a small gap during articulation. The other showed a rather large gap during compensatory articulation. Both received a simultaneous biofeedback trial therapy using the nasopharyngeal endoscope. RESULTS: Both patients were successfully diagnosed and treated at once using biofeedback trial therapy with nasopharyngeal endoscopy. By giving direct visual feedback to the patient, they were both able to achieve complete velopharyngeal closure during production of 2~3 nonsence syllables and hypernasality was not detected in both of them. CONCLUSION: The authors were able to help patients with velopharyngeal inadequacy to have velopharyngeal closure through biofeedback trial therapy. The accurate evaluation of velopharyngeal function and the possibility of closure prevented unnecessary operations.

Long-term Effectiveness of Post-operative Continuous Positive Airway Pressure(CPAP) Therapy for Treating Hypernasality: Case Report

PURPOSE: In some patients with velopharyngeal insufficiency(VPI), Hypernasality can persist after surgical management. Continuous Positive Airway Pressure(CPAP) is applied to these patients for treating hypernasality. The purpose of this study is to report follow-up results of postoperative CPAP therapy. METHODS: After performing palatal lengthening, CPAP therapy was applied to three patients for eight weeks from July of 2008 to November of 2009. Perceptual evaluation, nasometry, and nasopharyngeal endoscopy were performed to evaluate hypernasality, nasalance and size of the gap at velopharyngeal port. Each evaluation was made before surgery, right after CPAP therapy and during follow- up of more than a year after CPAP therapy. RESULTS: All of the patients showed improvement in hypernasality right after CPAP therapy according to the auditory perceptual evaluation, nasometry and nasopharyngeal endoscopy. But the improvement in hypernasality in these patients did not last during follow-up. CONCLUSION: In this study, our results suggest that CPAP therapy is effective in reducing hypernasality for postoperative VPI patients immediately after the therapy, but hypernasality may be worsen in some patients during follow-up. Therefore we recommend follow-ups after CPAP therapy to see if the efficacy of CPAP therapy lasts.

Effectiveness of Thick Acellular Dermal Matrix (Allocover(R)) in Burn and Burn Scar Contracture

PURPOSE: To treat burn and burn scar contracture, many types of dermal substitutes have been manufactured and used recently. Allogenic dermis is known to have best cellular affinity to the host, but it is the thinnest product among artificial dermis. Processed thick allogenic dermis (Allocover(R)) has been developed and applied to overcome the problems of preexisting materials as a permanent dermal substitute. METHODS: From June 2007 to May 2009, we have grafted thick acellular human dermal allograft with thin split-thickness skin graft on burn wound and burn scar contracture of feet and legs in 14 patients who had hypertrophic scar, joint contracture and various skin defect areas. Intraoperatively, we fixed spilt thickness skin graft to artificial dermis with suture fixation for avoiding the mobilization between them. RESULTS: Thirteen patients out of 14 patients had no problem. One patient underwent partial skin loss and secondary healing process. During the 18 months of follow up period, no contracture recurrence or skin loss was observed. CONCLUSION: The thick acellular human dermal allograft (Allocover(R)) could be very useful in the management of skin loss and burn scar contractures. Its vascularization has occurred fast enough that wounds can be covered in an adequate layer of dermal augmentation with minimal contracture and good cosmetic results.

A Case Report of a Giant Epidermal Nevus on the Scalp

PURPOSE: Epidermal nevi are hamartomas of the skin with multiple clinical variants. Normally, epidermal nevi present at an early age, are found on the head and neck area, and have a female predominance. Only very rarely do epidermal nevi have an adult onset. Most lesions are small and giant Epidermal nevi (> 5 cm at its greatest diameter) are quite rare. Huge verrucous plaque was observed on the scalp of a 70-year-old man. He had been reclusive for a long time, and this problem might have played a crucial role in the development of the giant epidermal nevi. METHODS: A punch biopsy and MRI imaging were performed. The huge mass was resected. A local flap and split thickness skin graft was used for reconstruction. RESULTS: The histology examination revealed the characteristic findings of epidermal nevus. Postoperatively, the patient did not suffer from complications or recurrence. CONCLUSION: A rare case of a huge epidermal nevus on the scalp of an elderly man was treated with a surgical excision. This is the oldest patient reported with an adult onset epidermal nevus in Korea.